Browse categories and answer follow-up questions to refine your symptom profile.
History
Exposure timeline
Exposure and timeline
Time last known well
Time found unresponsive
Time of naloxone given and response
Duration of response after naloxone
Opioid and co ingestion details
Substance details
Suspected opioid
Route
Amount
Formulation
Immediate release
Extended release
Source
Prescribed
Illicit
Unknown
Co ingestions
Alcohol
Benzodiazepines
Sedative hypnotics
Clonidine
Antipsychotics
Gabapentinoids
Stimulants
Symptom pattern and trajectory
Course
Progressive somnolence
Episodic apnea
Witnessed cyanosis
Emesis
Seizure like activity
Associated symptoms
Associated symptoms
Dyspnea
Chest pain
Cough
Fever
Headache
Trauma history
Prior episodes and baseline
Baseline and prior events
Prior overdose episodes
Prior naloxone response pattern
Baseline respiratory disease
Baseline mental status
Alarm Features
Immediate life threats
Immediate escalation triggers
Apnea
Respiratory rate less than 8 per minute
Oxygen saturation less than 90 percent despite oxygen
Persistent hypoventilation with rising carbon dioxide
GCS less than 13 with airway risk
Recurrent sedation after naloxone
Shock
Refractory hypoglycemia
High risk contexts
High risk contexts
Long acting opioid exposure
Body packing or stuffing concern
Mixed sedative co ingestion
Pregnancy
Significant comorbidity
COPD
Obstructive sleep apnea
Heart failure
Pediatric exposure
High risk exam findings
High risk exam findings
Inability to protect airway
Rales or frothy sputum
Focal neurologic deficit
Hyperthermia
Hypothermia
Medications
Home and recent medications
Medication exposures
Prescribed opioids
Methadone
Buprenorphine
Benzodiazepines
Z drugs
Clonidine
Gabapentin
Pregabalin
Antipsychotics
Tricyclic antidepressants
Beta blockers
Opioid reversal and sedation management
Naloxone strategy
IV naloxone initial dose
0.04 mg
Escalate every 2 to 3 minutes if inadequate ventilation
0.1 mg
0.2 mg
0.4 mg
2 mg
Intranasal naloxone
4 mg device
Repeat every 2 to 3 minutes if inadequate ventilation
IM naloxone
0.4 mg
Repeat every 2 to 3 minutes if inadequate ventilation
Naloxone infusion
Indication
Recurrent respiratory depression after bolus
Long acting opioid exposure
Starting rate
Two thirds of effective bolus dose per hour
Titration
Titrate every 5 to 15 minutes to ventilation target
Wean after sustained clinical stability and falling opioid effect
Naloxone adverse effects
Acute withdrawal
Agitation
Vomiting
Aspiration risk
Pulmonary edema
Medication contraindications and traps
Cautions
Avoid flumazenil in mixed overdose with chronic benzodiazepine use
Avoid excessive naloxone dosing in chronic opioid use when ventilation adequate
Avoid sedatives for agitation until hypoxia and hypercapnia addressed
Diet
Recent intake and exposures
Intake context
Fasting
Poor oral intake
Recent vomiting
Dehydration risk
Alcohol and other exposures
Co exposures
Alcohol
Energy drinks
Cannabis edibles
Inhalants
Review of Systems
Respiratory and cardiovascular
Cardiopulmonary symptoms
Dyspnea
Cough
Chest pain
Palpitations
Orthopnea
Hemoptysis
Neurologic and toxidrome
Neuro symptoms
Altered level of consciousness
Syncope
Seizure
Headache
Weakness
Visual changes
Infectious and systemic
Systemic symptoms
Fever
Chills
Myalgias
Rash
Collateral History and Family History
Collateral source
Collateral
Source
EMS
Family
Friends
Bystanders
Reliability
Witnessed ingestion
Pill bottles present
Prior similar events
Family history
Family history
Sudden cardiac death
Seizure disorder (G40.909)
Long QT syndrome
Substance use disorder
Risk Factors
Patient factors
Patient risk factors
Opioid use disorder (F11.20)
Prior overdose
Recent abstinence
Post detox
Post incarceration
Sleep disordered breathing
Chronic lung disease
Exposure factors
Exposure risks
Unknown potency supply
Fentanyl analog exposure risk
Methadone exposure risk
Transdermal opioid exposure risk
Special populations
Special populations
Pregnancy
Older adult
Pediatric unintentional ingestion
Differential Diagnosis
Life threatening
Life threatening
Opioid toxicity (T40.2)
Triad
Central nervous system depression
Respiratory depression
Miosis
Mixed sedative overdose
Benzodiazepines (T42.4)
Z drugs (T42.6)
Alcohol (T51.0)
Hypoglycemia (E16.2)
Rapid point of care glucose differentiation
Intracranial hemorrhage (I61.9)
Trauma
Focal deficits
Acute airway obstruction
Aspiration
Foreign body
Sepsis (A41.9)
Fever
Hypotension
Common
Common
Intoxication with other substances
Cannabis
Antihistamines
Syncope with post event confusion
Post ictal state
Dehydration with altered mentation
Less common
Less common
Clonidine toxicity (T46.5)
Miosis
Bradycardia
Carbon monoxide exposure (T58)
Multiple affected
Headache
Myxedema coma (E03.5)
Hypothermia
Bradycardia
Adrenal crisis (E27.2)
Hypotension
Hyponatremia
Past Medical History
Relevant conditions
Relevant history
Opioid use disorder (F11.20)
Chronic pain
COPD (J44.9)
Obstructive sleep apnea (G47.33)
Heart failure (I50.9)
Chronic kidney disease (N18.9)
Liver disease
Prior procedures and devices
Procedures and devices
Tracheostomy history
Home oxygen
CPAP use
Implanted pumps
Baseline function
Baseline
Baseline mental status
Baseline mobility
Baseline oxygen requirement
Physical Exam
General and airway
Initial appearance
Level of consciousness
Work of breathing
Cyanosis
Vomitus in oropharynx
Airway protective reflexes
Vitals interpretation
Vitals patterns
Bradypnea
Hypoxia
Hypothermia
Hypotension
Bradycardia
Pupils and neurologic
Neuro exam
Pupils
Size
Reactivity
Focal deficits
Seizure activity
Signs of head trauma
Respiratory and pulmonary edema
Chest exam
Breath sounds
Wheeze
Crackles
Signs of aspiration
Frothy sputum
Cardiovascular
Circulation
Perfusion
Heart rate and rhythm
Jugular venous distension
Skin and tox clues
Skin findings
Track marks
Diaphoresis
Rash
Pressure injury from down time
Trauma survey
Trauma screen
Scalp and face injury
Cervical spine tenderness
Long bone deformity
Lab Studies
Point of care and core labs
Initial labs
Point of care glucose
Venous blood gas
pH
Carbon dioxide mmHg
Bicarbonate mmol/L
Electrolytes
Sodium mmol/L
Potassium mmol/L
Chloride mmol/L
Bicarbonate mmol/L
Creatinine and urea
CBC
Targeted tox and complications
Targeted studies
Acetaminophen level
Timing pitfall
Early level may be misleading without known ingestion time
Salicylate level
Ethanol level
Creatine kinase
Rhabdomyolysis risk with prolonged down time
Troponin if chest pain or hypoxia
Lactate if shock or sepsis concern
Infectious and aspiration evaluation
Infection and aspiration
Blood cultures if febrile or shock
Procalcitonin local protocol dependent
Respiratory viral testing when clinically indicated
Toxicology testing limitations
Toxicology screening limitations
Urine immunoassay false negatives for synthetic opioids
Urine immunoassay false positives with some medications
Management should be clinical syndrome based
Imaging
Scoring Systems
Decision tools
Canadian CT Head Rule
Use
Minor head injury with GCS 13 to 15
Concern for clinically important brain injury
Not use
Anticoagulated on warfarin or DOACs
Age younger than 16
NEXUS C spine
Use
Trauma with possible cervical spine injury
Low risk criteria assessment
Not use
Unreliable exam from intoxication with inability to assess midline tenderness
Focal neurologic deficit present
MRI
MRI role
Indications
Suspected anoxic brain injury with persistent coma
Suspected spinal cord injury with normal CT and persistent deficit
Limitations
Limited availability in unstable patients
Motion artifact in agitated patients
CT
CT indications
CT head
Persistent altered mental status without clear toxidrome resolution
Focal neurologic deficit
Head trauma signs
CT cervical spine
Trauma with unreliable exam
Midline tenderness
CT chest angiography
Only if alternate diagnosis suspected
Pulmonary embolism features
Ultrasound
POCUS applications
Lung ultrasound
B lines suggesting pulmonary edema
Consolidation suggesting aspiration pneumonia
Cardiac ultrasound
Gross LV function
Pericardial effusion
IVC assessment
Volume status adjunct
Pitfalls in ventilated patients
Special Tests
Bedside monitoring and diagnostics
Bedside tests
Continuous pulse oximetry
Capnography
Hypoventilation detection
Response to naloxone monitoring
Temperature
Hypothermia detection
Hyperthermia detection
Airway and aspiration evaluation
Airway and aspiration
Airway assessment criteria
Gag and cough reflexes
Ability to handle secretions
Chest radiograph
Aspiration pneumonitis patterns
Noncardiogenic pulmonary edema patterns
ECG
Indications and high risk patterns
ECG use
Co ingestion concern for cardiotoxic agents
Chest pain
Syncope
Dysrhythmia on monitor
High risk findings
QRS widening
QTc prolongation
Brugada pattern
Ischemic changes
Serial ECG
Repeat if evolving symptoms
Repeat if delayed absorption concern
Assessment
Working diagnosis and severity
Opioid toxicity (T40.2)
Severity markers
Degree of respiratory depression
Need for repeated naloxone
Need for naloxone infusion
Pulmonary edema presence
Complications to rule out
Aspiration pneumonitis
Noncardiogenic pulmonary edema
Trauma from collapse
Rhabdomyolysis
Hypoxic brain injury
Diagnostic uncertainty
Alternative diagnoses
Persistent coma despite adequate ventilation and naloxone response absent
Focal neurologic deficits
Fever with meningismus
Severe metabolic derangement on labs
Plan
First 5 minutes
Immediate stabilization
Airway positioning
Bag valve mask ventilation for apnea or hypoventilation
Oxygen to target saturation 92 to 96 percent
Cardiac monitor
IV access
Point of care glucose with immediate correction if low
Naloxone and ventilation targets
Reversal strategy
Naloxone titration target
Adequate ventilation
Airway protection
Avoid full arousal if not needed for ventilation
If recurrent respiratory depression after initial response
Start naloxone infusion
Continue close capnography monitoring
Supportive care and complications
Supportive care
Aspiration risk reduction
Lateral positioning
Suction readiness
Fluids if hypotension after ventilation corrected
Active warming if hypothermia
Treat agitation from withdrawal
Verbal de escalation
Antiemetic for vomiting
Avoid respiratory depressant sedatives when possible
Reassessment loop
Reassessment
Repeat mental status and ventilation checks every 5 to 15 minutes until stable
Repeat vitals every 15 minutes until stable
Repeat capnography trend after each naloxone dose change
Escalate to airway intervention if persistent hypoventilation despite naloxone
Consultation
Consultation plan
Poison control or toxicology
Critical care if infusion or airway support needed
Addiction medicine or social work when clinically stable
Disposition
Level of care criteria
ICU criteria
Naloxone infusion requirement
Need for invasive ventilation
Persistent hypercapnia with acidemia
Hemodynamic instability
Pulmonary edema requiring high flow oxygen or positive pressure
Inpatient admission criteria
Recurrent respiratory depression during observation
Aspiration pneumonia requiring antibiotics and oxygen
Rhabdomyolysis with rising creatinine or high CK
Significant comorbid respiratory disease with prolonged monitoring need
Observation pathway
ED observation criteria
Short acting opioid suspected with complete response to naloxone
Stable vitals and ventilation after reversal
Reliable monitoring available
Discharge criteria
Discharge criteria
Normal mentation
Sustained adequate ventilation without naloxone re dosing
Oxygen saturation stable on room air at baseline
Ambulation at baseline
No concerning trauma findings
Safe supervision and follow up plan
Follow up timing
Follow up
Primary care within 1 to 7 days
Addiction services within 24 to 72 hours when available
Pharmacy or community naloxone program same day if possible
Discharge Instructions
Copy discharge instructions
Discharge text
Today you were treated for opioid poisoning that slowed your breathing
Your breathing and alertness improved after naloxone and observation
Do not use opioids or other sedatives for at least 24 hours
Avoid alcohol and sleeping pills
Do not drive or operate machinery for 24 hours
Naloxone kit provided or prescription provided
If you become very sleepy or your breathing slows again call emergency services immediately
Return now for
Trouble breathing
Blue lips or face
Fainting
Chest pain
Fever
Vomiting with choking
New weakness
Severe headache
Follow up with your doctor and addiction supports as arranged
References
Guidelines and key evidence
Sources
American Heart Association
2020 Guidelines for CPR and ECC opioid associated emergency updates 2020
World Health Organization
Community management of opioid overdose guideline 2014
Substance Abuse and Mental Health Services Administration
Opioid overdose prevention toolkit updated edition local protocol dependent
American College of Medical Toxicology and American Academy of Clinical Toxicology
Position statements on naloxone use and opioid poisoning management year varies local protocol dependent
Project instructions file
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.