Opiate Overdose in the ED. St.Emlyn’s

Opiate OD in the ED

Listen to the podcast on the management of Opiate OD in the ED by clicking on the link below.

Opiate overdose is a common presentation to the ED. It has a significant mortality in the drug using population and although there are antidotes available the traditional approach to reversal may in itself cause harm. This week Iain and Simon explore how we might refine our approach to protect our patients (and ourselves).

 

Recognising opiate overdose in the ED.

Look for the toxidrome of opiate intoxication

  • Miosis
  • CNS depression
  • respiratory depression
  • complications of hypoxia: seizures, dysrrhythmias, brain injury

Whilst the obvious patient is a drug using, young man brought in apnoeic from a salubrious part of town you should consider other groups who are also at risk (and who are easier to miss).

OK I’ve recognised the OD what next.

Well first, stick to the ABC approach. Patients with opiate ED usually need resuscitation and you should establish and airway, ventilation and circulatory adequacy as you would for any critically ill patient.

The traditional model of opiate OD management is to give large quantities of naloxone (opiate antagonist) IV. In my experience it goes a little like this…..

You whack the naloxone in. This sends the patient into withdrawal (if you don’t kill them in the process), they swear at you, punch something(one) and leave the department.

This is VERY DANGEROUS as a strategy as in many cases you will not know whether the half life of your antidote (naloxone) is longer than the drugs they have taken. The half life of naloxone is shorter than heroin and much shorter than long acting opiates such as methadone. I am sadly aware of several deaths resulting from this approach. Rapid reversal leads to the patient absconding and later being found dead. This is terrible and unnecessary.

Naloxone is the drug of choice in the ED and it’s what we use in Virchester (other antagonists are available).

You can give Naloxone through a variety of routes.

  • IV works well. I often use the external jugular for access in patients who have damaged veins.
  • IO works well and is a good option in patients with no veins at all.
  • Nebulised naloxone can be useful, but the patient has to be breathing so can only be used in quite a small subset of patients who are sick enough to need naloxone, but who are still breathing.
  • IM was used in the past as a protective mechanism for the patient who might abscond. The theory is that IM administration will lead to a longer action of the antidote. Personally I don’t do this anymore. IM absorbtion is unpredictable and will still not protect against long term opiates such as methadone. There is a real risk that a patient experiencing withdrawal may then take even more opiates whilst naloxone is having some effect only to then effectively ‘re’overdose later as the naloxone wears off. The IM route is a pharmacological tightrope and I urge you to be careful

How much naloxone should I give?

If your patient is in cardiorespiratory arrest then knock yourself out, give 800mcg IV stat and save the patient’s life.

For other patients who are not in cardiorespiratory arrest then total reversal is a bad idea for several reasons.

  1. The patient may abscond as described above.
  2. In a patient who is very hypercapnic and acidotic rapid reversal is thought (by some – not great evidence) to be risky in precipitating cardiovascular collapse. In our department we will establish ABC and ensure that we are able to ventilate the patient before giving naloxone.
  3. You might reveal a hidden disaster. An example would be a mixed overdose patient who has taken opiates, tricyclics and cocaine. They may appear initially to have an opiate OD, but by reversing all the opiates the full effect of other drugs are then revealed (plus the new cold turkey you have just induced). I still wake at night thinking back to a case when we did this some years ago. Take my advice – do not try this!

You should be aiming to reverse the patient to the point where they are breathing, communicating if stimulated, with good cardiovascular parameters and without them experiencing withdrawal or the desire to abscond. We do this by titrating naloxone in aliquots of 40-80mcg. ALiEM has a great post on how to do this.

Keep a record of how much naloxone you require to get the patient to the point you want them. You can then roughly estimate how much naloxone to infuse/hour to keep them just how you want them until the drugs wear off. You will obviously titrate to effect but a reasonable starting point is 2/3 of the dose required to wake them up per hour.

Where and how should I look after my patient?

initially you will deal with most of these patients in the resus room. Following resuscitation they need to be closely monitored and in many ways you might consider them patients who are undergoing sedation in the ED. So use the same techniques, observations as you would for a sedated patient. We recommend that the patient is cared for in a well observed area and that they are, initially at least, treated with the same respect and care that we would give to a patient undergoing sedation for a painful procedure.

  • ECG monitoring
  • Close clinical observation
  • ETCO2 monitoring for resp rate and effectiveness
  • SaO2 pulse oximetry

Remember that a patient who has been breathing oxygen may be apnoeic for a very long time before O2 sats fall. Respiratory monitoring is essential.

Where you can deliver this will depend on your local circumstances. It may be a medical ward, it may be HDU. The bottom line is that the patient must be safe.

What else should I consider?

It’s all too easy to dismiss opiate ED patients as a single issue problem. Don’t. There are several issues you need to consider.

  • Was this really accidental or was the opiate OD deliberate self harm? This applies to all groups irrespective of age, whether they injected or drug. Consider mental health referral if DSH suspected.
  • Consider soft tissue injury in patients who have been unconscious for long periods of time. Be aware of the possibility of rhabdomyolysis or compartment syndromes in patients who have been unconscious.
  • Consider and encourage patients with social and psychosocial problems to access drug, alcohol, addiction and housing services. Your ED should have good liaison with such services to ensure patients are offered help.

 

Finally.

Managing opiate OD in the ED can be interesting and it can be rewarding. The days of a nurse handing you 1200mcg IM and 1200mcg IV to a patient who you then put into withdrawal before they storm out to die under a bush later should be long gone.

Be elegant and show some panache. Think about how you treat opiate OD in the ED.

As always we’d love to hear your comments, and we fully expect some disagreement on this one. Please, disagree with joyful abandonment, your comments will help us all.

 

vb

Simon and Iain

 

 

 Selected references

  1. Common complication of crush injury, but a rare compartment syndrome. Shaikh N1.J Emerg Trauma Shock. 2010 Apr;3(2):177-81. doi: 10.4103/0974-2700.62124.
  2. Opiate Overdose at Life in the Fast Lane
  3. Naloxone at Life in the Fast Lane
  4. Nebulised Naloxone for heroin induced bronchospasm at The Poison Review
  5. Nebulised Naloxone for opiate OD at The Poison Review
  6. Nebulised Naloxone at Academic Life in Emergency Medicine
  7. Diluting Naloxone at Academic Life in Emergency Medicine
  8. Naloxone in opioid poisoning: walking the tightrope. Clarke SF1, Dargan PI, Jones AL. Emerg Med J. 2005 Sep;22(9):612-6.
  9. Rhabdomyolysis: an evaluation of 475 hospitalized patients. Melli G1, Chaudhry V, Cornblath DR. Medicine (Baltimore). 2005 Nov;84(6):377-85.

 

How NOT to manage Opiate ED in the ED!

 

Flow chart

CDSG Opiate OD 2015

13 Comments

  1. H

    Great post guys. You mention the elderly but this group often don’t have classic opiate features of toxicity sometimes just hypotension hypothermia with renal impairment – evidently other pathology is also often involved but titrated naloxone can be beneficial in managing the opitate toxicity.

    Reply
    1. Simon Carley (Post author)

      Thanks Henry.
      You’re right of course and that makes them even more tricky to diagnose so I guess we must maintain a high index of concern for any elderly patient presenting to the ED who has a history of opiates.

      Any top tips for spotting toxicity in the elderly? What makes you stop and think – this could be drug induced?

      S

      Reply
      1. Kate Lambert

        Thanks for this. No top tips for recognition other than being alert to how fever increases absorption from opiate patches (and a bit of AKI only makes things worse). We learnt from an adverse incident and it’s been useful in my checklist for febrile obtunded people.
        I would also encourage people to get those links working with substance misuse teams so that information on adverse events gets out to community teams too.

  2. Jake Turner (@Jake_Turner2503)

    Thanks for the article! Brilliant, pertinent and useful as always. I do have one question though. If we do over-reverse somebody, and they become agitated and violent, and require sedation, what should we do then?

    Obviously if I give benzo’s there is a good chance they could become apnoeic or LOC, and then we have a crash intubation on our hands. Would this be a time to turn to other sedatives such as haloperidol? Or would it be suitable to go for our wonderdrug of the moment, ketamine?

    My big worry in this group is around sudden oversedation, but also around when they wake up, and I don’t particularly want these patients coming round from a nasty emergence phenomena after we’ve made them cold turkey…

    Jake

    Reply
    1. Simon Carley (Post author)

      I would agree with your cautious approach to this tricky dilemma. Adding ‘another’ drug to the patient to try and recapture the sedation is fraught with risk and I’d only go in that direction if I had a need to specifically treat another element of a mixed OD.

      In general it’s a bad idea to add other drugs onto an OD, you do risk the over sedation rebound that you describe.

      In my experience we usually appease, cajole, persuade and delay until the naloxone starts to wear off and the opiates kick back in. It can take all your powers of persuasion and delay, but it’s almost always effective and most importantly ‘safe’

      vb

      S

      Reply
  3. Tom Mitchell

    Great review Simon and really echoes my experience, best to never get to the fully reversed scenario. Recent NPSA alert would agree

    http://www.england.nhs.uk/wp-content/uploads/2014/11/psa-inappropriate-doses-naloxone.pdf

    Do you ever use IN naloxone? Has gained favour in prehospital environment (&BEST BET 2005)and I can really see the advantage in less needles. Having said that, the period before you give the naloxone is the most humane one to try and establish any difficult intravenous access if you have time.
    Tom

    Reply
  4. Darrell Whittle

    Coming to Virchester to work last year, I noted the use of Nalaxone titration in opiate OD and was intrigued by the approach. I was used to the: ‘call security then give 400mcg IM + 400mcg IV Nalaxone’ method. Sometimes this resulted in successful reversal but often it just lit a fuse to an angry and uncooperative patient – a bit like a unpredictable firework. Not nice and potentially dangerous for the patient but also a nursing nightmare (for it was often the nurse left to deal with result). This often required much more input than a generally compliant patient with ‘just’ ABC needs in the Resus. The danger to health care professionals and other patients is also a point which needs to be taken into account. I find the titration method clinically justified, humane and practical.

    Reply
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  6. zr5clinicaled

    Hey Simon,

    Thanks for the great review. I am a paramedic in Melbourne Victoria and our guidelines for the reversal of narcotic overdose still recommend 1.6 to 2mg IMI. Even with regard to the Australian Medicines Handbook these doses appear out of date and large. Despite this we rarely encounter combative or agitated patient’s post reversal. The priority in our management is reversal of hypoxic with bag-mask-ventilation to ensure that sats recover prior to the administration of Narcan IMI. The teaching here has always been that combativeness and agitation are most likely due to hypoxia/hypercarbia rather than rapid reversal/withdrawal and I have honestly never seen this reaction when using the technique I mention.
    How would you apply the principles you mention above to the prehospital environment? My concern would be that reversal that enables adequate oxygenation, ventilation and communication would soon result in the patient refusing further treatment and transport to the ED. My experience is that these patient’s never accept transport to hospital. Then I feel like I’d be stuck watching a patient walk away post OD with only 400mcgs of Narcan on board, knowing full well I’ll be called back in less than an hr! In my practice the only patient’s we don’t currently reverse are those that clearly need transport to ED and they fall into two categories…either post arrest or where significant head trauma is suspected.

    Would appreciate your comments,

    Bart

    Reply
  7. tombircher

    Excellent post. Have had a few ‘Narcan Suprise’ patient’s delivered to ED’s I work in fully reversed by paramedics (no criticism from me here, but they are harder to manage). I think you also have challenging capacity issues here too. As once a patient is fully reversed, agitated, and ‘wants to leave’ you can’t do that much to stop them. I much prefer to keep them sleepy, but breathing with an infusion!

    Reply
  8. 5&2RN

    A cogent argument for judicious titration of naloxone…something I frequently advocate for in my emergency nursing practice. I was surprised you made no mention of aspiration pneumonia/pneumonitis in your list of post-reversal considerations. I come across this much more frequently than either suicidal ideation or rhabdomyolysis/compartment syndrome in opioid overdose. I have learned to ask the medics about any emesis on scene, if any BVM breaths were delivered prior to reversal, and to look for bits of food or dried emesis in the oropharynx, the hair, or in the folds of the patient’s clothing on arrival in the ED. The course I often observe in my practice is one of worsening or new hypoxia despite the metabolizing of the offending opioid and the development of tachycardia and fever, usually sometime between the 4-6 hour mark. I advocate for repeat chest radiography as needed.

    Reply
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