START: Suspected Opioid Overdose
Reduced consciousness with slow, shallow or absent breathing
All Pathways
Emergency MedicineEmergency
Opioid Overdose Management (AHA 2025)
Opioid Overdose Management (AHA 2025): START: Suspected Opioid Overdose → Recognize Opioid Toxicity → Check Response and Call for Help → Breathing Norma...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action Recognize Opioid Toxicity
Coma, slow breathing and pinpoint pupils suggest opioids
- Reduced consciousness, confusion or slurred speech
- Slow, shallow or absent breathing
- Pinpoint pupils (not always present)
- Evidence of opioid use: packets, patches, injecting equipment, prescriptions
- Check for danger, such as needles and syringes
03Action Check Response and Call for Help
Shout and shake. Call for help: 000 in Australia; in hospital, MET or code blue
- Get naloxone, bag-valve-mask, oxygen and a defibrillator
- Do not wait for a response to naloxone before you call for help
- Stay with the person
04Decision Breathing Normally?
Look for no more than 10 seconds. Gasping is not normal breathing
- If Yes
05Action Breathing Normally: Prevent Deterioration
Recovery position, oxygen if needed, watch breathing. Adult doses below; child: weight-based. Opioid dependent: small doses
- If drowsy: recovery position and clear the airway
- Monitor breathing rate, SpO2 and conscious level often
- Breathing becomes slow or shallow: support ventilation; naloxone 100-200 microgram IV every 2-3 min
- Stops breathing or no pulse: start CPR
- Stay with the person until handover
06Action Breathing Adequate: Observe for Recurrence
Observe in hospital. Naloxone lasts 45-70 min, but opioid breathing depression can last 4-5 h. Long-acting opioids (methadone, slow-release, patches, buprenorphine): longer observation or admission
- Observe until breathing and conscious level stay normal without further naloxone
- Remove any opioid patch
- Recurrent toxicity: repeat naloxone or start an infusion (2 mg in 500 mL = 4 microgram/mL), titrated to adequate breathing; seek toxicology advice
- Check BGL; paracetamol level if deliberate self-poisoning; consider co-ingestants
- Tramadol: watch for seizures and serotonin toxicity
07Outcome Discharge Only When Safe: Prevent Next Overdose
Discharge only if alert with normal breathing and SpO2 without further naloxone; long-acting opioid or infusion: admit. Then take-home naloxone, drug treatment referral, mental health review if deliberate
- Offer take-home naloxone and teach family or friends how to use it
- Refer to alcohol and other drug services; offer opioid treatment
- Deliberate overdose: mental health risk assessment
- Poisons Information Centre: 13 11 26
If No08Decision Not Breathing Normally: Definite Pulse?
Check the pulse for no more than 10 seconds
- If Yes
09Action Pulse Present, Breathing Absent or Inadequate: Ventilate
Not breathing, or slow or shallow breathing: bag-valve-mask ventilation with oxygen first, then naloxone
- Open the airway: head tilt-chin lift or jaw thrust; use adjuncts
- Bag-valve-mask with high-flow oxygen: adult 1 breath every 6 seconds; child: rate per paediatric ALS
- Continue until normal breathing returns
- Recheck pulse every 2 minutes; no pulse: start CPR
10Action Pulse Present: Give Naloxone
Aim: adequate breathing, not full waking. Opioid dependent or pregnant: small doses (withdrawal, including in the fetus). Child: weight-based dose
- Adult, apnoeic: 400 microgram IV (or 800 microgram IM or subcut); repeat every 2-3 min
- Adult, breathing but inadequate or opioid dependent: 100-200 microgram IV every 2-3 min to adequate breathing
- Child: 10 microgram/kg IV or IM (max 400 microgram); no response: 100 microgram/kg (max 2 mg)
- No IV access: intranasal spray or IM pre-filled syringe, as per pack
- No response after 10 mg total: question the diagnosis
- Buprenorphine: higher doses may be needed; reversal is slow and may be partial
- Withdrawal can cause vomiting and agitation: have suction ready
11Decision Adequate Breathing After Naloxone?
Breathing rate and depth adequate, SpO2 normal, airway reflexes present
- If Yes
- Path rejoins step 06Shared downstream outcome
If No12Warning Breathing Still Inadequate After Naloxone
Keep ventilating. Look for other causes
- Continue bag-valve-mask ventilation; recheck pulse every 2 minutes
- Repeat naloxone every 2-3 min; after 10 mg total, question the diagnosis
- Check BGL; consider head injury, stroke, hypoxic injury and sedative co-ingestants
13Outcome Not Responding to Naloxone: Airway and ICU
Secure the airway (intubation) and refer to ICU. Treat other causes
If No14Warning No Pulse: Start CPR Now
Cardiac arrest. CPR and defibrillation first. Naloxone must not delay CPR
- Compressions 100-120/min, one third of chest depth (adult more than 5 cm; child about 5 cm; infant 4 cm)
- 30:2 compressions to breaths; attach defibrillator as soon as possible
- Naloxone may be given only if it does not delay CPR or defibrillation
15Outcome Cardiac Arrest: Follow ALS Algorithm
Standard adult ALS; pregnant over 20 weeks: manual left uterine displacement. After ROSC: ICU care and watch for recurrent opioid toxicity
- Continue ALS: rhythm checks, adrenaline, shocks as indicated
- After ROSC: post-arrest care in ICU; watch for recurrent opioid toxicity
- Pregnant over 20 weeks: manual left uterine displacement; call obstetric team for perimortem caesarean delivery
Guideline Source
Part 10: Adult and Pediatric Special Circumstances of Resuscitation: 2025 American Heart Association Guidelines for CPR and ECC (opioid poisoning)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Written for healthcare providers. Lay rescuers do not check a pulse: they start CPR if the person is unresponsive and not breathing normally.
- Doses are for adults. Children need weight-based naloxone doses and paediatric resuscitation guidelines.
- Potent synthetic opioids (fentanyl analogues, nitazenes) may need repeated naloxone doses.
- Co-ingested sedatives, alcohol or stimulants can cause coma or poor breathing that naloxone does not reverse.
Contraindicated Populations
Newborn infants at birth (use a newborn resuscitation guideline)
Applicable Regions
AUUSEUGlobal
AU: ANZCOR Guidelines 9.5.2 and 11.10 apply. Call 000. Take-home naloxone (nasal spray, pre-filled syringe or ampoules) is free without prescription under the Take Home Naloxone Program. Poisons Information Centre 13 11 26.
NZ: Call 111. ANZCOR guidelines apply. National Poisons Centre 0800 764 766.
US: Call 911. AHA 2025 Part 10 is the primary source. US intranasal products differ in strength (for example 4 mg sprays).
Version 2Next review: 2027-09-30
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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 Part 10: Adult and Pediatric Special Circumstances of Resuscitation: 2025 American Heart Association Guidelines for CPR and ECC (opioid poisoning).
What guideline is the Opioid Overdose Management (AHA 2025) based on?
This algorithm is based on Part 10: Adult and Pediatric Special Circumstances of Resuscitation: 2025 American Heart Association Guidelines for CPR and ECC (opioid poisoning) (DOI: 10.1161/CIR.0000000000001380).
What are the limitations of the Opioid Overdose Management (AHA 2025)?
Known limitations include: Written for healthcare providers. Lay rescuers do not check a pulse: they start CPR if the person is unresponsive and not breathing normally.; Doses are for adults. Children need weight-based naloxone doses and paediatric resuscitation guidelines.; Potent synthetic opioids (fentanyl analogues, nitazenes) may need repeated naloxone doses.; Co-ingested sedatives, alcohol or stimulants can cause coma or poor breathing that naloxone does not reverse.. Individual patient factors may require deviation from these recommendations.
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