Case #9: 38 year old found down
Author: Michael Gottlieb, MD
Peer Reviewer: Jill Theobold, MD, PhD
A 38 year old female is brought to the ED by ambulance after being found unresponsive on the street. Upon initial presentation, she is lethargic with brief periods of apnea that resolve with a sternal rub. There is no additional history from the paramedics and they did not give any medications in the field. On exam, she has no signs of trauma and her pupils are markedly constricted bilaterally with minimal reaction to light. The remainder of the examination is normal.
Vitals: Temp: 98.9, HR: 68, RR: 6, BP: 108/72, O2 sat: 94% on RA
What is the most likely etiology of this patient’s presentation?
This patient presents with the classic triad of opioid intoxication, which is coma, respiratory depression, and miosis.
What other clinical findings might you see with this type of intoxication?
CNS: Confusion → Lethargy → Coma → Anoxic Encephalopathy
HEENT: Miosis (Note: This may not be present in all patients)
Cardiovascular: Hypotension
Respiratory: Respiratory Depression, Pulmonary Edema, and Aspiration Pneumonia
GI: Nausea, Constipation
MSK: Rhabdomyolysis and Compartment Syndrome
Skin: Decubitus Ulcers, “Track marks”, Cellulitis, and Abscesses
What is the initial treatment for this patient?
Naloxone is the first line agent. It can be given in children and adults at a dose of
0.05 to 2 mg IV/IM/SC slowly Q2-3 mins, titrating to improvement in respiratory rate. (
Note: Start with a low dose in opioid-dependent patients with minimal respiratory symptoms to avoid precipitating acute withdrawal.)
Alternatively, consider nebulized naloxone (1-2 mg naloxone diluted with normal saline to a volume of 3-5 mL), which will allow the patient to self-titrate the dosing.
What further work-up is required?
Opioid Intoxication is a clinical diagnosis and urine toxicologic screens are rarely helpful. Consider obtaining an APAP and ASA level to evaluate for possible co-ingestion or combination medications.
What is the disposition of these patients?
It is important to monitor these patients for respiratory depression for at least 4-6 hours AFTER the last dose of naloxone because the half-life of naloxone is often shorter than that of the opioid (Duration of Action: 20-90 mins). This time may need to be increased in patients with renal failure.
References:
Baumann BM, Patterson RA, Parone DA, et al. Use and efficacy of nebulized naloxone in patients with suspected opioid intoxication. Am J Emerg Med. 2013 Mar;31(3):585-8.
Clarke SF, Dargan PI, Jones AL. Naloxone in opioid poisoning: walking the tightrope. Emerg Med J. 2005 Sep;22(9):612-6.
Dowling J, Isbister GK, Kirkpatrick CM, et al. Population pharmacokinetics of intravenous, intramuscular, and intranasal naloxone in human volunteers. Ther Drug Monit. 2008 Aug;30(4):490-6.
Mycyk MB, Szyszko AL, Aks SE. Nebulized naloxone gently and effectively reverses methadone intoxication. J Emerg Med. 2003 Feb;24(2):185-7.
Schug SA, Zech D, Grond S. Adverse effects of systemic opioid analgesics. Drug Saf. 1992 May-Jun;7(3):200-13.
Sporer KA. Acute heroin overdose. Ann Intern Med. 1999 Apr 6;130(7):584-90.
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