Transcript Opiates

OPIATES
Dr. Zolfaghari
Assistant Professor of Emergency Medicine
Dr. Farahmand Rad
Assistant Professor of Emergency Medicine
‫‪OPIUM‬‬
‫اوپیوم شیره گیاهی است که از تیغ‬
‫زدن گیاه پاپاورسومینیفرم بدست می‬
‫آید و حاوی تعدادی از آلکالوئیدها‬
‫است‪.‬‬
‫اوپیوئیدها به سه دسته تقسیم می‬
‫شوند‪:‬‬
‫طبیعی‪ ،‬نیمه صناعی‪ ،‬صناعی‬
‫اوپیات ها به مشتقات طبیعی اوپیوم‬
‫‪OPIOIDS‬‬
‫مشتقات نیمه صناعی‪ :‬بوپرنورفین‪،‬‬
‫هیدروکدون و اکسی کدون‪،‬‬
‫هیدرومورفین و اکسی مورفین‬
‫مشتقات صناعی اپیوم‪:‬‬
‫پتدین‪ ,‬متادون‪ ,‬پنتازوسین‪,‬‬
‫پروپوکسی فن‪ ,‬دیفنوکسیالت‪,‬‬
‫فنتانیل‪ ,‬ترامادول‬
‫‪PATOPHYSIOLOGY‬‬
‫سه گیرنده عمده برای مواد‬
‫مخدر در بدن وجود دارد‪:‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪Mu‬‬
‫‪kappa‬‬
‫‪delta‬‬
‫جدول اثرات بالینی گیرنده ها‬
Mu : analgesia, euphoria, sedation, prolactin
secretion, analgesia, respiratory depression,
bradycardia, itching, GI dysmotility,
dependency
K: analgesia, myosis, diuresis
dysphoria, analgesia
Delta: analgesia, inhibition of dopamine
secretion
CLINICAL PERESENTATION
Pin point myosis, respiratory depression, loss of
consciousness
 Cardiovascular: hypotension, bradycardia,
cyanosis, cardiac dysrhythmia
 Respiratory: respiratory depression, pulmonary
edema, hypoxia, bronchospasm
 GI: constipation, Ileus, GI movement dysfunction
 Renal: retention, ATN, GN, proteinuria,
myoglubinuria

CLINICAL PERESENTATION
Musculoskeletal: rhabdomyolysis
 Nervous system: loss of consciousness, coma,
seizure, tremor
 Others: hypo or hyperthermia, nausea & vomiting

CLINICAL PERESENTATION
Myosis there is not in all opium toxic patient.
 Mydriasis is present with intoxication with some
opioids such as” diphenoxylate, meperidine,
morphine, pentazocine, propoxyphene”

OPIATE AGONISTS









Heroin
Morphine
Methadone
Diphenoxylate & atropine
Meperidine
Propoxyphene
Codeine, Hydrocodone, & Dihydrocodeine
Pentazocine & oxycodone
Butorphanol & nalbuphine
OPIATE AGONISTS
Paregoric
 Hyromorphone
 Tramadol

OPIATE AGONIST-ANTAGONISTS
Buprenorphine(B2)
 Pentazocine
 Butorphanol
 Nalbuphine

OPIATE ANTAGONISTS
Naloxone
 Naltrexone
 Nalmefene

DIAGNOSIS
Pin point myosis
 Respiratory depression (RR<12)
 loss of consciousness
OR
 Pin point myosis
 Respiratory depression (RR<12)
 Circumstantial evidence of opioid use

DD
Intoxication with:
 Clonidine
 Organophosphate
 Carbamate
 Phenothiazine
 Atypical antipsychotic medications
 Sedative-Hypnotic medications
 Carbon monoxide
MANAGEMENT
Respiratory depression is the major morbidity
and the cause of essentially all the mortality
from opioid intoxication.
 Airway protection and ventilatory management
are the most important treatment for opioidintoxicated individuals.

MANAGEMENT
Adequate oxygenation
 Naloxone or endotracheal intubation
 Single-dose activated charcoal
 Delayed and multiple doses of activated charcoal

•
Diphenoxylate hydrochloride
•
Atropine sulfate overdoses
Large ingestions of sustained-release preparations
•
MANAGEMENT

Naloxone is a pure competitive antagonist at all
opioid receptors

Naloxone fully reverses all the effects of
opioids,

Naloxone antagonizes opioid-induced seizures,
except those induced by meperidine and
tramadol
ROUTE OF ADMINISTRATION
IV, SC, or IM or deposited on mucosa
(intratracheally or intranasally, but not SL)
 onset of action after IV administration : 1 to 2
minutes
 duration of action: 20 to 90 minutes.


Intranasal administered naloxone can used by
EMS personnel and in bystander naloxone
administration programs
ROUTE OF ADMINISTRATION
Naloxone effects are largely dependent on the
dose administered and the amount of opioid
that needs to be reversed.
ROUTE OF ADMINISTRATION
Apnea or Near Apnea
Opioid Dependent
Patients
Non - Opioid
Dependent
Patients
2 mg – IV
Every 3 minute until to maximum
10 mg
2 mg – IV
Every 3 minute until to maximum
10 mg
LOC plus Minimal
Respiratory Depression
0.05 mg – IV
Every 3 minute until to
maximum 10 mg
0.4 mg – IV
Every 3 minute until to
maximum 10 mg
ROUTE OF ADMINISTRATION
Recent literature recommends the same dose
ranges in pediatric patients.
In neonatal patients naloxone, 0.01 milligram/kg
IV, is recommended to treat mental and respiratory
depression.
ROUTE OF ADMINISTRATION
Exposures to synthetic opioids, such as
propoxyphene, fentanyl, pentazocine, or
dextromethorphan, and to sustained-release
preparations may require these larger-than-ordinary
doses
Toxicity from leaking opioid-containing packets in the
intestinal tract (i.e., in "body packers") can be
extremely severe, and such patients require large and
sustained naloxone doses until the drug-containing
packets are expelled or removed.
NALOXONE INFUSION
A continuous infusion should be considered only if
the patient responded to the naloxone bolus and
required repeat administration to support
respiration
 For long-acting opioids: buprenorphine,
methadone, and propoxyphene.
 for exposures to sustained-release preparations.
 Ingestions of dermal patches.
NALOXONE INFUSION
To calculate the naloxone continuous infusion
dose, determine the "wakeup dose" and
administer two thirds of that dose per hour by
IV infusion.
It is recommended that patients maintained on
naloxone infusions be admitted to a monitored
unit.
NALOXONE ADVERSE EFFECTS
serious complications are rare
Common adverse effects are: anxiety, nausea,
vomiting, diarrhea, abdominal cramps,
piloerection, yawning
Careful dosing of naloxone can prevent the
precipitation of opioid withdrawal symptoms
ENDOTRACHEAL INTUBATION
1) Severe respiratory depression unresponsive or
poorly responsive to naloxone
2) In cases in which acute lung injury is suspected.
Rapid-sequence intubation, omitting anestheticsedative agents, is the preferred technique
ADVANTAGES
1.
2.
3.
4.
protection of the airway.
easy access for suctioning.
provision of an alternate route of administration
for some medications.
total airway control.
HYPOGLYCEMIA
Definition:
Plasma Glucose less than 50 mg/dl in adult
patients.
Hypoglycemia is defined as a plasma glucose level
of <45 mg/dL in any symptomatic patient or <35
mg/dL in an asymptomatic neonate.
DEFINITION
Serum glucose level is affected when there is an
imbalance between insulin (hypoglycemic
hormone) and its counterregulatory hormones
cortisol, growth hormone, glucagon, and
epinephrine (hyperglycemic hormones)
ETIOLOGY
1.
2.
3.
4.
5.
6.
7.
Inadequate intake of food
Inaccurate administration of insulin
Infection
Renal failure
Acute coronary syndrome
Unusual physical or mental stress
Metabolic Disorder
SIGNS & SYMPTOMS



Neuroglycopenic symptoms:
drowsiness, confusion, dizziness, tiredness,
inability to concentrate, and difficulty
speaking.
Adrenergic symptoms: tremor, sweating, anxiety,
nausea, palpitations, feelings of warmth, and
shivering, tachycardia, tachypnea.
Other symptoms such as hunger, weakness, and
blurred vision.
SIGNS & SYMPTOMS IN NEONATES AND
INFANTS

Alterations in mental status, coma or seizures.

Nonspecific symptoms: poor feeding, an abnormal
or high-pitched cry, cyanosis, and hypothermia and
varying degrees of irritability and jitteriness or
lethargy.

symptoms of vomiting, diarrhea, abnormal urine
output, jaundice, and temperature instability.
SIGNS & SYMPTOMS IN NEONATES AND
INFANTS
Neonates and infants may not manifest these
signs, and lethargy, apnea, or seizures may be
the prominent finding
DIAGNOSIS
rapid bedside screen for serum glucose level is
the most important diagnostic test.
Confirm abnormal results with a venous sample
sent to the laboratory.
A gray-topped sample tube should be filled and
placed on ice for additional studies
TREATMENT
Treat hypoglycemia promptly while awaiting
diagnostic results.
IV dextrose is the primary treatment (PO, NGT,PR,
IV or IO).
The dose of dextrose is 0.5 to 1.0 gram/kg
regardless of the route of administration.
TREATMENT
In alert patients with mild symptoms, oral
consumption of sugar containing foods or
beverages is often adequate.
In other patients, after blood is drawn for glucose
determination, one to three ampules of 50%
dextrose in water (D W) is administered
intravenously while The patient’s airway,
breathing, and circulation are assessed and
maintained
DOSE OF DEXTROSE
Newborns: 5 mL/kg of 10% dextrose
infants and children : 2 mL/kg of 25% dextrose
Adult: 0.5 to 1.0 gram/kg of 50% dextrose
repeated if hypoglycemia persists after 15 minutes.
Glucagon, 0.3 milligram/kg IM or SQ (1 mg has an effect
similar to that of one ampule of DW)
Maintenance dextrose at a rate of 6 to 8
milligrams/kg/min with D10
TREATMENT
Refractory hypoglycemia: more than 6 to 8
mg/kg/min
Frequent reevaluation and titration of infused
dextrose is necessary in this situation.
TREATMENT
Administration of an ampule of DW 50% may
range from less than 40 mg/dL to more than 350
mg/dL.
All patients with severe hypoglycemic reactions
require aspiration and seizure precautions.
ADRENAL INSUFFICIENCY
hydrocortisone:
• 25 grams IV or IM for neonates and infants
•
50 grams for toddlers and school-aged children
•
100 grams for adolescents