What is the management for an 18-year-old male with intentional hydromorphone and ibuprofen overdose, presenting with vomiting and bradycardia?

From the Guidelines

This patient requires immediate administration of naloxone 0.4-2 mg IV/IM/intranasal to reverse opioid effects, particularly addressing the concerning bradycardia and altered mental status, as recommended by the 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1. The patient's presentation with a mixed overdose of hydromorphone (an opioid) and ibuprofen necessitates a comprehensive approach to management.

• The initial focus should be on supporting the patient's airway and breathing, with provision of supplemental oxygen if respiratory depression is present.
• Naloxone administration can be repeated every 2-3 minutes as needed, with careful monitoring for signs of opioid withdrawal.
• Securing the airway and providing supplemental oxygen are crucial steps in managing the patient's respiratory depression.
• Additionally, starting IV fluids for hydration and to support blood pressure is essential, as well as considering activated charcoal (50g orally) if presentation is within 1-2 hours of ingestion and the airway is protected.
• For the ibuprofen component, checking renal function, electrolytes, and obtaining a serum ibuprofen level are necessary to assess the severity of the overdose.
• Sodium bicarbonate may be needed if metabolic acidosis develops from the ibuprofen, and continuous cardiac monitoring is essential due to the bradycardia.
• The patient will also require psychiatric evaluation once medically stable, as this was an intentional overdose.
• It is worth noting that the 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care also emphasize the importance of naloxone administration in opioid-associated resuscitative emergencies 1.
• However, the most recent and highest quality study, the 2020 guidelines, should take precedence in guiding management decisions 1.

From the FDA Drug Label

Approximately 1½ hours after the reported ingestion of from 7 to 10 ibuprofen tablets (400 mg), a 19-month old child weighing 12 kg was seen in the hospital emergency room, apneic and cyanotic, responding only to painful stimuli. In cases of acute overdosage, the stomach should be emptied by vomiting or lavage, though little drug will likely be recovered if more than an hour has elapsed since ingestion. Because the drug is acidic and is excreted in the urine, it is theoretically beneficial to administer alkali and induce diuresis In addition to supportive measures, the use of oral activated charcoal may help to reduce the absorption and reabsorption of ibuprofen tablets.

The patient is presenting with vomiting and bradycardia, which may be related to the overdose.

• The patient's GCS of 14 indicates that they are somewhat alert, but the bradycardia at 51 bpm is a concern.
• Given the unknown amount of ibuprofen ingested, it is essential to take a conservative approach.
• Supportive measures should be taken, including monitoring of vital signs and management of symptoms.
• The use of oral activated charcoal may be considered to help reduce the absorption and reabsorption of ibuprofen tablets 2.

From the Research

Patient Assessment and Treatment

• The patient is an 18-year-old male with an intentional overdose of hydromorphone and ibuprofen, presenting with a Glasgow Coma Scale (GCS) score of 14, vomiting, and bradycardia at 51 bpm 3, 4.
• The primary goal in the emergency department is to immediately recognize patients at risk and initiate appropriate therapy, which depends on the identification of critical risk upon arrival 5.
• In cases of opioid overdose, naloxone is the primary reversal agent, but its efficacy against high-potency opioids like fentanyl and fentanyl analogs has been debated 3.

Naloxone Administration and Efficacy

• Naloxone is commonly used to treat opioid overdoses, and its administration has been studied in various settings, including emergency departments 4, 6.
• The efficacy of naloxone against fentanyl and fentanyl analogs has been questioned, but current literature provides limited evidence to suggest that naloxone is ineffective against these substances 3.
• Alternative pharmacological approaches, such as other opioid receptor antagonists, respiratory stimulants, and buprenorphine, are being studied in humans, but none of these approaches target polysubstance overdose 3.

Pain Management and Opioid Use

• The management of acute pain in emergency settings varies across countries and healthcare systems, and there is no single standard of care for pain treatment in emergencies 7.
• Opioid prescribing and naloxone co-prescribing have increased, but overall prescribing remains minimal, and additional efforts are needed to increase naloxone prescribing for patients at risk for opioid overdose 6.
• Patient factors associated with receiving naloxone include high opioid daily dosage, concurrent benzodiazepines, and history of opioid use disorder, but history of opioid overdose was not associated with naloxone prescribing 6.