Overdose – Opiate poisoning accidental

A 80 year old patient with a background of severe osteoarthritis, osteoporosis and HFREF has been admitted after a fall and a suspected right neck of femur fracture. The patient was admitted to a medical outlier ward waiting for a MRI of his hip and you are called to see the patient as the patient is less responsive now. Over the last 3 hours he had been complaining of severe right hip pain.

Answer –
I would start by getting a focused history if the patient is able to give a brief history or review the notes and speak to the nurse looking after the patient to get a handover. Given that he is less responsive, I would review his past medical history and medication list to see if there are any medications that could have led to him being less responsive. After this I would go on to do a focussed assessment using A to E approach

Airway – I would ensure the airway is patent and if necessary insert an airway adjunct such as OP or NP airway. If the patient is tolerating an airway adjunct I would be really worried and seek the help of the critical care team after my assessment

Breathing – I would look at the observations specifically the oxygen saturation and the respiratory rate. If the patient is hypoxic or if the patient has an increased work of breathing I’ll start the patient on supplemental oxygen therapy. I would also get a PEFR and an ABG done for this patient to see what the ph, Po2 , pco2 and hcO3 and lactate. I would be very concerned if the pCO2 rising. I would also arrange a portable CXR for the patient

Circulation – I would look at the observations specifically the BP, heart rate and CRT. If there is evidence of hypotension or tachycardia I would give a fluid challenge to the patient to see if there is an adequate response. And if the patient remains hypotension despite the first fluid challenge I will give another fluid challenge and ensure the critical care team is aware of the patient . I would also ensure the patient has a working cannula and send basic bloods including septic screening. I would also request an ECG for the patient.

Disability – I would check the patients blood glucose, temperature and do a focused neurological assessment that includes GCS. Specifically if the GCS is less than 8 or if there is a focal neurological deficits I would be concerned and investigate this further.

Questions – You notice that the patient is naïve to opiates and has been prescribed oral morphine of which he has taken 60 mg of oral morphine in the last 4 hours. His chest exam is unremarkable but his respiratory rate is 8/minute and his GCS is E3V3M5 at best with pin point pupils that are reactive to light. The ABG that you requested is as follows PH 7.2, PO2 8.0 on 5L/min, PCO2 10.0, HCO3 24, Lactate 3.0.

Answer – based on the available information his symptoms and signs are in keeping with possible opiate toxicity and the ABG shows evidence of opiate overdose. I would give the patient a trial of naloxone IV or IM, the dose would be 400 mcg IV. If there is no response that is if there is no response in terms of respiratory rate I would given another bolus of 800 mcg IV and repeat it if needed.

I would request a senior review and if the patient continues to deteriorate I would escalate to the critical care team if there is a worry that the patient is not responding or if the airway is compromised. I would also ensure that the patients family is updated regarding this clinical deterioration. Once he starts responding, I would start the patient on naloxone infusion as per the trust protocol and ensure that alternative non-opiate pain medications are prescribed for the patient. To ensure that this doesn’t happen again I would ensure the ward team is fed back regarding the opiate toxicity and do an incident report form.