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Approach to the Critical Patient
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
Recurrent respiratory depression after reversal
Naloxone infusion pathway
Higher level of care planning
Monitoring and access
Monitoring bundle
Continuous pulse oximetry
Room air reassessment after stabilization
Artifact recognition with poor perfusion
Continuous capnography when available
ETCO2 trend for ventilatory failure
Sudden ETCO2 drop for apnea
Cardiac monitoring
Dysrhythmia screening with co ingestion
QT interval awareness with methadone risk
Noninvasive blood pressure cycling
Frequency based on instability
Hypotension persistence triggers broader workup
Access and readiness
IV access
Low dose naloxone titration capability
Blood draw for co ingestion screening
IO access
If no IV with immediate life threat
Not required solely for naloxone
Airway equipment at bedside
Suction functioning
BVM with PEEP option when needed
Key concepts
Primary lethal mechanism
Respiratory depression
Hypercapnia progression
Hypoxia progression
Airway compromise
Loss of protective reflexes
Aspiration risk
Naloxone goals
Adequate ventilation
Not necessarily full wakefulness
Avoid precipitated withdrawal when possible
Re sedation risk
Short naloxone duration relative to long acting opioids
Observation plan tied to opioid type and dosing pattern
History
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
Co exposures and red flags
Co ingestion screen
Alcohol
Sedation synergy
Hypoglycemia risk
Benzodiazepines
Prolonged sedation
Naloxone non response clues
Stimulants
Hyperthermia risk
Dysrhythmia risk
Alternative cause flags
Head trauma history
Unwitnessed fall
Anticoagulant use
Infection risk
Fever history
Aspiration event
Metabolic risk
Diabetes history
Seizure history
Physical Exam
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
Hyperthermia
Stimulant co use
Serotonin toxicity differential
Complications and pitfalls
Pulmonary complications
Aspiration findings
Rales
Wheeze
Noncardiogenic pulmonary edema concern
Hypoxia disproportionate to exam
Pink frothy sputum if present
Trauma screen
Head and neck injury signs
Scalp hematoma
Cervical tenderness
Extremity injuries
Deformity
Compartment concern with prolonged compression
Skin and exposure
Cyanosis
Late sign of hypoventilation
Alternative hypoxia etiologies
Injection stigmata
Infection concern
Endocarditis risk context
Differential Diagnosis
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
Opioid related diagnoses and coding
Opioid poisoning ICD 10 T40 series
Heroin poisoning ICD 10 T40.1
Rapid onset respiratory depression
Needle exposure context
Methadone poisoning ICD 10 T40.3
Prolonged course
QT prolongation risk
Other opioids poisoning ICD 10 T40.2
Prescription exposure context
Extended release concern
Opioid intoxication with complications
Aspiration pneumonitis ICD 10 J69.0
Hypoxia with abnormal lung exam
Fever later
Rhabdomyolysis ICD 10 M62.82
Prolonged down time
Dark urine history
Laboratory Tests
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
Anemia for occult bleeding if trauma suspected
Blood cultures
If sepsis concern
If endocarditis concern
Toxicology and co ingestion labs
Targeted toxicology evaluation
Acetaminophen level
Unknown ingestion time
Early treatment window relevance
Salicylate level
Tachypnea with mixed picture
Metabolic acidosis evaluation
Ethanol level
Sedation synergy
Hypoglycemia risk context
Urine drug immunoassay
False negatives with synthetic opioids
False positives and limited clinical utility
Diagnostic Tests
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
Focal neurologic deficit
Persistent coma after adequate ventilation and naloxone
CT chest
Severe hypoxia with unclear etiology
Alternative pulmonary process concern
CT abdomen pelvis
Body packing concern
Obstruction symptoms
Ultrasound (or US)
Point of care ultrasound
Lung ultrasound
Pulmonary edema pattern
Consolidation pattern for aspiration pneumonia
Cardiac ultrasound
Hypotension evaluation
Pericardial effusion exclusion
IVC ultrasound
Volume status estimation
Shock phenotype support
Radiography
Plain films
Chest x ray
Persistent hypoxia
Abnormal lung sounds
Fever
Trauma imaging
Based on mechanism and exam
Unwitnessed fall with high risk features
Disposition
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
Delayed toxicity with extended release ingestion
Discharge readiness
Normal vital signs on room air
Oxygen saturation stable
Respiratory rate normal without stimulation
Normal mental status or baseline
Ambulation as usual
Reliable observation at home when possible
Harm reduction and linkage
Take home naloxone offer
Substance use services referral pathway
Treatment
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
Special Populations
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
Unintentional ingestion
Household opioid access
Naloxone weight based dosing
Naloxone 0.1 mg per kg IV IO IM
Repeat dosing by response and recurrence
Mandatory safeguarding
Child protection notification pathway
Safe discharge environment confirmation
Higher risk observation
Longer monitoring with long acting exposure
Toxicology consultation triggers
Background
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
Competitive receptor antagonism
Shorter duration than many opioids
Titrated reversal principle
Aim for breathing restoration
Avoid unnecessary withdrawal and agitation
Observation principle
Re sedation after naloxone
Monitoring duration individualized
Higher risk with long acting opioids and infusion use
Early discharge rule consideration
HOUR rule as risk stratification tool
Not a substitute for clinician judgment in high risk contexts
Patient Discharge Instructions
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
References
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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.