Overdose Order Set
Initial Assessment
Check Airway, Breathing, Circulation (If abnormal vitals contact MD immediately)
IV / O2 / Cardiac Monitoring / Accucheck
Orders
Overdose Order Protocol
Urine Specimen
Additional Labs:
ECG
Urine Drug Screen
CXR
Other investigations:
Vitals
Vitals: HR, RR, BP, SpO2 q15mins
Neurovitals
Neurovitals q15 min and PRN
If change in level of consciousness, notify MD immediately
Monitoring
Continuous Cardiac/SpO2
Glasgow Coma Scale q4h and PRN
Intake and Output q1h
Overdose Management
Known Ingestant(s):
Unknown Ingestant
Treatment (see protocol below
Lipid 20%
Injectable NaHCO3
N-Acetylycysteine (NAC)
Glucagon
CaCl2
Naloxone (Narcan)
Tubes/Respiratory
Nasogastric Tube
Contact Poison Control (P: 1-800-268-9017 ext.268)
Advice Given:
Yes
No
Overdose Order Set
Urinary Catheter
Insert Foley Catheter and initiate Indwelling Urinary Catheter (Short Term) Protocols
Yes
No
Respiratory (no ventilation)
Titrate O2 to keep SpO2 greater then 92% and less than 96%. If SpO2 greater than 96% discontinue O2
Patient with known chronically elevated PaCO2: Titrate O2 to keep SpO2 between 88% and 92%
O2
L/min via nasal prongs or
Diet
NPO, no PO medications
GI Decontamination:
THEN
Other:
Activated Charcoal (50 g) x 1 dose
PO OR
NG
Activated Charcoal 25 g q4h stop when stool contains charcoal
Activated Charcoal 50 g (225 mL) q4h stop when stool contains charcoal
Whole Bowel Irrigation –Stock Electrolyte Lavage at 500 mL/h NG until stool
is liquid
Lipid 20% Protocol (recommended for overdose of lipid soluble medications: i.e. psychotropic
drugs (TCA’s, SSRI’s, Atypical Antipsychotics, Anticonvulsants, Buproprion), calcium channel
blockers, beta blockers, herbicides/pesticides
20% Lipid Emulsion 1.5 mL/kg (lean body mass) over 1 minute, then infuse 0.25 mg/kg/minute
Repeat bolus dose x 1-2 if persistent cardiovascular collapse
Continue infusion for at least 10 minutes after achieving circulatory stability
If blood pressure remains low, increase infusion rate to 0.50 mg/kg/minute
**Recommend upper limit: approximately 10-12 mL/kg over the first 30 minutes (as per The American
Society of Regional Anesthesia guidelines [Attached])
NAC Protocol
21 Hour N-acetylcysteine IV Infusion Regimen
(If within 10 hours of acetaminophen ingestion)
21 Hour N-acetylcysteine IV Infusion Regimen (Total 3 doses; total dose delivered 300 mg/kg)
*** Recommended for patients intolerant to PO intake or with hepatic failure***
*** Fluid volume should be reduced in patients weighing less than 40 kg***
Loading Dose
Overdose Order Set
N-acetylcysteine
mg IV over 60 minutes (150 mg/kg) (max 15 g)
Second Dose
N-acetylcysteine
mg IV over 4 hours (50 mg/kg) (max 5 g)
Third Dose
N-acetylcysteine
mg IV over 16 hours (100 mg/kg) (max 10 g)
Notify MD to reassess need for further N-acetylcysteine 2 hours prior to end of regimen
NaHCO3 Protocol
Sodium Bicarbonate 150 mmol in 1 litre D5W bolus______ mL over
_____minutes, then
Infuse at 150 mL/h or ______ mL/h IV infusion (goal pH 7.45-7.55) when goal is achieved, notify MD
Glucagon Protocol
Refer to ACLS guidelines (attached)
Glucagon
mg (0.05-0.15 mg/kg) IV bolus, then infuse at
mg/hour (0.05-0.1 mg/kg/hour)
Titrate infusion rate to achieve adequate hemodynamic response
CaCl2 Protocol (100 mg/mL)
For Beta blocker overdose refractory to Glucagon:
20 mg/kg IV over 5-10 minutes, then 20 mg/kg/hour infusion (titrating based on hemodynamic
response)
For Calcium Channel Blocker overdose: (as per Lexicomp)
Initial: 1000-2000 mg over 5 minutes; may repeat every 10-20 minutes with 3-4 additional doses
or 1000 mg every 2-3 minutes until clinical effect is achieved (DeWitt, 2004); if favorable response
obtained, consider I.V. infusion, then:
Infusion: 20-40 mg/kg/hour (DeWitt, 2004; Salhanick, 2003)
Naloxone Protocol
Adult
IV/IM/SC: 0.1-0.4mg (single max. dose of 2mg), repeat q2-3 minutes until reversal is seen
(if no response is observed after 10mg, there may be another cause of respiratory
depression)
OR
IV infusion: 2mg in 500mL D5W/NS (0.004mg/mL = 4mcg/mL)
Administer two-thirds of bolus dose that resulted in reversal each hr.,
ie. If 0.4mg bolus resulted in reversal, run drip 0.27mg/hr = 67mL/hr. Titrate to
effect.
If no reversal with bolus, start drip at 0.4mg/hr. and titrate to effect.
Children
0.01mg/kg IV/IM/SC q2-3 min. for 2-3 doses
Overdose Order Set
Bolus Administration
Naloxone
(0.4-2mg) IV bolus, repeat q2-3 minutes if necessary. (if no
response after 10mg, consider other causes for respiratory depression)
Continuous Infusion (for use with exposure to long-acting opioids or extended release products)
Infuse 2/3 of the initial effective bolus naloxone dose on an hourly basis; administer ½ of the
initial effective bolus naloxone dose within 15 minutes of starting the infusion. Adjust infusion rate
as needed to ensure adequate ventilation and prevent withdrawal symptoms. (As per Lexicomp)
Attempt to Identify Toxidromes:
Anticholinergic (hyperthermia, dilated pupils, dry skin, flushing, agitation/hallucinations)
Sympathomimetic (tachycardia, hypertension, diaphoresis, piloerection, seizures, hyperthermia,
dilated pupils)
Opiate/Sedative (miosis, nausea, vomiting, respiratory depression, hypothermia)
Cholinergic (salivation, lacrimation, urination, defecation, GI distress, emesis)
Serotonin Syndrome (agitation, diarrhea, tachycardia, hallucinations, hyperthermia, nausea,
vomiting)
Ethanol Posioning (confusion, vomiting, seizures, respiratory depression, hypothermia, cyanosis,
unconciousness) Add protocol
Management of Identified toxidrome(s):
____________________________________
Seizure Control
Avoid phenytoin in TCA overdose***
Lorazepam 4mg slow IV over 1-2 minutes (max rate 4mg/min) q 10-15mins prn if necessary
(max dose usually 8 mg)
Diazepam 5-10 mg IV given over <5 mg/min q5-10min prn (max dose: 30 mg)
Overdose Order Set
Intubation Protocol
Pre Intubation
Etomidate _____ mg IV
fentaNYL _____ micrograms IV
Ketamine _____ mg IV
_____ mg IV
Propofol _____ mg IV
Rocuronium _____ mg IV
Succinylcholine _____ mg IV
Midazolam
Other:
_________________________________________________________
Post Intubation
fentaNYL _____ micrograms IV q _____ minutes PRN (max _____ micrograms)
Morphine _____ mg IV q _____ minutes PRN (max _____ mg)
_____ mg IV q _____ minutes PRN (max _____ mg)
Phenylephrine ___ micrograms IV q2minutes PRN if Systolic BP less than ____ (max ___mcg
Rocuronium _____mg IV q____ minutes PRN (max _____ mg)
Midazolam
Maintain sedation if patient paralyzed with Rocuronium
Other:
_________________________________________________________
Disposition
Additional Orders
Overdose Order Set
Overdose Order Set