What is the management of drug overdose in the emergency room (ER)?

Management of Drug Overdose in the Emergency Room

The management of drug overdose in the emergency room requires immediate identification of the substance involved, administration of specific antidotes when available, and implementation of supportive care measures to prevent morbidity and mortality. 1

Initial Assessment and Stabilization

• Airway, Breathing, Circulation (ABC) Assessment:

  • Ensure airway patency
  • Provide rescue breathing or bag-mask ventilation for respiratory depression
  • Begin high-quality CPR immediately if no pulse is detected 2

• Vital Signs Monitoring:

  • Monitor respiratory rate, heart rate, blood pressure, temperature, oxygen saturation
  • Check blood glucose levels (particularly important in opioid overdoses) 1

Specific Drug Overdose Management

Opioid Overdose

1. Administer naloxone if suspected opioid overdose with respiratory depression:

   • Adults: 0.2-2 mg IV/IO/IM initially
   • Children: 0.1 mg/kg IV/IO/IM
   • Intranasal: 2-4 mg
   • Repeat every 2-3 minutes until respiratory function improves 1

2. Use lower initial doses (0.04-0.4 mg) in opioid-dependent patients to avoid precipitating severe withdrawal 1

3. Monitor for at least 2-4 hours after the last naloxone dose, with extended observation (12-24 hours) required for long-acting opioid overdose 1

Benzodiazepine Overdose

1. Administer flumazenil cautiously:

   • Initial dose: 0.2 mg IV over 30 seconds
   • If no response after 30 seconds, give 0.3 mg IV over 30 seconds
   • Further doses of 0.5 mg can be given at 1-minute intervals up to a maximum cumulative dose of 3 mg 3

2. Use with extreme caution in patients with:

   • History of seizures
   • Long-term benzodiazepine use (risk of withdrawal seizures)
   • Co-ingestion with tricyclic antidepressants (risk of seizures) 3

Cardiac Arrest from Drug Overdose

1. Begin high-quality CPR immediately
2. Use AED as soon as available
3. If possible opioid overdose, administer naloxone per protocol
4. Continue resuscitation efforts until ALS providers take over or victim shows signs of life 2

Supportive Care Measures

• Gastrointestinal Decontamination: Evidence suggests limited value of gastric lavage and whole-bowel irrigation for most overdose situations 4

• Activated Charcoal: May be considered for recent ingestions (within 1 hour) if airway is protected and the substance is adsorbed by charcoal 4

• Enhanced Elimination: Consider hemodialysis for specific toxins (methanol, ethylene glycol, salicylates, lithium)

• Monitoring and Support:

  • Continuous cardiac monitoring
  • IV fluid support as needed
  • Correction of electrolyte abnormalities
  • Temperature management
  • Seizure control if needed 1

Post-Overdose Care

• Refer patients to advanced healthcare services after initial stabilization due to risk of recurrent toxicity 1

• Connect patients to addiction treatment services after acute management 1

• Consider prescribing take-home naloxone for high-risk individuals 1

Common Pitfalls and Caveats

• Beware of polysubstance overdose: Multiple drug classes are involved in over half of overdose cases requiring resuscitation 5

• Naloxone precipitation of withdrawal: Can cause agitation, hypertension, tachycardia, vomiting in opioid-dependent patients 1

• Delayed toxicity: Some substances (acetaminophen, sustained-release preparations) may not show immediate toxic effects but can cause delayed organ damage 6

• Psychological manifestations: Drug overdose can present with behavioral, cognitive, and perceptual disturbances that may be the only signs of dangerous toxicity 7

• Resedation risk: Patients may require repeated doses of antidotes as the duration of action of many toxins exceeds that of the antidote 1, 3

The emergency management of drug overdose requires rapid assessment, targeted interventions based on the suspected substance, and comprehensive supportive care to reduce the significant morbidity and mortality associated with these cases 8.