What is the algorithm after administering Narcan (naloxone) for an opioid overdose?

Algorithm After Naloxone Administration for Opioid Overdose

After administering naloxone for opioid overdose, patients should be monitored for at least 2 hours, with extended observation (4-6 hours minimum) for long-acting opioids, as naloxone's duration of action (30-45 minutes) is shorter than many opioids' effects. 1

Immediate Post-Naloxone Algorithm

1. Assess Response to Initial Naloxone Dose

   • If respiratory function improves (adequate ventilation and alertness), continue monitoring
   • If no response after 2-3 minutes, administer additional naloxone dose 1

2. Continue Respiratory Support

   • Position patient on their side (recovery position)
   • Maintain airway patency
   • Provide rescue breathing or bag-mask ventilation if needed 1

3. Monitor Vital Signs

   • Respiratory rate and effort
   • Oxygen saturation
   • Heart rate and blood pressure
   • Level of consciousness
   • Pupillary response (pinpoint pupils strongly correlate with opioid overdose) 1

4. Repeat Naloxone as Needed

   • Administer additional doses every 2-3 minutes if inadequate response 2, 1
   • For initial reversal of respiratory depression, use increments of 0.1-0.2 mg IV 3
   • If no response after 10 mg total, question diagnosis of opioid-induced toxicity 3

Extended Monitoring Phase

1. Duration of Monitoring

   • Monitor for at least 2 hours after last naloxone dose 2
   • For long-acting opioids, extend observation to 12-24 hours 1
   • Minimum 4-6 hours observation after last naloxone dose for all patients 1

2. Watch for Recurrent Respiratory Depression

   • Naloxone's half-life (30-45 minutes) is shorter than many opioids 2, 1
   • Respiratory depression may recur after initial improvement

3. For Recurrent Depression

   • Administer repeated small doses of naloxone OR
   • Start naloxone infusion (especially for long-acting opioids) 1
   • For infusion: add 2 mg naloxone to 500 mL normal saline or 5% dextrose (0.004 mg/mL) 3
   • Titrate infusion rate according to patient response 3

Transport and Disposition

1. Transport to Emergency Department

   • All patients who receive naloxone should be transported to a healthcare facility 1
   • Studies show 2.7% of patients require hospital admission for complications 4
   • Common complications requiring admission include:
     • Non-cardiogenic pulmonary edema (most common)
     • Pneumonia
     • Persistent respiratory depression
     • Persistent altered mental status 4

2. Criteria for Safe Discharge

   • After minimum observation period (2-4 hours for short-acting, 4-6 hours for long-acting opioids)
   • Normal vital signs
   • Normal mental status (GCS ≥14)
   • Respiratory rate ≥10/min 5
   • No signs of complications

Special Considerations

1. Watch for Withdrawal Symptoms

   • Hypertension, tachycardia, piloerection, vomiting, agitation
   • More common with higher naloxone doses
   • Use lower initial doses (0.04-0.4 mg) in opioid-dependent patients 1

2. Co-ingestions

   • Naloxone is ineffective for reversing effects of non-opioid drugs 2
   • Consider toxicology screening for mixed overdoses
   • Monitor blood glucose levels frequently 1

3. Complications to Monitor For

   • Non-cardiogenic pulmonary edema
   • Aspiration pneumonia
   • Hypoxia (evident upon ED arrival if present) 4

4. Post-Overdose Care

   • Connect patients to addiction treatment services
   • Consider prescribing take-home naloxone for high-risk individuals 1

This algorithm emphasizes the importance of continued monitoring after naloxone administration due to the risk of recurrent respiratory depression, which is the primary concern for morbidity and mortality in opioid overdose cases.