01Approach to the Critical Patient/attcp67

Immediate stabilization

›Airway and breathing priorities

›Apnea

›Immediate bag valve mask ventilation

›Airway adjunct selection by mental status

›Hypoventilation

›Assisted ventilation with capnography when available

›Naloxone trial when opioid toxidrome suspected

›Oxygenation targets

›SpO2 94% to 98%

›Avoid hyperoxia after adequate ventilation

›Circulation threats

›Hypotension differential beyond opioids

›Shock triggers for vasopressor readiness

›Opioid toxidrome recognition

›Depressed respiratory drive

›Respiratory rate trend

›Tidal volume adequacy

›Depressed mental status

›Arousal response to voice

›Arousal response to pain

›Miosis

›Pupillary reactivity preserved

›Alternate pupil patterns with co intoxication

›Escalation triggers

›Persistent hypoxia despite ventilation

›Immediate advanced airway planning

›Aspiration management pathway

02History/hx47

Exposure and timeline

›Exposure profile

›Suspected opioid

›Heroin

›Prescription opioid

›Synthetic opioid concern

›Route

›Oral ingestion

›Intranasal use

›Injection exposure

›Time course

›Last known well time

›Time of found down

›Treatment before arrival

›Naloxone administration

›Route and total doses

›Clinical response pattern

›Bystander ventilation

›Duration

›CPR performed

›Baseline risk context

›Opioid tolerance

›Chronic opioid therapy

›Opioid use disorder history

›Long acting opioid exposure

›Methadone

›Extended release formulations

›Transdermal products

03Physical Exam/exam51

Toxidrome and vital signs

›Respiratory pattern

›Bradypnea

›Rate threshold for assisted ventilation

›Shallow breathing recognition

›Apnea

›Immediate ventilation priority

›Pulse check integration

›Upper airway obstruction signs

›Snoring respirations

›Gurgling secretions

›Neurologic status

›Level of consciousness

›GCS trend

›Arousal with stimulation

›Pupils

›Size and reactivity

›Anisocoria concern for intracranial process

›Focal deficits

›Stroke pathway trigger

›Intracranial hemorrhage pathway trigger

›Hemodynamics and temperature

›Hypotension

›Sepsis differential

›Co ingestion differential

›Hypothermia

›Environmental exposure

›Prolonged down time

04Differential Diagnosis/ddx44

Life threatening mimics

›Central nervous system catastrophe

›Intracranial hemorrhage ICD 10 I61

›Sudden coma

›Focal neurologic signs

›Ischemic stroke ICD 10 I63

›Focal deficits

›Aphasia

›Status epilepticus ICD 10 G40.901

›Postictal state

›Tongue trauma

›Metabolic and endocrine

›Hypoglycemia ICD 10 E16.2

›Rapid bedside glucose confirmation

›Persistent altered mental status after ventilation

›Hypercapnic respiratory failure ICD 10 J96.22

›COPD baseline

›Wheeze with CO2 retention

›Toxicologic

›Benzodiazepine intoxication SNOMED 295199007

›Normal pupils

›Prominent ataxia

›Carbon monoxide poisoning ICD 10 T58

›Headache history

›Multiple patients exposed

›Clonidine intoxication

›Miosis with bradycardia

›Hypotension prominence

05Laboratory Tests/lt43

Bedside tests

›Immediate point of care evaluation

›Glucose mmol/L

›Hypoglycemia threshold 3.0 mmol/L

›Recheck after dextrose if treated

›Venous blood gas

›pH for ventilatory failure severity

›pCO2 mmHg for hypoventilation quantification

›Pregnancy test

›Reproductive age with unknown status

›Management and disposition implications

Core laboratory panel

›Baseline labs by risk profile

›Electrolytes and renal function

›Creatinine for rhabdomyolysis risk

›Potassium for dysrhythmia risk

›Liver enzymes

›Co ingestion evaluation

›Hypoxic injury context

›Creatine kinase

›Prolonged immobilization concern

›Trend if elevated

›Lactate mmol/L

›Hypoxia severity marker

›Alternate shock etiologies

›Infection and aspiration evaluation

›Complete blood count

›Leukocytosis nonspecific

06Diagnostic Tests/dt51

Scoring Systems

›Risk stratification tools

›Glasgow Coma Scale

›Trend over time

›Not a sole trigger for naloxone dosing

›HOUR rule after naloxone

›Assessment at 1 hour after last naloxone dose

›Mobilize as usual

›Oxygen saturation at least 95% on room air

›Normal respiratory rate

›Normal temperature

›Normal heart rate

›Normal GCS

›Sedation scale

›RASS for agitation after reversal

›Withdrawal symptoms monitoring

MRI

›Neuroimaging escalation

›Brain MRI

›Persistent altered mental status with nondiagnostic CT head

›Stroke mimic evaluation

›Spine MRI

›Prolonged down time with focal weakness

›Epidural abscess concern in injection exposure

CT

›CT pathways

›CT head without contrast

›Head trauma concern

07Disposition/dispo37

Level of care selection

›ICU indications

›Advanced airway required

›Ongoing ventilation support

›Refractory hypoxia

›Naloxone infusion required

›Recurrent respiratory depression

›Long acting opioid exposure

›Significant complications

›Acute lung injury

›Severe aspiration

›Persistent hemodynamic instability

›Hypotension despite fluids

›Dysrhythmia requiring therapy

›Ward admission indications

›Prolonged sedation

›Ongoing oxygen requirement

›Monitoring needs beyond ED capacity

›Rhabdomyolysis risk

›CK elevation with renal risk

›Need for IV fluids and monitoring

Observation and discharge criteria

›Observation planning

›Re sedation monitoring

›Longer observation for long acting opioids

›Longer observation after naloxone infusion stop

›Co ingestion monitoring

›Benzodiazepine and alcohol prolongation

08Treatment/t96

Airway and ventilation

›Oxygenation and ventilation support

›Positioning

›Head tilt chin lift when no trauma concern

›Jaw thrust when trauma concern

›Airway adjuncts

›Oropharyngeal airway if absent gag

›Nasopharyngeal airway if partial reflexes

›Bag valve mask ventilation

›Two person technique when available

›PEEP titration for hypoxia

›Advanced airway pathway

›If ventilation cannot be maintained

›If recurrent aspiration with inability to protect airway

Naloxone

›Naloxone strategy

›Indications

›Respiratory depression with suspected opioid exposure

›Apnea with suspected opioid exposure

›Target endpoints

›Adequate spontaneous ventilation

›Adequate oxygenation

›Avoid full reversal when not required for ventilation

›IV titration in monitored clinical setting

›Naloxone IV 0.04 mg

›Repeat every 2 minutes

›Escalate to 0.1 mg if inadequate response

›Escalation sequence if inadequate response

›Naloxone IV 0.4 mg

›Repeat every 2 minutes as needed

›Monitor for withdrawal and agitation

›Naloxone IV 0.8 mg

›Repeat every 2 minutes as needed

›Reassess for alternative causes if no response

›Naloxone IV 2 mg

›Repeat every 2 minutes as needed

›Airway escalation readiness

›Naloxone IV 4 mg

›Repeat every 2 minutes as needed

›Co ingestion consideration if partial response

›Naloxone IV 10 mg

›If high clinical suspicion persists

›If no response then alternative diagnosis focus

›IM or intranasal dosing when IV not available

›Naloxone IM 0.4 mg

›Repeat every 3 minutes as needed

›Alternate injection sites

›Naloxone intranasal 4 mg

›Repeat every 3 minutes as needed

›Alternate nostrils for subsequent doses

›Naloxone infusion for recurrent toxicity

›Indications

›Multiple boluses required after initial reversal

›Long acting opioid exposure

›Infusion options

›Naloxone infusion 0.4 mg per hour

›Titrate to adequate respiratory effort

›Continue capnography when possible

›Naloxone infusion 0.8 mg per hour

›If recurrent depression on lower rate

›Reassess for complications and co ingestion

›Two thirds of effective bolus per hour

›Use last effective bolus dose

›Adjust for recurrent sedation

›Weaning and stop plan

›Stepwise reduction with close monitoring

›Observation period after infusion stop

Supportive and complication focused care

›Aspiration management

›Suction and airway clearance

›Oropharyngeal suction

›Consider intubation if unable to protect airway

›Imaging guided evaluation

›Chest x ray by clinical triggers

›Lung ultrasound when available

›Fluids and hemodynamics

›Isotonic crystalloid bolus

›If hypotension present

›Reassess for alternate shock causes

›Vasopressor support

›If refractory hypotension

›Early critical care involvement

›Agitation after reversal

›Environmental de escalation

›Reduce stimulation

›Safety measures for staff and patient

›Sedation choice

›Short acting agent selection by vitals

›Avoid oversedation with respiratory compromise

OUD linkage and ED initiated therapy

›Post stabilization pathway

›Brief intervention

›Overdose risk education

›Safer use counseling

›Take home naloxone

›Dispense when available

›Training on recognition and response

›ED initiated buprenorphine for withdrawal

›ACEP Clinical Policy Level B recommendation

›Initiation only when objective withdrawal present

09Special Populations/sp36

Pregnancy

›Pregnancy considerations

›Maternal priority

›Oxygenation and ventilation as primary fetal protection

›Naloxone benefits outweigh withdrawal risk

›Naloxone dosing approach

›Prefer IV low dose titration 0.04 mg to 0.1 mg

›Avoid high dose intranasal when alternatives available

›Positioning after 20 weeks

›Left uterine displacement

›Left tilt positioning

›Obstetric coordination

›Fetal monitoring when viable gestation and resources available

›Early obstetrics consult when severe toxicity or withdrawal

Geriatric

›Geriatric considerations

›Polypharmacy

›Sedative co prescriptions

›Renal impairment prolonging toxicity

›Lower physiologic reserve

›Rapid decompensation with hypoxia

›Higher aspiration risk

›Naloxone titration preference

›Lower initial IV doses

›Close monitoring for pulmonary edema and dysrhythmia

Pediatrics

›Pediatric considerations

›Exposure patterns

10Background/b37

Epidemiology

›Epidemiology snapshot

›High burden mortality

›Opioid overdose major contributor to poisoning deaths

›Unintentional overdose predominance

›Common ED presentation

›Altered mental status with hypoventilation

›Co ingestion frequent

›Community response importance

›Bystander naloxone effectiveness

›Training improves recognition and administration

Pathophysiology

›Mechanism of toxicity

›Mu opioid receptor agonism

›Brainstem respiratory center suppression

›Decreased ventilatory response to CO2

›Airway and reflex effects

›Sedation with loss of protective reflexes

›Aspiration susceptibility

›Variable duration

›Short acting opioid toxicity

›Long acting opioid toxicity

Therapeutic Considerations

›Ventilation as definitive temporizing therapy

›Hypoxia prevention as primary objective

›BVM ventilation effective immediately

›CPR with ventilation when arrest occurs

›Naloxone as targeted reversal

11Patient Discharge Instructions/pdi23

copy discharge instructions

›Discharge instructions

›What happened

›Opioids can slow or stop breathing

›Naloxone can wear off before the opioid wears off

›What to do now

›Avoid alcohol and sedatives today

›Do not use opioids alone

›Keep a phone nearby and have someone check on you if possible

›Naloxone plan

›Keep naloxone where it can be reached quickly

›Teach family or friends how to use it

›Return to ED now if any of the following

›Trouble breathing

›Extreme sleepiness or cannot stay awake

›Blue lips or face

›Chest pain

›Severe vomiting

›Fever

›New confusion

›Fainting

›Follow up

›Addiction medicine or primary care appointment within 1 week

›Opioid use disorder treatment resources provided before leaving

12References/r26

Clinical guidelines and evidence sources

›American Heart Association opioid associated emergency algorithm for healthcare providers

›Ventilation and CPR as cornerstone therapy

›Naloxone as adjunct when opioid poisoning suspected

›American Heart Association 2023 focused update on poisoning related arrest and life threatening toxicity

›Class of Recommendation and Level of Evidence framework

›Opioid poisoning recommendations updated from 2020 AHA guidelines

›BCCDC Naloxone Administration Decision Support Tool

›IM 0.4 mg dosing and q3 minute repeats

›Intranasal 4 mg dosing and q3 minute repeats

›IV 0.04 mg to 0.1 mg titration q2 minutes in clinical settings

›Escalation sequence up to 10 mg IV when high suspicion persists

›Emergency Care BC opioid poisoning in hospital management summary

›Naloxone escalation schedule and infusion options

›Admission criteria and discharge criteria framework

›HOUR rule validation study after naloxone reversal

›One hour assessment criteria set

›Use as discharge risk stratification aid

›CDC naloxone education for overdose response

›Naloxone reverses opioid overdose including fentanyl involved overdose

›Community access and training emphasis

›WHO community management of opioid overdose guideline

›Naloxone and basic life support for reversal

›Post reversal monitoring emphasis

›ACEP opioid reference materials and clinical policy related to opioids

›ED linkage to treatment and harm reduction

›Buprenorphine recommendations for withdrawal management

Evidence & Review

Evidence & Review