ACLS Provider: Course

Opioid Overdose Algorithm

Opioid overdose is an increasingly common cause of respiratory arrest and cardiac arrest. The ACLS Opioid-Associated Emergency Algorithm addresses the recognition and management of suspected opioid overdose in both pre-arrest and arrest scenarios. The key objective is to reverse respiratory depression quickly while initiating full ACLS support if cardiac arrest occurs. Early intervention with naloxone and ventilation support can be lifesaving.

Recognition of Opioid Overdose

Suspect opioid overdose in any unresponsive individual with signs of respiratory depression, especially if opioid use is known or likely. Key findings may include:

  • Unresponsiveness or decreased level of consciousness
  • Slow or absent respirations (agonal, irregular, or less than 8 breaths/min)
  • Pinpoint pupils (miosis), though not always present
  • Cyanosis, hypoxia, or apnea in severe cases
  • Drug paraphernalia or known opioid use history

When in doubt, treat. Naloxone has minimal downside in most cases and may restore spontaneous breathing rapidly.

Initial Management (Not in Cardiac Arrest)

  • Ensure scene safety — be alert for needles, bystanders, or signs of fentanyl contamination (rare but possible in high-volume EMS scenarios).
  • Assess responsiveness and breathing. If the patient is not breathing adequately, begin bag-valve-mask ventilation immediately with high-flow oxygen.
  • Administer naloxone (Narcan):
    • 0.4–2 mg IV/IM/SC or 2–4 mg intranasal
    • May repeat every 2–3 minutes as needed (up to 10 mg total)
  • Support ventilation until spontaneous breathing resumes. Do not delay ventilation while waiting for naloxone to take effect.
  • Monitor for recurrence. Naloxone has a shorter half-life than most opioids — respiratory depression can recur after initial improvement.

If the Patient Is in Cardiac Arrest

  • Begin full ACLS protocol for cardiac arrest (e.g., VF/pVT or asystole/PEA algorithm as appropriate).
  • Administer naloxone concurrently with resuscitation efforts (IV/IO if available).
  • Secure airway and provide aggressive ventilation. Hypoxia is often the primary cause of arrest in these cases — restoring oxygenation is critical.
  • Continue standard ACLS medications and rhythm management in parallel.

Post-Resuscitation and Disposition

  • Monitor for recurrent hypoventilation or sedation. Repeated naloxone doses or infusion may be necessary if long-acting opioids are involved.
  • Prepare for withdrawal symptoms. Naloxone may precipitate acute opioid withdrawal, especially in dependent individuals.
  • Refer to emergency department or addiction services for further evaluation, support, and safe discharge planning.

Summary

  • Recognize the signs of opioid overdose early: unresponsiveness, respiratory depression, and miosis.
  • Support airway and breathing immediately. Don’t delay ventilation.
  • Administer naloxone promptly and repeat as needed.
  • If the patient arrests, follow ACLS cardiac arrest algorithms in full, while continuing naloxone and ventilation support.
  • Watch for recurrence and transition care to a facility prepared for longer-term management.