Introduction: Opioid use is an epidemic that plagues the United States. Patients frequently present to the emergency department (ED) after opioid toxicity, which can lead to respiratory failure, apnea, and death. Although there is an effective antidote, naloxone, the current guidelines surrounding post-naloxone administration monitoring are loosely defined.

Case Report: We present a case in which an individual was administered naloxone after an intentional opioid overdose and was monitored for four hours, as is standard in our institution. He remained in the ED for additional workup following this observation period and subsequently experienced signs of severe respiratory depression, requiring bag-valve-mask ventilation, naloxone, and admission. Had he been discharged, as is typical after a four-hour observation period, the consequences could have been fatal. We present multiple theories as to why his opioid toxidrome may have presented in a delayed manner, including ingestion of fentanyl analogues and variability in metabolization of both opioids and naloxone. We also explore alternative overdose antidote products approved by the US Food and Drug Administration, which may impact post overdose care.

Conclusion: This case suggests that the correct amount of time to monitor patients after naloxone administration may be longer than originally thought. Our aim in this article was to further the discussion regarding the most appropriate observation period in cases of opioid toxicity.

Case Presentation

A 73-year-old female with chronic obstructive pulmonary disease presents via emergency medical services for shortness of breath. She is found to be hypoxic, tachypneic, and in notable distress. She is treated with inhaled albuterol, oral dexamethasone, and intravenous magnesium sulfate. Upon arrival to the emergency department her had was noted to have significant bleeding, and on further investigation it was determined that the intravenous catheter has inadvertently become extravasated, and the magnesium had entered the subcutaneous space. The bleed with significant and pulsatile, a tourniquet was applied, and the vessel was ultimately tied off by the trauma surgery service. 

Discussion

Intravenous medication administration is ubiquitous with emergency care in both the hospital and prehospital environments.  Medications use is paramount to treatment of a vast majority of emergent clinical conditions, furthermore, the route of administration is often intravenous in the patient with emergent illness.  The placement of intravenous catheters is a skill that nurses, paramedics, and advanced emergency medical technicians learn early in their training.  The care team is tasked with not only starting intravenous lines, but also in monitoring them and ensuring medication is delivered into the systemic circulation, and not elsewhere.  Certain medications, notably potassium preparations and vasoactive medications, are known vesicants.  We present a case of vascular extravasation of magnesium sulfate, not know for causing significant tissue damage, that led to significant venous and arterial injury.  This case highlights the need for prehospital clinicians as well members of the emergency department care team to be ever vigilant for medication extravasation.