Management considerations following overdoses of modified—release morphine preparations.docVIP

Management considerations following overdoses of modified—release morphine preparations INTRODUCTION Analgesics have consistently remained the most common substance involved in human poisonings in the United States， with immediate action opioid analgesics associated with the greatest percent of fatalities per exposure.[1] Often current practice dictates that patients with presumed opioid overdose can be safely discharged one hour after naloxone administration if they meet certain criteria： 1） ambulate as usual； 2） have oxygen saturation on room air of92%； 3） have a respiratory rate10 breaths/min and35.0°C and50 beats/min and5000 ng/ml， free codeine concentration 9.9 ng/ml， and free hydromorphone concentration 105 ng/ml. 　　Case-2： A 16， year-old-boy recently released from a psychiatric facility for a previous overdose attempt， was brought to the ED after ingesting an unknown amount of his father’s morphine. The patient was lethargic， oriented and had slurred speech. Vital signs： blood pressure 123/78 mmHg， heart rate 60 beats per minute， temperature 36.7°C， and respiratory rate 15 breaths per minute. His oxygen saturation was 99% on room air. The patient was given 2 mg of naloxone. This caused minimal improvement in mental status. Serum chemistries were within normal limits， ethanol， acetaminophen and aspirin concentrations were all negative. Approximately two hours later the patient’s systolic blood pressure had dropped into the 90’s with a heart rate of 50 beats per minute. He remained lethargic but was able to maintain his airway. The patient was given a fluid bolus and transferred to a pediatric intensive care unit （PICU）. Approximately nine hours following presentation the patient was awake， alert and oriented， with no evidence of respiratory insufficiency， normal vital signs， and had not required any naloxone since admission. The patient was medically cleared and awaiting admission to a psychiatric ward in the PICU under one-on-one observation. During that