EMT · Patient Treatment and Transport · 7 min read
Opioid Overdose, Poisoning and Behavioral Emergencies
- Prioritize immediate airway management and ventilation over medication administration in suspected acute opioid overdose.
- Differentiate clinical presentations and emergency basic life support interventions across the four routes of toxic exposure.
- Apply safe scene practices, verbal de-escalation, and protocol-based restraint standards during behavioral emergencies.
Opioid Overdose and Respiratory Management
Opioids cause central nervous system depression, leading directly to a decreased respiratory rate and depth. An acute opioid overdose may cause the classic triad of unresponsiveness, respiratory depression, and pinpoint pupils (miosis), but not every patient has all three findings. The primary life threat in an acute opioid overdose is respiratory arrest leading to fatal hypoxia. When cellular oxygen levels drop, cardiac arrest quickly follows if basic life support care is not rapidly initiated.
Because fatal hypoxia is the central life threat, opening the airway and supporting ventilation with a bag-valve mask takes immediate priority over administering naloxone. Naloxone is an opioid receptor antagonist that rapidly reverses opioid-induced respiratory depression. Under local protocol and medical direction, EMTs may administer naloxone for suspected opioid overdose with inadequate breathing or apnea while supporting the airway and ventilation. Depending on local authorization and available equipment, EMTs may administer naloxone intranasally or with an intramuscular auto-injector.
The therapeutic goal of naloxone administration is restoring adequate spontaneous ventilation, not full patient consciousness. Overly aggressive treatment brings significant clinical hazards. Rapid administration of naloxone can precipitate acute opioid withdrawal, resulting in agitation, nausea, vomiting, and tachycardia. EMTs must have suction available when caring for a patient with suspected opioid overdose because vomiting can occur, particularly after naloxone administration. Furthermore, synthetic opioids like fentanyl may require higher or repeated doses of naloxone to reverse severe respiratory depression.
EMTs must maintain constant vigilance throughout transport because naloxone often has a shorter half-life than the opioid, creating a risk that the patient may relapse into respiratory arrest. For instance, an individual who begins breathing adequately following naloxone administration may slip back into apnea minutes later as the medication wears off while the opioid remains active in the body. The EMT must continuously reassess the patient and remain prepared to resume bag-valve mask ventilations at any time.
Common mistakes
- Administering naloxone before opening the airway and providing bag-valve mask ventilations in an apneic opioid overdose patient.
- Giving activated charcoal to a patient who has an altered mental status, a compromised airway, or who ingested corrosive acids, strong alkalis, or petroleum hydrocarbons.
- Transporting a physically restrained patient in the prone position, which severely restricts ventilation and creates a lethal risk of positional asphyxia.
- Relying on a normal pulse oximetry reading in suspected carbon monoxide poisoning, as the device cannot distinguish carboxyhemoglobin from oxyhemoglobin.
Key points
- Acute opioid overdoses can cause unresponsiveness, respiratory depression, and pinpoint pupils (miosis), but the full classic triad is not always present.
- Airway management and bag-valve mask ventilation take immediate priority over naloxone administration, which aims to restore adequate spontaneous breathing rather than full consciousness.
- Activated charcoal binds ingested toxins to reduce absorption, but it is strictly contraindicated in patients with an altered mental status, compromised airways, or ingestions of corrosives and petroleum hydrocarbons.
- Carbon monoxide can cause falsely normal standard pulse oximetry readings; provide high-concentration oxygen by nonrebreather mask when breathing is adequate, or assist inadequate breathing with a bag-valve mask.
- Dry chemical exposures require brushing powder off the skin before flushing, liquid exposures require at least 15 to 20 minutes of water irrigation, and chemical neutralization is completely contraindicated.
- Behavioral emergencies require identifying underlying medical causes such as hypoxia or hypoglycemia, practicing verbal de-escalation, and maintaining an unblocked path of exit.
- Physical restraints are a last resort that must never place a patient in the prone position, requiring frequent documentation of distal pulses, motor function, and sensation in all restrained limbs.
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