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Q1: Recognition and resuscitation (3 min)
A young man is brought in unconscious with a respiratory rate of 6/min and pinpoint pupils.
- Define the opioid triad and justify a clinical diagnosis.
- Walk through your immediate resuscitation step by step. Why bag-valve-mask ventilation before naloxone?
- State your naloxone dose, route, and titration endpoint.
Examiner expects: triad (coma + respiratory depression + miosis); airway, BMV + oxygen FIRST then naloxone (prevents hypoxic arrest while naloxone takes 1 to 2 min); naloxone 0.04 to 0.4 mg IV/IM/IN titrated to respiratory rate over 10 to 12/min, not full alertness.
Q2: Pharmacology and the re-narcotisation trap (3 min)
- Describe the molecular action of opioids at the mu-receptor (Gi/o coupling, GIRK and Ca-channel effects).
- Why does naloxone reverse the overdose, and why does re-narcotisation occur?
- How would you manage a patient on long-term methadone who overdoses?
Examiner expects: Gi/o inhibits adenylate cyclase (cAMP falls), opens GIRK K+ (hyperpolarisation), closes N-type Ca2+ (less transmitter release); naloxone is a competitive mu-antagonist; re-narcotisation because naloxone half-life (1 to 2 h) is shorter than most opioids; for methadone use a naloxone infusion (two-thirds of the effective bolus per hour) and observe 24 to 48 h with QTc monitoring.
Q3: Complications and special situations (2 min)
- What is non-cardiogenic pulmonary oedema in opioid overdose and how is it treated?
- Name two complications of prolonged coma in opioid overdose.
- How would your approach differ for a fentanyl overdose versus a heroin overdose?
Examiner expects: NCOPE = capillary-permeability oedema, treated with oxygen and PEEP/NIV, NOT reversed by naloxone; complications include aspiration, rhabdomyolysis/compartment syndrome, anoxic brain injury; fentanyl may need higher/repeated naloxone and miosis may be absent.
Q4: Disposition and harm reduction (2 min)
- What are your safe discharge criteria after a short-acting opioid overdose?
- What harm-reduction interventions prevent the next overdose?
- State the paediatric naloxone dose.
Examiner expects: asymptomatic at least 4 h after last naloxone, normal vitals, no co-ingestant/NCOPE/recurrent apnoea, take-home naloxone and OAT referral; harm reduction = take-home naloxone + OAT (methadone/buprenorphine) + blood-borne virus testing; paediatric naloxone 0.1 mg/kg (max 2 mg per dose).