Case Study
The bedside nurse initiated a rapid response event for a patient because of acute onset of unresponsiveness. The registered nurse (RN) was doing his morning medication rounds and found the patient unresponsive. The patient was also taking infrequent shallow breaths. On arrival of the rapid response team, the bedside RN informed that the patient is a 23-year-old male with a history of heroin abuse and anxiety, admitted two days ago for suspected infective endocarditis. He was started on antibiotics via a peripherally inserted central catheter (PICC) line for tricuspid endocarditis. The only other medication he was receiving was sertraline. While performing a fingerstick glucose check, the nursing staff found a needle and syringe by the patient’s side. Additionally, two small plastic bags with a white powder residue were found on the floor.
Vital Signs
Temperature: 98.9 °F, axillary.
Blood Pressure: 118/60 mmHg
Heart Rate: 74 beats per min – normal sinus rhythm on telemetry
Respiratory Rate: 6 breaths per min
Pulse Oximetry: 84% on room air
Physical Examination
A quick exam revealed a young adult male with a Glasgow Coma Scale (GCS) score of ten (E3 V3 M4) with pinpoint pupils. He was initially noted to have cyanosis of his lips and agonal breathing. His heart rate was regular without an appreciable murmur. His extremities were warm with good distal pulses.
Interventions
Initially, the cause for the patient’s respiratory depression was unknown, so a bag-valve mask with high flow supplemental oxygen was placed on the patient for ventilatory support. While the nursing staff was obtaining a fingerstick glucose level, drug paraphernalia was found. The patient was immediately given 0.5 mg of IV naloxone. His GCS and respiratory rate improved slightly. He ultimately received a total of 1.0 mg of naloxone. His GCS improved to 15, and he maintained oxygen saturations above 97% on room air with a normal respiratory rate. The patient admitted to using heroin via his PICC line. An EKG was performed and demonstrated normal sinus rhythm with normal intervals. Due to the patient’s rapid return to baseline after naloxone administration and the patient admitting to heroin use, it was suspected that this was an accidental opioid overdose. The patient remained on the floor with a 1:1 sitter.
Final Diagnosis
Heroin overdose.
Opioid Overdose
Heroin is a derivative of the opioid morphine and shares a similar drug profile to opioid-based pain medications. According to the Centers for Disease Control and Prevention data, with the initial opioid epidemic and subsequent tightening of prescribing opioid pain medications, heroin use has dramatically increased over the last several years. Heroin tends to be more readily available and cheaper than prescription opioid drugs. Heroin can be snorted, smoked, or injected subcutaneously, intramuscularly, or intravenously. Purified heroin is typically a white or brownish powder that is often mixed with other substances, such as baking soda, powdered milk, fentanyl, to dilute the heroin, so more is available to sell. Black tar heroin is an impure form of heroin and typically has a sticky, hard consistency.
Since heroin and narcotic pain medications share similar biochemical characteristics, the signs and symptoms of overdose, along with their mechanism of action, are practically identical. Both heroin and narcotic pain medications act on opioid receptors found in the central and peripheral nervous systems. Depending on the administration route, the amount of drug used and length of abuse history can both play a role in the clinical manifestations of overdose. The telltale sign of heroin or opioid overdose is respiratory depression in the setting of other vital signs being relatively normal. Another clue on physical exam of acute opioid overdose is pinpoint pupils (miosis).
Naloxone (Narcan) is the antidote for acute opioid or heroin overdose. Naloxone works by competing and displacing opioids at their specific opioid receptors in the central and peripheral nervous systems. The most common routes of administration are intravenous and intranasal. Typically, multiple doses of naloxone are needed in an acute overdose setting because the duration of action for naloxone is shorter than the duration of action for opioids. Initial dosing, frequency of administration, and maximum dosing will be discussed later in the “Therapeutic Interventions” section. If too much naloxone is used quickly, it can precipitate symptoms of acute withdrawal; therefore, it is essential to remember that naloxone therapy aims to restore the respiratory status and not mental status.
Suggested Approach to a Patient With an Opioid Overdose in a Rapid Response Event
For a patient with a suspected opioid overdose, we suggest the following approach to evaluate and treat the acute event. The ultimate management decisions are based on the treating clinician’s discretion and institutional guidelines. See Fig. 38.1 for a flowchart of management of such patients. The usual sequence of history taking, physical exam, investigations, and resuscitative interventions is often not followed during a rapid response; these measures often run parallel to each other in a code situation. The following components of the rapid response are discussed in the traditional sequence only to ease understanding.
