What is the workup for opioid overdose in a patient who attempted suicide?

Workup for Opioid Overdose in Suicide Attempt

The comprehensive workup for opioid overdose in a suicide attempt must prioritize immediate life-saving interventions including airway assessment, naloxone administration, and cardiopulmonary resuscitation if indicated, followed by careful monitoring for at least 4-6 hours and psychiatric evaluation before discharge. 1

Immediate Assessment and Interventions

Initial Evaluation

• Verify scene safety
• Check responsiveness
• Assess airway, breathing, and circulation (ABCs)
• Determine pulse status and breathing pattern

Based on Initial Assessment:

1. If no pulse and no normal breathing:

   • Begin high-quality CPR immediately
   • Activate emergency response system
   • Get AED and emergency equipment
   • Consider naloxone administration after CPR initiation if opioid overdose is suspected 2

2. If pulse present but no normal breathing or only gasping:

   • Administer naloxone immediately
   • Provide rescue breathing (1 breath every 5-6 seconds, or 10-12 breaths/min)
   • Monitor until emergency responders arrive 2

3. If pulse and normal breathing present:

   • Place in recovery position
   • Monitor closely
   • Prepare for possible deterioration

Naloxone Administration

Dosing and Route

• Initial dose:
  • 0.4 mg IV/IM (preferred starting dose) 3
  • May titrate up to 2 mg as needed 1
  • For intranasal administration: 2-4 mg 1

Important Considerations

• Use lower initial doses (0.04-0.4 mg) in opioid-dependent patients to avoid precipitating severe withdrawal 1, 4
• Repeat doses every 2-3 minutes if no response 1, 3
• If no response after 10 mg total, question diagnosis of opioid-induced toxicity 3

Post-Naloxone Monitoring

• Monitor vital signs, level of consciousness, and respiratory status for at least 4-6 hours after last naloxone dose 1
• Extended observation (12-24 hours) is required for long-acting opioid overdose 1
• Be alert for recurrence of respiratory depression as naloxone's duration of action may be shorter than that of the opioid 1

Laboratory and Diagnostic Testing

• Comprehensive toxicology screen (urine and blood)
• Basic metabolic panel to assess electrolyte abnormalities and renal function
• Liver function tests (especially with hepatic dysfunction which can impair opioid clearance) 2
• ECG to assess for cardiac abnormalities
• Chest X-ray if respiratory complications are suspected
• Consider CT head if altered mental status persists after naloxone administration

Psychiatric Evaluation

• Comprehensive suicide risk assessment once medically stable
• Evaluate for underlying mental health conditions (particularly depression, as it's a significant risk factor for overdose) 2, 5
• Assess for previous suicide attempts
• Document intent, planning, and access to means
• Evaluate support systems and protective factors

Complications to Monitor

Opioid-Related Complications

• Respiratory depression recurrence
• Non-cardiogenic pulmonary edema
• Aspiration pneumonia
• Rhabdomyolysis
• Hypoxic brain injury

Naloxone-Related Complications

• Acute withdrawal syndrome (hypertension, tachycardia, piloerection, vomiting, agitation) 1
• Consider buprenorphine for severe naloxone-precipitated withdrawal 6

Disposition Planning

• All patients who respond to naloxone should be referred to advanced healthcare services 1
• Do not discharge patients who attempted suicide with opioids without psychiatric evaluation
• Consider inpatient psychiatric admission for patients with ongoing suicidal ideation
• Connect patients to addiction treatment services if opioid use disorder is present 1
• Consider prescribing take-home naloxone for high-risk individuals 1
• Provide education to patients and families about overdose recognition and response 1

Special Considerations

• Assess for co-ingestions, particularly alcohol or benzodiazepines, which significantly increase overdose risk 2
• Evaluate for underlying hepatic or renal dysfunction, which can impair opioid clearance 2
• Be aware that suicide attempts may be underreported in opioid overdose cases 5
• The suicide rate among those with opioid use disorder is six times higher than the general population 5

Remember that opioid overdose in the context of suicide requires both medical stabilization and comprehensive psychiatric care to address the underlying suicidal behavior.