Written by Doug Wallace
With notable exclusion criteria, the incidence of intubation in opiate overdose patients after 4 hours was rare in this study: 9/1591 (0.6%).
A little obs never hurt anyone
Opiate overdose deaths continue to rise. These patients frequently present to the ED. Recommendations for the duration of ED observation have largely not been evidence based.
This multicenter study analyzed outcomes in 1,591 patients. Inclusion criteria included adults that had suspected acute opioid overdose, with blood available for confirmatory testing. Exclusion criteria included children, incarceration, trauma, and, interestingly, patients that were intubated within 4 hours of arrival.
9/1591 or 0.6% required intubation more than 4 hours after arrival to the ED. 78% of the intubated patients received multiple doses of naloxone. 8/9 had additional indications for intubation outside of hypoventilation-induced respiratory failure. At least two substances were found on drug screening of all intubated patients. The authors acknowledge the limitations of the study, including a relatively small sample size in the context of multiple exclusion criteria. Notably, incidence of intubation jumped to 101/1591 or 6% when including patients intubated prior to 4 hours.
How will this change my practice?
This study reaffirms my practice of observing opiate OD patients for at least four hours. While the authors note a low incidence of “delayed intubation”, the study doesn’t provide much reassurance that there is a low incidence of intubation within the first four hours after overdose, given the exclusion of these patients.
Source
Risk of Delayed Intubation After Presumed Opioid Overdose in the Emergency Department. Ann Emerg Med. 2025 Mar 3:S0196-0644(25)00060-5. doi: 10.1016/j.annemergmed.2025.01.022. Epub ahead of print. PMID: 40047773
