Opioid toxidrome — naloxone titration and infusion

Airway. Lateral position, suction, oxygen; bag-valve assist if needed; intubate only if ventilation fails despite naloxone or the airway cannot be protected.^[1]

Naloxone. Support ventilation first. Williams prefers intravenous naloxone because it can be titrated and could not GRADE a milligram increment or interval. Clinical reversal doses sit at 0.4 to 1.2 mg IV (Melichar). Titrate to ventilation, not full wakefulness. No IV: 2 mg intramuscular or concentrated intranasal (Kerr: 77.5% vs 72.3% response by 10 minutes; IN reversed 82%).^[1][13][12]

Re-narcotisation. Methadone mean elimination half-life 59 hours in a switch cohort vs short-acting naloxone → start a Goldfrank infusion at two-thirds of the effective bolus per hour; do not discharge after a bolus; ECG for QT. If incomplete response: clonidine (naloxone awoke 40/51 somnolent children in Seger), co-ingestant, pons — check glucose and image if atypical.^[17][14][5]