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CE ARTICLE Activated Charcoal Activated charcoal (AC) can efectively bind with a wide spectrum of drugs and poisons, and animal and human studies have shown it can prevent systemic absorption of drugs and poisons when administered within 1–2 hours of ingestion, perhaps longer after ingestion of sustained-release medications. However, the use of AC is not without controversy. Randomized, controlled studies have failed to show improved outcomes in patients treated with AC, and its use is not without risks, such as aspiration.13 If considering the use of AC, prehospital providers must determine if the ingested medication or poison will bind with AC and if the benefts of administration outweigh the risks. Utilizing medical control or a poison control center (800/222-1222) can aid in this decision. Darvocet) overdose. In addition, the coingestion of another drug can alter the clinical presentation of the patient with an opioid overdose. About half of prescription painkiller deaths involve at least one other drug (benzodiazepines, cocaine, heroin), and alcohol is a component in many overdose deaths.8 Mydriasis (dilated pupils) can occur secondary to coingestants or signal cerebral hypoxia secondary to respiratory depression.9 If miosis is absent but other symptoms of the opioid toxidrome are present along with physical evidence on scene, it is safe to treat with opioid overdose as your working diagnosis. The hypotension associated with opioid ingestion and overdose is typically orthostatic in nature and presents secondary to histamine release. Nausea and vomiting can occur secondary to delayed gastric emptying, indirect stimulation of the vomit center in the medulla and vestibular stimulation. Decreased gastrointestinal motility is a common finding with both therapeutic use and overdose of opioids. Ileus, a severe decrease in motility leading to bowel obstruction, can occur in severe cases. For reasons that are unclear, hypoglycemia often occurs with opiate overdose. It is thought that coingestants such as 60 JUNE 2013 | EMSWORLD.com alcohol may play a role.6 Obtain an accurate and thorough patient history from bystanders, family members, friends or the patient, if they are alert, oriented and reliable. Pertinent aspects of the history include: • Does the patient have a history of opioid abuse, either via prescription medications or illicit drugs? Is there a history of substance abuse? Is there a history of suicide attempt? • Does the patient have access to opioid painkillers? Does the patient have chronic pain/recent surgery/cancer that could predispose them to accidental overdose? Are they prescribed painkiller medication, or does anyone in the home have a prescription? Does a friend or family member outside the home have a prescription? • Are prescription medication bottles present on scene? What are the medications? Do the bottles actually contain the medications listed on them? To whom are they prescribed? Are there pills missing? • Does the patient have any pills on their person or in personal items such as their purse or backpack? Has an attempt been made to identify unknown pills or tablets? (Remember to bring all pill bottles to the ED.) • What was the time of ingestion? How much was ingested? Were other medications or alcohol also ingested? • Has the patient vomited? Were there pills in the vomit? Treatment Respiratory depression is the primary morbidity and cause of almost all the mortality associated with opioid toxicity and overdose.9 Therefore, opening the airway, keeping the airway open, correcting inadequate ventilation and reversing hypoxia is the most important treatment for the patient with opiate toxicity or overdose. Open the airway with a manual maneuver such as the head-tilt chin-lift. A modified jaw thrust or other manual maneuver that maintains inline cervical spine stabilization can be used for patients who require it; however, except in cases where overdose is complicated by major trauma, spine stabilization is rarely indicated. Inspect the airway for vomit and secretions and suction as needed. Snoring is indicative of the tongue acting as an airway obstruction and can be anticipated in the comatose patient who is lying supine. In such a case, an oropharyngeal or nasopharyngeal airway opens the airway adequately. Patients with inadequate breathing require ventilations with a bag-valve mask and 100% oxygen. The goal is to correct the bradypnea and hypopnea associated with opioid toxicity. A ventilation rate of 10–12 per minute with enough tidal volume to result in normal chest rise and fall should be adequate. Use a pulse oximeter to monitor the SpO2, which will reflect the effectiveness of ventilation and correction of the hypoxia. If available, monitoring end-tidal carbon dioxide can help gauge the effectiveness of ventilation and correction of hypercarbia. For patients with acute lung injury and pulmonary edema, continuous positive airway pressure is an effective adjunct that improves lung ventilation, pushes pulmonary edema back into the bloodstream and helps keep alveoli inflated in diseased states. If airway control and ventilation are successful with BLS measures, endotracheal intubation can be withheld until after administration of naloxone, as the patient's altered level of consciousness and respiratory depression can be expected to resolve. Reserve endotracheal intubation for those with uncontrollable airways or who remain in prolonged comatose conditions. Naloxone is the antidote of choice for opiate intoxication and overdose. It is a pure opioid antagonist that competes for and blocks opiate receptors, reversing the effects of circulating opioids in the blood. Because naloxone has a greater affinity for opioid receptors than the opioid drugs themselves, it is effective in reversing the effects opioids have on the body. Naloxone can be administered via the oral, intravenous, intramuscular, subcutaneous, endotracheal and intranasal routes. While the IV administration of naloxone has been the domain of paramedics for many years, the ease and efficacy of intransal (IN) administra-