What are the orders for managing a suspected drug overdose?

Management of Suspected Drug Overdose

Immediately check responsiveness, activate emergency response systems without delay, and assess breathing and pulse for less than 10 seconds—prioritizing airway management and high-quality CPR over any pharmacologic intervention. 1, 2

Immediate Assessment and Stabilization

Primary Survey (First 60 Seconds)

• Check responsiveness and activate emergency response system immediately—do not delay activation while awaiting response to any intervention 3, 1, 2
• Assess breathing and pulse for less than 10 seconds 1, 2
• Obtain bedside glucose immediately to rule out hypoglycemia as a cause of altered mental status 4, 1
• Establish IV access and initiate continuous cardiorespiratory monitoring 4

Airway and Breathing Management

• For patients with a pulse but no normal breathing or only gasping: open the airway, reposition, and provide rescue breathing or bag-mask ventilation until spontaneous breathing returns 3, 1, 2
• Secure airway with endotracheal intubation if Glasgow Coma Scale ≤8 or protective airway reflexes are lost 4
• Continue standard BLS/ACLS measures if spontaneous breathing does not occur 3, 2

Cardiac Arrest Management

• For patients with no pulse: start high-quality CPR immediately with focus on compressions plus ventilation—standard resuscitative measures take priority over naloxone administration 3, 1, 2
• Use automated external defibrillator if available 2
• Naloxone can be administered along with standard ACLS care only if it does not delay high-quality CPR 3

Monitoring and Diagnostic Workup

Continuous Monitoring Parameters

• Respiratory rate (watch for <8 breaths/min), blood pressure, heart rate, oxygen saturation, and cardiac rhythm 4
• Serial ECGs to detect conduction delays or dysrhythmias (particularly important with lamotrigine or other cardiotoxic agents) 4
• Arterial or venous blood gas if respiratory depression is present to assess for hypoxemia and hypercarbia 4

Laboratory Studies

• Urine drug screen to identify co-ingestants, particularly opioids, alcohol, or other CNS depressants 4
• Serum acetaminophen and salicylate levels as part of standard overdose workup 4
• Comprehensive metabolic panel including electrolytes, renal function, and hepatic function 4
• Complete blood count 4

Opioid-Specific Management

Naloxone Administration Algorithm

• For patients with a definite pulse but no normal breathing or only gasping: administer naloxone while continuing standard BLS/ACLS care 3, 1, 2
• Naloxone can be administered via IV, IM, or subcutaneous routes 2
• Repeat doses at 2-3 minute intervals if respiratory function does not improve 2
• Goal is improved ventilatory effort, not full awakening—avoid excessive doses attempting to achieve full consciousness 1
• Monitor for improvement in respiratory status and level of consciousness after administration 2

Critical Caveat About Naloxone

• Naloxone is ineffective for non-opioid substances including xylazine, benzodiazepines, and other CNS depressants 3, 1
• Consider polysubstance overdose involving non-opioid substances if there is no response to naloxone 1
• Metabolic insults such as hypoxia or hypercarbia may contribute to non-response 1

Mixed Overdose Considerations

Benzodiazepine/Mixed Overdoses

• Flumazenil should NOT be routinely administered in mixed overdose scenarios due to multiple contraindications 4
• Standard supportive care with airway management and mechanical ventilation is preferred over flumazenil in mixed overdoses 4

Post-Resuscitation Observation

Minimum Observation Periods

• Observe patients who respond to naloxone for at least 2 hours after administration 1, 2
• Longer observation periods needed for patients suspected of taking long-acting opioids 1, 2
• Minimum observation period of 6-8 hours for benzodiazepine overdose, with longer periods if CNS depression persists 4
• Monitor for at least 2 hours after any intervention to assess for recurrent toxicity 4
• Continue observation until risk of recurrent toxicity is low and vital signs have normalized 4, 2

Repeated Dosing Strategy

• Repeated small doses or an infusion of naloxone beneficial if recurrent opioid toxicity develops 2

Disposition Criteria

ICU Admission Indications

• Respiratory depression requiring mechanical ventilation 4
• Persistent hemodynamic instability 4
• Cardiac dysrhythmias requiring continuous monitoring 4

Mandatory Pre-Discharge Requirements

• Psychiatric evaluation before discharge to assess suicide risk 4
• Vital signs normalized and risk of recurrent toxicity low 4, 2

Common Pitfalls to Avoid

• Never delay activating emergency response systems while awaiting response to naloxone or other interventions 3, 1
• Do not focus solely on opioid reversal when polysubstance overdose may be present 1
• Avoid administering excessive naloxone doses attempting to achieve full consciousness rather than adequate ventilation 1
• Do not assume clinical condition is due to opioid-induced respiratory depression alone—rescuers cannot be certain, particularly in first aid and BLS settings where pulse determination is unreliable 3