Simulated Patient Scenario

Suspected Heroin Overdose

Scenario Details

Scenario: Young adult found unresponsive with suspected opioid overdose.

Simulated Patient: 28-year-old Male Mannequin or Actor

Actor/Actress: Friend (panicked, provides limited history)

MDT Information

Urgent response - Unresponsive Person / Overdose
28-year-old male found unresponsive by friend
Possible drug overdose
Patient not breathing normally
Friend on scene

On Arrival

Paramedics arrive at a small apartment. A distressed friend directs them to the bathroom where the patient is lying slumped against the wall, unresponsive. There is drug paraphernalia (syringe, spoon, lighter) visible on the floor nearby. The patient appears cyanotic around the lips.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Unresponsive, cyanotic, signs of IV drug use nearby.
Response	Unresponsive to voice or painful stimuli (AVPU=U).
Airway	Partially obstructed by tongue due to decreased LOC, occasional snoring respirations heard initially, then apnoea.
Breathing	Apnoeic / Occasional gasping respirations initially, rapidly becoming apnoeic. Minimal chest wall movement.
Circulation	Pale, cool skin. Peripheral cyanosis. Carotid pulse palpable but may be slow/thready. Radial pulse weak or absent.
Disability	Unresponsive (GCS 3). Pupils pinpoint (miosis).
Exposure/Environment	Bathroom environment. Drug paraphernalia present (sharps risk). Patient partially clothed. Need to check for injuries/other issues.

Secondary Survey and Simulation Progression

History (Collateral from Friend, Patient unresponsive)

Allergies	Unknown (Friend unsure)
Medications	None known prescribed. Known history of heroin use.
Past Medical History	History of opioid dependence, previous non-fatal overdoses. Possible Hepatitis C.
Last Oral Intake	Unknown.
Events Preceding	Friend reports they used heroin together approx 15-20 minutes ago. Friend states the patient used "his usual amount". Patient went to the bathroom shortly after. Friend became concerned after hearing no noise, found patient unresponsive and called emergency services.

Vital Signs/Assessment (Initial)

Parameter	Value (Approximate/Expected)
Resp. Rate (/min.)	0-4 (Apnoeic or occasional gasps)
Lung Sounds (L/R)	Minimal/absent air entry.
SpO2 (%)	< 70% or unreadable initially (due to poor perfusion/hypoxia)
EtCO2 (mmHg)	Likely very high if measurable, or absent waveform if apnoeic.
Pulse Rate (/min.)	40-60, may be normal or bradycardic initially. Can deteriorate to PEA/asystole if prolonged hypoxia.
CRT (sec.)	> 3-4 seconds, sluggish.
ECG rhythm	Sinus bradycardia initially, potential for deterioration.
12-lead ECG	(Obtain if possible post-resuscitation) Check for hypoxic changes, underlying rhythm.
BP (mmHg)	May be low (e.g., 80/50) or initially maintained.
Skin	Pale, cool, cyanotic.
Pain (/10)	Unresponsive.
GCS (/15: E,V,M)	3/15 (U)
BGL (mmol/L)	Within normal limits (e.g., 6.2) - Rule out hypoglycaemia.
Pupils (mmL/mmR)	Pinpoint (1-2mm), equal, may be sluggishly reactive or non-reactive if severe hypoxia.
Pupil reac. (L/R)	Pinpoint, potentially sluggish/non-reactive.
Temp. (°C)	May be normal or low (hypothermic).

Physical Examination (Focused - once safe/during resuscitation)

**General:** Unresponsive, cyanotic, poor respiratory effort/apnoea.
**Airway:** Check for foreign body obstruction (vomitus).
**Skin:** Look for track marks (arms, legs, neck, groin), signs of skin popping/abscesses. Check for medication patches (e.g., fentanyl).
**Chest:** Check for signs of trauma, aspiration (crackles on auscultation later).
**Neurology:** Confirm GCS 3, pinpoint pupils.
**Environment:** Note paraphernalia present (needles - sharps safety!).

Assessment and Treatment

Appropriate Management

Recognise opioid toxidrome / overdose leading to respiratory arrest. **Time critical emergency.**
**Safety:** Ensure scene safety (sharps!). Use PPE.
**Airway Management:** Open airway (head-tilt/chin-lift or jaw thrust). Insert OPA/NPA if tolerated (unlikely initially). Suction if needed.
**Breathing Support:** **Immediate assisted ventilation** with Bag-Valve-Mask (BVM) and high-flow oxygen (15L/min). Aim for adequate chest rise and improving SpO2. Ventilate at approx 10-12 breaths/min.
**Naloxone Administration:** Administer Naloxone (opioid antagonist) promptly. Route depends on access and local protocols:
- **IM:** Often preferred initially if IV access not readily available (e.g., 0.8mg - 2mg depending on protocol). Can be repeated.
- **IN:** Intranasal naloxone is an option if available (e.g., 1.6mg - 2mg).
- **IV:** If IV access established, smaller titrated doses (e.g., 0.1mg - 0.4mg) can be given, titrating to adequate respiratory effort (aim RR > 10-12/min), not necessarily full consciousness.
**Monitor Response:** Continuously monitor respiratory rate, effort, SpO2, EtCO2, LOC, and pupils after naloxone. Repeat naloxone doses as needed if initial response is inadequate or wears off (naloxone half-life is shorter than many opioids).
**Circulation Support:** Monitor pulse and BP. IV access establishment. Fluids usually not required unless hypotensive or other factors present. Manage cardiac arrest according to standard ALS protocols if patient deteriorates.
**Consider Co-ingestions/Other Causes:** Rule out hypoglycaemia (check BGL). Consider other sedatives or causes of decreased LOC if poor response to naloxone.
**Post-Naloxone Care:**
- Patient may wake up agitated or combative (withdrawal). Manage calmly.
- Risk of vomiting/aspiration as LOC improves. Position appropriately (recovery position if appropriate and C-spine cleared).
- Risk of re-narcosis as naloxone wears off. Continuous monitoring is essential.
**Transport:** All patients receiving naloxone require transport to hospital for observation and further management, due to risk of re-narcosis and potential complications (e.g., aspiration pneumonia, hypoxic brain injury, rhabdomyolysis).
**Pre-notify:** Inform receiving hospital about suspected opioid overdose, patient's initial state (apnoeic, GCS 3), naloxone administered (dose, route, response), current vital signs and GCS.
Documentation: Record details of assessment, interventions (ventilation, naloxone dose/route/time), patient response, and monitoring.