Opioid overdose

Case history

A 21-year-old man presents to the emergency room with central nervous system depression, respiratory depression, and miosis (1 mm pupils). Friends state that the patient was seen injecting himself at a party, at which time he became unresponsive. He is deeply unresponsive to pain and gives no history. The patient is a known drug user. He has track marks on both upper extremities and syringes are found among his belongings.

Other presentations

Acute respiratory distress syndrome (noncardiogenic pulmonary edema) can complicate opioid overdose. This can occur as a result of rapid reversal with naloxone or the effects of the opioid itself. Patients may present with respiratory distress and have rales on auscultation.

Some opioids may cause clinical features other than the classical opioid toxidrome after overdose. Propoxyphene can cause sodium channel blockade and lead to wide complex dysrhythmias in overdose. Meperidine, propoxyphene, and tramadol can cause seizures. Dextromethorphan and tramadol may cause features of serotonin toxicity.

Opiates are sometimes illegally imported by "body packing." Sealed drug-filled packets are designed to be swallowed and defecated at the destination. If a packet ruptures, large amounts of pure undiluted (uncut) opiate, often heroin, are released, requiring large amounts of naloxone. Body packers are at risk of delayed or prolonged poisoning as a result of package rupture.