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Opioid and sedative overdose
Opioid overdose shows as coma, small pupils and slow breathing; the essentials are bag-mask ventilation and naloxone in a dose that restores adequate breathing — not necessarily full wakefulness — and observation, because naloxone is shorter-acting than most opioids.
Why it matters in the exam
Questions test the correct treatment of a patient with slow breathing: first bag-mask ventilation and oxygen, then naloxone — in a dependent patient in small titrated doses (0.04–0.4 mg IV) to avoid acute withdrawal, vomiting and agitation, and in apnoea in larger doses (intranasal 4 mg). The goal is a respiratory rate of at least 10–12 per minute.
The length of observation is also asked: after reversal of a heroin overdose, discharge after about one hour can be considered if the patient is awake, breathing and walking, but methadone, long-acting opioids and body packers need prolonged observation or a naloxone infusion (about two thirds of the effective dose per hour). Fentanyl and its analogues may need repeated doses, and methadone prolongs the QT.
As for sedatives: benzodiazepines alone usually cause drowsiness with preserved breathing, and the danger rises sharply in combination with opioids or alcohol. Flumazenil is not given routinely, because in a patient with chronic use or a mixed overdose with TCAs it may cause seizures. GHB causes sudden deep coma from which the patient sometimes wakes quickly. Every patient after an intentional overdose is referred for psychiatric assessment once stable.
Key points
- Coma, small pupils, slow breathing — opioids.
- Ventilate first; naloxone in titrated doses until breathing is adequate.
- Naloxone is short-acting — prolonged observation for methadone and long-acting opioids.
- Benzodiazepines are dangerous mainly in combination; no routine flumazenil.
- Intentional overdose — paracetamol, salicylates, ECG and psychiatric assessment.
Summary table
| Substance | Picture | Treatment | Observation |
|---|---|---|---|
| Heroin and short-acting opioids | Coma, small pupils, slow breathing | Ventilation, naloxone | About one hour after reversal, if awake and breathing |
| Methadone and long-acting opioids | As above; long QT with methadone | Repeated or infused naloxone | Prolonged, at least 12–24 hours |
| Fentanyl and analogues | Rapid respiratory depression, chest-wall rigidity | Repeated naloxone doses, ventilation | According to response |
| Benzodiazepines | Drowsiness, breathing usually preserved | Support; no routine flumazenil | Until consciousness improves |
| Combination with alcohol or opioids | Severe respiratory depression | Ventilation, naloxone, sometimes intubation | Prolonged |
Free exam questions
מבין התרופות הניתנות לטיפול בכאב במלר״ד, מהו השילוב, בו תופעת הלוואי תואמת לסוג התרופה? (the question as examined, in Hebrew)
- א. קטמין(Ketamine) גורם ל Chest wall rigidity
- ב. פנטניל(Fentanyl) גורם לריור מוגבר
- ג. פטידין(Pethidine) גורם ל Serotonine Syndrome בשילוב עם Monoamine Oxidase Inhibitors
- ד. לידוקאין(Lidocaine) גורם לשחרור היסטמין מקומית וסיסטמית, הגורם לירידת לחץ הדם
רוכב אופנוע בן ,40 עם השמנת יתר ניכרת וללא רקע רפואי ידוע אחר, הובא לאחר תאונת דרכים. הונשם בחדר הטראומה, תוך מתן 140mg ROCURONIUM ו- 30mg .ETOMIDATE בנוסף, קיבל אנטיביוטיקה, חיסון טטנוס MORPHINE -ו. הפצוע השלים הערכה בחדר הטראומה והוא שמור המודינמית, מונשם בקלות ומחמצן היטב. כיצד יש לנהל את המשך הסדציה של הפצוע לצורך השלמת CT? (the question as examined, in Hebrew)
- א. הודות למשך הפעולה הארוך של רוקורוניום, אין צורך בתוספת הרדמה לחצי השעה הקרובה
- ב. דריפ MIDAZOLAM במינון של 0.05 מ"ג לדקה
- ג. חישוב SCORE RASS לפני מתן טיפול נוסף
- ד. דריפ PROPOFOL במינון של 12 מ"ג לדקה
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
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Sources
- AHA Focused Update on Adult Advanced Cardiovascular Life Support: opioid-associated emergencies, 2023 — Naloxone and ventilation
- Goldfrank's Toxicologic Emergencies, 11th edition (2019) — Opioids; Sedative-hypnotics
- Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9th edition (2020) — Opioids
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.