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Rule predicts which patients can be safely discharged after opioid overdose

Brian Clemency

Patients treated with naloxone in the ED can be safely released following positive findings of six evaluation criteria, according to findings recently published in Academic Emergency Medicine.

Collectively these six criteria – usual mobilization, normal oxygen saturation, temperature between 35° and 37.5°C, Glasgow Coma Scale score of 15 or lower, heart rate of between 50 beats and 100 beats per minute, and respiratory rate between 10 and 20 breaths per minutes – are a modified version of the St Paul’s Early Discharge Rule, according to researchers.

“There was a single study done on the rule many years ago, but it was limited to hospitals and paramedics. Many other professionals carry naloxone now,” Brian M. Clemency, DO, of the department of emergency medicine at the University at Buffalo, told Healio Primary Care Today.

Researchers followed progress of 538 patients from one ED who received at least one dose of prehospital naloxone. Unlike the previous study, researchers set the threshold for normal oxygen saturation at 95% and patients were not immediately discharged after a normal 1hour evaluation.

Clemency and colleagues found the St. Paul’s Early Discharge Rule had sensitivity of 84.1% (95% CI, 76.2-92.1), a specificity of 62.1% (95% CI, 57.6-66.5) and a negative predictive value of 95.6% (95% CI, 93.3-97.9). Only one patient with a normal 1hour evaluation subsequently received more naloxone after a presumed heroin overdose. Adverse events — supplemental O₂ for hypoxia (n = 61), repeat naloxone for hypoventilation (n = 16), assisted ventilations (n = 14), IV antibiotics for serious infection and antiarrhythmic medications (n for both = 4), bicarbonate for severe acidosis and fluid bolus for hypotension (n for both = 3) and IV inotropic agents and dialysis (n for both = 2) — occurred in 82 of patients.

“Overall the rule performed well,” Clemency said in the interview. “My one caution is that the rule is appropriate for patients who have overdosed on heroin or another opiate in an IV fashion or internasal fashion. It should not be applied to those who have suffered an oral overdose such as methadone.”

Clemency said he is now researching how the rule performs in different environments and administration patterns. – by Janel Miller

Disclosures: The authors report no relevant financial disclosures.