Are you concerned about inducing withdrawal symptoms in possible chronic abuse? Yes No

Suspected Adolescent/Adult Opioid Overdose

Yes1

Yes

No

No

Yes

x Attach patient to cardiac monitor, pulse oximetry, and ETCO2 monitor

x Establish IV/IO access x Obtain POC glucose

Naloxone 2 mg IN2 - or - Naloxone 0.4 mg IV/IM Q 3 minutes up to 2 doses until respiratory rate ≥ 12 bpm

Disposition Adults: Immediate transfer to adult facility Adolescents: Admission versus 4-6 hour observation prior to discharge

Follow ACLS Cardiac Arrest Algorithm Use 2 mg Naloxone IV/IM Q 3 minutes

Is respiratory rate > 12 bpm?

Naloxone 2 mg IV/IM Q 3 minutes up to 2 doses until respiratory rate > 12 bpm

Naloxone 4 mg IV/IM3

Q 3 minutes up to 2 doses until respiratory rate > 12 bpm4

2First dose of Naloxone can be IN, but need to push for IV/IO access if no response

See back page for information regarding naloxone drip

3Some heroin is cut/mixed with fentanyl or synthetic fentanyl, which can require larger doses of naloxone to reverse effects 4If no response consider other causes for respiratory depression/altered mental status

Does the patient have Pulses?

ABCs (maintain airway, provide oxygen & support ventilation as needed)

No

Additional Considerations: x Diagnostic testing: Renal, UA, CPK, acetaminophen/ethanol levels, pregnancy test,

EKG, CXR, Abdominal X-ray x For agitation: benzodiazepines x If drug patches found, remove residual drug from patch area on skin with soap and

water x Watch for drug paraphernalia, needles, and weapons on patient x Protective Services to search clothing for needles/drug paraphernalia

Carefully remove clothing and search for medication patches on patient. Security to wand for needles and weapons.

If patient demands discharge prior to transfer or completion of observation

period, must be alert and oriented and sign out AMA

1If not in cardiopulmonary arrest the goal of the resuscitation is to reverse the patient’s respiratory depression, as you are assuming risk of withdrawal symptoms including agitation and combativeness

Is respiratory rate > 12 bpm?

Use code book weight dosing for Naloxone

This algorithm has been developed by the Medical Resuscitation Committee Last revised: February 2019 "The contents of this publication, including text, graphics and other materials ("Contents") is a recitation of general scientific principles, intended for broad and general physician understanding and knowledge and is offered solely for educational and informational purposes as an academic service of Cincinnati Children's Hospital Medical Center (CCHMC). The information should in no way be considered as an establishment of any type of standard of care, nor is it offering medical advice for a particular patient or as constituting medical consultation services, either formal or informal. While the Content may be consulted for guidance, it is not intended for use as a substitute for independent professional medical judgment, advice, diagnosis, or treatment.

Suspected Adolescent/Adult Opioid Overdose Clinical features: Most common: Bradypnea/Apnea/Hypoventilation - BEST PREDICTOR OF OPIOID INTOXICATION IS RESP RATE ≤ 12/MINUTE Miosis (pinpoint pupils) - Normal pupil examination does not exclude opioid intoxication Stupor

Other findings: Decreased mental status, bradycardia, hypoglycemia, normotension/hypotension, hypothermia (from environmental exposure, impaired thermoregulation), seizures (often due to hypoxia; or from meperidine, propoxyphene, tramadol), pulmonary edema (O2 Sat <90% while on ambient air with ventilation), myoclonus, rhabdomyolysis (CK 5 times the upper limit of normal), myoglobinuric renal failure, and/or compartment syndrome

Note: Mydriasis (enlarged pupils) can result from polysubstance ingestion (or meperidine, propoxyphene, tramadol) Treatment: Goal: Adequate ventilation

Naloxone o Onset of action: ~2 mins (IV); ~2-5 mins (IM/IN) o Duration of action: ~20 – 90 mins o Pediatric patients: 0.1 mg/kg (max 2 mg) IV/IM/IN q 2-3 minutes prn (fully reverse patient) o Children ≥ 5 years OR >20 kg:

� Initial dose (full reversal): 0.4 mg – 2 mg IV/IM every 2-3 minutes prn � Intranasal: 2 mg via mucosal atomization device (MAD), using 1 mg/mL concentration, 1 mL per nostril. � Subsequent doses: 2 mg IV/IM (2 mg IN) every 3 minutes. Larger doses may be required for some opioids (longer-

acting or extended/sustained release products) o Pregnant women: Use lowest dose possible to reverse respiratory depression, prevent fetal harm. o No maximum dose of naloxone, although if clinical effect does not occur after 5-10 mg, consider alternative diagnosis.

Naloxone Continuous Infusion o Indicated for recurrent respiratory depression, ingestion of longer-acting agents (i.e. methadone, extended/sustained release

product, fentanyl patches, body packers) o Give additional naloxone doses until ventilation is adequate, then start naloxone infusion. o Calculate the total milligram amount needed in the first hour of resuscitation (including EMS doses) to maintain sufficient

ventilation for 15 minutes. Multiply by 2/3. This is the hourly infusion mg amount. o Order continuous infusion in EPIC using the 0.4 mg/mL concentration and enter the “X” mg/hour dose. o 15 minutes after infusion is started, administer ½ of initial hourly bolus dose (previously needed in that 1st hour of

resuscitation). This is a bolus in addition to the continuous infusion. o Titrate infusion to patient’s clinical response (adequate ventilation and to prevent withdrawal symptoms).

o If withdrawal symptoms develop (flushing, sweating, N/V, trembling, ↑HR, delirium, agitation), stop the infusion. If intoxication returns, restart the infusion at ½ the initial rate.

o If respiratory depression occurs during the infusion, re-administer ½ the initial bolus every 3 minutes until symptoms improve, then increase the infusion by ½ the initial rate.

Monitoring:

o Patients should be observed for a minimum of 4-6 hours for recurrence of respiratory depression after naloxone administration. Complications of opioid reversal:

o Opioid dependent users may show signs of withdrawal (agitation, combativeness) � Start with low doses of Naloxone � Supportive care – do not give opioids � Agitation—give Benzodiazepines

o Acute respiratory distress syndrome: rales, hypoxia, pulmonary edema. Starting lower dose naloxone may help prevent ARDS. Persistent hypoxia after reversal is concerning for pulmonary edema.

Additional Work-Up:

Test Indication Rapid Glucose Always Renal, UA, CPK Concern for rhabdomyolysis (prolonged down time) Chest x-ray Concern for ARDS EKG Concern for dysrhythmia (palpitations, syncope, etc.) Acetaminophen level Concern for co-ingestion or if ingested Hydrocodone or Oxycodone Ethanol level Concern for co-ingestion Abdominal x-ray Concern for body packing/stuffing Pregnancy test Post-menarchal females Trauma activation As indicated for signs or concerns of trauma

*UDS should NOT be routinely done

This algorithm has been developed by the Medical Resuscitation Committee Last revised: February 2019 "The contents of this publication, including text, graphics and other materials ("Contents") is a recitation of general scientific principles, intended for broad and general physician understanding and knowledge and is offered solely for educational and informational purposes as an academic service of Cincinnati Children's Hospital Medical Center (CCHMC). The information should in no way be considered as an establishment of any type of standard of care, nor is it offering medical advice for a particular patient or as constituting medical consultation services, either formal or informal. While the Content may be consulted for guidance, it is not intended for use as a substitute for independent professional medical judgment, advice, diagnosis, or treatment.