You are working on the floor, caring for a 56 yo admitted with humerus fracture requiring surgical repair. Beyond pain control, you are also treating him for alcohol withdrawal. He has a history of appendectomy but is otherwise healthy. You know the patient to work part-time doing lawn care.
You check on him at 1000 and find him non-responsive.
What do you do?
Call for help from your colleagues, either with colleagues or by calling Code Blue if you deem it necessary.
Take charge as the primary nurse. Ask your colleagues to:
- Assess his vitals, which reveal:
- pulse of 50
- BP 80/60
- resps approx 6/min; his breaths are shallow
- sats 70% on RA
- Provide PPV using a BVM, with high flow oxygen; ensure the airway is open, using a jaw thrust and/or OPA as tolerated.
- If you have not called a code blue, call for CCOT, RT, and MRP.
- Obtain IV access if not available.
- Obtain the chart and record events.
Thankfully, with ventilation, his sats steadily increase to 88% and his colour slowly improves. He remains non responsive.
Discussion point: where are the OPAs? How are they sized?
What do you do next?
Examine the patient, exposing his chest. Listen to breath sounds.
As you do so, you find a short straw in his bed with some white residue on it. You look and also find some of this residue on his nose.
What are you now concerned about? What should you do?
Your concern is now on drug overdose, with synthetic opioid (eg fentanyl) being high on the list of possibility.
Wear gloves to ensure you are not contaminating yourself.
Assess his pupils – they are pinpoint.
Regularly check his ABCs.
What do you do next?
Call MRP with an update, and ask for consideration of naloxone to be given.
He responds with an order for 0.2-0.4mg IV, given every 1 min until effect.
Thankfully the patient rapidly rouses with the second dose and pulls the OPA out. He looks at you, confused.
How do you further manage the situation?
The patient should be closely monitored, as naloxone’s duration of action is 30-120 minutes, and he may again fall unresponsive.
Staff who may have been exposed to the drug should be carefully monitored for symptoms of opioid toxicity.
Any drugs or paraphernalia should be gathered and stored. The situation should be reviewed with MRP and administration for further management, given the circumstances.
