Location: Emergency room
Vitals: BP 100/60 mm Hg; HR is 50/min, regular; RR is 10/min; Temp. 37C(98.6).
28-yr old white female is brought to ER in unconscious state. Family reports that she is a very healthy female, has no medical problems, not on any medications, and did not find any empty bottles. She has no allergies. She doesn't smoke or drink alcohol. She has a boyfriend. She has never been pregnant. Her father is very healthy except borderline hypertension. Mother has diabetes. No other history is available.
How do you approach this patient?
Step I: Emergent management: This patient is hemodynamically unstable, so A, B, C, D is the most important component of the management of this patient.
A: Airway suction, pulse oximetry, stat, and continuous monitoring, O2
B: Endotracheal intubation is indicated in patients who cannot protect their airway or if O2 saturation does not improve with O2 nasal/face mask, or PaO2<55, or PCO2>50 on ABG.
C: IV access; continuous cardiac monitor; place a Foley; obtain a finger stick glucose.
D: Drugs: Administer thiamine, dextrose 50%, and naloxone - all are IV bolus one time dose
Respiratory (assess the breathing pattern)
Suction airway, stat
Pulse oximetry, stat and continuous
Oxygen, inhalation, stat or Intubation
IV access, stat
Cardiac monitor , continuous
Finger stick glucose, stat
Thiamine, IV stat, one time
Dextrose 50%, stat, one time
Naloxone, IV stat, one time
Normal saline 0.9% NaCl, stat, continuous
*She is slightly awake with the above treatment
Step II: Physical Examination:
On examinations she found to have pinpoint pupils. She is very drowsy.
So, she has bradycardia, hypotension, and pinpoint pupils, which are classic symptoms for narcotic overdose.
Step III: Diagnostic Investigations:
EKG 12 lead, stat
CBC with differential, stat
CXR, portable, PA, stat
Urine toxicology screen, stat
B-HCG, serum, qualitative, stat
Blood alcohol, stat
NG tube, gastric lavage, stat (which revealed pill fragments)
Activated charcoal, oral, one time
Naloxone, IV, stat, continuous
Decision about changing patient location
Move patient to ICU
Bed rest, complete
BMP, next day
*Once the patient is better
D/C oxygen, NG tube, cardiac monitor, IV fluids, and naloxone
Step V: Educate patient and family:
Psychiatry consult, stat (Reason: 28-year-old with suicide attempt)
No illegal drug use
Seat belts use
*Start the patient on antidepressant if needed
Orthostatic hypotension resulting from mild peripheral vasodilation is common. However, persistent or severe hypotension should raise the suspicion of co-ingestants.
In all patients with moderate-to-severe toxicity, it is important to obtain baseline studies, including a CBC with diff, basic metabolic panel, LFT's, ABG, and CK (Creatine kinase level).
Positive urine drug screens are observed up to 36-48 hours postexposure.
A 12 lead EKG should be obtained on all patients with intentional overdose, as there is always a possibility of cardiotoxic co-ingestants.
Chest x-ray is important to rule out any pulmonary edema or aspiration especially in a patient with an unprotected airway.
Naloxone should be given to patients with significant CNS and/or respiratory depression.
Continuous IV infusion of naloxone is very safe in patients who were not opioid dependent. However, in patients who are opioid dependent this practice is dangerous and may precipitate withdrawal symptoms.
Activated charcoal should be administered to all patients with opiate intoxication following ingestion. Because of the delayed gastric emptying produced by opiate intoxication, it is effective even in patients who present late following ingestion. Orogastric lavage is indicated if the patient presents within one hour of ingestion.
All patients with significant respiratory depression, recurrent sedation should be observed in the hospital for at least a period of 12-24 hours. Most physicians admit the patients if they require a second dose of naloxone. Patients should have continuous cardio respiratory monitoring.
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