What is the initial management and complete list of medications for a patient in a code blue situation due to a suspected drug overdose?

Code Blue Drug Overdose: Complete Medication List and Management Protocol

In a code blue drug overdose situation, the complete medication list includes: epinephrine 1 mg IV/IO every 3-5 minutes for cardiac arrest, naloxone 0.4-2 mg IV/IO/IM for opioid overdose, and specific antidotes based on the suspected toxin, with standard ACLS medications (amiodarone 300 mg or lidocaine 1-1.5 mg/kg for refractory VF/pVT) used according to cardiac rhythm. 1

Immediate Assessment and Drug Administration Algorithm

Standard ACLS Medications (All Drug Overdose Cardiac Arrests)

Core resuscitation medications:

• Epinephrine 1 mg IV/IO every 3-5 minutes - administered throughout the resuscitation for all cardiac arrest rhythms 1
• Amiodarone 300 mg IV/IO bolus (first dose), then 150 mg (second dose) - for refractory VF/pVT only 1
• Lidocaine 1-1.5 mg/kg IV/IO (first dose), then 0.5-0.75 mg/kg (second dose) - alternative to amiodarone for refractory VF/pVT 1
• Atropine - not routinely recommended in standard cardiac arrest but may be considered for specific toxidromes 1

Toxin-Specific Antidotes for Critical Poisoning

Opioid overdose:

• Naloxone 0.4-2 mg IV/IO/IM - initial dose, repeat every 2-3 minutes if inadequate response 1
• Naloxone 2-4 mg intranasal - repeat every 2-3 minutes as needed 1
• Naloxone infusion: two-thirds of the waking dose per hour - for sustained effect after initial reversal 1

Benzodiazepine overdose:

• Flumazenil 0.2 mg IV, titrated up to 1 mg total - only in select patients without contraindications 1
• Pediatric dose: 0.01 mg/kg (up to 0.2 mg) 2
• Critical caveat: Multiple contraindications exist - do not use in patients with seizure history, chronic benzodiazepine use, or suspected co-ingestion with tricyclic antidepressants 1

Beta-blocker/Calcium channel blocker overdose:

• Calcium chloride 2000 mg (20 mL of 100 mg/mL solution) - initial dose 1
• Maintenance infusion: 20-40 mg/kg/h 1
• Calcium gluconate 6000 mg (60 mL of 100 mg/mL solution) - alternative to calcium chloride 1
• Glucagon 2-10 mg IV/IO - initial bolus, followed by 1-15 mg/h infusion 1
• High-dose insulin 1 U/kg bolus - followed by 1-10 U/kg/h infusion with dextrose supplementation 1
• Atropine 0.5-1.0 mg every 3-5 minutes up to 3 mg - for bradycardia 1

Digoxin/cardiac glycoside overdose:

• Digoxin immune Fab 10-20 vials - for acute overdose when critically ill and ingested dose unknown 1
• Calculated dosing: 1 vial for every 0.5 mg digoxin ingested 1

Sodium channel blocker overdose (tricyclic antidepressants, cocaine):

• Sodium bicarbonate 50-150 mEq IV bolus - titrate to QRS narrowing 1
• Maintenance infusion: 150 mEq/L solution at 1-3 mL/kg/h 1

Local anesthetic toxicity:

• Intravenous lipid emulsion (ILE) 1.5 mL/kg (up to 100 mL) of 20% solution - initial bolus 1
• Infusion: 0.25 mL/kg/min for up to 30 minutes 1

Organophosphate/carbamate poisoning:

• Atropine 1-2 mg, doubled every 5 minutes - titrate to reversal of bronchorrhea and bronchospasm 1
• Maintenance: 10-20% of total loading dose per hour 1
• Pralidoxime 1-2 g IV - followed by 400-600 mg/h infusion 1

Cyanide poisoning:

• Hydroxocobalamin 5 g IV - initial dose 1
• Sodium nitrite 300 mg IV - alternative, monitor for hypotension 1
• Sodium thiosulfate 12.5 g IV - adjunctive therapy 1

Methemoglobinemia:

• Methylene blue 1-2 mg/kg IV - repeat every hour if needed, maximum 5-7 mg/kg 1

Critical Decision Points and Pitfalls

Priority hierarchy in drug overdose cardiac arrest:

1. High-quality CPR takes absolute priority over all medications 1, 3, 4
2. Establish IV/IO access immediately 1
3. Administer epinephrine every 3-5 minutes per standard ACLS 1
4. Consider toxin-specific antidotes only after initiating standard resuscitation 1, 4

Common pitfalls to avoid:

• Never delay CPR to administer naloxone - standard resuscitative measures take priority 3, 4, 5
• Do not administer flumazenil in undifferentiated overdose - risk of precipitating seizures in mixed ingestions with tricyclic antidepressants or in patients with chronic benzodiazepine use 1
• Always administer naloxone first when combined opioid-benzodiazepine overdose is suspected - before considering flumazenil 1
• Monitor for resedation after naloxone - naloxone's duration of action (30-90 minutes) is shorter than most opioids, requiring continuous infusion or repeated doses 1, 3
• Titrate naloxone to respiratory effort, not full consciousness - using the lowest effective dose minimizes acute withdrawal in opioid-dependent patients 1, 5

Addressing reversible causes (the H's and T's):

• Toxins is specifically listed as a reversible cause in the AHA algorithm 1
• Consider other reversible causes: hypovolemia, hypoxia, hydrogen ion (acidosis), hypo/hyperkalemia, hypothermia, tension pneumothorax, tamponade, thrombosis (pulmonary/coronary) 1

Post-Resuscitation Monitoring Requirements

Observation periods after antidote administration:

• Naloxone: minimum 2 hours observation - longer for long-acting opioids (methadone, sustained-release formulations) 3, 4, 5
• Flumazenil: continuous monitoring until risk of resedation is low - resedation occurred in 7-15% of patients in clinical trials 2
• All overdose patients: monitor until vital signs normalized and risk of recurrent toxicity is low 3, 4