An opioid-associated life-threatening emergency with a pulse describes a severe medical situation where a person’s breathing is dangerously suppressed due to opioid effects, yet their heart is still beating. This condition demands immediate intervention to prevent further deterioration and potential fatality.
Recognizing the Emergency
Identifying an opioid-associated life-threatening emergency involves observing a distinct set of signs and symptoms. A person experiencing this emergency will often exhibit severe respiratory depression, characterized by breathing that is unusually slow, shallow, or has stopped entirely. They may also be unresponsive to external stimuli or extremely difficult to awaken, indicating a decreased level of consciousness.
A notable physical sign is constricted pupils, often described as “pinpoint pupils,” which are unusually small and do not react to light. Discoloration of the skin, such as blue or gray lips and fingernails (cyanosis), signals a lack of oxygen. Other indicators can include a limp body, cold or clammy skin, or gurgling sounds resembling snoring, sometimes called a “death rattle.”
Taking Immediate Action
Immediately call emergency services (e.g., 911 in the U.S.), stating the person is unresponsive and not breathing normally. If naloxone is available, administer it.
Naloxone can be administered either intranasally or intramuscularly. For intranasal naloxone, peel back the tab to open the package, then hold the nasal spray with your thumb on the plunger and your fingers on either side of the nozzle. Gently insert the nozzle into one nostril until your fingers touch the bottom of the person’s nose, then press the plunger firmly to release the entire dose. For intramuscular injection, draw up the prescribed dose, usually 0.4 mg to 2 mg, into a syringe with a 1 to 1.5-inch needle, and inject it into a large muscle like the thigh or upper arm, even through clothing if necessary.
While waiting for naloxone to take effect (2-3 minutes) or for emergency services to arrive, perform rescue breathing if the person is not breathing or breathing very slowly (less than one breath every 5 seconds). Lay the person on their back, tilt their head back by lifting their chin to open the airway, and check for any obstructions in their mouth. Pinch their nose, create a seal with your mouth over theirs, and give one slow breath every 5 seconds, ensuring their chest rises. If breathing resumes, or if you need to leave the person momentarily, place them in the recovery position by turning them onto their side with a bent knee and an arm supporting their head to help maintain an open airway and prevent choking on vomit.
The Underlying Danger
Opioids profoundly affect the central nervous system, particularly the brainstem. Opioids bind to mu-opioid receptors located in brainstem regions that regulate breathing. This interaction suppresses the neural circuits that control breathing.
This suppression causes breathing to become slow, shallow, or stop. Even with a pulse, the body does not receive enough oxygen, leading to hypoxemia. Opioids also impair reflexes that normally increase breathing in response to low oxygen or high carbon dioxide levels, further compromising oxygen intake. The danger is lack of oxygen to the brain and vital organs, which can lead to brain damage and cardiac arrest if not reversed.
What Happens Next
After administering naloxone, remain with the person until medical professionals arrive. Naloxone’s effects are temporary, typically lasting between 30 to 90 minutes, while the effects of some opioids can persist much longer. This discrepancy means there is a risk of respiratory depression returning once the naloxone wears off, potentially leading to re-overdose.
If the initial dose of naloxone does not produce a response within 2 to 3 minutes, a second dose should be administered. When emergency services arrive, they will take over care, which may include administering additional naloxone doses, providing ventilatory support, and monitoring vital signs. In a hospital setting, further medical care may involve ongoing monitoring, drug tests to confirm the overdose, and treatment for any complications. It is important for individuals who have experienced an opioid overdose to receive follow-up care, including referrals to substance use disorder treatment programs, as this can reduce the risk of future overdoses.