Management protocol for opiates & opiods intoxication

1. MANAGEMENT PROTOCOL
FOR
INTOXICATION
By
Kerolus Ekram Gad Shehata
• PGY-III IM Resident, Ain Shams University
• ECFMG certified

2. General Hints
 History: May by absent or misleading
 Presentation: Differs according to: Type of the
substance, Type of the patient “ addict Vs. non-
addict”, dose, delay…etc.
 A high index of suspicion is a must as every
minute for these patients counts for his
survival.

3. How these patients get intoxicated?
 Accidental overdose in an addict.
 Suicidal attempt. Mode
 Accidental: mainly in kids.
 Route IV, Sniffing or Oral.
 Most common types: Heroin, Morphine,
Tramadol.

4. Typical Presentation
 Most common symptoms ( if present ): drowsiness
(esp. in non-addicts and children) & Convulsions ( in
case of TRAMADOL or prolonged coma causing
ischaemic encephalopathy ).
 Most common signs: CNS depression up to a
comatosed pt., Bradypnea ( most specific ) up to
cyanosis, miosis +/- pinpoint pupil, hypotension,
bradycardia.

5. Atypical Presentation
 Stimulant effect of Tramadol: Hypertensive, tachycardic,
tachypneic with manifestations of CNS stimulation up to
seizures.
 Signs of Lateralization: due to Intra cerebral hemorrhage
due to either head trauma during convulsions, ischaemic
encephalopathy, associated stroke…etc. ( CENTRAL cause ).
 Heroin-related noncardiogenic pulmonary edema.
 IVDA fever, sweating, malaise, palpitations
source of infection e.g. Infective Endocarditis ( TR ).
 Post-ictal state : DCL, dilated pupil +/- aspiration..etc.

6. So, what are the signs of lateralization?
 Unsynchronized response of the limbs to pain or to nasal
alcohol.
 +ve Babiniski sign.
 Unequal pupil size: usually late and indicate impending
herniation.
 Marked muscle rigidity on one side & Flaccidity on the
other side.
 Hyperactive DTRs on one side & absent on the other.

7. How to proceed Initially..?
 Our main goal here is to give this patient the “potential
for survival” Through our ABCD.
 Firstly: General concise assessment of the pt.’s condition.
 Determine the need for any immediate intervention e.g.
ETT, starting CPR…etc. before you think of anything else
(what did this pt. take? Or whether it is toxicologically
related or not ).
 Seizing Pt. IV Diazepam repeated as needed + apply
seizure protocol then admission is mandatory.

8. How to proceed after stabilization of the Pt. ?
 VITALS are vital: B.P, pulse, Temp. & R.R.
 Take a thorough history from the relatives or friends (If
available) about type, amount, route, time delay, addict
or not, co-ingestions…etc.
 Perform a general & focused physical examination to
determine the cause and also to exclude other causes of
that presentation.
 Ideally: Any pt. with DCL must get a CT scan to exclude
any central cause before getting admitted to our PCC.

9. What is NEXT…?
 Any symptomatic Pt. whatever the severity = admission.
 Main purpose of admission = Supportive TTT+ Follow up
+/- Antidote therapy.
 Any agitated Pt., pt. with history of convulsions or
comatosed pt. = ICU admission.
 Documentation is necessary whenever possible e.g.
perform urine toxicology screen for possible drugs of
abuse.

10. Investigations
 Routine labs: Glucose, Na, K.
 Arterial blood gases: Respiratory acidosis +/- Metabolic
acidosis (esp. in postictal states). Done serially esp. for
MV pts.
 Urine screen for Opiate, Tramadol…etc.
 RFTs & LFTs: esp. for pt. with chronic hepatic or renal
diseases, elderly and prolonged stay in ICU.
 ECG: to detect possible arrhythmia.
 CXR: if you suspect aspiration (esp. during convulsions)
or to Dx. HAP, ARDS

11. Investigations…Cont’d
 Non-contrast CT-brain: should be done early to
detect possible intra-cranial hemorrhage.
 Brain MRI: usually done in cases not responding
to TTT to detect possible stroke (generalized
ischaemic encephalopathy esp. in the basal
ganglia ).

12. Treatment
 Serial follow up of Vitals.
 IV fluids e.g. Ringer, 0.9 % saline, D5%, Panthol,
Pediment (for kids)..etc. adjusted according to the need
of the patient, the fluid chart +/- CVP
 If recurrent seizures: IV Diazepam +/- Barbiturates
immediately & may get phenytoin maintenance.
 If vomiting: Cortiplex B6, Metoclopramide up to
Ondansetron.
 Care of the coma.

13. Treatment…Cont’d
 Insert a urinary catheter: Input Vs. Output
 For hypotension: IV fluids Dopamine+/-Dobutamine
up to Norepinephrine.
 For Bradycardia <55 BPM: Atropine.
 For Ventricular arrhythmias: Amiodarone (LD+MD) or
Lidocaine.
 For prolonged QTc & TDP: Mg + K
 Serial monitoring by ABG and vital data till the pt. gets
gradually weaned off the ventilator.

14. Naloxone
 Pure competitive opioid antagonist (Mu receptors).
 Part of the cocktail given for any undiagnosed come
along with Dextrose & Thiamine.
 Given in cases of opiate or opioid intoxication
associated with (Respiratory depression).
 For opioid addicts with unintentional poisoning: start
with small doses to avoid severe withdrawal Sx.
 For intentional overdose in non-addicts & for children
with accidental ingestions: start with large doses as
there won’t be withdrawal Sx.

15. Naloxone…Cont’d
 Initial dose: 0.1 : 0.4 mg IV up to 2 mg ( ¼:5 amp.)
 In pure Opiate or opioid intoxication: Miraculous very
rapid response.
 For cases with concomitant ingestion of BZPs, EtOH or
antipsychotics weak or no effect.
 Drawbacks: Expensive, Not readily available & Short
t1/2 (30:90 min.) so must be given as a maintenance.

16. Questions & Comments