Question 11 – Methadone overdose A 24 year old man is brought to the ED, in a car, by his friends following a suspected overdose of methadone. He has a GCS of 7 and pinpoint pupils.

a) Outline your three (3) immediate management priorities for this patient (3 marks) Pass criteria: Support airway and breathing, administer oxygen via BVM. Administer naloxone 100mcg IV in increments until adequate spontaneous respiration established Check BSL & treat hypoglycaemia i.e. the basic life-saving measures expected of any ED doctor! Other acceptable answers: 400mcg naloxone IM Transfer to resus/full monitoring etc Support of ventilation/oxygenation should be the priority. “You die from not breathing, not from lack of naloxone” ”Apply oxygen via face mask” is not enough if hypoventilating You are told he arrives by car, so must assume no BLS has been provided yet. Dose of naloxone important – demonstrates consultant level knowledge. If administer > 1mg IV naloxone as a bolus, risk of precipitating opioid withdrawal in assumed opioid dependent patient. Better answers provided an end-point to naloxone treatment ie adequate respiration.

a) Outline your three (3) immediate management priorities for this patient (3 marks) Did not accept: “Exclude other causes of reduced e.g. trauma” – too vague/general. You’re told he ingested methadone. “200 - 400mcg IV” – Does that mean you might give 400mcg IV first up? – that’s a big dose!

He responds appropriately to your initial treatment, but twenty minutes later his observations are: GCS 12 RR 8/min HR 100 bpm BP 140/70 mmHg O2 Sat 94% on room air   b) Outline your next four steps in his management. (4 marks) 1. Administer naloxone 50 - 100mcg IV in increments until adequate spontaneous respiration established – RR > 8-10, rousable but not fully reversed. 2. Commence naloxone infusion at 2/3 initial dose required, per hour 3. Check for and correct hypoglycaemia with 50mL 50% glucose IV 4. Seek and treat any co-ingestants Other acceptable answers: - Monitor conscious state and adequacy of ventilation and adjust naloxone infusion as necessary - Admit to HDU, consult Toxicology or Addiction Med Unit  

b) Outline your next four steps in his management. (4 marks) Did not accept: CTB – unless you qualified with: “if doesn’t respond appropriately to initial treament”. I don’t think he needs a CTB if he wakes. Big doses of naloxone Intubation – unless good description of naloxone administration (bolus & infusion) with endpoints given. E.g. Intubate if unable to achieve adequate ventilation/oxygenation despite adequate naloxone.

c) List five (5) clinical features of opioid withdrawal (5 Marks) Anxiety 
 Restlessness 
 Abdo cramps Insomnia 
 Intense craving 
 Many other acceptable options: Yawning 
 Lacrimation 
 Salivation 
 Diarrhoea 
 N&V Mydriasis 
 Diaphoresis 
 Piloerection Myalgia HT Tachycardia Tremor

Revise the naloxone chapter! Good luck!