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CCS Case: Opioid Overdose

Case: Opioid Overdose

Clinical Setup

  • Presentation: 27-year-old male found unresponsive, respiratory rate 6, SpO2 82%, pinpoint pupils, track marks, needle at bedside, BP 100/60, HR 58.
  • Location: Emergency Department.

Optimal Order Pathway

  1. Immediate Orders (Minute 0–1):
    • Pulse oximetry, continuous cardiac monitoring, BP q15min.
    • IV access, Normal saline 0.9% IV.
    • Bag-valve ventilation + supplemental O2 FIRST (ventilate before/in parallel with antidote); airway positioning, suction.
  2. Focused Exam (Minute 1–2):
    • Pupils (miosis), respiratory effort, track marks/abscesses, trauma signs, temperature (hypothermia).
  3. Diagnostics (Minute 2–5):
    • Fingerstick glucose stat, ABG/VBG (respiratory acidosis), CBC, BMP, ECG.
    • Urine/serum tox screen, acetaminophen and salicylate levels (co-ingestion screen).
  4. Therapeutics (Minute 5–15):
    • Naloxone IV/IM/IN stat, titrated to adequate respirations (not full alertness — avoid precipitated withdrawal); repeat or start naloxone IV infusion if long-acting opioid or re-sedation.
    • Observe for re-sedation as naloxone wears off (30–90 min half-life vs longer opioid effect).
    • Treat complications: aspiration precautions/CXR, rhabdomyolysis labs (CK), compartment syndrome check after prolonged downtime.
    • Screen for co-ingestions; give thiamine/dextrose if indicated.
  5. Disposition (Minute 15–20):
    • Admit to monitored unit until naloxone-free and stable (longer for methadone/sustained-release ingestions).
    • Addiction medicine + psychiatry + social work consults.
  6. Final 2 Minutes:
    • Offer take-home naloxone kit with bystander training; discuss medication-assisted treatment (buprenorphine/methadone referral).
    • Counsel on overdose prevention, needle exchange, hepatitis/HIV screening; schedule addiction follow-up within days.