OPIATESDr. ZolfaghariAssistant Professor of Emergency Medicine

Dr. Farahmand RadAssistant Professor of Emergency Medicine

OPIUM

شیره گیاهی است که از تیغ زدن گیاه اوپیوم پاپاورسومینیفرم بدست می آید و حاوی تعدادی

.از آلکالوئیدها است

: به سه دسته تقسیم می شونداوپیوئیدهاطبیعی، نیمه صناعی، صناعی

به مشتقات طبیعی اوپیوم اطالق می اوپیات ها «شود مانند

هرویین, کدئین، مورفین

OPIOIDS

مشتقات نیمه صناعی: بوپرنورفین، هیدروکدون و اکسی کدون، هیدرومورفین و اکسی مورفین

:مشتقات صناعی اپیومپتدین, متادون, پنتازوسین, پروپوکسی فن,

دیفنوکسیالت, فنتانیل, ترامادول

سه گیرنده عمده برای مواد مخدر در بدن وجود دارد:

Mukappadelta

PATOPHYSIOLOGY

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

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”

CLINICAL PERESENTATION

OPIATE AGONISTS

Heroin Morphine Methadone Diphenoxylate & atropine Meperidine Propoxyphene Codeine, Hydrocodone, & Dihydrocodeine Pentazocine & oxycodone Butorphanol & nalbuphine

Paregoric Hyromorphone Tramadol

OPIATE AGONISTS

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 opioid-intoxicated individuals.

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

MANAGEMENT

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

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 ApneaLOC plus Minimal

Respiratory Depression

Opioid Dependent

Patients

2 mg – IVEvery 3 minute until to

maximum 10 mg

0.05 mg – IVEvery 3 minute until to maximum 10 mg

Non - Opioid Dependent

Patients

2 mg – IVEvery 3 minute until to

maximum 10 mg

0.4 mg – IVEvery 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.

ROUTE OF ADMINISTRATION

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.

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 INFUSION

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 anesthetic-sedative agents, is the preferred technique

ADVANTAGES

1. protection of the airway.

2. easy access for suctioning.

3. provision of an alternate route of administration for some medications.

4. 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. Inadequate intake of food

2. Inaccurate administration of insulin

3. Infection

4. Renal failure

5. Acute coronary syndrome

6. Unusual physical or mental stress

7. 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

Thanks

For Your

Attentio

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