1
Scene Size-Up & SCENE SAFETY ▼
HIGHEST RISK SCENE TYPE. Fentanyl/carfentanil powder contact or inhalation can incapacitate responders. Do not rush in.
- Fentanyl/Carfentanil: Do NOT touch powder residue — dermal/inhalation exposure risk. Ensure ventilation. If residue visible, consider HazMat.
- Needles/Sharps: Assume sharps present. Do not reach into bags, pockets, or under furniture blindly.
- Violence/Agitation: Post-Narcan patients can wake combative. Assess for weapons.
- Bystanders: May also be exposed — assess others at scene.
- PPE: Double gloves minimum. Consider N95 if powder/spray suspected. Avoid touching face.
- Law Enforcement: Request if situation unknown, combative patient possible, or clandestine lab suspected.
- Note # of patients — poly-drug scenes may have multiple victims.
↓
2
Initial Assessment — ABCs with Toxicology Focus
- Airway: Check for vomit, secretions, gurgling — suction immediately if obstructed
- Breathing: Rate AND depth — opioids suppress both rate and tidal volume; count 30 seconds
- Circulation: Pulse rate/quality; stimulants ⇧ HR/BP, depressants ⇩ HR/BP
- LOC: AVPU — note baseline and any changes over time
- Pupils: Miosis (pinpoint) = opioids/cholinergic; Mydriasis (dilated) = stimulants/anticholinergic
- Skin: Diaphoresis (wet), dry/flushed, pallor, cyanosis, temperature, track marks
- Odor Clues: Alcohol (EtOH), garlic/musty (organophosphate), bitter almond (cyanide), fruity/acetone (DKA)
↓
🧪 Step 3 — Interactive Toxidrome Identifier
🔍 Identify the Toxidrome
Select observed findings (tap all that apply)
Select observed findings above to identify possible toxidrome
↓
💉 Step 4 — Opioid Overdose Management
🔔 NALOXONE (NARCAN) — Most Common OD
Intranasal (IN)
2–4 mg each nostril
IM / IV
0.4–2 mg
⚠ Fentanyl/Analogues: May require 4–8 mg+ IN. Repeat every 2–3 min if no response. Carfentanil may require even higher doses.
Goal: Adequate breathing — NOT full awakening. Full reversal causes acute withdrawal and combativeness.
⚠ Re-Sedation Risk: Naloxone duration 30–90 min is often SHORTER than fentanyl — patient CAN re-sedate after you leave. Transport ALL patients.
Goal: Adequate breathing — NOT full awakening. Full reversal causes acute withdrawal and combativeness.
⚠ Re-Sedation Risk: Naloxone duration 30–90 min is often SHORTER than fentanyl — patient CAN re-sedate after you leave. Transport ALL patients.
4
Opioid OD — Step-by-Step
- Apneic / not breathing: BVM with O2 first — ventilate 2 breaths before Narcan
- Breathing but unconscious: Recovery position (left lateral), O2, administer Narcan IN
- After Narcan: Reassess breathing in 2–3 min; repeat dose if inadequate respiratory rate (<12/min)
- Position: Recovery position if breathing; BVM if apneic; do NOT leave patient alone
- Classic Triad: Miosis + respiratory depression + LOC
- BLS Naloxone IN — authorized in most state EMT protocols
- ALS IV naloxone, repeat dosing protocols, airway management
↓
5
SAMPLE History ▼
- Substance(s): What was taken? Route (injection, IN, oral, smoked)? Amount? Multi-drug use is common and complicates presentation.
- Time: When was it taken? How long have they been unresponsive?
- Bystander info: Friends/witnesses are critical — ask what was used
- Prescription bottles at scene: Collect and bring to hospital (opioids, benzos, TCAs, cardiac meds)
- Prior OD history: Tolerance, history of fentanyl use, prior Narcan use
- Mental health history: Intentional overdose vs accidental — safety concern post-resuscitation
- Allergies: Naloxone allergy (rare but ask)
↓
6
Other Toxidrome Management
- Stimulant (cocaine/meth/MDMA): Cool environment, calm reassurance, O2, monitor cardiac; ALS benzos for severe agitation or seizure
- Depressant/Alcohol/Benzo: Airway management priority, recovery position, O2/BVM as needed, monitor temperature (hypothermia risk), NO specific reversal agent at BLS level
- Carbon Monoxide: 100% O2 via NRB IMMEDIATELY. SpO2 is FALSELY NORMAL — pulse oximetry CANNOT detect CO poisoning. Evacuate all occupants including asymptomatic persons. Hyperbaric O2 at hospital.
- Anticholinergic (TCAs, antihistamines, Benadryl, Jimsonweed): Actively cool patient (hyperthermia is life-threatening), calm dark environment, O2; ALS physostigmine/benzos. Mnemonic: "Mad as a hatter, dry as a bone, blind as a bat, red as a beet, hot as a hare"
- Organophosphate/Nerve Agent: Decontaminate FIRST — remove clothing, brush off powder, water flush skin. PPE is CRITICAL for responders. ALS for atropine and pralidoxime.
↓
☎
1-800-222-1222
US Poison Control Center — 24/7 for provider guidance on unknown substances, dosing, decontamination, and hospital preparation
8
Transport & ALS Triggers
ALL overdose patients must be transported regardless of Narcan response. Re-sedation risk, unknown substances, and poly-drug combinations require hospital evaluation.
🔴 ALS Intercept — Any of the following:
- Respiratory depression not responding to repeated Narcan doses
- Seizure activity
- Hypotension (SBP < 90)
- Cardiac dysrhythmia suspected
- Unknown substance (especially with multiple toxidromes)
- Poly-drug use suspected
- Altered LOC not improving after Narcan
- Organophosphate / nerve agent exposure (atropine needed)
- Carbon monoxide with symptoms (LOC, cardiac)
- Suspected intentional overdose with psychiatric risk