Collapse in a Young Adult After a Night Out

Airway first, then ventilation, then circulation - not the other way round.

1. Airway protection. GCS ≤8 with a sluggish gag and one episode of vomiting means he cannot reliably protect his airway; aspiration is the immediate lethal risk. Position in the recovery position if not intubated, have suction ready, and call for anesthesia for a rapid-sequence intubation decision. Do not wait for deterioration - the trajectory of a mixed overdose with declining consciousness is unpredictable.
2. Oxygenation/ventilation. SpO2 91% on room air with a respiratory rate of only 10/min indicates hypoventilation, not shunt. Give oxygen and support ventilation; if opioids are suspected, titrate naloxone, but remember naloxone has a shorter half-life than most opioids and will need infusion or repeat dosing.
3. Glucose and temperature. Bedside glucose is normal now but recheck - hypoglycemia can be masked by co-ingestants and by alcohol. Keep him warm; hypothermia worsens drug clearance and coagulopathy.
4. Identify the toxidrome. Miosis + respiratory depression = opioid. But a normal pupil size, normal temperature and tachycardia do not exclude co-ingestion (e.g., a sedative-hypnotic plus alcohol plus an opioid). Obtain a 12-lead ECG urgently - QRS widening or QT prolongation changes management (sodium bicarbonate for a tricyclic; avoidance of certain drugs for QT).
5. Investigations. Venous blood gas, paracetamol and salicylate levels, urea/electrolytes, LFTs, coagulation, pregnancy test if relevant, and urine/blood toxicology where available. Paracetamol is the classic silent co-ingestant - never omit it.
6. Disposition. He needs a monitored bed, not a ward bed and certainly not home. If ICU is 40 minutes away, stabilize and intubate before transfer rather than transferring a patient who is deteriorating en route.

The judgement point: the parents' request to take him home is declined firmly but kindly; capacity is absent, and observation after a sedative overdose is mandatory because delayed effects (e.g., paracetamol hepatotoxicity, opioid re-sedation after naloxone wears off) occur hours later.

Do not wait for the level to decide on the antidote when the history is unreliable and the time of ingestion is uncertain.

• Give N-acetylcysteine empirically if the ingestion was >8 hours ago or the timing is unknown, after taking blood for paracetamol level, LFTs, INR and creatinine. NAC is most effective within 8 hours but retains benefit later; the risk of withholding it in an unreliable history outweighs the risk of a course of NAC in a young person.
• Interpret the level against time since ingestion using the treatment nomogram. If the time of ingestion is unknown, the level cannot be plotted reliably - treat and reassess. A level taken <4 hours after ingestion may be falsely low.
• Look for the high-risk features that lower the treatment threshold: chronic alcohol use, malnutrition, enzyme induction (e.g., antiepileptics), and repeated supratherapeutic dosing - all deplete glutathione and increase risk at lower levels.
• Monitor for hepatic injury: repeat INR, ALT and creatinine; rising INR and ALT with falling glucose indicate evolving hepatic failure, which may need referral to a transplant centre.
• Beware the mixed overdose: if he also took an opioid, the paracetamol may be the slower killer; the opioid is what you see now, the paracetamol is what you will see in 48–72 hours.

Judgement: the correct answer is not 'wait for the level'; it is 'treat now, refine later'. Document the reasoning and the time NAC was started.