A 25-year-old man is brought to the emergency department by paramedics for altered mental status. He was found lying down at a bus stop unresponsive. On arrival, the patient has slurred speech and is somnolent. Further is unable to be elicited. His temperature is 98.0°F (36.7°C), blood pressure is 130/80 mmHg, pulse is 80/min, and respirations are 12/min with a saturation of 97% on room air. Physical exam reveals a sleeping man with miotic pupils. The patient is easily arousable to voice and sternal rub but falls asleep rapidly. He has decreased bowel sounds. He is able to state his name and knows that he is at the hospital and has an otherwise normal neurologic exam. Which of the following is the most appropriate management?
Atropine
Flumazenil
Observation
Naloxone
Observation
This patient's presentation with altered mental status, pinpoint pupils, and decreased bowel sounds is most consistent with an opioid overdose. Given his stable respiratory status and oxygen saturation without notable bradypnea, observation alone until the patient is clinically sober is the most appropriate management.

Opioids are commonly used to treat painful conditions but have the potential to become drugs of abuse. Opioid overdose presents with bradypnea, somnolence, decreased bowel sounds, and pinpoint pupils. Any patient who is not protecting their airway, failing to oxygenate, or failing to ventilate should immediately be given naloxone which rapidly reverses the effect of opioids. However, this precipitates withdrawal which is unpleasant for patients and leads to nausea, vomiting, agitation, and diaphoresis among other findings. For this reason, patients who have overdosed on opioids and are stable can be observed until clinically sober.

Dietze et al. studied the effect of intranasal versus intramuscular naloxone for opioid overdose in a randomized control trial. The authors found that patients who received intranasal naloxone needed a second dose of naloxone more frequently compared to patients who received intramuscular naloxone. The authors recommend further study of optimal dosing and concentration of intranasal naloxone to respond to opioid overdoses outside of the hospital.

Incorrect Answers:
Answer A: Atropine is an appropriate treatment for a cholinergic toxidrome. This would manifest with bronchorrhea, bronchospasm, bradycardia, urinary incontinence, diarrhea, and drooling. Atropine should be administered until respiratory symptoms improve; large doses may be required.

Answer B: Disulfiram inhibits the enzyme acetaldehyde dehydrogenase causing severe nausea, vomiting, and a very ill feeling when a patient drinks alcohol from the accumulation of byproducts. This drug is a second-line agent used to reduce drinking in chronic alcohol use disorder but has no indication in managing acute alcohol intoxication as it is a preventive medication.

Answer C: Flumazenil is the reversal agent for benzodiazepines. Its use has fallen out of favor as it can precipitate seizures in chronic benzodiazepine users. Any patient with a suspected benzodiazepine overdose who is protecting their airway should be observed until clinically sober as there is no need to rapidly reverse them and possibly cause seizures.

Answer D: Naloxone is the antidote of choice in opioid overdose in patients who are not adequately oxygenating, ventilating, or protecting their airway. It is not indicated in opioid overdose in a clinically stable patient as the patient can merely be observed without the unpleasant side effects of immediate withdrawal from naloxone (including vomiting which in some cases could lead to aspiration). This patient is oxygenating well, protecting his airway, and does not have profound bradypnea.

Bullet Summary:
Opioid overdose presents with somnolence, pinpoint pupils, decreased bowel sounds, and bradypnea; stable patients who are adequately breathing and protecting their airway require only observation until clinically sober.