Opioid overdoseMANAGEMENT

TOXICOLOGIC PRESENTATIONS · 12 SECTIONS

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493 items

☷ Legend

01Approach to the Critical Patient/attcp68

Immediate priorities

›Resuscitation priorities

›Airway patency

›Gurgling

›Stridor

›Vomitus

›Breathing adequacy

›Respiratory rate <10/min

›Apnea

›SpO2 <90% on room air

›Circulation status

›SBP <90 mmHg

›Shock index >1

›Bradycardia

›Neurologic status

›GCS <13

›Unresponsive

›Opioid toxidrome recognition

›Miosis

›Pinpoint pupils not required

›Normal pupils possible with hypoxia or coingestants

›CNS depression

›Somnolence

›Coma

›Respiratory depression

›Hypoventilation

›Hypercapnia

›Immediate stabilization actions

›Bag valve mask ventilation for hypoventilation

›Two person technique

›Oropharyngeal or nasopharyngeal airway

›Oxygen supplementation

›Nasal cannula

›Nonrebreather

›High flow nasal cannula

›Naloxone for respiratory depression

›Titrated reversal strategy

›Full reversal not required if ventilation adequate

›Point of care glucose for altered mental status

›Treat hypoglycemia per local protocol

Monitoring and escalation

›Monitoring bundle

›Continuous pulse oximetry

›SpO2 target 92% to 96%

›Cardiac monitoring

›Bradyarrhythmia

›QT prolongation concern

›Frequent respiratory reassessment

›Respiratory rate

›Work of breathing

›Mental status trajectory

›Capnography when available

›Rising ETCO2 as early hypoventilation marker

›Escalation triggers

›Persistent apnea despite naloxone

›Immediate airway control

›Inability to protect airway

›Early intubation strategy

›Recurrent respiratory depression

›Continuous naloxone infusion pathway

›Suspected polysubstance ingestion

›Expanded tox workup

›Higher level of care

Key concepts

›Core principles

›Primary lethal mechanism is hypoventilation with hypoxia and hypercapnia

›Ventilation support is definitive in the moment

›Naloxone duration often shorter than opioid duration

›Renarcotization risk after initial response

›Goal is adequate spontaneous ventilation

›Withdrawal precipitation avoided when possible

02History/hx60

Focused overdose history

›Exposure context

›Suspected substance

›Prescription opioid

›Heroin

›Fentanyl or analog

›Methadone

›Buprenorphine

›Route

›Oral

›Intranasal

›Inhaled

›Injection

›Timing

›Last known well

›Time found down

›Witnessed apnea

›Quantity

›Number of tablets

›Patch count

›Bag or powder estimate

›Prehospital course

›Bystander actions

›Rescue breaths

›Bystander naloxone

›EMS care

›Naloxone total dose

›Response pattern

›Bag valve mask duration

›Complications during transport

›Coingestants and risk modifiers

›Sedatives

›Benzodiazepines

›Z drugs

›Alcohol

›Stimulants

›Cocaine

›Methamphetamine

›Acetaminophen exposure risk

›Combination products

›Extended release formulations

›Long acting opioid use

›Methadone maintenance

›Sustained release oxycodone

›Medical risk history

›Chronic lung disease

›Obstructive sleep apnea

›Heart disease

›Seizure disorder

›Pregnancy

›Social and safety context

›Prior overdose episodes

›Naloxone access at home

›Using alone

›Housing insecurity

›Recent abstinence with relapse risk

Pitfalls

›Common pitfalls

›Assuming normal pupils excludes opioid overdose

›Assuming urine drug screen rules in or rules out fentanyl exposure

›Missing head trauma in found down patient

›Missing hypoglycemia as contributor to coma

03Physical Exam/exam42

Toxidrome and respiratory assessment

›Airway and breathing

›Respiratory rate

›Bradypnea

›Apnea episodes

›Work of breathing

›Shallow respirations

›Accessory muscle use after reversal

›Auscultation

›Aspiration findings

›Pulmonary edema findings

›Cyanosis

›Neurologic

›Mental status

›Arousability

›Post naloxone agitation

›Pupillary size and reactivity

›Miosis

›Mydriasis with coingestants

›Focal deficits

›Stroke mimic consideration

›Circulation

›Heart rate

›Bradycardia

›Tachycardia with withdrawal or hypoxia

›Blood pressure

›Hypotension

›Hypertension post reversal

›Temperature

›Hypothermia in exposure

›Skin and injection findings

›Track marks

›Abscess

›Cellulitis

›Transdermal patch locations

›Trauma survey for found down

›Head and face injury

›Cervical spine concern

›Rhabdomyolysis risk signs

PITFALLS

›Missed complications

›Aspiration pneumonitis after emesis

›Noncardiogenic pulmonary edema after reversal

›Prolonged immobilization compartment syndrome

04Differential Diagnosis/ddx26

Life threats and mimics

›Opioid related diagnoses

›Opioid poisoning with respiratory depression (ICD-10 T40.2X1A)

›Heroin poisoning (ICD-10 T40.1X1A)

›Synthetic narcotics poisoning including fentanyl (ICD-10 T40.4X1A)

›Methadone poisoning (ICD-10 T40.3X1A)

›Adverse effect opioid, therapeutic use (ICD-10 T40.2X5A)

›Other toxicologic causes of coma

›Benzodiazepine intoxication (ICD-10 T42.4X1A)

›Ethanol intoxication (ICD-10 F10.129)

›Clonidine or imidazoline poisoning

›Carbon monoxide poisoning (ICD-10 T58.91XA)

›Non toxicologic causes of altered mental status

›Hypoglycemia (SNOMED CT Hypoglycemia)

›Seizure with postictal state

›Intracranial hemorrhage (ICD-10 I61.9)

›Ischemic stroke (ICD-10 I63.9)

›CNS infection

›Hypothermia

›Respiratory failure mimics

›COPD exacerbation

›Acute asthma

›Pulmonary embolism

›Anaphylaxis

›Cardiac arrest or peri arrest

›Primary dysrhythmia

›Acute coronary syndrome

05Laboratory Tests/lt31

Immediate bedside tests

›Rapid screen labs

›Point of care glucose

›Hypoglycemia threshold per local protocol

›Recheck after treatment

›Venous blood gas or arterial blood gas

›pH

›PaCO2 in mmHg

›PaO2 in mmHg

›Electrolytes and renal function

›Sodium mmol/L

›Potassium mmol/L

›Creatinine micromol/L

›Targeted tox labs

›Acetaminophen concentration for unknown ingestion

›Timing unreliable treated as potentially toxic until proven otherwise

›Salicylate concentration for unknown ingestion

›Ethanol level if altered mental status unclear

Complication assessment

›Complication labs

›Creatine kinase for rhabdomyolysis concern

›Rising CK trend

›AKI risk support

›Lactate mmol/L for shock or prolonged down time

›Troponin for chest pain or arrest

›CBC for infection concern

›Infection related labs when indicated

›Blood cultures for sepsis concern

›HIV and hepatitis testing per consent and local practice

Test limitations

›Toxicology limitations

›Urine drug screen false negatives for fentanyl common with standard immunoassays

›Urine drug screen false positives possible

›Clinical toxidrome prioritized over screening assays

06Diagnostic Tests/dt42

Scoring Systems

›Clinical scoring and structured assessment

›Glasgow Coma Scale

›Trend over time after ventilation and naloxone

›Persistent low GCS triggers alternative diagnosis evaluation

›Richmond Agitation Sedation Scale

›Post reversal agitation documentation

›Sedation safety tracking if needed

›Respiratory risk stratification

›Recurrent hypoventilation within 2 hours of last naloxone as high risk

›Long acting opioid exposure as high risk

MRI

›MRI indications

›Persistent coma without clear tox explanation

›Diffusion restriction concern for hypoxic ischemic injury

›Focal neurologic deficits with nondiagnostic CT

›Posterior circulation stroke concern

›MRI limitations

›Not first line in unstable patient

›Time to imaging delays definitive care

›CT head decision pathway

›Found down with trauma concern

›Anticoagulant use

›Evidence of head injury

›Persistent altered mental status after adequate ventilation and naloxone

›Stroke concern

›Focal deficits

›Asymmetric pupils not explained by hypoxia

›CT chest considerations

›Severe hypoxia with aspiration concern

›Alternative diagnosis evaluation

›Pulmonary edema after reversal

›Supportive evaluation when diagnosis uncertain

Ultrasound

›Point of care ultrasound applications

›Lung ultrasound

›B lines for pulmonary edema pattern

›Consolidation for aspiration or pneumonia pattern

›Cardiac ultrasound

›Global function for shock assessment

›Pericardial effusion if arrest

›IVC assessment

›Volume status adjunct

›Soft tissue ultrasound

›Abscess identification at injection sites

07Disposition/dispo32

Level of care decisions

›Disposition framework

›ICU criteria

›Ongoing naloxone infusion requirement

›Recurrent apnea or hypoventilation

›Mechanical ventilation

›Persistent hypercapnia despite therapy

›Stepdown or monitored bed criteria

›Multiple naloxone boluses needed

›Long acting opioid exposure

›Significant comorbidity increasing respiratory risk

›ED observation criteria

›Single naloxone response with sustained ventilation

›No concerning coingestants

›Normal vital signs trend

Observation timing

›Observation principles

›Minimum observation after last naloxone dose based on agent risk

›Longer observation for methadone and sustained release opioids

›Longer observation when fentanyl exposure suspected with recurrent depression

›Renarcotization monitoring focus

›Respiratory rate trend

›ETCO2 trend when available

Discharge readiness

›Discharge criteria

›Normal mental status baseline

›Sustained spontaneous ventilation without supplemental oxygen beyond baseline

›Stable hemodynamics

›Ambulation at baseline

›Safe supervision and follow up plan

›Harm reduction and naloxone provided when possible

Transfer and consultation

›Consultation triggers

›Poison center or toxicology for complex or refractory cases

›Critical care for infusion or ventilation

›Addiction medicine or social work for linkage to treatment

08Treatment/t96

Airway and ventilation

›Ventilation support

›Bag valve mask ventilation

›Two person seal

›Airway adjuncts as needed

›Consider PEEP valve if oxygenation poor

›Noninvasive ventilation considerations

›Post reversal pulmonary edema

›Cooperative patient

›Endotracheal intubation pathway

›Persistent apnea

›Refractory hypoventilation

›Inability to protect airway with aspiration risk

Naloxone protocols

›Naloxone titration strategy

›Initial dosing selection based on severity

›Apnea or near apnea

›Naloxone IV 2 mg

›Repeat every 2 to 3 minutes to ventilation target

›Severe respiratory depression with pulse present

›Naloxone IV 0.4 mg

›Repeat doubling dose sequence 0.4 mg then 0.8 mg then 2 mg then 4 mg as needed

›Mild to moderate respiratory depression

›Naloxone IV 0.04 mg

›Titrate every 2 to 3 minutes to respiratory rate >=12/min

›Intranasal route

›Naloxone IN 4 mg single spray

›Repeat every 2 to 3 minutes as needed

›Intramuscular route

›Naloxone IM 0.4 mg to 2 mg

›Repeat every 2 to 3 minutes as needed

›Target endpoints

›Adequate ventilation

›Airway protection

›Avoid full arousal when possible

›Adverse effects management

›Acute withdrawal

›Antiemetic therapy if vomiting

›Fluids for volume depletion

›Agitation

›Verbal de escalation first

›If severe agitation threatens safety, short acting sedative per local protocol with close respiratory monitoring

›Pulmonary edema

›Oxygen support escalation

›Noninvasive ventilation consideration

›Naloxone infusion pathway

›Indications

›Recurrent respiratory depression after effective bolus

›Long acting opioid exposure

›Infusion calculation

›Infusion rate as two thirds of effective bolus dose per hour

›Example effective bolus 1.5 mg total

›Infusion 1.0 mg/hour

›Bridging strategy

›Repeat bolus dose if respiratory depression recurs while infusion started

›Titration and monitoring

›Titrate every 10 to 20 minutes to ventilation target

›Observation after stopping infusion for renarcotization risk

Circulation and supportive care

›Hemodynamic support

›IV access

›Two large bore peripheral lines

›Intraosseous access if needed

›Crystalloid bolus for hypotension

›Reassess after each bolus

›Vasopressor support for refractory hypotension

›Norepinephrine infusion per local protocol

›Temperature management

›Passive rewarming for hypothermia

›Complication treatment

›Aspiration pneumonitis

›Supportive oxygenation

›Antibiotics only if bacterial pneumonia concern

›Rhabdomyolysis

›IV fluids with urine output monitoring

›Electrolyte monitoring

›Hypoglycemia

›Dextrose therapy per local protocol

›Seizure

›Benzodiazepine therapy per local protocol

Withdrawal and linkage to care

›Opioid withdrawal considerations

›Precipitated withdrawal risk with high dose naloxone

›Titrate to ventilation strategy preferred when possible

›Symptom control

›Antiemetic therapy

›Antidiarrheal therapy per local protocol

›Clonidine consideration per local protocol with blood pressure monitoring

›Opioid use disorder linkage

›Take home naloxone provision when available

›Harm reduction counseling

›Referral to addiction services

›Consider buprenorphine initiation pathway when appropriate and available

Evidence levels and guideline alignment

›Evidence and consensus framing

›Naloxone for suspected opioid induced respiratory depression is standard of care

›ACEP Level B consensus alignment commonly cited in emergency care pathways

›Ventilation support prioritized over antidote in apnea

›Resuscitation consensus Class I style recommendation in many emergency algorithms

›Continuous infusion for recurrent depression is widely recommended in toxicology practice

›Class IIa style recommendation by expert consensus

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Maternal resuscitation priority

›Oxygenation and ventilation optimization

›Left uterine displacement in late pregnancy if hypotensive

›Naloxone use

›Indicated for maternal respiratory depression

›Withdrawal may cause fetal distress

›Fetal monitoring

›Viable gestation with significant event

›Obstetric consultation

Geriatric

›Geriatric considerations

›Higher respiratory depression risk

›Lower physiologic reserve

›Comorbid COPD or heart failure

›Polypharmacy coingestants

›Benzodiazepines common

›Gabapentinoids common

›Lower naloxone titration preference when not apneic

›Avoid severe agitation and catecholamine surge

Pediatrics

›Pediatric considerations

›Weight based naloxone dosing

›Naloxone IV 0.1 mg/kg

›Maximum single dose 2 mg

›Repeat every 2 to 3 minutes as needed

›Accidental ingestion risk

›Caregiver medication access

›Fentanyl exposure concern

›Mandatory reporting considerations per jurisdiction

›Observation emphasis

›Longer observation for long acting exposures

10Background/b27

Epidemiology

›Epidemiology overview

›Opioid overdose is a leading cause of preventable death in many regions

›Fentanyl and analogs associated with rapid onset respiratory depression

›Polysubstance exposure common in modern overdose presentations

Pathophysiology

›Pathophysiology summary

›Mu opioid receptor agonism

›Brainstem respiratory drive suppression

›Reduced ventilatory response to hypercapnia

›Upper airway obstruction contribution

›Loss of pharyngeal tone

›Hypoxia complications

›Dysrhythmia

›Hypoxic ischemic brain injury

›Naloxone mechanism

›Competitive opioid receptor antagonism

›Shorter half life than many opioids

Therapeutic Considerations

›Treatment principles

›Ventilation is time critical

›Hypoxia prevention is primary mortality reduction pathway

›Naloxone titration balances goals

›Restore ventilation

›Minimize withdrawal severity

›Renarcotization risk management

›Repeat bolus or infusion strategy

›Harm reduction integration reduces recurrent overdose risk

›Take home naloxone

›Linkage to opioid agonist therapy programs

11Patient Discharge Instructions/pdi26

copy discharge instructions

›Discharge instructions text

›Diagnosis

›Opioid overdose treated with naloxone and monitoring

›Safety today

›No driving for 24 hours

›No alcohol or sedatives for 24 hours

›Stay with a responsible adult for the rest of the day

›Naloxone

›Keep naloxone available

›Teach household how to use it

›Return to ED now for

›Sleepiness that is hard to wake from

›Slow breathing

›Blue lips or face

›Chest pain

›Severe shortness of breath

›Repeated vomiting

›New confusion

›Follow up

›Primary care within 1 to 3 days

›Addiction care referral as offered

›Harm reduction

›Avoid using alone

›Test dose if returning to use

›Avoid mixing with alcohol or benzos

›Use supervised consumption services where available

12References/r13

Clinical guidelines and key sources

›Reference set

›American Heart Association resuscitation guidance relevant to opioid associated emergencies

›Ventilation prioritization in respiratory arrest

›ACEP clinical policy and emergency toxicology practice summaries relevant to naloxone use

›Titrated reversal strategy framing

›Toxicology and poison center consensus recommendations

›Naloxone infusion for recurrent respiratory depression

›CDC overdose prevention resources

›Harm reduction strategies

›SNOMED CT concept mapping

›Opioid overdose

›ICD-10 coding references

›T40.0X1A to T40.4X1A opioid poisoning categories

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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