Ep 116 Emergency Management of Opioid Misuse, Overdose and Withdrawal

This is EM Cases Episode 116 - Emergency Management of Opioid Misuse, Overdose and Withdrawal

Unless you've been living in a hut on an island in the South Pacific, you are certainly aware of the opioid epidemic. Its roots are deep. Its social, medical, and economic considerations are varied and complex. To even the most seasoned EM physician, opioid-addicted, opioid-overdosed, and opioid-withdrawing patients can be a challenge. But by the end of this episode, the discomfort you feel managing these patients will be at least partly dispelled, thanks to Drs. Kathryn Dong, Michelle Klaiman, and Aaron Orkin. They are champions of this complex issue whose management is rapidly evolving, and with them, we’ll unpack the dizzying world of opioids, and help you set in motion the movement that will lead the way to tackle one of the biggest challenges we face in the 21st century. And the beauty of it is that individual treatments don’t have to be complicated. You might be surprised to find that just taking the first step in being part of the solution to the opioid epidemic makes these interactions become more meaningful, satisfying and impactful.



Podcast production, sound design & editing by Anton Helman

Written Summary and blog post by Taryn Lloyd, edited by Anton Helman Oct 2018

Cite this podcast as: Helman, A, Lloyd, T, Klaiman, M, Orkin, A, Dong, K. Emergency Management of Opioid Misuse, Overdose and Withdrawal. Emergency Medicine Cases. October, 2018. https://emergencymedicinecases.com/opioid-misuse-overdose-withdrawal/. Accessed [date].

Cardiac arrest in the setting of suspected opioid overdose

While the current trend of priorities in cardiac arrest favour CABC rather than ABC, in the patient suspected of opioid overdose, the priorities should be ABC-N - the 'N' standing for Naloxone. Because these are usually respiratory arrests, Airway should be a priority and naloxone should be considered a priority early in the resuscitation.

Naloxone dosing in cardiac arrest:



* 2mg IV or IM

* Repeat dose every 2 minutes, up to at least 12mg



Unclear conditions leading to cardiac arrest?

Still consider high dose naloxone IV or IM given empirically. Consider any potential bias you may have in what a person who uses opioids may look like. Opioid overdose comes in many forms and is not always obvious. Many complex medical patients are on high dose opioids.

Pitfall: A major pitfall is assuming no opioid overdose in the patient with normal or enlarged pupil size. The classic sign of pinpoint pupils is not always present when mixed substances, sometimes without the patient’s awareness of drug mixing or contamination, is at at play.

AHA Guidelines for CPR and Emergency Cardiovascular Care for Opioid overdose

Opioid overdose: The pending respiratory arrest & decreased LOA

Empiric naloxone prevents respiratory arrest.

Naloxone dosing in non-cardiac arrest opioid overdose

The goal with naloxone administration is to avoid worsening respiratory depression, aspiration and cardiac arrest on the one hand, while on the other hand avoiding sending the patient into severe opioid withdrawal and an agitated state.

Targets of naloxone dosing



* RR>12

* SpO2 >90%

* EtCO2 12mg naloxone have been given without achieving the above targets, consider endotracheal intubation and mechanical ventilation. Earlier intubation may be required.

Pitfall: A major pitfall is sending a patient home soon after clinical stability has been achieved with naloxone. Most opioids last longer than naloxone. It is therefore imperative to observe opioid overdose patients for at least 2 hours after targets have been achieved with nal...