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tox.opioid-overdose.core.v1PRODUCTION
tox.opioid-overdose.core.v1

Acute opioid overdose

toxicologyacuteadult
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0 / 14
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm acute opioid toxidrome; distinguish from other causes of CNS/respiratory depression — AHA 2020

Inputs
4
Actions
0
Advance rule
Set
Advance when

Opioid toxidrome pattern confirmed (respiratory depression + miosis + CNS depression) — AHA 2020

Patient inputs (18)

RR <12 defines opioid-induced respiratory depression; titrate naloxone to RR not consciousness — AHA 2020

SpO2 <92% triggers supplemental O2 and escalation; pulse ox may lag in hypothermia — AHA 2020

GCS quantifies CNS depression depth; GCS <8 = airway-protection threshold — AHA 2020

Miosis (pinpoint pupils) classic for opioid toxidrome; mydriasis suggests co-ingestion or anoxic injury — van Lemmen et al, Anesthesiology 2023

Age influences naloxone dosing caution and MOUD eligibility — SAMHSA 2024

Long-acting opioids (methadone) and fentanyl require extended observation (>4 h) for renarcotization — van Lemmen et al, Anesthesiology 2023

Time of last use guides observation window and renarcotization risk — SAMHSA 2024

Benzodiazepine, alcohol, stimulant co-ingestion changes management and observation — SAMHSA 2024

UDS confirms opioid class exposure; may miss synthetics (fentanyl analogs) — SAMHSA 2024

Fentanyl-specific immunoassay detects fentanyl/norfentanyl missed by standard UDS — van Lemmen et al, Anesthesiology 2023

Lactate elevation reflects tissue hypoperfusion from prolonged respiratory arrest — AHA 2020

ABG reveals respiratory acidosis (CO2 narcosis) and hypoxemia severity — van Lemmen et al, Anesthesiology 2023

ECG screens for QTc prolongation (methadone, fentanyl analogs) and hypoxic cardiac injury — van Lemmen et al, Anesthesiology 2023

BMP screens for rhabdomyolysis (K+, Cr), hypoglycemia, AKI from prolonged immobility — van Lemmen et al, Anesthesiology 2023

Weight-based naloxone dosing in extremes; buprenorphine induction dosing — SAMHSA 2024

Number of prehospital naloxone doses predicts fentanyl analog involvement and refractory course — AHA 2020

OUD history drives MOUD bridge initiation before discharge — SAMHSA 2024

CK >5000 IU/L defines rhabdomyolysis from prolonged immobility/compression — van Lemmen et al, Anesthesiology 2023

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningrespiratory_arrest
    Apnea or RR <6 with opioid toxidrome — AHA 2020 ACLS opioid-associated emergency
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_to_naloxone
    No response to naloxone 10 mg total — consider fentanyl analog, non-opioid etiology, or mixed ingestion — AHA 2020; van Lemmen et al, Anesthesiology 2023
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremixed_ingestion
    Opioid + benzodiazepine or opioid + alcohol co-ingestion with synergistic respiratory depression — SAMHSA 2024
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererhabdomyolysis
    CK >5000 IU/L from prolonged immobility/compression during opioid-induced unconsciousness — van Lemmen et al, Anesthesiology 2023
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecompartment_syndrome
    Tense compartment with pain disproportionate to exam after prolonged limb compression during opioid-induced unconsciousness — van Lemmen et al, Anesthesiology 2023
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererenarcotization
    Recurrent respiratory depression after initial naloxone response; opioid half-life exceeds naloxone duration (30-90 min) — van Lemmen et al, Anesthesiology 2023
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Naloxone dosing ladder for opioid-induced respiratory depression — AHA 2020; FDA 2023
axis: naloxone_rescuestep 1 - IV naloxone low-dose titration — AHA 2020
Selected step "IV naloxone low-dose titration — AHA 2020" — Opioid-induced respiratory depression with RR <12 and IV access available — AHA 2020
  • naloxone
    first line
    opioid_antagonist
    0.04 mg IV • IV • q2-3min titrate to RR >12 (max: 10 mg total (if no response after 10 mg reconsider diagnosis) — AHA 2020)
    triggers: RR_lt_12, opioid_toxidrome_confirmed
    Start low (0.04 mg) to restore ventilation without precipitating severe withdrawal; titrate to respiratory rate NOT consciousness — AHA 2020 ACLS opioid algorithm
    rxcui 7242

ed playbook — drug actions (5)

  1. 1. naloxone_IV_titrated
    rxcui 7242
    0.04 mg IV initial, titrate q2-3min • IV • q2-3min PRN
    trigger: RR <12 or apnea with opioid toxidrome — AHA 2020
    Start low to avoid precipitated withdrawal; goal is RR >12, not full arousal — AHA 2020
  2. 2. naloxone_escalation
    rxcui 7242
    0.4 mg IV • IV • q2-3min
    trigger: No response to 0.04 mg × 2 — AHA 2020
    Escalate 10-fold; most conventional opioid OD responds at this dose — AHA 2020
  3. 3. naloxone_high_dose
    rxcui 7242
    2 mg IV • IV • q2-3min, up to 10 mg total
    trigger: Refractory to 0.8 mg cumulative; suspect fentanyl analog — AHA 2020
    High-dose for fentanyl analogs; if no response after 10 mg, reconsider diagnosis — AHA 2020; van Lemmen et al, Anesthesiology 2023
  4. 4. naloxone_infusion
    rxcui 7242
    2/3 of effective bolus dose per hour • IV continuous • continuous
    trigger: Recurrent respiratory depression or long-acting opioid (methadone, fentanyl patch) — van Lemmen et al, Anesthesiology 2023
    Infusion prevents renarcotization; wean over 1-2 hours when stable — van Lemmen et al, Anesthesiology 2023
  5. 5. buprenorphine_induction
    rxcui 1819
    4 mg SL, may repeat to 16 mg • sublingual • q1-2h on day 1
    trigger: OUD confirmed, COWS >=8, patient willing — SAMHSA 2024
    ED-initiated buprenorphine reduces 30-day opioid use — D'Onofrio JAMA 2015; SAMHSA 2024

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Respiratory depression + miosis + altered mental status — AHA 2020 opioid-associated emergency triad; Witnessed opioid ingestion or injection with obtundation — SAMHSA 2024; Found unresponsive with opioid paraphernalia or known opioid use — AHA 2020.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute opioid overdose** (tox.opioid-overdose.core.v1).
Phenotype framing: Rule out benzodiazepine OD alone, clonidine OD, organophosphate poisoning (miosis + bradycardia), pontine hemorrhage (miosis + coma), hypoglycemia — van Lemmen et al, Anesthesiology 2023
Scope: Confirm acute opioid toxidrome; distinguish from other causes of CNS/respiratory depression — AHA 2020

No severity triggers fired against current inputs.

Plan

Regimen axis: **Naloxone dosing ladder for opioid-induced respiratory depression — AHA 2020; FDA 2023** — step "IV naloxone low-dose titration — AHA 2020".
1. naloxone 0.04 mg IV IV q2-3min titrate to RR >12 (opioid_antagonist, first line) — Start low (0.04 mg) to restore ventilation without precipitating severe withdrawal; titrate to respiratory rate NOT consciousness — AHA 2020 ACLS opioid algorithm

Setting playbook (ed) — Restore ventilation with titrated naloxone, identify opioid type and co-ingestants, observe for renarcotization, initiate MOUD bridge if OUD — AHA 2020; SAMHSA 2024
2. naloxone_IV_titrated 0.04 mg IV initial, titrate q2-3min IV q2-3min PRN — RR <12 or apnea with opioid toxidrome — AHA 2020 (Start low to avoid precipitated withdrawal; goal is RR >12, not full arousal — AHA 2020)
3. naloxone_escalation 0.4 mg IV IV q2-3min — No response to 0.04 mg × 2 — AHA 2020 (Escalate 10-fold; most conventional opioid OD responds at this dose — AHA 2020)
4. naloxone_high_dose 2 mg IV IV q2-3min, up to 10 mg total — Refractory to 0.8 mg cumulative; suspect fentanyl analog — AHA 2020 (High-dose for fentanyl analogs; if no response after 10 mg, reconsider diagnosis — AHA 2020; van Lemmen et al, Anesthesiology 2023)
5. naloxone_infusion 2/3 of effective bolus dose per hour IV continuous continuous — Recurrent respiratory depression or long-acting opioid (methadone, fentanyl patch) — van Lemmen et al, Anesthesiology 2023 (Infusion prevents renarcotization; wean over 1-2 hours when stable — van Lemmen et al, Anesthesiology 2023)
6. buprenorphine_induction 4 mg SL, may repeat to 16 mg sublingual q1-2h on day 1 — OUD confirmed, COWS >=8, patient willing — SAMHSA 2024 (ED-initiated buprenorphine reduces 30-day opioid use — D'Onofrio JAMA 2015; SAMHSA 2024)

Non-pharmacologic actions:
- Bag-valve-mask ventilation before and during naloxone onset if apneic — AHA 2020
- Supplemental O2 to maintain SpO2 >94% — AHA 2020
- Recovery position if unresponsive but breathing adequately — AHA 2020
- Remove transdermal fentanyl patches and decontaminate skin — van Lemmen et al, Anesthesiology 2023
- IV access × 2 large-bore — AHA 2020
- Continuous cardiac + SpO2 monitoring — AHA 2020
- Notify poison center / toxicology consult if atypical presentation — SAMHSA 2024
- Social work / addiction medicine consult for MOUD and harm reduction — SAMHSA 2024
- Naloxone rescue kit prescription at discharge — FDA 2023 OTC

AVOID / contraindication checks:
- Titrate_naloxone_to_RR_not_consciousness_to_avoid_precipitated_withdrawal — AHA 2020
- Precipitated_withdrawal_with_full_2mg_dose_in_opioid_dependent_patients — AHA 2020; SAMHSA 2024
- Naloxone_shorter_half_life_than_most_opioids_risk_of_renarcotization — van Lemmen et al, Anesthesiology 2023

Monitoring

Regimen monitoring:
- continuous SpO2 and RR during naloxone titration — AHA 2020
- q15min GCS first 2h then q30min — AHA 2020
- watch for renarcotization RR drop resedation after naloxone offset 30-90min — van Lemmen et al, Anesthesiology 2023
- monitor for precipitated withdrawal symptoms — SAMHSA 2024
- ECG QTc if methadone or fentanyl analog suspected — van Lemmen et al, Anesthesiology 2023

Setting (ed) monitoring:
- Continuous SpO2 + capnography (if intubated) + cardiac telemetry — AHA 2020
- RR + GCS q15min × 2 h then q30min — AHA 2020
- Renarcotization watch: minimum 4-6 h post last naloxone for short-acting opioids; 12-24 h for methadone — van Lemmen et al, Anesthesiology 2023
- Repeat ABG if persistent respiratory acidosis after naloxone — van Lemmen et al, Anesthesiology 2023

Follow-up plan: 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
- Close-out criterion: Naloxone kit dispensed, MOUD plan documented, harm reduction education complete — SAMHSA 2024; FDA 2023

Monitoring phase: 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

Disposition

Current setting: ed — Restore ventilation with titrated naloxone, identify opioid type and co-ingestants, observe for renarcotization, initiate MOUD bridge if OUD — AHA 2020; SAMHSA 2024

Disposition criteria:
- Discharge home: RR >12 and SpO2 >94% and GCS 15 for >1 h after naloxone offset AND no recurrence AND co-ingestant cleared AND naloxone kit prescribed — van Lemmen et al, Anesthesiology 2023; FDA 2023
- Admit observation: long-acting opioid (methadone/fentanyl patch) requiring extended monitoring OR naloxone infusion required OR mixed OD with benzo — van Lemmen et al, Anesthesiology 2023
- Admit ICU: intubated OR refractory respiratory depression OR cardiac arrest survivor OR aspiration OR rhabdomyolysis with AKI — van Lemmen et al, Anesthesiology 2023; AHA 2020

Escalation triggers (move to higher acuity):
- Respiratory arrest → BVM + naloxone 2 mg IV + prepare for intubation — AHA 2020
- Cardiac arrest → standard ACLS with emphasis on oxygenation/ventilation — AHA 2020
- Refractory to naloxone 10 mg → intubation, ICU, consider non-opioid etiology — AHA 2020; van Lemmen et al, Anesthesiology 2023
- Aspiration pneumonitis (CXR infiltrate + hypoxia post-rescue) → antibiotics + ICU — van Lemmen et al, Anesthesiology 2023
- Rhabdomyolysis CK >5000 + AKI → aggressive IVF + ICU monitoring — van Lemmen et al, Anesthesiology 2023
- Compartment syndrome (tense compartment + pain out of proportion) → emergent surgical consult — van Lemmen et al, Anesthesiology 2023

Patient Action Plan

**Opioid overdose survival action plan — SAMHSA 2024; FDA 2023**
Personalised values: opioid_type, OUD_status, MOUD_plan, housing_status.

**Recovery — stable after overdose reversal — van Lemmen et al, Anesthesiology 2023** (green):
Triggers:
- Breathing normally (RR >12) without naloxone support for >1 h — AHA 2020
- Alert and oriented — AHA 2020
- No recurrent drowsiness — van Lemmen et al, Anesthesiology 2023
Actions:
- Keep naloxone rescue kit (Narcan 4 mg nasal spray) accessible at all times — FDA 2023 OTC
- Teach household members / close contacts naloxone administration — SAMHSA 2024
- Attend MOUD appointment within 72 h of discharge — SAMHSA 2024
- Do not use opioids alone; call 911 if witnessed overdose — SAMHSA 2024
- Understand tolerance loss after abstinence increases overdose risk — SAMHSA 2024
- Consider fentanyl test strips to detect fentanyl contamination — SAMHSA 2024

**Caution — return precautions after opioid OD — van Lemmen et al, Anesthesiology 2023** (yellow):
Triggers:
- Feeling drowsy or "nodding off" after discharge — van Lemmen et al, Anesthesiology 2023
- Slowed breathing noticed by others — AHA 2020
- Confusion or difficulty staying awake — AHA 2020
- Nausea/vomiting (aspiration risk) — van Lemmen et al, Anesthesiology 2023
Actions:
- Have someone administer naloxone nasal spray immediately — FDA 2023
- Call 911 — do not drive yourself — AHA 2020
- Lie in recovery position (on side) to protect airway — AHA 2020

**Crisis — unresponsive or not breathing — AHA 2020** (red):
Triggers:
- Not breathing or gasping — AHA 2020
- Unresponsive to voice or sternal rub — AHA 2020
- Blue/gray lips or fingertips (cyanosis) — AHA 2020
Actions:
- Bystander: give naloxone 4 mg intranasal spray NOW — FDA 2023
- Call 911 immediately — AHA 2020
- Start rescue breathing or CPR if no pulse — AHA 2020
- Repeat naloxone in 2-3 min if no response — AHA 2020
- Stay until EMS arrives — Good Samaritan laws protect in most states — SAMHSA 2024

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Apnea or RR <6 with opioid toxidrome — AHA 2020 ACLS opioid-associated emergency
- [LIFE_THREATENING] No response to naloxone 10 mg total — consider fentanyl analog, non-opioid etiology, or mixed ingestion — AHA 2020; van Lemmen et al, Anesthesiology 2023
- [SEVERE] Opioid + benzodiazepine or opioid + alcohol co-ingestion with synergistic respiratory depression — SAMHSA 2024

Citations

- AHA 2020 Part 3 Adult BLS/ALS — opioid-associated emergency algorithm (Circulation) + AHA 2021 opioid-associated out-of-hospital cardiac arrest scientific statement + van Lemmen et al, Anesthesiology 2023 opioid overdose / naloxone review + SAMHSA 2024 overdose prevention toolkit + FDA 2023 OTC naloxone [PMID:33081529](https://pubmed.ncbi.nlm.nih.gov/33081529/)
- Cited evidence (PMID 33682423) [PMID:33682423](https://pubmed.ncbi.nlm.nih.gov/33682423/)
- Cited evidence (PMID 37402248) [PMID:37402248](https://pubmed.ncbi.nlm.nih.gov/37402248/)
- Cited evidence (PMID 40133970) [PMID:40133970](https://pubmed.ncbi.nlm.nih.gov/40133970/)

Last reconciled with current guidelines: 2026-05-30.
References
  • AHA 2020 Part 3 Adult BLS/ALS — opioid-associated emergency algorithm (Circulation) + AHA 2021 opioid-associated out-of-hospital cardiac arrest scientific statement + van Lemmen et al, Anesthesiology 2023 opioid overdose / naloxone review + SAMHSA 2024 overdose prevention toolkit + FDA 2023 OTC naloxone — PMID:33081529
  • Cited evidence (PMID 33682423) — PMID:33682423
  • Cited evidence (PMID 37402248) — PMID:37402248
  • Cited evidence (PMID 40133970) — PMID:40133970