What is the treatment protocol for opium (opioid) poisoning in crystal form in an adult patient presenting to the emergency room or casualty department?

Treatment Protocol for Opioid Poisoning in Crystal Form in the Emergency Department

For opioid poisoning presenting to the emergency room, immediately prioritize airway management and ventilatory support over antidote administration, with naloxone reserved for patients in respiratory arrest who have a definite pulse. 1

Immediate Assessment and Stabilization

Primary Survey (ABCs)

• Assess airway patency and breathing first - opioid overdoses progress to cardiac arrest through loss of airway patency and respiratory failure, not primary cardiac pathology 1
• Check for pulse presence to differentiate respiratory arrest from cardiac arrest 1
• Activate emergency response systems immediately without waiting for naloxone response 1

Clinical Presentation to Identify

Look specifically for these objective criteria (at least 3 of 5 confirms opioid toxicity): 2

• Respiratory rate <6 breaths/minute
• Pinpoint pupils (miosis)
• Evidence of drug use (track marks, paraphernalia)
• Glasgow Coma Scale score <12
• Cyanosis

Common pitfall: Hypotension and bradycardia are rare in pure opioid overdose (bradycardia seen in only 2% of cases); if present, consider co-ingestions or alternative diagnoses 2

Respiratory Management Algorithm

If Patient Has Pulse But No Normal Breathing (Respiratory Arrest):

1. Open airway and provide rescue breathing immediately 1

   • Use bag-mask ventilation with barrier device
   • Continue until spontaneous breathing returns

2. Administer naloxone while maintaining ventilation 1

   • Adult dosing (IV/IO/IM): 0.4-2 mg initial dose 1, 3
   • Repeat every 2-3 minutes if inadequate response 3
   • Intranasal route: 2-4 mg, repeat every 2-3 minutes as needed 1
   • Pediatric dosing: 0.01 mg/kg IV initial dose; if inadequate, give 0.1 mg/kg 3

3. Titrate naloxone to restore adequate ventilation and airway reflexes, NOT full consciousness 1, 3

   • Goal: respiratory rate ≥10/min and adequate protective airway reflexes
   • Avoid excessive dosing which causes acute withdrawal, hypertension, and agitation 3

4. If no response after 10 mg total naloxone, question the diagnosis - consider non-opioid causes or co-ingestions 3

If Patient is in Cardiac Arrest:

1. Focus on high-quality CPR (compressions PLUS ventilation) 1

   • Standard BLS/ACLS protocols take absolute priority
   • No evidence that naloxone improves outcomes in cardiac arrest 1

2. Naloxone may be given alongside CPR if it does not delay resuscitation 1

   • However, effective ventilation during CPR is more critical than antidote administration

Critical distinction: The evidence shows opioid-associated cardiac arrest patients have extremely poor outcomes (none survived in one urban cohort), emphasizing prevention of progression to arrest through early respiratory support 2

Route of Administration Considerations

• IV/IO route: Fastest onset, preferred in emergency situations 3
• IM route: Equally effective (94% response rate vs 90% IV) when combined with bag-valve-mask ventilation 2
  • Use when IV access delayed or unavailable 3
  • Provides longer duration of action 3
• Intranasal route: 2-4 mg dose, practical for lay responders 1

Post-Resuscitation Management

Continuous Monitoring Requirements

All patients must be observed in a healthcare setting until risk of recurrent toxicity is low and vital signs normalized 1

Key monitoring points:

• Naloxone's duration of action (30-90 minutes) is often shorter than the opioid's effect 1, 4
• Recurrent CNS and respiratory depression commonly occurs 1
• Crystal/long-acting opioid formulations require extended observation periods 1

Management of Recurrent Toxicity

If respiratory depression recurs, administer repeated small naloxone doses or continuous infusion 1

Naloxone infusion preparation: 3

• Add 2 mg naloxone to 500 mL normal saline or 5% dextrose (concentration: 0.004 mg/mL)
• Infusion rate: Two-thirds of the initial waking dose per hour 1
• Use within 24 hours; discard after 24 hours 3

Gastrointestinal Decontamination

Activated charcoal is NOT routinely indicated for opioid poisoning - opioids are rapidly absorbed and charcoal is only effective if given within 1-2 hours of ingestion in a patient with intact airway reflexes 4, 5

Gastric lavage and ipecac are contraindicated - risk of aspiration outweighs any benefit 4

Admission Criteria

Admit patients with: 2

• Persistent respiratory depression requiring repeated naloxone
• Noncardiogenic pulmonary edema (occurs in minority of cases, evident on ED arrival)
• Persistent altered mental status
• Suspected long-acting opioid ingestion
• Co-ingestions requiring specific management
• Intentional self-harm requiring psychiatric evaluation 4

Note: In one urban cohort, only 2.7% of opioid overdose patients with initial blood pressure required admission, indicating most respond well to naloxone and supportive care 2

Special Considerations for Crystal/Synthetic Opioids

• Crystal methamphetamine co-ingestion is common and creates mixed toxidrome 6
• Synthetic opioids (fentanyl analogs) may require higher or repeated naloxone doses 6
• Polysubstance toxicity is the rule, not the exception, in current opioid epidemic 6