6.3 Opioid-Associated Emergencies & Opioid Antagonists

6.3 Opioid-Associated Emergencies & Opioid Antagonists

Opioids can suppress the brain's drive to breathe. A person may progress from slowed, shallow breathing to apnea, severe hypoxia, and cardiac arrest. The BLS provider's first job is not to prove which drug was taken; it is to recognize abnormal breathing, activate emergency response, assess for a definite pulse, and provide the oxygenation and circulation the person lacks.

Recognition without delaying care

Possible clues include unusual sleepiness or unresponsiveness, slow or absent breathing, drug packaging or paraphernalia, a witness report, or an available opioid antagonist such as naloxone. Small pupils can occur, but pupil size is not reliable enough to confirm or exclude opioid poisoning. Other emergencies—including stroke, head injury, hypoglycemia, seizure, and non-opioid poisoning—can also cause unresponsiveness.

Use the standard BLS assessment:

1. Confirm scene safety and use appropriate personal protective equipment.
2. Check responsiveness and call for help.
3. Activate the emergency response system and obtain an AED and ventilation equipment.
4. Assess breathing and a central pulse simultaneously for no more than 10 seconds.
5. Choose the pulse-present or no-pulse pathway.

Definite pulse, absent or inadequate breathing

When a definite pulse is present but the person is not breathing normally, begin rescue breathing immediately:

• Adult: 1 breath every 6 seconds.
• Infant or child: 1 breath every 2-3 seconds.
• Give each breath over about 1 second, using only enough volume for visible chest rise.
• Reassess the pulse and breathing about every 2 minutes.

Administer an available opioid antagonist as soon as it can be done without interrupting ventilation. Use the labeled directions for the exact product or follow local protocol and dispatcher guidance. Intranasal sprays, injectable products, and local responder kits are not interchangeable in dose or operation, so a BLS guide should not assign one universal dose to every device.

Continue rescue breaths after the antagonist is given. The medication is not a substitute for ventilation, and response may not be immediate. If the person begins breathing normally, keep the airway open, monitor continuously, and be prepared for breathing to worsen again.

No definite pulse: cardiac arrest

If no definite pulse is felt within 10 seconds, begin high-quality CPR with breaths and apply the AED as soon as it is available. The 2025 AHA special-circumstances guideline says an opioid antagonist may be reasonable during suspected opioid-associated cardiac arrest, provided its administration does not interfere with standard resuscitation.

That wording creates a clear priority order:

1. Start compressions.
2. Provide breaths because the arrest may be hypoxic.
3. Attach and use the AED.
4. Give the antagonist only while those actions continue without delay.

Do not stop compressions to assemble a spray, search belongings, calculate a drug dose, or wait for a response. No clinical trial has established that an opioid antagonist reverses cardiac arrest; CPR with breaths and AED use remain the immediate treatment.

After an apparent response

An opioid antagonist may wear off before the opioid effect has ended, so respiratory depression can recur. The ideal observation time varies with the substance, formulation, dose, route, and patient; it is not a single universal number that BLS providers should promise. Keep emergency services involved, monitor breathing and responsiveness, and follow product or dispatcher instructions for repeat dosing.

A person who awakens may be confused, nauseated, or agitated. Maintain scene safety, explain what happened, and do not let an apparent recovery end monitoring. If vomiting occurs and the person is breathing normally, position the airway to allow drainage when safe. If breathing becomes inadequate, resume ventilatory support. If the pulse is lost, begin CPR.

Decision table

Common errors

• Giving an antagonist before opening the airway and supporting breathing.
• Treating pinpoint pupils as a required finding.
• Stopping CPR to administer medication.
• Using one memorized dose for every formulation.
• Assuming that awakening means the emergency has ended.

On the exam, identify the pulse first. A pulse with inadequate breathing calls for rescue breaths and an antagonist; no pulse calls for CPR with breaths and an AED, with the antagonist only as a noninterrupting adjunct.