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Review Question - QID 210470

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QID 210470 (Type "210470" in App Search)
A 68-year-old woman is brought to the emergency department by her son for confusion. She recently had a right knee arthroplasty and was discharged 2 days ago. Her medical history is significant for type 2 diabetes mellitus and hypertension, for which she takes metformin and hydrochlorothiazide, respectively. She also had left cataract surgery 1 year ago. Her temperature is 97°F (36.1°C), blood pressure is 99/70 mmHg, pulse is 60/min, respirations are 8/min. Her exam is notable for anisocoria with an irregularly shaped left pupil and a 1 mm in diameter right pupil. She opens her eyes and withdraws all of her limbs to loud voice and painful stimulation. Her fingerstick glucose level is 79 mg/dL. The patient does not have any intravenous access at this time. Which of the following is the most appropriate next step in management?

CT of head without contrast



Forced air warmer



Intranasal naloxone






Orange juice by mouth



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This postoperative patient with miosis, sedation, and bradypnea raises concern for opioid overdose. Intranasal naloxone is the most appropriate next step in management for a patient with opioid overdose.

Opioid overdose is a common cause of death. Mu agonism by opioids mediates analgesia but also respiratory depression, which can lead to hypercapnic respiratory failure. Other symptoms and signs include constipation, pupillary constriction, and complications of intravenous drug use, including endocarditis. Naloxone is a mu-receptor antagonist that can be administered through multiple routes of administration, including oral, intravenous, intranasal, intramuscular, sublingual, and subcutaneous. A postoperative patient with bradypnea should raise concerns about opioid overdose and should be initially managed with naloxone.

Van Dorp et al. review the evidence regarding the diagnosis and treatment of patients with opioid overdose and addiction. They discuss how naloxone is used in order to reverse the opioid intoxication. They recommend monitoring the patient carefully in order to prevent withdrawal phenomena.

Incorrect Answers:
Answer 1: CT of the head without contrast would be appropriate if the patient had focal unilateral findings or if naloxone does not improve mental status. This would allow for detection of the strokes, bleeds, and other intracranial pathologies.

Answer 2: A forced air warmer is excellent for addressing hypothermia but does not treat the underlying condition. Patients who are acutely intoxicated with opioids require reversal with naloxone if they are not protecting their airway.

Answer 4: Intubation should be considered if the patient's mental status remains altered or they are not oxygenating or ventilating adequately.

Answer 5: Orange juice by mouth is appropriate for a hypoglycemic patient who can protect their airway. Rapid correction of hypoglycemia in confusion or stroke may resolve symptoms.

Bullet Summary:
Naloxone is the treatment of choice for an opioid overdose.

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