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geekymedics.com/acute-management-of-opioid-overdose
This guide provides an overview of the recognition and immediate management of opioid
overdose using an ABCDE approach.
The ABCDE approach is used to systematically assess an acutely unwell patient. It involves
working through the following steps:
Airway
Breathing
Circulation
Disability
Exposure
Each stage of the ABCDE approach involves clinical assessment, investigations and
interventions. Problems are addressed as they are identified, and the patient is re-
assessed regularly to monitor their response to treatment.
This guide has been created to assist healthcare students in preparing for
emergency simulation sessions as part of their training. It is not intended to be relied
upon for patient care.
You may also be interested in our overview of the ABCDE approach, other ABCDE
approach guidesand our opioid overdose overview.
An opiate is a naturally occurring alkaloid drug derived from the opium poppy (e.g.
morphine and codeine)
An opioid is any synthetic or semi-synthetic drug derived from the opium poppy (e.g.
fentanyl and oxycodone)
Opioid is used as the broad term for any substance that binds opioid receptors to produce
an opiate-like toxidrome.
Clinical features
Nausea
Vomiting
Confusion
It is crucial to always consider the possibility of opioid overdose in any patient presenting
with a reduced level of consciousness.
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Initial steps
Acute scenarios typically begin with a brief handover, including the patient’s
name, age, background and the reason the review has been requested.
You may be asked to review a patient with opioid overdose due to agitation, bradypnoea
and/or reduced level of consciousness.
Introduction
Introduce yourself to whoever has requested a review of the patient and listen carefully to
their handover.
Interaction
Introduce yourself to the patient, including your name and role.
Ask how the patient is feeling, as this may provide useful information about their current
condition.
If the patient is unconscious or unresponsive, and there are no signs of life, start the basic
life support (BLS) algorithm as per resuscitation guidelines.
Preparation
Ensure the patient’s notes, observation chart, and prescription chart are easily
accessible.
Airway
Clinical assessment
Yes: if the patient can talk, their airway is patent, and you can move on to the assessment of
breathing.
No:
Look for signs of airway compromise: angioedema, cyanosis, see-saw breathing, use
of accessory muscles
Listen for abnormal airway noises: stridor, snoring, gurgling
Open the mouth and inspect: look for anything obstructing the airway, such as
secretions or a foreign object
Interventions
1. Place one hand on the patient’s forehead and the other under the chin
2. Tilt the forehead back whilst lifting the chin forwards to extend the neck
3. Inspect the airway for obvious obstruction. If an obstruction is visible within the
airway, use a finger sweep or suction to try and remove it. Be careful not to push it
further into the airway.
Jaw thrust
If the patient is suspected of having suffered significant trauma with potential spinal
involvement, perform a jaw-thrust rather than a head-tilt chin-lift manoeuvre:
Other interventions
Airway adjuncts are helpful and, in some cases, essential to maintain a patient’s airway.
They should be used in conjunction with the manoeuvres mentioned above.
An oropharyngeal airway is a curved plastic tube with a flange on one end that sits
between the tongue and hard palate to relieve soft palate obstruction. It should only be
inserted in unconscious patients as it may induce gagging and aspiration in semi-conscious
patients.
A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the
other. NPAs are typically better tolerated in partly or fully conscious patients than
oropharyngeal airways.
Re-assessment
Breathing
Clinical assessment
Observations
Inspection
Auscultation
Auscultate the chest to screen for evidence of other respiratory pathology (e.g. coarse
crackles may be present if the patient has developed aspiration pneumonia).
Take an ABG if indicated (e.g. low SpO2) to quantify the degree of hypoxia.
Patients may develop type 2 respiratory failure (i.e. low PaO2 and raised CO2) following an
opioid overdose due to respiratory depression.
Chest X-ray
A chest X-ray may be indicated if abnormalities are noted on auscultation (e.g. reduced air
entry, coarse crackles) to screen for evidence of aspiration pneumonia. A chest X-ray should
not delay the emergency management of opioid overdose.
Interventions
Ventilation
Respiratory depression is common in opioid overdose, which can lead to critical hypoxia.
If breathing is inadequate (<10 breaths per minute), support breathing with bag-valve-mask
ventilation and call for senior clinical support.
Oxygen
Administer oxygen to all critically unwell patients during your initial assessment. This
typically involves using a non-rebreathe mask with an oxygen flow rate of 15L. You can
then trial titrating oxygen levels downwards after your initial assessment.
Naloxone
The initial dose is 400 micrograms IV. If there is no response, two subsequent doses of 800
micrograms can be given at 1-minute intervals. Naloxone can also be administered via the
subcutaneous or intramuscular route. However, the intravenous route has the quickest
onset of action.
Naloxone has a short half-life, and some patients may require a naloxone infusion after a
discussion with a senior clinician.
Naloxone rapidly reverses the effects of opioids, and as a result, it can precipitate symptoms
of opioid withdrawal, including pain, confusion and agitation. Consider involving the drug
and alcohol team to discuss appropriate opioid replacement therapy to treat symptoms of
withdrawal.
Re-assessment
Circulation
Clinical assessment
Blood pressure
Intravenous cannulation
Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as
discussed below.
Request a full blood count (FBC), urea & electrolytes (U&E) and liver function tests
(LFTs) for all acutely unwell patients. In the context of an opioid overdose, also request:
Interventions
Fluid resuscitation
After each fluid bolus, reassess for clinical evidence of fluid overload (e.g. auscultation of
the lungs, assessment of JVP).
Repeat administration of fluid boluses up to four times (e.g. 2000ml or 1000ml in patients
at increased risk of fluid overload), reassessing the patient each time.
Seek senior input if the patient has a negative response (e.g. increased chest crackles) or
isn’t responding adequately to repeated boluses (i.e. persistent hypotension).
See our fluid prescribing guide for more details on resuscitation fluids.
Re-assessment
Make sure to re-assess the patient after any intervention.
Disability
Clinical assessment
Consciousness
Pupils
Inspect the size and symmetry of the patient’s pupils: pin-point pupils are associated
with opioid overdose
Assess direct and consensual pupillary responses: pupillary reflexes may be
reduced
Review the patient’s drug chart for medications which may cause neurological
abnormalities (e.g. opioids, sedatives, anxiolytics).
Investigations
Measure the patient’s capillary blood glucose level to screen for other causes of a reduced
level of consciousness (e.g. hypoglycaemia or hyperglycaemia).
A blood glucose level may already be available from earlier investigations (e.g. ABG,
venepuncture).
The normal reference range for fasting plasma glucose is 4.0 – 5.8 mmol/l.
If the blood glucose is elevated, check ketone levels which, if also elevated, may suggest a
diagnosis of diabetic ketoacidosis (DKA).
See our blood glucose measurement, hypoglycaemia and diabetic ketoacidosis guides for
more details.
Imaging
Interventions
Alert a senior clinician immediately if you have concerns about a patient’s consciousness
level.
A GCS of 8 or below, or a P or U on the ACVPU scale, warrants urgent expert help from
an anaesthetist. In the meantime, you should re-assess and maintain the patient’s
airway, as explained in the airway section of this guide.
Correct hypoglycaemia
Re-assessment
Clinical assessment
Inspection
Inspect the patient’s skin for evidence of medication patches (Figure 1), injection sites,
injuries or infection (e.g. erythema).
Review the output of the patient’s catheter and any surgical drains.
Temperature
Interventions
Any clinical deterioration should be recognised quickly and acted upon immediately.
Seek senior help if the patient shows no signs of improvement or if you have any concerns.
Escalation
Patients unresponsive to naloxone will require senior medical input to consider a naloxone
infusion. Haemodynamically unstable patients will require urgent critical care input.
Use an effective SBAR handover to communicate the key information to other medical staff.
Next steps
Take a history
Revisit history taking to explore relevant medical history. If the patient is confused, you
might be able to get a collateral history from staff or family members as appropriate.
Review the patient’s current medications and check any regular medications
are prescribed appropriately.
Document
Discuss the patient’s clinical condition with a senior clinician using an SBAR handover.
The next team of clinicians on shift should be informed of any acutely unwell patient.
References
1. Patient.co.uk. Opiate poisoning. Available from: [LINK].
2. British National Formulary. Naloxone. Available from: [LINK].
3. British National Formulary. Poisoning, emergency treatment. Available from: [LINK]
Image references