1. Question 11 – Methadone overdose
A 24 year old man is brought to the ED, in a car, by his friends following a suspected overdose of methadone. He has a GCS of 7 and pinpoint pupils.

2. a) Outline your three (3) immediate management priorities for this patient (3 marks)
Pass criteria:
Support airway and breathing, administer oxygen via BVM.
Administer naloxone 100mcg IV in increments until adequate spontaneous respiration established
Check BSL & treat hypoglycaemia
i.e. the basic life-saving measures expected of any ED doctor!
Other acceptable answers:
400mcg naloxone IM
Transfer to resus/full monitoring etc
Support of ventilation/oxygenation should be the priority. “You die from not breathing, not from lack of naloxone”
”Apply oxygen via face mask” is not enough if hypoventilating
You are told he arrives by car, so must assume no BLS has been provided yet.
Dose of naloxone important – demonstrates consultant level knowledge. If administer > 1mg IV naloxone as a bolus, risk of precipitating opioid withdrawal in assumed opioid dependent patient.
Better answers provided an end-point to naloxone treatment ie adequate respiration.

3. a) Outline your three (3) immediate management priorities for this patient (3 marks)
Did not accept:
“Exclude other causes of reduced e.g. trauma” – too vague/general. You’re told he ingested methadone.
“ mcg IV” – Does that mean you might give 400mcg IV first up? – that’s a big dose!

4. He responds appropriately to your initial treatment, but twenty minutes later his observations are: GCS 12 RR 8/min HR bpm BP 140/70 mmHg O2 Sat 94% on room air   b) Outline your next four steps in his management. (4 marks)
1. Administer naloxone mcg IV in increments until adequate spontaneous respiration established – RR > 8-10, rousable but not fully reversed.
2. Commence naloxone infusion at 2/3 initial dose required, per hour
3. Check for and correct hypoglycaemia with 50mL 50% glucose IV
4. Seek and treat any co-ingestants
Other acceptable answers:
- Monitor conscious state and adequacy of ventilation and adjust naloxone infusion as necessary
- Admit to HDU, consult Toxicology or Addiction Med Unit

5. b) Outline your next four steps in his management. (4 marks)
Did not accept:
CTB – unless you qualified with: “if doesn’t respond appropriately to initial treament”. I don’t think he needs a CTB if he wakes.
Big doses of naloxone
Intubation – unless good description of naloxone administration (bolus & infusion) with endpoints given.
E.g. Intubate if unable to achieve adequate ventilation/oxygenation despite adequate naloxone.

6. c) List five (5) clinical features of opioid withdrawal (5 Marks)
Anxiety 

Restlessness 

Abdo cramps
Insomnia 

Intense craving 

Many other acceptable options:
Yawning 

Lacrimation 

Salivation 

Diarrhoea 

N&V
Mydriasis 

Diaphoresis 

Piloerection
Myalgia HT
Tachycardia
Tremor

7. Revise the naloxone chapter!
Good luck!