section name header

Introduction

  1. Assessment. Common factors contributing to death from drug overdose or poisoning include loss of airway-protective reflexes with subsequent airway obstruction caused by the flaccid tongue; pulmonary aspiration of gastric contents; and respiratory arrest. All poisoned patients should be evaluated for a potentially compromised airway.
    1. Patients who are awake and talking are likely to have intact airway reflexes but should be monitored closely because worsening intoxication can result in rapid loss of airway control.
    2. In a lethargic or obtunded patient, the response to stimulation of the nasopharynx (eg, does the patient react to placement of a nasal airway?) or the presence of a spontaneous cough reflex may provide an indirect indication of the patient's ability to protect the airway. If there is any doubt, it is best to perform endotracheal intubation (see below).
  2. Treatment. Optimize the airway position and perform endotracheal intubation if necessary. Early use of naloxone or flumazenil may awaken a patient intoxicated with opioids or benzodiazepines, respectively, and obviate the need for endotracheal intubation. (Note: Flumazenil is not recommended except in very select circumstances, as its use may precipitate seizures.)
    1. Position the patient and clear the airway.
      1. Optimize the airway position to force the flaccid tongue forward and maximize the airway opening. The following techniques are useful. Caution: Do not perform neck manipulation if you suspect a neck injury.
        1. Place the neck and head in the “sniffing” position, with the neck flexed forward and the head extended.
        2. Apply the “jaw thrust” maneuver to create forward movement of the tongue without flexing or extending the neck. Pull the jaw forward by placing the fingers of each hand on the angle of the mandible just below the ears. (This motion also causes a painful stimulus to the angle of the jaw, the response to which reflects the patient's depth of coma.)
        3. Place the patient in a head-down, left-sided position that allows the tongue to fall forward and secretions or vomitus to drain out of the mouth.
      2. If the airway is still not patent, examine the oropharynx and remove any obstruction or secretions by suction, a sweep with the finger, or with Magill forceps.
      3. The airway can also be maintained with oropharyngeal or nasopharyngeal airway devices. These devices are placed in the mouth or nose to lift the tongue and push it forward. They are only temporary measures. A patient who can tolerate an artificial airway without complaint probably needs an endotracheal tube.
    2. Perform endotracheal intubation if personnel trained in the procedure are available. Intubation of the trachea provides the most reliable protection of the airway, preventing obstruction and reducing the risk for pulmonary aspiration of gastric contents as well as allowing mechanically assisted ventilation. However, it is not a simple procedure and should only be performed by those with training and experience. Complications include vomiting with pulmonary aspiration; local trauma to the oropharynx, nasopharynx, and larynx; inadvertent intubation of the esophagus or a mainstem bronchus; worsening acidosis due to apnea; and failure to intubate the patient after respiratory arrest has been induced by a neuromuscular blocker. There are two routes for endotracheal intubation: nasotracheal and orotracheal.
      1. Nasotracheal intubation. In nasotracheal intubation, a soft, flexible tube is passed through the nose and into the trachea by using a “blind” technique.
      2. Orotracheal intubation. In orotracheal intubation, the tube is passed through the patient's mouth into the trachea under direct vision, with the aid of a video laryngoscope device, or with the aid of a long, flexible stylet (bougie).
      3. Cricothyrotomy or tracheotomy may be necessary in the rare patient whose larynx is damaged or distorted making endotracheal intubation through the pharynx impossible.
    3. The role of extraglottic airway devices, such as the laryngeal mask airway (LMA), in patients with poisoning or drug overdose is not known; although these devices are easier to insert than endotracheal tubes, especially in some patients with “difficult” airways, they do not provide adequate protection against pulmonary aspiration of gastric contents, and they cannot be used in patients with laryngeal edema, injury, or laryngospasm. They may be useful in the prehospital setting, as a bridging airway technique during transport to an emergency department.