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Note: links from this entry are not printed automatically; please access and print
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The information on TOXBASE® requires expert clinical
interpretation and, therefore, should only be used by
UK NPIS 0844 892 0111
clinically trained healthcare professionals, who are aware of
the relevant clinical case history. In severe or complex
Ireland NPIC (01) 809 2566
cases, including multiple ingestions, you should always
[email protected]
0844 892 0111, in Ireland NPIC (01) 809 2566
discuss your case with your poisons service: in the UK NPIS
Heroin
Updated Updated 12/2012
Type of Product
Opioid analgesic. Recreational drug of abuse. Also available as a licensed product as
diamorphine hydrochloride.
Synonyms
Heroin hydrochloride
Slang terms: Boy, Brown Sugar, Chinese, Chinese rock, Climax (also used for butyl nitrite
and crack) Crap, Dana, Elephant, H (also used for cannabis), Harry, Horse, Joy powder,
Junk, Mexican brown, Noise, Persian, Rock, Rock 'n' Roll, Rufus, Smack (also used for
cocaine), Stuff, TNT (also used for alkyl nitrites), White elephant, White junk, White stuff.
Caution: using a slang term to try and identify a drug of abuse is potentially dangerous
since there are many regional variations and the terms change over time.
Toxicity
Is due to opioid effects. In addition, the purity of street drugs cannot be guaranteed;
impurities and/or adulterants may lead to atypical complications. Intravenous use of street
heroin may result in local bacterial infections at the site of injection (e.g. abscesses) and at
distant sites such as endocarditis. Viral infections such as HIV and hepatitis may occur.
With street drugs, consider the route of exposure and refer to the TOXBASE ® entry for
Body Packers, Body Stuffers and "Parachuting" as required.
Discuss with your local poisons information service: in the UK NPIS 0844 892 0111, in
Ireland NPIC (01) 809 2566.
Click here for details you may be required to give when telephoning NPIS.
ALERT BOX
All patients who have taken a deliberate overdose should be referred for
assessment.
All children and symptomatic adults should be referred for medical assessment.
All adults who are not daily users of opioid drugs or medications should be
referred for medical assessment if they have ingested, injected or smoked a toxic
dose or more (click here for estimated toxic doses).
All adults who are daily users of opioid drugs or medications should be referred
for medical assessment if they have ingested, injected or smoked a toxic dose or
more (click here for estimated toxic doses), if more than their usual dose.
Asymptomatic adults who have ingested, injected or smoked less than the
estimated toxic dose; or less than their usual dose do not need to be referred. All
patients should be advised to seek medical attention if symptoms develop.
Opioid features and management
Updated* 9/2012
Features
Severe opiate toxicity produces depression of the respiratory and central nervous systems
and pin-point pupils. If untreated the depression of the level of consciousness can lead to
deep coma, convulsions and respiratory arrest.
The effects in overdosage will be potentiated by simultaneous ingestion of alcohol and
other centrally acting drugs.
Milder opiate toxicity may produce nausea, vomiting, nightmares, anxiety, agitation,
euphoria, dysphoria, depression, paranoia and hallucinations. While pin-point pupils are
often present, this is not a reliable clinical sign and their absence does not exclude opiate
toxicity.
For certain opiates (such as morphine, diamorphine, codeine and pethidine), the risk of
toxicity is significantly increased if kidney function is impaired due to reduced elimination
of the parent opioid or active metabolite.
Opioids, in particular codeine, can cause histamine release, most commonly causing
urticaria and pruritis. Non-cardiac pulmonary oedema and rhabdomyolysis may occur after
intravenous injection of opioid analgesics.
Some opioids may cause cardiotoxicity e.g. methadone causing prolonged QT and
dextropropoxyphene causing sodium channel blockade and QRS prolongation.
The route of opiate administration may produce important clinical features such as softtissue infections and abscesses at the sites of intravenous heroin injection. The presence of
infections distant to the injection site should also be specifically determined (for example,
endocarditis, lung abscesses).
The possibility of viral hepatitis and HIV infection should be considered in all intravenous
drug users and testing should be routinely offered or recommended.
Management in Unconscious Patients
Management in Conscious Patients
Codeine in pregnancy
Heroin in pregnancy
Oxycodone in pregnancy
Meptazinol in pregnancy
Morphine in pregnancy
National Naloxone Programme - Scotland
Drugs of abuse - time limits for detection
References
All material on TOXBASE® is subject to Crown copyright protection unless otherwise stated. Material should
only be used to assist in the clinical management of poisoned patients and may be printed using the
"Printable version" button, however we strongly advise that printouts should NOT be kept for any length of
time, or for “future reference” as they can rapidly become out of date. For any other use of material you
must apply for permission to NPIS Edinburgh, RIE, EH16 4SA or via [email protected].
Management
Suggested nursing
care plan - click here
1. Maintain a clear airway and ensure adequate ventilation.
2. In the event of cardiac arrest in hospital or witnessed out of hospital cardiac arrest with
bystander CPR, resuscitation should be continued for at least 1 hour.
Prolonged resuscitation for cardiac arrest is recommended following poisoning as
recovery with good neurological outcome may occur.
Discuss with your local poisons information service: in the UK NPIS 0844 892 0111, in
Ireland NPIC (01) 809 2566.
Click here for details you may be required to give when telephoning NPIS.
3. Naloxone
If the patient has respiratory depression, inadequate airway protection, or has
decreased consciousness, give naloxone.
For children aged 12 years or over and adults:





mg).
Give an initial dose of 400 micrograms (0.4 mg).
If there is no response after 60 seconds, give a further 800 micrograms (0.8
If there is still no response after another 60 seconds, give another 800
micrograms (0.8 mg).
If still no response (after a total of 2 mg), give a further 2 mg dose. Large
doses (4 mg) may be required in a seriously poisoned patient.
Aim for reversal of respiratory depression, not full reversal of consciousness.
For children (under 12 years of age):


mg.
Give an initial dose of 100 micrograms/kg (0.1 mg/kg) up to a maximum of 2
If there is no response after 60 seconds give another 100 micrograms/kg (0.1
mg/kg) and repeat until a satisfactory response has been obtained or a maximum of
2 mg has been given.
Once an adequate response has occurred, monitor blood gases, oxygen saturation, and
respiratory rate.
Intramuscular naloxone is an alternative in the event that IV access is not possible or is
delayed. Failure of a definite opioid overdose to respond to large doses of
naloxone suggests that another CNS depressant drug or brain damage is
present.
Observe the patient carefully for recurrence of CNS and respiratory depression. The
duration of action of naloxone is shorter than that of all opioid analgesics - REPEATED
DOSES OF NALOXONE MAY BE REQUIRED.
Intravenous infusions following resuscitation
Intravenous infusions of naloxone are often useful where repeated doses are required.
An infusion of 60% of the initial dose required for resuscitation per hour is a useful
starting point.
For adults, a solution containing 10 mg (25 vials) made up to a final volume of 50 mL
with dextrose will produce a 200 micrograms/mL solution for infusion using an IV pump
(dose adjusted to clinical response).
For children weighing less than 20 kg, a more dilute solution may be appropriate to
allow accurate dose adjustment. For example, a solution containing 0.5 mg/kg body
weight of naloxone made up to a final volume of 50 mL with dextrose would deliver
0.01 mg/kg/hour if infused at 1 mL/hour.
Naloxone can be used undiluted provided an appropriate pump is available. Note this is
an off-licence use.
Infusions are not a substitute for frequent review of the patient's clinical
state.
4. Look for and REMOVE ANY TRANSDERMAL PATCHES. Be aware that the patient may
have ingested multiple packets of opiate drugs. Click here for features and
management of body packers/body stuffers.
5. Consider oral activated charcoal (charcoal dose: 50 g for adults; 1 g/kg for children) if
a toxic amount or more has been ingested by an adult or a child, provided the patient's
airway can be protected. It should be given as soon as possible after ingestion.
It is reasonable to assume that administration of activated charcoal later than 1 hour
post ingestion may be beneficial for sustained release (SR, MR) preparations but there
is no clinical trial evidence to support this.
Although it may seem reasonable to assume that late administration of activated
charcoal may be beneficial for preparations which delay gastric emptying there are few
data to support this.
6. Observe all patients until able to maintain adequate respiration for at least 6 hours.
Patients treated with naloxone should be monitored until able to maintain adequate
respiration for at least 6 hours after the last dose.
Monitor BP, pulse, respiratory rate and conscious level every 15 minutes initially.
Monitor oxygen saturation continuously in patients with a reduced level of
consciousness. Consider arterial blood gas analysis to test for hypercapnia or hypoxia in
patients with reduced respiration.
Check U&Es, creatinine and CK activity in patients at risk of rhabdomyolysis, for
example those with a history of prolonged unconsciousness.
7. Perform a 12 lead ECG and measure the QRS duration and QT interval. Repeat 12 lead
ECG is recommended, especially in symptomatic patients or in those who have ingested
slow release preparations. There are specific treatments for QRS prolongation (such as
sodium bicarbonate) and QT prolongation (such as magnesium sulphate) - click here for
further advice and management of ECG abnormalities.
8. Rhabdomyolysis
If rhabdomyolysis is present (CK activity greater than 5 x the upper limit of the normal
range), renal failure can develop particularly if the CK activity is greater than 5000 iu/L.
There are theoretical and experimental reasons why early volume replacement and
urine alkalinization may be helpful in preventing or reducing the severity of
rhabdomyolysis-induced renal failure. There is no strong evidence base from
randomized controlled trials in poisoning but there is some evidence in crush injury.
Give volume replacement as soon as possible and consider the need for urine
alkalinization. In an adult give 225 mmol of 8.4% sodium bicarbonate (in a child 3 - 5
mmol/kg) over one hour to increase the urine pH to greater than 7.5; further doses of
bicarbonate will be required to maintain pH greater than 7.5.
Since bicarbonate is irritant to veins and can cause local necrosis in cases of
extravasation, administration by a central venous line is recommended where
possible.
Haemodiafiltration can effectively remove myoglobin from the circulation;
haemodiafiltration combined with urine alkalinization is more effective than urine
alkalinization alone (Peltonen et al, 2007).
Monitor fluid balance, plasma sodium and potassium and urine pH. Beware severe
hyperkalaemia.
Haemodialysis / haemodiafiltration / haemofiltration may be required if acute renal
failure develops or severe hyperkalaemia is present.
If initial CK is normal but there is concern about muscle damage consider repeat
measurement.
9. Adult patients who become agitated following naloxone treatment can be sedated
carefully with oral or IV diazepam (0.1 - 0.3 mg/kg body weight). If ineffective
consider oral (5 - 10 mg) or parenteral (2 - 10 mg) haloperidol, 0.5 - 2 mg (oral or IV)
initially in the elderly.
In children it is better to manage agitation without sedation and exclude other causes
(e.g. hypoxia, infection, hypoglycaemia and raised ICP). Consider nursing in a dark and
quiet environment with a close relative present; seek expert paediatric advice. If
required, for children over 3 years buccal (3-5 years 5 mg; 5-10 years 7.5 mg; 10-16
years 10 mg) or IV midazolam (150 - 200 microgram/kg body weight) is generally the
most appropriate drug for managing agitation and requires specialist paediatric care.
10.Treat urticaria and pruritis with an antihistamine e.g. chlorphenamine (4 - 8 mg orally,
10 mg IV).
11.Check for infection at sites of injection and for signs of endocarditis, pneumonia and
pulmonary oedema.
12.Discuss testing for HIV and hepatitis in all patients using intravenous drugs.
13.Other measures as indicated by the patient's clinical condition.
Patients should be advised on discharge to seek medical attention if symptoms
subsequently develop.
Links
Activated charcoal
References
Nursing guide - opioid analgesics
Contact Page | sitemap | About the NPIS | Contributors
All material on TOXBASE® is subject to Crown copyright protection unless otherwise stated. Material should
only be used to assist in the clinical management of poisoned patients and may be printed using the
"Printable version" button, however we strongly advise that printouts should NOT be kept for any length of
time, or for “future reference” as they can rapidly become out of date. For any other use of material you
must apply for permission to NPIS Edinburgh, RIE, EH16 4SA or via [email protected].
TOXBASE® © Crown copyright 1983-2013
Management
Suggested nursing
care plan - click here
1. Consider oral activated charcoal (charcoal dose: 50 g in adults, 1 g/kg in children) if a
toxic amount or more has been ingested by an adult or a child, provided the patient's
airway can be protected. It should be given as soon as possible after ingestion.
It is reasonable to assume that administration of activated charcoal later than 1 hour
post ingestion may be beneficial for sustained release (SR, MR) preparations but there
is no clinical trial evidence to support this.
Although it may seem reasonable to assume that late administration of activated
charcoal may be beneficial for preparations which delay gastric emptying there are few
data to support this.
2. If the patient has signs of opioid toxicity observe until fully awake.
3. Look for and REMOVE ANY TRANSDERMAL PATCHES. Be aware that the patient may
have ingested multiple packets of opiate drugs. Click here for features and
management of body packers/body stuffers.
4. Monitor BP, pulse, respiratory rate, oxygen saturation and conscious level at least
hourly for at least 4 hours after exposure or 8 hours if a sustained release preparation
has been taken.
Very large overdoses may require longer periods of observation.
5. Perform a 12 lead ECG and measure the QRS duration and QT interval. Repeat 12 lead
ECG is recommended, especially in symptomatic patients or in those who have ingested
slow release preparations. There are specific treatments for QRS prolongation (such as
sodium bicarbonate) and QT prolongation (such as magnesium sulphate) - click here for
further advice and management of ECG abnormalities.
6. If the patient has signs of opioid toxicity (pinpoint pupils, reduced consciousness, or
reduced respiration [snoring/stridor, slow or shallow breathing, hypoxia or respiratory
acidosis]) observe until able to maintain adequate respiration for at least 6 hours.
Consider giving naloxone. Patients treated with naloxone should be monitored until able
to maintain adequate respiration for at least 6 hours after the last dose.
Monitor BP, pulse, respiratory rate and conscious level every 15 minutes initially.
Monitor oxygen saturation continuously in patients with a reduced level of
consciousness. Consider arterial blood gas analysis to test for hypercapnia or hypoxia in
patients with reduced respiration.
Check U&Es, creatinine and CK activity in patients at risk of rhabdomyolysis, for
example those with a history of prolonged unconsciousness.
Do not delay establishing a clear airway, adequate ventilation and oxygenation if there
is no response to naloxone.
7. Naloxone
If the patient has respiratory depression, inadequate airway protection, or has
decreased consciousness, give naloxone.
For children aged 12 years or over and adults:





mg).
Give an initial dose of 400 micrograms (0.4 mg).
If there is no response after 60 seconds, give a further 800 micrograms (0.8
If there is still no response after another 60 seconds, give another 800
micrograms (0.8 mg).
If still no response (after a total of 2 mg), give a further 2 mg dose. Large
doses (4 mg) may be required in a seriously poisoned patient.
Aim for reversal of respiratory depression, not full reversal of consciousness.
For children (under 12 years of age):


Give an initial dose of 100 micrograms/kg (0.1 mg/kg) up to a maximum of 2
mg.
If there is no response after 60 seconds give another 100 micrograms/kg (0.1
mg/kg) and repeat until a satisfactory response has been obtained or a maximum of
2 mg has been given.
Once an adequate response has occurred, monitor blood gases, oxygen saturation, and
respiratory rate.
Intramuscular naloxone is an alternative in the event that IV access is not possible or is
delayed. Failure of a definite opioid overdose to respond to large doses of
naloxone suggests that another CNS depressant drug or brain damage is
present.
Observe the patient carefully for recurrence of CNS and respiratory depression. The
duration of action of naloxone is shorter than that of all opioid analgesics - REPEATED
DOSES OF NALOXONE MAY BE REQUIRED.
Intravenous infusions following resuscitation
Intravenous infusions of naloxone are often useful where repeated doses are required.
An infusion of 60% of the initial dose required for resuscitation per hour is a useful
starting point.
For adults, a solution containing 10 mg (25 vials) made up to a final volume of 50 mL
with dextrose will produce a 200 micrograms/mL solution for infusion using an IV pump
(dose adjusted to clinical response).
For children weighing less than 20 kg, a more dilute solution may be appropriate to
allow accurate dose adjustment. For example, a solution containing 0.5 mg/kg body
weight of naloxone made up to a final volume of 50 mL with dextrose would deliver
0.01 mg/kg/hour if infused at 1 mL/hour.
Naloxone can be used undiluted provided an appropriate pump is available. Note this is
an off-licence use.
Infusions are not a substitute for frequent review of the patient's clinical
state.
8. Adult patients who become agitated following naloxone treatment can be sedated
carefully with oral or IV diazepam (0.1 - 0.3 mg/kg body weight). If ineffective
consider oral (5 - 10 mg) or parenteral (2 - 10 mg) haloperidol, 0.5 - 2 mg (oral or IV)
initially in the elderly.
In children it is better to manage agitation without sedation and exclude other causes
(e.g. hypoxia, infection, hypoglycaemia and raised ICP). Consider nursing in a dark and
quiet environment with a close relative present; seek expert paediatric advice. If
required, for children over 3 years buccal (3-5 years 5 mg; 5-10 years 7.5 mg; 10-16
years 10 mg) or IV midazolam (150 - 200 microgram/kg body weight) is generally the
most appropriate drug for managing agitation and requires specialist paediatric care.
9. Treat urticaria and pruritis with an antihistamine e.g. chlorphenamine (4 - 8 mg orally,
10 mg IV).
10.Check for infection at sites of injection and for clinical signs of endocarditis, pneumonia
and pulmonary oedema.
11.Discuss testing for HIV and hepatitis in all patients using intravenous drugs.
12.Other measures as indicated by the patient's clinical condition.
Patients should be advised on discharge to seek medical attention if symptoms
subsequently develop.
Links
Activated charcoal
References
Nursing guide - opioid analgesics
Contact Page | sitemap | About the NPIS | Contributors
All material on TOXBASE® is subject to Crown copyright protection unless otherwise stated. Material should
only be used to assist in the clinical management of poisoned patients and may be printed using the
"Printable version" button, however we strongly advise that printouts should NOT be kept for any length of
time, or for “future reference” as they can rapidly become out of date. For any other use of material you
must apply for permission to NPIS Edinburgh, RIE, EH16 4SA or via [email protected].
TOXBASE® © Crown copyright 1983-2013