Opioid Overdose Management (AHA 2025)

Algorithm Steps

1. ▶

   Start

   START: Suspected Opioid Overdose

   Unresponsive with respiratory depression

   1. ●

      Action

      Recognize Opioid Overdose

      Classic presentation

      • Unresponsive or decreased consciousness
      • Slow, shallow, or absent breathing
      • Pinpoint pupils (miosis)
      • Drug paraphernalia nearby
      • Known opioid use history
      1. ◆

         Decision

         Check Responsiveness

         Shout and shake

         1. ●

            Action

            Responsive

            Monitor closely

            • Continue to monitor
            • Keep in recovery position
            • Prevent re-administration of opioids
            • Consider naloxone if deteriorating
            1. ✓

               Outcome

               Observation

               Monitor for recurrence

               • Observe for at least 4 hours (longer for long-acting opioids)
               • Naloxone half-life 30-90 min - may re-sedate
               • Repeat naloxone PRN
               • Address addiction - offer treatment resources
               • Prescribe take-home naloxone
         2. ●

            Action

            Unresponsive - Call for Help

            Activate emergency response

            • Call 911/EMS
            • Get AED and naloxone if available
            • Prepare for CPR if no pulse/breathing
            1. ◆

               Decision

               Normal Breathing?

               Check for 5-10 seconds

               1. ●

                  Action

                  Breathing Normally

                  Prevent aspiration

                  • Position in recovery position
                  • Monitor breathing continuously
                  • Give naloxone if opioid suspected
                  • Be prepared to start CPR
               2. ⚠

                  Warning

                  Not Breathing Normally

                  Immediate intervention

                  1. ●

                     Action

                     Administer Naloxone

                     Opioid reversal

                     • INTRANASAL: 4 mg in one nostril (Narcan)
                     • OR 8 mg in one nostril (Kloxxado)
                     • IM: 0.4-2 mg IM (can use auto-injector)
                     • IV: 0.4-2 mg IV (hospital setting)
                     • May repeat q2-3 min if no response
                     • Fentanyl may require multiple doses
                     1. ◆

                        Decision

                        Definite Pulse?

                        Check carotid for 5-10 seconds

                        1. ⚠

                           Warning

                           No Pulse - Start CPR

                           High-quality CPR

                           • Compressions 100-120/min, depth 2-2.4 inches
                           • 30:2 compression:ventilation ratio
                           • Use AED as soon as available
                           • Continue naloxone administration
                           • Follow ACLS algorithm
                           1. ◆

                              Decision

                              Response to Naloxone?

                              Assess for improvement

                              1. ⚠

                                 Warning

                                 No Response

                                 Consider other causes

                                 • Continue CPR/support
                                 • Consider non-opioid overdose
                                 • Polysubstance ingestion
                                 • Other causes of coma (head injury, stroke, hypoglycemia)
                        2. ●

                           Action

                           Pulse Present - Continue Support

                           Maintain oxygenation

                           • Continue rescue breathing (1 breath/5-6 sec)
                           • Repeat naloxone q2-3 min as needed
                           • Recheck pulse every 2 minutes
                           • Monitor for return of spontaneous breathing
                  2. ●

                     Action

                     Support Ventilation

                     Provide rescue breaths

                     • Open airway (head-tilt/chin-lift or jaw thrust)
                     • Give 1 breath every 5-6 seconds
                     • Use bag-valve-mask if available
                     • Watch for chest rise