Naloxone — a how to


    Naloxone — a how to

    Have you ever tried to figure out what the appropriate starting dose of naloxone is? When you dig in the literature it’s pretty clear that its a lot of hand waving and muddy water — but let me give you an approach and some of the literate that is out there

    Apneic patient: 1-2mg naloxone

    Altered with respiratory depression: 0.1 mg and repeat with increasing doses* every 2 minutes with close monitoring for response

    Goal: sleepy, but with adequate respirations

    Duration of action: 30-45 minutes (most patients need repeat dosing or a drip)

    How to make a drip?

    1. Calculate the dose the patient required for response, for example 1mg.
    2. Then reduce to 2/3 (0.6 mg) because you would like to keep them breathing but sleepy and not alert and agitated
    3. Give that amount (2/3 of response dose or in our example 0.6) over 1 hour
    Mechanism of Action: Pure opioid antagonist that competes and displaces opioids at opioid receptor sites

    *A recent article on initial naloxone doses / titration 

    included one-hundred opioid-dependent patients with signs/symptoms of methadone overdose. Patients were split in to 2 groups. Group 1 received naloxone with the dose 0.1 mg given every two to three minutes while group 2 received naloxone with the initial dose of 0.04 mg increasing to 0.4, 2, and 10 mg every two to three minutes to reverse respiratory depression. The time to reversal of the overdose signs/symptoms was significantly less in group 2 (P<0.001). Frequency of withdrawal syndrome and recurrence of respiratory depression were not significantly different between the two groups.

    So, the jury is still out, but I hope this gives you a sense of the options out there and clarifies some of the nebulous answer provided by UTD.


    Berlot G et al. Naloxone in cardiorespiratory arrest. Anaesthesia. 1985;40(8):819.

    Goldfrank L, et al. A dosing nomogram for continuous infusion intravenous naloxone. Ann Emerg Med. 1986 May;15(5):566-70.

    Khosravi N, et al. Comparison of Two Naloxone Regimens in Opioid-dependent Methadone overdosed Patients: A Clinical Trial Study. Current Clinical Pharmacology. Vol 12 :4 . 2017.

    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • Cervical Artery Dissection

      Cervical artery dissection (CAD) accounts for 1-2% of all ischemic strokes but 10-25% of strokes in younger individuals.  CAD includes extracranial carotid and vertebral artery dissections.  A review of the literature suggests that there mayRead more

    • Opioid Substitution Therapy

      ED physicians need to be comfortable with the various modalities of opioid substitution therapy (OST) and their associated complications.  We are all familiar with the patient who has missed a daily dose of methadone onRead more

    • Use the HEART Score

      There are approximately 8 million ED visits annually in the United States for chest pain. 10%-20% go on to receive an acute coronary syndrome diagnosis. The goal of the ED physician is to differentiate betweenRead more

    • Permissive Hypotension

      Resist the urge to administer a large crystalloid bolus in hypotensive trauma patients. Doing so worsens coagulopathy and acidosis. This practice should be abandoned. Normotensive trauma patients need no fluid resuscitation. The practice of permissiveRead more

    • PE Risk after Induced Abortion

      It’s well known that the risk of venous thromboembolism is increased during pregnancy.  It is thought to be two-to-six times higher than the risk in non-pregnant women.  However, these risk estimates are based on pregnantRead more

    • Bag Mask Ventilation During Intubation

      A few days ago NEJM published the results of an investigation with profound implications for our specialty.  A group of intensivists and anesthesiologists conducted a multicenter, randomized trial conducted in seven ICUs to study theRead more

    • Gastric Emptying for Acute Poisonings

      At the request of department leadership, we will be revisiting methods of gastric decontamination for today’s pearl.  Two methods in particular. Ipecac-induced emesis and gastric lavage are two procedures that we read about in medicalRead more

    • Pacemakers Review pt. 3

      Today we will review complications associated w/ implanted pacemakers that you may encounter in the ED and thus ought to be familiar with. Generally, complications can be divided into two categories: early vs. late EarlyRead more