Thread by @RosenelliEM

Lazarus rises: #NarcoticOverdose and reversal

emboardbombs.com/papers/2020/8/…

Check out this great short board-style review on #Opioid overdose and reversal agents #Narcan @EMBoardBombs

or follow along this short thread below 👇👇

Opioid abuse is an epidemic that has its roots in poor prescribing practices by physicians.

In the US alone, ~5 million people were estimated in 2015 to have used heroin at least once in their lives.

329,000 reported use within the past month.

Nearly 70% of people who use heroin have been reported to also use prescription opioids.

Illicit use of fentanyl is also on the rise, as this highly potent synthetic is used to “cut” heroin.

Signs of opioid overdose

-Depressed mental status

-Decreased respiratory rate

-Decreased tidal volume

-Decreased bowel sounds

-Miotic (constricted) pupils

A normal pupillary exam does not exclude opioid withdrawal (#louderforthoseintheback).

For ex, meperidine does not change pupils, and often the presence of adulterants or co-ingestants like sympathomimetics and anticholinergics can make the pupils appear nml or even enlarged

The best predictor of opioid toxicity is respiratory rate <12.

Heart rate is typically normal or low normal (60-70).

Look for evidence of trauma, certainly check a fingerstick glucose. An EKG is never a bad idea, especially in cases of suspected self-harm or where LOC occurred.

We do not recommend routinely checking urine toxicologic screens.

In fact, in a young patient where opioid abuse is clinically suspected and responds well the naloxone, no evidence supports further diagnostic workup.

Opioid overdose is a clinical diagnosis!

Ddx: in patients who present obtunded U must consider other sedative-hypnotics like clonidine, ethanol, benzodiazepines, and barbiturates.

Hypoglycemia is a commonly missed medical diagnosis.

Clonidine, which has opioid-like effects, causes miosis w/e bradycardia & hypotension

Management: Naloxone is a pure opioid antagonist, immediately displaces opioids at receptors.

It reverses all respiratory and central nervous system depression within 1 minute.

Reversal effects depend on the type and duration of the opioid(s) taken, from 20 minutes to an hour

Is the patient in respiratory or cardiac arrest or in critical condition (keywords: non-arousable or no spontaneous ventilations)?

Yes. By all means, give large doses of naloxone.

If not, then give smaller doses of naloxone to avoid precipitating withdrawal.

Naloxone in life-threatening situations

If available, intranasal naloxone is recommended in life-threatening situations.

Otherwise, initial dose: 2 mg IV rapid push. You can also do intramuscular or intraosseous for similar effects, but not as predictable as IV.

If the initial dose is partially effective, give the same dose again. If no effects observed, give a 👆dose.

There’s no literature on how many times you should administer naloxone & watch for an effect, but wouldn’t advise >10 mg total of naloxone if no clinical improvement

When an opioid effect is expected to be prolonged (e.g. massive overdose, suicide attempt, methadone usage), a continuous infusion or naloxone should be used.

You likely have this stocked at your hospital, but it’s easy to make: mix 4 mg naloxone in 100 mL D5W.

The initial naloxone infusion rate should be 2/3 of the naloxone dose that reversed the patient’s symptoms.
Example: initial bolus dose which reversed symptoms = 2 mg; Start infusion at 1.3 mg/hr.

Titrate the infusion as needed: increase by 0.1 to 0.2 mg/hr if symptoms return.

To wean off the infusion:

1. Decrease by 0.1 to 0.2 mg/hr every 2 hours.
2. Check the patient for signs/symptoms.
3. If decreased respiratory rate or responsiveness is noted, return to the previous rate and attempt to decrease again in 1 to 2 hours.

Monitoring post-naloxone.

Its controversial how long patients who received naloxone should be watched in the ED.

The underlying concern is that the duration of naloxone is shorter than the duration of most opioids.

So, if naloxone wears off in about 40 minutes, close monitoring is needed for a few hours to be sure there are no recurrent symptoms.

No one really agrees on the amount of time to observe, and that’s honestly never going to happen.

When the choice is made to discharge, bystander-administered naloxone should be prescribed.

Providing the patient, w/ this medication can 👇overdose mortality.

One study showed a comprehensive opioid overdose prevention program 🔽 deaths from 46 to 29 per 100,000.

Complications of opioid toxicity

One unique complication is lung injury and noncardiogenic pulmonary edema; it is rare (<3% of patients receiving naloxone).

The pathophysiology is unclear, but it can be a major adverse effect of narcotic overdose

It seems that the trigger is iatrogenic from reversal of narcotic toxicity with naloxone.

Rapid precipitation of withdrawal in the setting of elevated pCO2 causes a surge of catecholamines, therefore increasing afterload and vascular permeability in the lungs.

This is another reason to use small doses of naloxone if possible.

t has a rapid onset, often with crackles, hypoxia, and frothy sputum. Expect hypertension and tachcardia.

There are no published, evidence-based guidelines on how to manage this. It will not be on board exams.

Supportive management is indicated: supplemental oxygen, likely with NIPPV, is standard of care.

Diuretics have been quoted as helpful, along with nitroglycerin if patients are hypertensive.

Great work
@blakebriggsMD & Mary Claire O'Brien

emboardbombs.com/s/Narcotic-OD.…