START: Suspected Opioid Overdose
Unresponsive with respiratory depression
All Pathways
Emergency MedicineEmergency
Opioid Overdose Management (AHA 2025)
Opioid Overdose Management (AHA 2025): START: Suspected Opioid Overdose → Recognize Opioid Overdose → Check Responsiveness → Responsive → Observation.
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action Recognize Opioid Overdose
Classic presentation
- Unresponsive or decreased consciousness
- Slow, shallow, or absent breathing
- Pinpoint pupils (miosis)
- Drug paraphernalia nearby
- Known opioid use history
03Decision Check Responsiveness
Shout and shake
04Action Responsive
Monitor closely
- Continue to monitor
- Keep in recovery position
- Prevent re-administration of opioids
- Consider naloxone if deteriorating
05Outcome 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
06Action Unresponsive - Call for Help
Activate emergency response
- Call 911/EMS
- Get AED and naloxone if available
- Prepare for CPR if no pulse/breathing
07Decision Normal Breathing?
Check for 5-10 seconds
08Action Breathing Normally
Prevent aspiration
- Position in recovery position
- Monitor breathing continuously
- Give naloxone if opioid suspected
- Be prepared to start CPR
- Path rejoins step 05Shared downstream outcome
09Warning Not Breathing Normally
Immediate intervention
10Action 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
11Decision Definite Pulse?
Check carotid for 5-10 seconds
12Warning 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
13Decision Response to Naloxone?
Assess for improvement
- Path rejoins step 05Shared downstream outcome
14Warning No Response
Consider other causes
- Continue CPR/support
- Consider non-opioid overdose
- Polysubstance ingestion
- Other causes of coma (head injury, stroke, hypoglycemia)
15Action 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
- Path rejoins step 13Shared downstream outcome
16Action 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
- Path rejoins step 11Shared downstream outcome
Guideline Source
AHA 2025 Guidelines Part 9: Opioid-Associated Emergency
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Naloxone dose may need repetition for long-acting opioids
- Co-ingestions may complicate management
- Fentanyl analogs may require higher doses
- Observation time varies by opioid half-life
Applicable Regions
USEUGlobal
US: AHA 2025 current standard
Version 1Next review: 2028-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Opioid Overdose Management (AHA 2025)?
The Opioid Overdose Management (AHA 2025) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on AHA 2025 Guidelines Part 9: Opioid-Associated Emergency.
What guideline is the Opioid Overdose Management (AHA 2025) based on?
This algorithm is based on AHA 2025 Guidelines Part 9: Opioid-Associated Emergency (DOI: Part 9 Adult Advanced Life Support).
What are the limitations of the Opioid Overdose Management (AHA 2025)?
Known limitations include: Naloxone dose may need repetition for long-acting opioids; Co-ingestions may complicate management; Fentanyl analogs may require higher doses; Observation time varies by opioid half-life. Individual patient factors may require deviation from these recommendations.
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