CURRENT Essentials of Critical Care.pdf

236 Current Essentials of Critical Care■■■Opioid OverdoseEssentials of Diagnosis• Depressed level of consciousness, decreased respirations, whichcan be pronounced, miotic pupils• Less commonly pulmonary edema, hypo- or hyperthermia, emesis,hypoxia, hypotension, depressed deep tendon reflexesDifferential Diagnosis• Alcohol intoxication• Sedative-hypnotic overdose• Cardiogenic pulmonary edema• Altered mental status due to CNS infection, encephalopathy, hypoglycemia,seizure, hypothyroidism, strokeTreatment• Send blood for electrolytes, toxicology screen, blood gases, liverfunction tests; ethanol and acetaminophen levels to evaluate forco-ingestion• CXR to evaluate for pulmonary edema or aspiration pneumonia• Establish airway and ventilation in the comatose patient• Patients with respiratory depression should receive naloxone, 2mg IV initially; may be repeated up to a total of 10–20 mg ifno reversal of symptoms follows initial dose• Patients with central nervous system depression without respiratorydepression should receive naloxone 0.1–0.4 mg IV initially;partial or absent responses should be followed by naloxone2 mg IV as described for patients with respiratory depression• Continuous naloxone infusion or repeated naloxone doses every20–60 minutes may be required following initial response, especiallywhen long-acting narcotics have been ingested• Gastrointestinal decontamination with nasogastric lavage followedby activated charcoal and a cathartic can be helpful■ PearlAcute complications of narcotic use due to sharing of needles includepulmonary hypertension, endocarditis, necrotizing fasciitis, andtetanus.ReferenceWatson WA et al: Opioid toxicity recurrence after an initial response to naloxone.J Toxicol Clin Toxicol 1998;36:11. [PMID: 9541035]