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

Published online by Cambridge University Press:  21 May 2015

Jeremy Etherington ,
James Christenson ,
Grant Innes ,
Eric Grafstein ,
Sarah Pennington ,
John J. Spinelli ,
Min Gao ,
Brian Lahiffe ,
Karen Wanger  and
Christopher Fernandes
Jeremy Etherington*
Affiliation:
Department of Emergency Medicine, St. Paul’s Hospital, Vancouver, BC, and the Centre for Health Evaluation and Outcome Sciences, University of British Columbia, Vancouver
James Christenson
Affiliation:
Department of Emergency Medicine, St. Paul’s Hospital, Vancouver, BC, and the Centre for Health Evaluation and Outcome Sciences, University of British Columbia, Vancouver
Grant Innes
Affiliation:
Department of Emergency Medicine, St. Paul’s Hospital, Vancouver, BC, and the Centre for Health Evaluation and Outcome Sciences, University of British Columbia, Vancouver
Eric Grafstein
Affiliation:
Department of Emergency Medicine, St. Paul’s Hospital, Vancouver, BC, and the Centre for Health Evaluation and Outcome Sciences, University of British Columbia, Vancouver
Sarah Pennington
Affiliation:
Department of Emergency Medicine, St. Paul’s Hospital, Vancouver, BC, and the Centre for Health Evaluation and Outcome Sciences, University of British Columbia, Vancouver
John J. Spinelli
Affiliation:
Department of Emergency Medicine, St. Paul’s Hospital, Vancouver, BC, and the Centre for Health Evaluation and Outcome Sciences, University of British Columbia, Vancouver
Min Gao
Affiliation:
Department of Emergency Medicine, St. Paul’s Hospital, Vancouver, BC, and the Centre for Health Evaluation and Outcome Sciences, University of British Columbia, Vancouver
Brian Lahiffe
Affiliation:
Department of Emergency Medicine, St. Paul’s Hospital, Vancouver, BC, and the Centre for Health Evaluation and Outcome Sciences, University of British Columbia, Vancouver
Karen Wanger
Affiliation:
Department of Emergency Medicine, St. Paul’s Hospital, Vancouver, BC, and the Centre for Health Evaluation and Outcome Sciences, University of British Columbia, Vancouver
Christopher Fernandes
Affiliation:
Department of Emergency Medicine, St. Paul’s Hospital, Vancouver, BC, and the Centre for Health Evaluation and Outcome Sciences, University of British Columbia, Vancouver
*
Department of Emergency Medicine, St. Paul’s Hospital, 1081 Burrard St., Vancouver BC V6Z 1Y6; 604 682-2344 x65480; [email protected]

Abstract

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Introduction:

Patients with suspected opioid overdose frequently require naloxone treatment. Despite recommendations to observe such patients for 4 to 24 hours after naloxone, earlier discharge is becoming more common. This prospective, observational study of patients with presumed opioid overdose examines the safety of early disposition decisions and the accuracy of outcome prediction by physicians 1 hour after the administration of naloxone.

Methods:

The study was carried out at St. Paul’s Hospital, an inner city teaching centre that cares for most of the injection drug users in Vancouver, BC. Patients were formally assessed 1 hour after receiving naloxone for presumed opioid overdose. Demographics, medical history and physical examination were documented on specific data forms, and physicians recorded their comfort with early discharge. Patients were followed up, and those who required a critical intervention or suffered a pre-defined adverse event (AE) within 24 hours of their 1-hour assessment were identified.

Results:

Of 573 patients, 48% were discharged in less than 2 hours, 23% in 2–4 hours and 29% in >4 hours. 94 patients who were held in the emergency department (ED) or admitted required a critical intervention, including supplemental oxygen for hypoxia (74), repeat naloxone (52), antibiotics administered intravenously (IV) (14), assisted ventilations (13), fluid bolus for hypotension (12), charcoal for associated life-threatening overdose (6), IV inotropic agents (2), antiarrhythmics for sustained tachycardia >130 beats/min (1), and administration of bicarbonate for arterial [HCO3] <5 or venous CO2 <5 (1). Physicians predicted adverse events with 94% sensitivity and 59% specificity. No discharged patients suffered a serious AE within 24 hours of ED discharge.

Conclusions:

Emergency physicians can clinically identify patients at risk of deterioration after naloxone reversal of suspected opioid overdose. Prolonged observation or hospital admission is not usually required. Selective early discharge of patients with presumed opioid overdose is feasible and appears safe. A clinical prediction rule may be useful in identifying patients eligible for early discharge.

Keywords

naloxoneheroinopioid overdoseoutcome
Type
EM Advances • Progrès De La MU
Information
Canadian Journal of Emergency Medicine , Volume 2 , Issue 3 , July 2000 , pp. 156 - 162
Copyright
Copyright © Canadian Association of Emergency Physicians 2000

References

1.Watson, WA, Steele, MT, Muelleman, RL, Rush, MD. Opioid toxicity recurrence after an initial response to naloxone. J Toxicol Clin Toxicol 1998;36:11–7.CrossRefGoogle ScholarPubMed
2.Allen, T. Narcotics. In: Rosen, P, Barkin, R, editors. Emergency medicine: concepts and clinical practice. St. Louis: Mosby–Year Book Inc; 1998. p. 2603–16.Google Scholar
3.Howland, MA. Antidotes in depth. In: Goldfrank, L, Flomenbaum, N, Lewin, N, Weisman, R, Howland, M, Hoffman, R, editors. Goldfrank’s toxicologic emergencies. Stamford: Appleton and Lange; 1998. p. 998–1009.Google Scholar
4.Opioids. In: Ellenhorn, MJ, et al, editors. Ellenhorn’s medical toxicology: diagnosis and treatment of human poisoning. 2nd ed. Baltimore: Williams and Wilkins; 1997. p. 430–46.Google Scholar
5.Wasson, J, Sox, H, Neff, R, Goldman, L.Clinical prediction rules: applications and methodological standards. N Engl J Med 1985; 313:793–9.CrossRefGoogle ScholarPubMed
6.Laupacis, A, Sekar, N, Stiell, I.Clinical prediction rules: a review and suggested modifications of methodological standards. JAMA 1997;277:488–94.CrossRefGoogle ScholarPubMed
7.Smith, D, Leake, L, Loflin, J, Yealy, D.Is admission after heroin overdose really necessary? Ann Emerg Med 1992;21:1326–30.CrossRefGoogle ScholarPubMed
8.Schwartz, M.Opiates and narcotics. In: Haddad, LM, Shannon, MW, Winchester, JF, editors. Clinical management of poisoning and drug overdose. 3rd ed. Philadelphia: WB Saunders; 1998. p. 505–22.Google Scholar
9.Acute, Sporer K.Acute heroin overdose. Ann Intern Med 1999; 130:584–90.Google Scholar
10.Reisine, T, Pasternak, G.Opioid analgesics and antagonists. In: Hardman, JG, Limbird, LE, Molinoff, PB, Ruddon, RW, Gilman, A, editors. Goodman & Gilman’s the pharmacological basis of therapeutics. 9th ed. New York: McGraw–Hill; 1996. p. 521–55.Google Scholar
11.Wanger, K, Brough, L, Macmillan, I, Goulding, J, MacPhail, I, Christenson, J.Intravenous vs subcutaneous naloxone for out-of-hospital management of presumed opioid overdose. Acad Emerg Med 1998;5:293–9.CrossRefGoogle Scholar
12.Doyon, S. Opioids. In: Tintanelli, J, Kelen, G, Stapczynski, JS, editors. Emergency medicine: a comprehensive study guide. 5th ed. New York: McGraw Hill; 2000. p. 1109–12.Google Scholar
13.Goldfrank, L, Weisman, R, Keith, J, Errick, JK, Lo, MW. A dosing nomogram for continuous infusion intravenous naloxone. Ann Emerg Med 1986;15:566–70.CrossRefGoogle ScholarPubMed
14.Dauberstein, JL, Kaufman, DM. A clinical study of an epidemic of heroin intoxication and heroin induced pulmonary edema. Am J Med 1971;51:704–14.CrossRefGoogle Scholar
15.Osterwalder, J.Patients intoxicated with heroin or heroin mixtures: How long should they be monitored? European J Emerg Med 1995;2:97–101.CrossRefGoogle ScholarPubMed
16.Larpin, R, Vincent, A, Perret, C.Hospital morbidity and mortality of acute opiate intoxication. Presse Medicale 1990;19:1403–6.Google ScholarPubMed
17.Sporer, K, Firestone, J, Isaacs, S.Out-of-hospital treatment of opioid overdoses in an urban setting. Acad Emerg Med 1996;3:660–7.CrossRefGoogle Scholar