Is early discharge safe after naloxone reversal of presumed opioid overdose?

Acute opioid overdose in pediatric patients

Recent increases in pediatric and adolescent opioid fatalities mandate an urgent need for early consideration of possible opioid exposure and specific diagnostic and management strategies and interventions tailored to these unique populations. In contrast to adults, pediatric methods of exposure include accidental ingestions, prescription misuse, and household exposure. Early recognition, appropriate diagnostic evaluation, along with specialized treatment for opioid toxicity in this demographic are discussed. A key focus is on Naloxone, an essential medication for opioid intoxication, addressing its unique challenges in pediatric use. Unique pediatric considerations include recognition of accidental ingestions in our youngest population, critical social aspects including home safety and intentional exposure, and harm reduction strategies, mainly through Naloxone distribution and education on safe medication practices. It calls for a multifaceted approach, including creating pediatric-specific guidelines, to combat the opioid crisis among children and to work to lower morbidity and mortality from opioid overdoses.

2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.

Outcomes associated with hospital admissions for accidental opioid overdose in British Columbia: a retrospective cohort study

OBJECTIVES

To study the association between accidental opioid overdose and neurological, respiratory, cardiac and other serious adverse events and whether risk of these adverse events was elevated during hospital readmissions compared with initial admissions.

DESIGN

Retrospective cohort study.

SETTING

Population-based study using linked administrative data in British Columbia, Canada.

PARTICIPANTS

The primary analysis included 2433 patients with 2554 admissions for accidental opioid overdose between 2006 and 2015, including 121 readmissions within 1 year of initial admission. The secondary analysis included 538 patients discharged following a total of 552 accidental opioid overdose hospitalizations and 11 040 matched controls from a cohort of patients with ≥180 days of prescription opioid use.

OUTCOME MEASURES

The primary outcome was encephalopathy; secondary outcomes were adult respiratory distress syndrome, respiratory failure, pulmonary haemorrhage, aspiration pneumonia, cardiac arrest, ventricular arrhythmia, heart failure, rhabdomyolysis, paraplegia or tetraplegia, acute renal failure, death, a composite outcome of encephalopathy or any secondary outcome and total serious adverse events (all-cause hospitalisation or death). We analysed these outcomes using generalised linear models with a logistic link function.

RESULTS

3% of accidental opioid overdose admissions included encephalopathy and 25% included one or more adverse events (composite outcome). We found no evidence of increased risk of encephalopathy (OR 0.57; 95% CI 0.13 to 2.49) or other outcomes during readmissions versus initial admissions. In the secondary analysis, <5 patients in each cohort experienced encephalopathy. Risk of the composite outcome (OR 2.15; 95% CI 1.48 to 3.12) and all-cause mortality (OR 2.13; 95% CI 1.18 to 3.86) were higher for patients in the year following overdose relative to controls.

CONCLUSIONS

We found no evidence that risk of encephalopathy or other adverse events was higher in readmissions compared with initial admissions for accidental opioid overdose. Risk of serious morbidity and mortality may be elevated in the year following an accidental opioid overdose.

Naloxone Administration in US Emergency Departments, 2000-2011

Rates of opioid overdose and opioid-related emergency department (ED) visits have increased dramatically. Naloxone is an effective antidote to potentially fatal opioid overdose, but little is known about naloxone administration in ED settings. We examined trends and correlates of naloxone administration in ED visits nationally from 2000 to 2011. Using data from the National Hospital Ambulatory Medical Care Survey, we examined ED visits involving (1) the administration of naloxone or (2) a diagnosis of opioid overdose, abuse, or dependence. We assessed patient characteristics in these visits, including concomitant administration of prescription opioid medications. We used logistic regression to identify correlates of naloxone administration. From 2000 to 2011, naloxone was administered in an estimated 1.7 million adult ED visits nationally; 19 % of these visits recorded a diagnosis of opioid overdose, abuse, or dependence. An estimated 2.9 million adult ED visits were related to opioid overdose, abuse, or dependence; 11 % of these visits involved naloxone administration. In multivariable logistic regression models, patient age, race, and insurance and non-rural facility location were independently associated with naloxone administration. An opioid medication was provided in 14 % of visits involving naloxone administration. Naloxone was administered in a minority of ED visits related to opioid overdose, abuse, or dependence. Among all ED visits involving naloxone administration, prescription opioids were also provided in one in seven visits. Further work should explore the provider decision-making in the management of opioid overdose in ED settings and examine patient outcomes following these visits.

Emergency patients receiving anaesthesiologist-based pre-hospital treatment and subsequently released at the scene

BACKGROUND

The Mobile Emergency Care Unit in Odense, Denmark consists of a rapid response car, manned with an anaesthesiologist and an emergency medical technician. Eleven per cent of the patients are released at the scene following treatment. The aim of the study was to investigate which diagnoses were assigned to patients released at the scene following treatment, to investigate the need for secondary contact with the hospital and to assess mortality in patients released at the scene.

METHODS

All records regarding patients released at the scene from 1 January 2008 to 31 December 2010 were investigated. In each patient, diagnosis as well as any renewed contact with the Mobile Emergency Care Unit or the hospital within 24 h was registered.

RESULTS

One thousand six hundred nine: patients were released at the scene. Diagnoses within the category 'examination and investigation' [International Classification of Diseases 10th revision (ICD-10) chapter XXI] represented the largest group of patients (28%). Diseases not elsewhere classified (ICD-10 chapter XVIII) including 'syncope and collapse' represented the second largest group of patients (24%). One hundred thirteen (7%) had a renewed contact with the Mobile Emergency Care Unit within 24 h. Of the 143 victims of traffic accidents, 19 (13%) required renewed contact with the emergency department and one required admission to hospital (0.7%). Of all 1609 patients, four died within 24 h of contact (0.2%).

CONCLUSION

Patients treated and released at the scene presented poorly defined conditions. Ninety-three per cent of all cases required no secondary contacts with the health care system. However, caution should be exercised when releasing patients at the scene following traffic accidents.

Prehospital treatment of opioid overdose in Copenhagen--is it safe to discharge on-scene?

INTRODUCTION

In the prehospital setting opioid overdose is often treated with naloxone. In our physician-based medical emergency care unit (MECU) we have adopted a discharge-on-scene policy, where patients are released on scene if no residual signs of opioid intoxication are found after treatment. The aim of this study was to describe our experience with the discharge-on-scene policy used during a 10-year-period with focus on the frequency of rebound opioid toxicity.

METHODS

Data were prospectively recorded in our MECU database and we reviewed all cases of opioid overdose between 1994 and 2003. The MECU database was cross-referenced with the Central Personal Registry. For patients who died within 48 h of MECU contact we reviewed the forensic autopsy reports to establish whether rebound opioid toxicity was likely.

RESULTS

We found 4762 cases of acute opioid overdose. In 3245 cases positive identification was obtained. Over this ten year period fourteen patients who were released on-scene after having been treated with naloxone died within 48 h, but only in 3 of these we found a rebound opioid toxicity to be the likely cause of death, corresponding to 0.13% of those 2241 released on scene who were identified.

CONCLUSION

Prehospital discharge-on-scene after naloxone treatment is associated with a low risk of death due to rebound toxicity.

Drugs of abuse: management of intoxication and antidotes

Illicit drug intoxications are an increasing public health problem for which, in most cases, no antidotes are clinically available. The diagnosis and treatment of these intoxications requires a trained clinician with experience in recognizing the specific signs and symptoms of intoxications to individual drugs as well as polydrug intoxications, which are more the rule than the exception. To make the diagnosis, the clinical observation and a urine toxicology test are often enough. Evaluating the blood levels of drugs is frequently not practical because the tests can be expensive and results may be delayed and unavailable to guide the establishment of a treatment plan. Other laboratory tests may be useful depending on the drug or drugs ingested and the presence of other medical complications. The treatment should be provided in a quiet, safe and reassuring environment. Vital signs should be closely monitored. Changes in blood pressure, respiratory frequency and temperature should be promptly treated, particularly respiratory depression (in cases of opiate intoxication) or hyperthermia (in cases of cocaine or amphetamine intoxication). Intravenous fluids should be administered as soon as possible. Other psychiatric and medical complication should receive appropriate symptomatic treatment. Research on immunotherapies, including vaccines, monoclonal and catalytic antibodies, seems to be a promising approach that may yield specific antidotes for drugs of abuse, helping to ameliorate the morbidity and mortality associated with illicit drug intoxications.