What are the initial steps in managing a drug overdose?

Initial Management of Drug Overdose

The initial management of a drug overdose should focus on supporting the patient's airway and breathing, beginning with opening the airway followed by delivery of rescue breaths, ideally using a bag-mask or barrier device. 1

Assessment and Immediate Actions

• Check for responsiveness and activate the emergency response system immediately - do not delay while awaiting response to interventions 1
• Assess breathing and pulse (for less than 10 seconds) 1
• If the patient is breathing normally but unresponsive, place in recovery position (left lateral head-down position) 2
• If the patient is not breathing normally but has a pulse:
  • Open the airway and reposition 1
  • Provide rescue breathing or bag-mask ventilation until spontaneous breathing returns 1
  • Consider naloxone administration for suspected opioid overdose 1
• If the patient is in cardiac arrest (no pulse):
  • Begin high-quality CPR immediately 1
  • Get an AED if available 1
  • Standard resuscitative measures should take priority over naloxone administration 1

Specific Interventions Based on Clinical Presentation

For Opioid Overdose

• For respiratory depression with a definite pulse, administer naloxone while continuing standard BLS/ACLS care 1, 3
• Naloxone can be administered via IV, IM, or subcutaneously, with doses repeated at 2-3 minute intervals if respiratory function does not improve 3
• Monitor for improvement in respiratory status and level of consciousness after naloxone administration 3
• Be prepared for possible recurrence of respiratory depression as naloxone's duration of action may be shorter than many opioids 3

For Benzodiazepine Overdose

• For benzodiazepine overdose with respiratory depression, flumazenil may be considered 4
• Initial dose of flumazenil 0.2 mg IV over 15 seconds; if no response after 45 seconds, additional doses can be administered 4
• Use caution with flumazenil as it may precipitate seizures in patients with benzodiazepine dependence or mixed overdoses 4

For Other Emergencies

• For status epilepticus: administer anticonvulsants (e.g., diazepam) 2
• For extreme agitation: consider sedatives (diazepam or clorazepate if no risk of respiratory depression; otherwise haloperidol) 2
• For severe bradycardia: administer atropine 2
• For hypotension: elevate the legs 2
• For unconscious patients: place in recovery position and consider glucose injection 2

Gastrointestinal Decontamination

• Activated charcoal can reduce gastrointestinal absorption of some drugs 2
• Should be given as soon as possible, preferably within 2 hours after ingestion 2
• Only administer if patient is fully conscious and capable of swallowing safely 2
• Gastric lavage carries risk of serious adverse effects and is only justified in rare cases where the patient's life is at risk following ingestion of a drug not adsorbed by activated charcoal 2
• Ipecac syrup should not be used under any circumstances 2

Post-Resuscitation Management

• After return of spontaneous breathing, patients should be observed in a healthcare setting until the risk of recurrent toxicity is low and vital signs have normalized 1
• If recurrent opioid toxicity develops, repeated small doses or an infusion of naloxone can be beneficial 1
• Monitor patients for at least 2 hours after naloxone administration, with longer observation periods for patients on long-acting opioids 3
• For self-poisoning cases, evaluate the risk of short-term suicide relapse even when the condition is not life-threatening 2

Special Considerations

• Patients with multiple drug ingestions require careful monitoring as clinical presentation may be complex 5
• Children can experience more profound effects from small amounts of medication 6
• Paracetamol (acetaminophen) poisoning requires specific management with acetylcysteine within 24 hours to prevent hepatocellular necrosis 2
• Consider delayed effects from certain medications, especially extended-release formulations 2
• Psychological disturbances may be the only sign of dangerous toxicity in some cases 7

Remember that less than 1 percent of poisonings are fatal, and management in most cases is supportive unless a specific antidote is available 6. However, patients can have rapid decline in mental or hemodynamic status even when they initially appear to be compensating 6.