Illicit fentanyl is a very potent synthetic opioid, often mixed into other drugs, and it can stop breathing within minutes. Field care focuses on ventilation and naloxone, and additives such as xylazine can keep patients sedated after naloxone.
Key symptoms
- Unresponsive or very hard to wake
- Slow, shallow or snoring breathing, or no breathing
- Blue or gray lips and fingertips
- Pinpoint pupils
- Drug paraphernalia, powder or pills at the scene
What you find on exam
- Scene safety and gloves; brief skin contact with powder rarely causes toxicity
- Breathing rate and depth, oxygen saturation and capnography
- Pulse check; start CPR if there is no pulse
- Pupils, level of consciousness and signs of trauma
- Signs of other drugs, such as xylazine skin wounds
Tests
- Glucose check to rule out low blood sugar
- Waveform capnography: rising carbon dioxide shows hypoventilation
- ECG if the patient was down for long or has an arrhythmia
- Standard urine drug screens often miss fentanyl; diagnosis is clinical
Treatment basics
- Open the airway and ventilate with a bag-valve mask and oxygen first
- Naloxone 0.4 to 2 mg IV or IM, or 4 mg intranasal, repeated every 2 to 3 minutes; aim for breathing, not full waking
- Pulseless patient: standard CPR and ACLS; naloxone never replaces CPR
- Watch for withdrawal, vomiting and agitation after naloxone
- Transport and observe, since fentanyl can outlast naloxone; offer a naloxone kit and treatment referral
Red flags
- Apnea or cardiac arrest
- Breathing still inadequate after repeated naloxone doses
- Sedation returning as naloxone wears off
Practice it in Making Synapses
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Related guides
Sources: NASEMSO National Model EMS Clinical Guidelines; NREMT psychomotor skill sheets (EMT and Paramedic); National EMS Education Standards (2021). Written by Making Synapses. Making Synapses is not affiliated with these organizations.