Risk of Delayed Intubation After Presumed Opioid Overdose in the Emergency Department - 04/03/25

Doi : 10.1016/j.annemergmed.2025.01.022

Daniel J. McCabe, MD ^a,^b,^c,^⁎ , Heath Gibbs, BA ^a, Alessandra A. Pratt, PhD, MS ^d, Rachel Culbreth, PhD ^e, Amanda M. Sutphin, BSHCA, EMT-P ^e, Stephanie Abston, BS ^e, Shao Li, MPH ^e, Paul Wax, MD ^e, Jeffrey Brent, MD, PhD ^f, Sharan Campleman, PhD, MPH ^g, Kim Aldy, DO, MS ^e,^g, Alyssa Falise, PhD, MSPH ^e, Alex F. Manini, MD, MS ^h
for the
ToxIC Fentalog Study Group
^a Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
^b Iowa Poison Control Center, Sioux City, IA
^c Department of Pharmacy Practice and Science, College of Pharmacy, University of Iowa, Iowa City, IA
^d Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA
^e American College of Medical Toxicology, Phoenix, AZ
^f Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
^g Department of Emergency Medicine, Baylor University Medical Center, Dallas, TX
^h Department of Emergency Medicine, Center for Research on Emerging Substances, Poisoning, Overdose, and New Discoveries, Icahn School of Medicine at Mount Sinai, NYC Health + Hospitals/Elmhurst, New York, NY

^∗Corresponding Author.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Tuesday 04 March 2025

Abstract

Study objective

The objective of this study was to evaluate the optimal duration of monitoring for patients with presumed opioid overdoses prior to a non-ICU admission, particularly in the context of the increasing prevalence of fentanyl analogs and other potent synthetic opioids. Given the critical role of emergency physicians in managing this public health crisis, the study aims to inform clinical decisionmaking regarding patient disposition after the initial overdose treatment.

Methods

The Fentalog Study, conducted through the American College of Medical Toxicology’s Toxicology Investigators Consortium, is a prospective, multi-institutional project designed to identify patients presenting to the emergency department with acute opioid overdose, gather clinical details, and confirm substances through biologic testing. This study is a secondary analysis of the Fentalog Study that assessed the risk of “delayed intubation,” defined as any intubation occurring after 4 hours of arrival to the emergency department.

Results

Of the 1,591 patients included, only 9 (0.6%) required delayed intubation. Eight of these patients had nonrespiratory-related conditions contributing to the need for intubation. One patient only had respiratory-related conditions, had respiratory acidosis, and received a total of 6.4 mg naloxone before intubation.

Conclusion

This study provides evidence that delayed intubation after 4 hours of monitoring in patients with presumed opioid overdose is exceedingly rare.

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Keywords : Intubation, Opioid, Overdose

Plan

Introduction

Methods

Study Design and Setting

Inclusion

Protocol and Data Collection

Comprehensive Toxicology Analysis

	Please see page XX for the Editor’s Capsule Summary of this article.
	Supervising editor: Lewis S. Nelson, MD. Speciﬁc detailed information about possible conﬂict of interest for individual editors is available at editors.
	Author contributions: DJM and HG contributed equally to this work. DJM conceived the study. DJM, HG, RC, and KA designed the study. AM obtained research funding. RC, AS, SA, SL, PW, JB, SC, KA, AF, and AM supervised the conduct of the trial, data collection, and undertook recruitment of participating center and patients and managed the data, including quality control. RC and AP provided statistical advice on study design and analyzed the data. DJM and HG drafted the manuscript, and all authors contributed substantially to its revision. DJM takes responsibility for the paper as a whole.
	Data sharing statement: Partial or complete dataset and data dictionary are available from February 19, 2025 upon request to Dr. McCabe to investigators who provide an IRB letter of approval.
	Authorship: All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Funding and support: By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under award number R01DA048009 (principal investigator, AFM). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors report no conflicts of interest.