Emergency Medicine · Year 3 · from Emergency Medicine

Case 2: Opioid Overdose - Respiratory Arrest

Patient Demographics

• Age: 28 years
• Sex: Male
• Occupation: Unemployed

Chief Complaint

"Found down, not breathing."

History of Present Illness

EMS called to a public restroom for an unresponsive male. Bystander found patient slumped against wall with blue lips and agonal respirations. Bystander administered intranasal naloxone from a community distribution kit before EMS arrival. On EMS arrival, patient had some respiratory effort but remained obtunded. Additional naloxone given en route.

Initial Assessment

ESI Level: 1 - Immediately life-threatening

First Impression:

• Appearance: Obtunded, cyanotic, track marks visible on arms
• Work of breathing: Shallow, slow respirations
• Circulation: Pale with mottled extremities

Vital Signs on Arrival:

• Heart rate: 52 bpm
• Blood pressure: 88/56 mmHg
• Respiratory rate: 6 breaths/min
• SpO2: 78% on room air
• Temperature: 35.8C
• GCS: 6 (E2V1M3)
• Pupils: 2mm, minimally reactive (pinpoint)

Primary Survey

Airway:

• Partially obstructed (tongue, secretions)
• Jaw thrust performed
• Oropharyngeal airway placed

Breathing:

• Hypoventilation (RR 6)
• Bag-valve-mask ventilation initiated
• Improving oxygenation with BVM

Circulation:

• Bradycardic
• Weak peripheral pulses
• IV access obtained

Disability:

• GCS 6
• Pinpoint pupils (classic opioid finding)
• No focal motor deficits noted

Exposure:

• Multiple track marks bilateral arms
• No trauma
• Drug paraphernalia in belongings (needle, spoon)

Opioid Toxidrome

Management

Immediate Interventions:

1. Airway support: BVM ventilation, improving SpO2 to 94%

1. Naloxone Administration:

• Pre-hospital: 4mg intranasal (bystander) + 2mg IN (EMS)
• ED: Naloxone 0.4mg IV, titrated
• Goal: Adequate respirations, NOT full arousal
• Avoid precipitating withdrawal if possible

1. Response to Naloxone:

• After 0.4mg IV: RR improved to 12, GCS 10
• After additional 0.4mg IV: RR 14, GCS 13
• Patient becoming agitated (expected with naloxone)

Naloxone Dosing Pearls:

• Start low (0.04-0.4mg IV) in opioid-dependent patients
• Goal is respiratory support, not arousal
• Duration of action: 30-90 minutes (shorter than most opioids)
• May need repeated doses or infusion for long-acting opioids

Secondary Survey (After Stabilization)

SAMPLE History (from patient once arousable):

• Symptoms: Reports using heroin "maybe fentanyl"
• Allergies: None known
• Medications: None prescribed
• PMH: Prior overdoses (x3), hepatitis C, opioid use disorder
• Last Meal: Yesterday
• Events: Injected heroin, doesn't remember after

Physical Exam:

• Track marks bilateral antecubital, dorsal hands
• No abscess or cellulitis
• Lungs: Coarse bilaterally (aspiration risk)
• Heart: Regular rate and rhythm
• Neuro: Now alert, oriented, moving all extremities

Diagnostic Testing

Point-of-Care:

• Glucose: 78 mg/dL
• ECG: Sinus rhythm, normal QRS and QTc

Labs:

• CBC: WBC 11.2, Hgb 13.1
• BMP: Normal
• Troponin: Negative
• Lactate: 2.8 (mildly elevated, improving)
• VBG: pH 7.32, pCO2 48 (resolving respiratory acidosis)
• Urine drug screen: Positive for opioids (note: may miss synthetic opioids like fentanyl)

Chest X-ray: Mild bilateral perihilar infiltrates (possible aspiration vs. ARDS from hypoxia)

Observation Period

Rationale for Extended Monitoring:

• Unknown opioid (fentanyl analogs have prolonged effects)
• Risk of re-sedation as naloxone wears off
• Aspiration pneumonia risk

Monitoring:

• Continuous pulse oximetry
• Frequent respiratory checks
• 4-6 hour observation minimum

Course:

• No recurrence of respiratory depression
• Oxygen weaned to room air
• Alert and conversant

Harm Reduction and Disposition

Interventions:

1. Addiction medicine consultation
2. Offered medication-assisted treatment (MAT):

• Buprenorphine initiation discussed
• Patient interested, bridge prescription provided

1. Naloxone kit prescribed and training provided
2. Hepatitis C treatment referral
3. Social work involvement for resources
4. HIV testing offered

Disposition:

• Discharged after 6-hour observation
• Prescription for naloxone rescue kit
• Appointment with addiction medicine in 48 hours for buprenorphine induction
• Given list of resources (needle exchange, NA meetings, crisis line)

Teaching Points

1. Opioid overdose is reversible: Naloxone is lifesaving; support respirations while it takes effect
2. Titrate naloxone: Start low to avoid precipitating severe withdrawal
3. Fentanyl consideration: May require higher doses of naloxone; prolonged monitoring needed
4. Observation period: Minimum 4-6 hours; longer for long-acting or sustained-release opioids
5. Harm reduction: Every overdose is an opportunity for intervention - offer MAT, naloxone kit, resources
6. Aspiration risk: Common complication; chest X-ray if hypoxia persists despite naloxone
7. Community naloxone: Bystander-administered naloxone saves lives; ED reinforcement important

Clinical Image

Image Description: Close-up photograph demonstrating bilateral miotic (pinpoint) pupils, a classic finding in opioid toxicity. The pupils are constricted to approximately 2mm and poorly reactive to light.

Attribution: Image from Wikimedia Commons, Miosis. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/File:Miosis.jpg

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