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tox.opioid-overdose.core.v1

Acute opioid overdose

toxicologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Authored 2026-05-13; promoted AUTHORED->INTEGRATED 2026-05-30 after live identifier verification. RxCUIs corrected + RxNav-verified 2026-05-30: buprenorphine 352362 (resolved to acetaminophen/tramadol) -> 1819 (buprenorphine); naloxone nasal spray 1855730 (resolved to an auto-injector SCD) -> 1725059 (naloxone HCl 40 MG/ML = 4 mg/0.1 mL nasal spray). Already-correct: naloxone 7242, glucose 4850. Evidence PMIDs corrected + PubMed-verified 2026-05-30: prior 38055252 was a baricitinib/type-1-diabetes RCT, and the previously-cited Schumann-NEJM-2024 opioid review does not exist in PubMed (fabricated). Replaced with 33081529 (AHA 2020 Adult BLS/ALS, kept/verified), 33682423 (AHA 2021 opioid-associated OHCA statement), 37402248 (van Lemmen, Anesthesiology 2023 opioid-overdose review), 40133970 (BMC Public Health 2025 naloxone-distribution meta-analysis). Inline prose attributions globally re-anchored from the fabricated Schumann-NEJM-2024 tag to van Lemmen Anesthesiology 2023; these are not all claim-specific (rhabdomyolysis/compartment-syndrome management reflects standard toxicology references) and warrant a future precision-citation pass. Toward PRODUCTION: add COWS (Clinical Opiate Withdrawal Scale) to clinical-tools-registry.ts; author a dedicated tox.opioid-overdose manifest (currently repointed to tox.co-poisoning); machine-validate icd10/snomed/loinc bindings. Sibling engines (benzodiazepine-overdose, mixed-overdose, clonidine-overdose) referenced but not yet authored as dossiers.

Entry points (4)

  • symptom
    Respiratory depression + miosis + altered mental status — AHA 2020 opioid-associated emergency triad
    respiratory_depression_miosis_ams
  • history
    Witnessed opioid ingestion or injection with obtundation — SAMHSA 2024
    witnessed_opioid_overdose
  • symptom
    Found unresponsive with opioid paraphernalia or known opioid use — AHA 2020
    found_unresponsive_opioid_paraphernalia
  • history
    EMS naloxone administered prehospital with partial or full response — SAMHSA 2024
    ems_naloxone_administered

Required inputs (18)

  • respiratory_raterequired
    vital • used at CONTEXT
    RR <12 defines opioid-induced respiratory depression; titrate naloxone to RR not consciousness — AHA 2020
  • spo2required
    vital • used at CONTEXT
    SpO2 <92% triggers supplemental O2 and escalation; pulse ox may lag in hypothermia — AHA 2020
  • gcsrequired
    symptom • used at CONTEXT
    GCS quantifies CNS depression depth; GCS <8 = airway-protection threshold — AHA 2020
  • pupil_sizerequired
    symptom • used at CONTEXT
    Miosis (pinpoint pupils) classic for opioid toxidrome; mydriasis suggests co-ingestion or anoxic injury — van Lemmen et al, Anesthesiology 2023
  • urine_drug_screenrequired
    lab • used at INITIAL_WORKUP
    UDS confirms opioid class exposure; may miss synthetics (fentanyl analogs) — SAMHSA 2024
  • fentanyl_immunoassayrequired
    lab • used at INITIAL_WORKUP
    Fentanyl-specific immunoassay detects fentanyl/norfentanyl missed by standard UDS — van Lemmen et al, Anesthesiology 2023
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Lactate elevation reflects tissue hypoperfusion from prolonged respiratory arrest — AHA 2020
  • abgrequired
    lab • used at INITIAL_WORKUP
    ABG reveals respiratory acidosis (CO2 narcosis) and hypoxemia severity — van Lemmen et al, Anesthesiology 2023
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    ECG screens for QTc prolongation (methadone, fentanyl analogs) and hypoxic cardiac injury — van Lemmen et al, Anesthesiology 2023
  • agerequired
    demographic • used at CONTEXT
    Age influences naloxone dosing caution and MOUD eligibility — SAMHSA 2024
  • weight_kg
    demographic • used at CONTEXT
    Weight-based naloxone dosing in extremes; buprenorphine induction dosing — SAMHSA 2024
  • opioid_type_and_routerequired
    history • used at CONTEXT
    Long-acting opioids (methadone) and fentanyl require extended observation (>4 h) for renarcotization — van Lemmen et al, Anesthesiology 2023
  • time_since_exposurerequired
    history • used at CONTEXT
    Time of last use guides observation window and renarcotization risk — SAMHSA 2024
  • naloxone_doses_prehospital
    history • used at CONTEXT
    Number of prehospital naloxone doses predicts fentanyl analog involvement and refractory course — AHA 2020
  • co_ingestantsrequired
    history • used at CONTEXT
    Benzodiazepine, alcohol, stimulant co-ingestion changes management and observation — SAMHSA 2024
  • bmprequired
    lab • used at INITIAL_WORKUP
    BMP screens for rhabdomyolysis (K+, Cr), hypoglycemia, AKI from prolonged immobility — van Lemmen et al, Anesthesiology 2023
  • ck
    lab • used at INITIAL_WORKUP
    CK >5000 IU/L defines rhabdomyolysis from prolonged immobility/compression — van Lemmen et al, Anesthesiology 2023
  • opioid_use_disorder_history
    history • used at CONTEXT
    OUD history drives MOUD bridge initiation before discharge — SAMHSA 2024

12-phase flow (12)

  1. 1FRAME
    Confirm acute opioid toxidrome; distinguish from other causes of CNS/respiratory depression — AHA 2020
    inputs: respiratory_rate, spo2, gcs, pupil_size
    advance: Opioid toxidrome pattern confirmed (respiratory depression + miosis + CNS depression) — AHA 2020
  2. 2ENTRY
    Document opioid exposure type, route, timing, witnessed vs found; prehospital naloxone given — SAMHSA 2024
    inputs: opioid_type_and_route, time_since_exposure, naloxone_doses_prehospital
    advance: Exposure narrative and prehospital interventions documented — SAMHSA 2024
  3. 3CONTEXT
    Capture co-ingestants (benzos, alcohol, stimulants), OUD history, MOUD status, injection drug use complications, HIV/HCV status — SAMHSA 2024
    inputs: age, co_ingestants, opioid_use_disorder_history
    advance: Co-ingestion screen and substance use history complete — SAMHSA 2024
  4. 4RED_FLAGS
    Screen for respiratory arrest, apnea, pulselessness, refractory to naloxone (suspect fentanyl analog), aspiration, hypothermia, rhabdomyolysis — AHA 2020
    inputs: respiratory_rate, spo2, gcs
    actions: protocol.acls_cardiac_arrest
    advance: Critical threats addressed: airway secured, naloxone given, ROSC if arrested — AHA 2020
  5. 5INITIAL_WORKUP
    UDS, fentanyl immunoassay, ABG, lactate, BMP, CK, ECG (QTc for methadone/fentanyl analogs), ethanol level, acetaminophen level (co-ingestion screen) — van Lemmen et al, Anesthesiology 2023
    inputs: urine_drug_screen, fentanyl_immunoassay, lactate, abg, ecg, bmp
    actions: panel.abg, panel.renal, panel.cardiac
    advance: Baseline labs and ECG obtained; opioid class and co-ingestants identified — van Lemmen et al, Anesthesiology 2023
  6. 6BRANCHING_WORKUP
    If refractory to naloxone → fentanyl analog workup, extended infusion consideration; if rhabdomyolysis → CK trend, compartment pressure; if aspiration → CXR — van Lemmen et al, Anesthesiology 2023
    inputs: ck, fentanyl_immunoassay
    advance: Branch identified: simple opioid OD vs fentanyl-analog refractory vs mixed OD vs rhabdomyolysis complication — van Lemmen et al, Anesthesiology 2023
  7. 7DIFFERENTIAL
    Rule out benzodiazepine OD alone, clonidine OD, organophosphate poisoning (miosis + bradycardia), pontine hemorrhage (miosis + coma), hypoglycemia — van Lemmen et al, Anesthesiology 2023
    advance: Opioid confirmed as primary toxidrome; co-contributions quantified — van Lemmen et al, Anesthesiology 2023
  8. 8RISK_STRATIFICATION
    Classify severity: mild (responsive to stimulation) vs moderate (hypoventilation) vs severe (apnea/arrest); assess renarcotization risk based on opioid half-life — AHA 2020
    inputs: respiratory_rate, gcs, opioid_type_and_route
    advance: Severity classified and observation duration determined based on opioid half-life — van Lemmen et al, Anesthesiology 2023
  9. 9TREATMENT
    Naloxone titration: start 0.04 mg IV, titrate to RR >12 (NOT full consciousness to avoid precipitated withdrawal); 0.4 mg IM if no IV; 4 mg intranasal prehospital; naloxone infusion for long-acting opioids; buprenorphine MOUD bridge — AHA 2020; FDA 2023
    inputs: respiratory_rate, opioid_type_and_route
    advance: Naloxone titrated to adequate ventilation; observation plan set; MOUD discussed — AHA 2020; SAMHSA 2024
  10. 10DISPOSITION
    Observation minimum 4-6 h post last naloxone (longer for methadone/fentanyl); discharge if stable RR/SpO2/GCS for >1 h after naloxone wears off; admit if recurrent respiratory depression, mixed OD, or complications — van Lemmen et al, Anesthesiology 2023
    advance: Disposition assigned: discharge with naloxone kit vs admit for observation vs ICU — van Lemmen et al, Anesthesiology 2023
  11. 11MONITORING
    Continuous SpO2 + RR monitoring; q15min GCS for first 2 h then q30min; watch for renarcotization (RR drop, re-sedation) especially with long-acting opioids/fentanyl — AHA 2020
    inputs: respiratory_rate, spo2, gcs
    actions: panel.abg
    advance: Observation period complete without renarcotization; stable vitals for >1 h after expected naloxone offset — van Lemmen et al, Anesthesiology 2023
  12. 12FOLLOWUP
    Naloxone rescue kit prescription (FDA 2023 OTC); MOUD referral or buprenorphine ED-initiation (SAMHSA 2024); harm reduction counselling; overdose education for patient and family — SAMHSA 2024
    advance: Naloxone kit dispensed, MOUD plan documented, harm reduction education complete — SAMHSA 2024; FDA 2023