Version May 2024
| To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222 for the nearest regional poison control center. Contact information for poison control centers around the world is available at the WHO website and in the UpToDate topic on regional poison control centers (society guideline links). |
| Clinical and laboratory features |
| Altered mental status ranging from mild euphoria or lethargy to coma |
| Miotic pupils |
| Decreased bowel sounds |
| Low to normal heart rate and blood pressure |
| Hypoventilation |
| Diagnostic evaluation |
| Obtain rapid bedside serum glucose concentration, to exclude hypoglycemia as cause of coma. |
| Obtain creatine kinase (if history indicates prolonged immobilization). |
| Obtain chest radiograph (if physical examination suggests acute lung injury or aspiration). |
| Obtain serum acetaminophen concentration (if opioid was taken with intent of self-harm or in opioid/acetaminophen combination product). |
| Obtain electrocardiogram (if methadone or loperamide toxicity is suspected). |
| Treatment |
| Ensure adequate ventilation. If respiratory rate is ≥12 breaths/minute and O2 saturation >90% on room air, observe the patient in a monitored setting and reassess frequently. End-tidal CO2 monitoring using capnography is an excellent means to monitor ventilation. |
| If the O2 saturation is <90% on room air but the patient is breathing spontaneously, administer supplemental oxygen followed by intravenous naloxone, 0.04 mg. In absence of IV access, naloxone can be given intramuscularly. Repeat until ventilation is adequate. The goal of treatment is adequate ventilation, NOT normal mental status. If the response is inadequate after 5 to 10 mg, reconsider the diagnosis. |
| If the patient is apneic, ventilate using a bag-valve mask attached to supplemental oxygen and administer naloxone in doses of 0.2 to 1 mg IV or IM. If no response occurs after a total of 5 to 10 mg of naloxone, reconsider the diagnosis and perform tracheal intubation. |
| If hypoventilation recurs following the initial naloxone bolus, give additional bolus doses to restore adequate ventilation. When ventilation is adequate, a naloxone infusion can be instituted in lieu of frequent rebolusing. Begin the infusion rate at 2/3 of the total dose of naloxone needed to restore breathing, delivered every hour. |
| If the patient develops respiratory depression despite a naloxone infusion, administer a naloxone bolus (using half the original bolus dose) and repeat if necessary until adequate ventilation returns, then increase the infusion rate. |
| If the patient develops signs of opioid withdrawal, stop the infusion. If respiratory depression returns, start the infusion at half the original rate. |
| The patient is medically stable for transfer or discharge when their mental status and ventilation remain normal for more than one hour after cessation of naloxone. |
| Psychiatry consultation may be required to assess suicidality. |
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