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Overdose-Poisoning

Date Last Search Run: Feb 01, 2022
Table last updated: Oct 25, 2021
Data last added: Oct 25, 2021

Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)  
2 (fair evidence exists)  
3 (weak evidence exists)  


Interventions

Activated Charcoal
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Plasma paracetamol level Patient ED-MD Underhill TJ., Greene MK., Dove AF. A comparison of the efficacy of gastric lavage, ipecacuanha and activated charcoal in the emergency management of paracetamol overdose. Arch Emerg Med 1990; 7(3):148-154. Medline
II Supportive (Green) Complications Patient PH-Paramedic Villarreal J., Kahn CA., Dunford JV., Patel E., Clark RF. A retrospective review of the prehospital use of activated charcoal. Am J Emerg Med 2015; 33(1):56-59. Medline
II Neutral (Yellow) Time to administration Process PH-Paramedic Crockett R., Krishel SJ., Manoguerra A., et al. Prehospital use of activated charcoal: A pilot study. J Emerg Med 1996; 14(3):335-8. Medline
III Supportive (Green) Compliance with treatment guidelines Patient PH-Paramedic Thakore S., Murphy N. The potential role of prehospital administration of activated charcoal. Emerg Med J 2002; 19(1):63-65. Medline
III Neutral (Yellow) Feasibility Process PH-Paramedic Alaspaa Ari O., Markku J. Kulsma, Kalle Hoppu, Pertti J. Neuvonen. Out of Hospital Administration of Activated Charcoal by Emergency Medical Services. Ann Emerg Med 2005; 45(2):207-12. Medline
III Opposes (Red) 1) Feasibility - time from ingestion to ambulance arrival 2) potential aspiration risk Process PH-Paramedic Isbister GK., Dawson AH., Whyte IM. Feasibility of prehospital treatment with activated charcoal: Who could we treat, who should we treat? Emerg Med J 2003; 20(4):375-8. Medline

Benzodiazepine antagonist (Benzo OD)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Improvement in CGIS score Patient ED-MD Spivey WH., Roberts JR., Derlet RW. A clinical trial of escalating doses of flumazenil for reversal of suspected benzodiazepine overdose in the emergency department. Ann Emerg Med 1993; 22(12):1813-1821. Medline
I Supportive (Green) Improvement in the CGIS Score Patient ED-MD The Flumazenil Study Group. Treatment of benzodiazepine overdose with flumazenil. the flumazenil in benzodiazepine intoxication multicenter study group. Clin Ther 1992; 14(6):978-995. Medline
I Neutral (Yellow) Adverse events Patient ED-MD Barnett R., Grace M., Boothe P., et al. Flumazenil in drug overdose: Randomized, placebo-controlled study to assess cost effectiveness. Crit Care Med 1999; 27(1):78-81. Medline
I Opposes (Red) Adverse events Patient ED-MD Penninga EI., Graudal N., Ladekarl MB., et al. Adverse events associated with flumazenil treatment for the management of suspected benzodiazepine intoxication: a systematic review with meta-analyses of randomised trials. Basic Clin Pharmacol Toxicol 2016; 118:37-44. Medline
II Opposes (Red) Change in LOC Patient ED-MD Gueye PN., Hoffman JR., Taboulet P., et al. Empiric use of flumazenil in comatose patients: Limited applicability of criteria to define low risk. Ann Emerg Med 1996; 27(6):730735. Medline
III Supportive (Green) Prevalence of adverse events Patient ED-MD Nguyen HB., Troendle M., Cumpston K., Rutherfoord Rose S., Wills BK. Lack of adverse effects from flumazenil administration: an ED observational study Tammy T. Am J of Emerg Med 2015; 33:1677–9. Medline

Capnography
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Hypoventilation Patient ED-MD Langhan ML. Acute alcohol intoxication in adolescents: Frequency of respiratory depression. J Emerg Med 2013; 44(6):1063-1069. Medline

Glucagon (Beta-Blocker OD)
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Reversal of cardiovascular depression Patient ED-MD Peterson CD., Leeder JS., Sterner S. Glucagon therapy for beta-blocker overdose. Drug Intell Clin Pharm 1984; 18(5):394-8. Medline
III Supportive (Green) Survival Patient ED-MD Tai YT., Lo CW., Chow WH., Cheng CH. Successful resuscitation and survival following massive overdose of metoprolol. Br J Clin Pract 1990; 44(12):746-747. Medline
III Supportive (Green) Survival Patient ED-MD Weinstein RS., Cole S., Knaster HB., Dahlbert T. Beta blocker overdose with propranolol and with atenolol. Ann Emerg Med 1985; 14(2):161-163. Medline
III Neutral (Yellow) Mortality Patient ED-MD Bailey B. Glucagon in beta-blocker and calcium channel blocker overdoses: A systematic review. J Toxicol Clin Toxicol 2003; 41(5):595-602. Medline
III Neutral (Yellow) Mortality Patient ED-MD Barton CA., Johnson NB., Mah ND., Beauchamp G., Hendrickson R. Successful treatment of a massive metoprolol overdose using intravenous lipid emulsion and hyperinsulinemia/euglycemia therapy. Pharmacotherapy 2015; 35(5):e56-60. Medline
III Neutral (Yellow) Survival Patient PH-Paramedic Lewis M., Kallenbach J., Germond C., Zaltzman M., Muller F., Steyn J., et al. Survival following massive overdose of adrenergic blocking agents (acebutolol and labetalol). Eur Heart J 1983; 4(5):328-32. Medline
III Neutral (Yellow) Mortality Patient ED-MD O'Mahony D., O'Leary P., Molloy MG. Severe oxprenolol poisoning: the importance of glucagon infusion. Hum Exp Toxicol 1990; 9(2):101-3. Medline

Haloperidol (cannabinoid hyperemesis)
Level Direction Primary Outcome Patient/Process Setting Reference

Naloxone-IM (Opiate OD)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Time to regain RR>10 Patient PH-Paramedic Kelly AM., Kerr D., Patrick I., Walker T., Koutsogiannis Z. Randomised trial of intranasal vs intramuscular naloxone in prehospital treatment for suspected opiod overdose. Med J Aus 2005; 182:24-7. Medline
I Supportive (Green) Response within 10 minutes of naloxone treatment Patient PH-Paramedic Kerr D., Kelly AM., Dietze P., Jolley D., Barger B. Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction 2009; 104(12):2067-74. Medline
II Supportive (Green) Adequate response Patient PH-Paramedic Chou R, Korthuis PT, McCarty D, Coffin PO, Griffin JC, Davis-O'Reilly C, et al. Management of Suspected Opioid Overdose With Naloxone in Out-of-Hospital Settings: A Systematic Review. Ann Intern Med 2017; 167(12) 867-75. Medline
II Supportive (Green) Safety and efficacy Patient Other Harris K, Page CB, Samantray S, Parker L, Brier AJ, Isoardi KZ. One single large intramuscular dose of naloxone is effective and safe in suspected heroin poisoning. EMA 2019. Medline
II Supportive (Green) Safety Process PH-Paramedic Tylleskar I, Gjersing L, Bjørnsen LP, Braarud A, Heyerdahl F, Dale O, et al. Prehospital naloxone administration - What influences choice of dose and route of administration? BMC Emerg Med 2020; 20(1). Medline
II Neutral (Yellow) Dose required to increase LOC and RR Process PH-Paramedic Cantwell K., Dietze P., Flander L. The relationship between naloxone dose and key patient variables in the treatment of non-fatal heroin overdose in the prehospital setting. Resuscitation 2005; 65: 315-9. Medline
III Supportive (Green) Adverse events in the ED Process PH-Paramedic Maloney LM, Alptunaer T, Coleman G, Ismael S, McKenna PJ, Marshall RT, et al. Prehospital Naloxone and Emergency Department Adverse Events: A Dose-Dependent Relationship. J Emerg Med 2020; 59(6):872-83. Medline
III Supportive (Green) Response within 5 minutes of naloxone treatment Patient ED-MD Sporer KA., Firestone J., Isaacs M. Out-of-hospital treatment of opioid overdoses in an urban setting. Acad Emerg Med 1996; 3(7):660-667. Medline
III Supportive (Green) Mortality Patient PH-Paramedic Vilke GM., Sloane C., Smith AM., Chan TC. Assessment for deaths in out-of-hospital heroin overdose patients treated with naloxone who refuse transport. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine 2003; 10(8):893-896. Medline
III Neutral (Yellow) Adverse events following Naloxone Process PH-Paramedic Buajordet I., Naess AC., Jacobsen D., Brors O. Adverse events after naloxone treatment of episodes of suspected acute opioid overdose. Eur J Emerg Med 2004; 11:19-23. Medline
III Neutral (Yellow) Response to D50W, appropriate diagnosis Patient PH-Paramedic Hoffman JR., Schriger DL., Votey SR., Luo JS. The empiric use of hypertonic dextrose in patients with altered mental status: A reappraisal. Ann Emerg Med 1992; 21(1):20-4. Medline

Naloxone-IN (Opiate OD)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Response within 10 minutes of naloxone treatment Patient PH-Paramedic Kerr D., Kelly AM., Dietze P., Jolley D., Barger B. Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction 2009; 104(12):2067-74. Medline
I Neutral (Yellow) Time to regain RR>10 Patient PH-Paramedic Kelly AM., Kerr D., Patrick I., Walker T., Koutsogiannis Z. Randomised trial of intranasal vs intramuscular naloxone in prehospital treatment for suspected opiod overdose. Med J Aus 2005; 182:24-7. Medline
II Supportive (Green) Time to positive clinical response Patient PH-Paramedic Barton ED., et al. Efficacy of IN naloxone as a needleless alternative treatment of opioid overdose in the prehospital setting. J Emerg Med 2005; 29:265-71. Medline
II Supportive (Green) Adequate response Patient PH-Paramedic Chou R, Korthuis PT, McCarty D, Coffin PO, Griffin JC, Davis-O'Reilly C, et al. Management of Suspected Opioid Overdose With Naloxone in Out-of-Hospital Settings: A Systematic Review. Ann Intern Med 2017; 167(12) 867-75. Medline
II Supportive (Green) Need for susbsequent doses Patient PH-Paramedic Fidacaro GA, Patel P, Carroll G, Bartimus H, Hunter K, Hong R. Do Patients Require Emergency Department Interventions After Prehospital Naloxone? J of addiction medicine 2019. Medline
II Supportive (Green) GCS Patient PH-Paramedic Merlin MA., Saybolt M., Kapitanyan R., et al. Intranasal naloxone delivery is an alternative to intravenous naloxone for opioid overdoses. Am J Emerg Med 2010; 28(3):296-303. Medline
II Supportive (Green) Improved vital signs Patient PH-Paramedic Nugent K, Matthews P, Gissendaner J, Papas M, Occident D, Patel A, et al. A Comparison of Efficacy of Treatment and Time to Administration of Naloxone by BLS and ALS Providers. Prehosp Disaster Med 2019; 34(4) 350-5. Medline
II Supportive (Green) Time to positive clinical response Patient PH-Paramedic Robertson TM., et al. Intranasal Naloxone is a Viable Alternative to Intravenous Naloxone for Prehospital Narcotic Overdoses. Prehospital Emergency Care 2009; 13(4):512-5. Medline
II Supportive (Green) Safety Process PH-Paramedic Tylleskar I, Gjersing L, Bjørnsen LP, Braarud A, Heyerdahl F, Dale O, et al. Prehospital naloxone administration - What influences choice of dose and route of administration? BMC Emerg Med 2020; 20(1). Medline
III Supportive (Green) Time to positive clinical response Process PH-Paramedic Barton E., Ramos J., Colwell C., Benson J., Baily J., Dunn W. Intranasal Administration of Naloxone by Paramedics. Prehospital Emergency Care 2002; 6(1):54-8. Medline
III Supportive (Green) Effective antidote response (EAR) Patient ED-MD Friedman M., Manini A. Validation of Criteria to Guide Prehospital Naloxone Administration for Drug-Related Altered Mental Status. Med Toxicol 2016; 12(2016):270–5. Medline
III Supportive (Green) Change in vitals Patient PH-Paramedic Loimer N., Hofmann P., Chaudhry HR. Nasal administration of naloxone is as effective as the intravenous route in opiate addicts. Int J Addict 1994; 29(6):819-827. Medline
III Supportive (Green) Adverse events in the ED Process PH-Paramedic Maloney LM, Alptunaer T, Coleman G, Ismael S, McKenna PJ, Marshall RT, et al. Prehospital Naloxone and Emergency Department Adverse Events: A Dose-Dependent Relationship. J Emerg Med 2020; 59(6):872-83. Medline
III Supportive (Green) Efficacy Patient ED-Paramedic & CCP Weiner SG, Mitchell PM, Temin ES, Langlois BK, Dyer KS. Use of Intranasal Naloxone by Basic Life Support Providers. Prehospital emergency care 2016; 21(3) 322-6. Medline
III Neutral (Yellow) Resolution of Symptoms Patient PH-Paramedic Zuckerman M., Weisberg SN., Boyer EW. Pitfalls of intranasal naloxone. Prehosp Emerg Care 2014; 18(4):550-554. Medline
X Not Yet Graded (White) - Kummer RL, Kempainen RR, Olives TD, Leatherman JW, Prekker ME. Naloxone-associated pulmonary edema following recreational opioid overdose: A case series. Am J Emerg Med 2021; 41–3. Medline
X Not Yet Graded (White) - Thompson J, Salter J, Bui P, Herbert L, Mills D, Wagner D, et al. Safety, Efficacy, and Cost of 0.4-mg Versus 2-mg Intranasal Naloxone for Treatment of Prehospital Opioid Overdose. Ann Pharmacother 2021; 10600280211030918. Medline

Naloxone-IV (Opiate OD)
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Time to positive clinical response Patient PH-Paramedic Robertson TM., et al. Intranasal Naloxone is a Viable Alternative to Intravenous Naloxone for Prehospital Narcotic Overdoses. Prehospital Emergency Care 2009; 13(4):512-5. Medline
II Supportive (Green) Route of administration Process PH-Paramedic Tylleskar I, Gjersing L, Bjørnsen LP, Braarud A, Heyerdahl F, Dale O, et al. Prehospital naloxone administration - What influences choice of dose and route of administration? BMC Emerg Med 2020; 20(1). Medline
II Supportive (Green) Time to regain RR ≥10 Patient PH-Paramedic Wanger K., Brough L., MacMillan I., et al. Intravenous vs subcutaneous naloxone for out-of-hospital management of presumed opioid overdose. Acad Emerg Med 1998; 5(4):293-9. Medline
II Neutral (Yellow) Time to re-dose Patient ED-MD Wong F, Edwards CJ, Jarrell DH, Patanwala AE. Comparison of lower-dose versus higher-dose intravenous naloxone on time to recurrence of opioid toxicity in the emergency department. Clinical toxicology (Philadelphia, Pa) 2019; 57(1) 19-24. Medline
III Supportive (Green) Patient response to treatment LOC and RR Process PH-Paramedic Belz D., Lieb J., Rea T., Eisenberg M. Narcan use in a tiered-EMS system. Prehosp Emerg Care 2006; 10:468-71. Medline
III Supportive (Green) Mortality rate Patient PH-Paramedic Bertini G., Russo L., Cricelli F., et al. Role of a prehospital medical system in reducing heroin-related deaths. Crit Care Measures 1992; 20(4):493-8. Medline
III Supportive (Green) Resolution of symptoms Patient PH-Paramedic Gonzva J., Prunet B., Deniel C., Benner P., Toppin F., Brun PM. Early antidote use associated with noninvasive ventilation in prehospital treatment of methadone intoxication. Am J Emerg Med 2013; 31(2):e5-6. Medline
III Supportive (Green) Change in vitals Patient PH-Paramedic Loimer N., Hofmann P., Chaudhry HR. Nasal administration of naloxone is as effective as the intravenous route in opiate addicts. Int J Addict 1994; 29(6):819-827. Medline
III Supportive (Green) Adverse events in the ED Process PH-Paramedic Maloney LM, Alptunaer T, Coleman G, Ismael S, McKenna PJ, Marshall RT, et al. Prehospital Naloxone and Emergency Department Adverse Events: A Dose-Dependent Relationship. J Emerg Med 2020; 59(6):872-83. Medline
III Supportive (Green) Change in cardiac rhythm. Patient PH-Paramedic Saybolt MD., Alter SM., Dos Santos F., et al. Naloxone in cardiac arrest with suspected opioid overdoses. Resuscitation 2010; 81(1):42-6. Medline
III Supportive (Green) GCS Patient ED-MD Solhi H., Mostafazadeh B., Vishteh HR., Ghezavati AR., Shooshtarizadeh A. Benefit effect of naloxone in benzodiazepines intoxication: Findings of a preliminary study. Hum Exp Toxicol 2011; 30(7):535-540. Medline
III Supportive (Green) Response within 5 minutes of naloxone treatment Patient ED-MD Sporer KA., Firestone J., Isaacs M. Out-of-hospital treatment of opioid overdoses in an urban setting. Acad Emerg Med 1996; 3(7):660-667. Medline
III Supportive (Green) Mortality Patient PH-Paramedic Vilke GM., Sloane C., Smith AM., Chan TC. Assessment for deaths in out-of-hospital heroin overdose patients treated with naloxone who refuse transport. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine 2003; 10(8):893-896. Medline
III Neutral (Yellow) Adverse events following Naloxone Process PH-Paramedic Buajordet I., Naess AC., Jacobsen D., Brors O. Adverse events after naloxone treatment of episodes of suspected acute opioid overdose. Eur J Emerg Med 2004; 11:19-23. Medline
III Neutral (Yellow) Adverse events following Naloxone Patient PH-Paramedic Osterwalder, JJ. Naloxone-For intoxications with intravenous heroin and heroin mixtures-harmless or hazardous? A prospective clinical study. Clinical Toxicology 1996; 34(4):409-16. Medline
III Opposes (Red) Pulmonary complications Patient PH-Paramedic Farkas A, Lynch MJ, Westover R, Giles J, Siripong N, Nalatwad A, et al. Pulmonary Complications of Opioid Overdose Treated With Naloxone. Ann Emerg Med 2019. Medline
X Not Yet Graded (White) - Kummer RL, Kempainen RR, Olives TD, Leatherman JW, Prekker ME. Naloxone-associated pulmonary edema following recreational opioid overdose: A case series. Am J Emerg Med 2021; 41–3. Medline

Naloxone-Nebulized (Opiate OD)
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Patient response to treatment Patient PH-Paramedic Weber JM., Tataris KL., Hoffman JD., Aks SE., Mycyk MB. Can nebulized naloxone be used safely and effectively by emergency medical services for suspected opioid overdose? Prehosp Emerg Care 2012; 16(2):289-292. Medline
III Neutral (Yellow) Clinical status post naloxone (improved, neutral, decline) Patient PH-Paramedic Tataris KL., Weber JM., Stein-Spencer L., Aks SE. The effect of prehospital nebulized naloxone on suspected heroin-induced bronchospasm. Am J Emerg Med 2013; 31(4):717-8. Medline

Naloxone-SQ (Opiate OD)
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Time to regain RR ≥10 Patient PH-Paramedic Wanger K., Brough L., MacMillan I., et al. Intravenous vs subcutaneous naloxone for out-of-hospital management of presumed opioid overdose. Acad Emerg Med 1998; 5(4):293-9. Medline

Oxygen
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Oxygenation Patient ED-MD Ridgway ZA., Pountney AJ. Acute respiratory distress syndrome induced by oral methadone managed with non-invasive ventilation. EMJ 2007; 24:681. Medline

Oxymetry Monitoring
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Hypoventilation Patient ED-MD Langhan ML. Acute alcohol intoxication in adolescents: Frequency of respiratory depression. J Emerg Med 2013; 44(6):1063-1069. Medline

Sodium Bicarb (TCA OD)
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Reversal of WCT Patient ED-MD Franco V. Wide complex tachycardia after bupropion overdose. Am J of Emerg Med 2015; 33(1540):e3–5. Medline
III Supportive (Green) Hypotension, Widening of QRS Patient ED-MD Hoffman JR., Votey SR., Bayer M., Silver L. Effect of hypertonic sodium bicarbonate in the treatment of moderate-to-severe cyclic antidepressant overdose. Am J Emerg Med 1993; 11(4):336-41. Medline
III Neutral (Yellow) Clinical improvement Process PH-Paramedic Calkins T., Chan TC., Clark RF., Stepanski B., Vilke GH. Review of prehospital sodium bicarbonate use for cyclic antidepressant overdose. Emerg Med J 2003; 20(5):483-6. Medline
III Neutral (Yellow) Presence of alkalemia Patient ED-MD Wrenn K., Smith BA., Slovis CM. Profound alkalemia during treatment of tricyclic antidepressant overdose: A potential hazard of combined hyperventilation and intravenous bicarbonate. Am J Emerg Med 1992; 10(6):553-555. Medline

Treat & Release (Opiate OD)
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) 48 hour mortality Patient ED-Paramedic & MD Greene JA, Deveau BJ, Dol JS, Butler MB.Incidence of mortality due to rebound toxicity after 'treat and release' practices in prehospital opioid overdose care: a systematic review. Emerg Med J 2019; 36(4):219-224. Medline
II Neutral (Yellow) Rate of refusal of transport Process PH-Paramedic Glenn MJ, Rice AD, Primeau K, Hollen A, Jado I, Hannan P, et al. Refusals after prehospital administration of naloxone during the COVID-19 pandemic. PEC 2020:1-15. Medline
II Neutral (Yellow) One-week mortality after pre-hospital discharge Patient PH-Paramedic Heyerdahl F., Hovda KE., Bjornaas MA., Nore AK., Figueiredo JC., Ekeberg O., Jacobsen D. Pre-hospital treatment of acute poisonings in oslo. BMC Emergency Medicine 2008; 8:15-227X-8-15. Medline
II Neutral (Yellow) Mortality Process PH-Paramedic McLeod KE, Slaunwhite AK, Zhao B, Moe J, Purssell R, Gan W, et al. Comparing mortality and healthcare utilization in the year following a paramedic-attended non-fatal overdose among people who were and were not transported to hospital: A prospective cohort study using linked administrative health data. Drug Alcohol Depend 2020:108381. Medline
II Neutral (Yellow) Repeat EMS encounter Patient PH-Paramedic Zozula A, Neth MR, Hogan AN, Stolz U, McMullan J. Non-transport after Prehospital Naloxone Administration Is Associated with Higher Risk of Subsequent Non-fatal Overdose. Prehosp Emerg Care 2021:1-11. Medline
III Supportive (Green) Mortality Patient PH-Paramedic Boyd JJ., Kuisma MJ., Alaspaa AO., Vuori E., Repo JV., Randell TT. Recurrent opioid toxicity after pre-hospital care of presumed heroin overdose patients. Acta Anaesthesiol Scand 2006; 50: 1266-70. Medline
III Supportive (Green) Safety Patient PH-Paramedic Levine M., Sanko S., Eckstein M. Assessing the risk of prehospital administration of naloxone with subsequent refusal of care. Prehosp Emerg Care 2016; 20:566–9. Medline
III Supportive (Green) Death and/or readmission Patient PH-Paramedic Seidler D., Stuhlinger GH., Fischer G., et al. After antagonization of acute opiate overdose: A survey at hospitals in Vienna. Addiction 1996; 91(10):1479-1487. Medline
III Supportive (Green) Safety Process PH-Paramedic Vilke G., Buhanan J., Dunford J., Chan T. Are Heroin Overdose Deaths Related to Patient Release After Prehospital Treatment with Naloxone? Prehospital Emergency Care 1999; 3(3):183-186. Medline
III Supportive (Green) Mortality Patient PH-Paramedic Vilke GM., Sloane C., Smith AM., Chan TC. Assessment for deaths in out-of-hospital heroin overdose patients treated with naloxone who refuse transport. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine 2003; 10(8):893-896. Medline
III Supportive (Green) Survival Patient PH-Paramedic Wampler DA., Molina DK., McManus J., Laws P., Manifold CA. No deaths associated with patient refusal of transport after naloxone-reversed opioid overdose. Prehosp Emerg Care 2011; 15(3):320-324. Medline
III Neutral (Yellow) Adverse Event Patient ED-MD Christenson J., Etherington J., Grafstein E., et al. Early discharge of patients with presumed opioid overdose: Development of a clinical prediction rule. Acad Emerg Med 2000; 7(10):1110-8. Medline
III Neutral (Yellow) Rebound toxicity Patient PH-Paramedic Rudolph SS., Jehu G., Nielsen SL., Nielsen K., Siersma V., Rasmussen LS. Prehospital treatment of opioid overdose in copenhagen--is it safe to discharge on-scene? Resuscitation 2011; 82(11):1414-8. Medline
III Opposes (Red) Deaths Patient PH-Bystander Chou R, Korthuis PT, McCarty D, Coffin PO, Griffin JC, Davis-O'Reilly C, et al. Management of Suspected Opioid Overdose With Naloxone in Out-of-Hospital Settings: A Systematic Review. Ann Intern Med 2017; 167(12) 867-75. Medline


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