overdose

[rohit76]

Is there an indication for tubing each and every overdose patients ( BDZ and opiates mostly) even if sats and ABGs are ok because of risk of aspiration?

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[southerndoc]

Is there an indication for tubing each and every overdose patients ( BDZ and opiates mostly) even if sats and ABGs are ok because of risk of aspiration?

If their GCS is low enough (8 or less), then yes.

Generally I reverse opioid overdoses, but benzo overdoses I will tube and allow them to wake up on their own. Flumazenil is a dangerous drug for overdose reversal in benzo overdoses IMHO.

 

[rohit76]

I used to think that GCS rule is for trauma patients (GCS < 8 intubate). Also, did u noticed that narcan can cause agitation if co existing cocaine use is present.

 

[Stitch]

If their GCS is low enough (8 or less), then yes.
Flumazenil is a dangerous drug for overdose reversal in benzo overdoses IMHO.

Couldn't agree more. Most toxicologists I've talked to say 'don't use it.'

 

[BADMD]

Is there an indication for tubing each and every overdose patients ( BDZ and opiates mostly) even if sats and ABGs are ok because of risk of aspiration?

Intubation needs to be a clinical decision based upon the patient's presentation and not what they have done. A call, sedate patient, who is not vomiting, breathing well and has a good gag, may not need to be intubated. Toss some vomit in there and the airway needs protection.

Alcohol intoxication is simply an overdose of a fermented sedative hypnotic. Would you intubate the same patient if you knew they were just drunk instead of benzo intoxicated? How about the other way around?

 

[southerndoc]

Alcohol intoxication is simply an overdose of a fermented sedative hypnotic. Would you intubate the same patient if you knew they were just drunk instead of benzo intoxicated? How about the other way around?

Yes, I do. If the alcohol intoxication cannot protect his airway, then he gets intubated until he awakens enough to protect his airway.

I've intubated alcoholic patients only to extubate them 5 hours later.

Having seen one alcoholic die from aspiration, I would rather intubate a 19 year old drunk kid than allow him to aspirate and die.

 

[kungfufishing]

totally agree about the alcohol and practice that way. have intubated 2 superintoxicated and starting to vomit patients in the past year.

 

[Arcan57]

Relying on sats and ABGs as your guideline to intubate usually puts you behind the eightball. GHB, benzos, ETOH, and significant TCA overdoses all have the potential to benefit from a controlled airway even in the abscence of desats/hypercarbia. It will be the rare time that you will be faulted for controlling the airway in an obtunded or progressively declining patient. If an opioid overdose if requiring large and frequent boluses of Narcan to stay breathing, I think about tubing them secondary to the usually wicked pulmonary edema that follows.

 

[dchristismi]

Also, did u noticed that narcan can cause agitation if co existing cocaine use is present.

Narcan causes agitation if only opiates are on board, too.

 

[BADMD]

Yes, I do. If the alcohol intoxication cannot protect his airway, then he gets intubated until he awakens enough to protect his airway.

I've intubated alcoholic patients only to extubate them 5 hours later.

Having seen one alcoholic die from aspiration, I would rather intubate a 19 year old drunk kid than allow him to aspirate and die.

Which is really my point. It is the presentation that matters.

 

[bartleby]

Agree on the sentiments about how intubation should depend on the overall clinical picture rather than getting hung up on a specific GCS number. Many highly sedated benzo OD's retain their respiratory drive and airway reflexes without a significant alcohol or opiate ingestion and do fine with observation alone. You should no feel bad about intubating someone for airway protection if they are obtunded. As Mel Herbert of EM:RAP has said (loosely paraphrased), you shouldn't feel bad about controlling someone's airway because intubating a patient is a sign of love...it means that you really care about them.

Flumazenil is not a drug you should be using in the ED.

 

[hyperbaric]

Generally I reverse opioid overdoses, but benzo overdoses I will tube and allow them to wake up on their own. Flumazenil is a dangerous drug for overdose reversal in benzo overdoses IMHO.

Couldn't agree more. Most toxicologists I've talked to say 'don't use it.'

That is what I was taught and the argument was convincing enough that I don't plan on challenging the teacher.