Diagnose It Answer — April 25, 2026

29-year-old male found unresponsive in a gas station bathroom by an employee. EMS arrived and found him slumped on the floor, cyanotic around the lips, with slow, irregular, gasping respirations and vomitus present around his mouth. A used syringe was found on the floor nearby. He was given intranasal naloxone 4mg by EMS en route — now minimally responsive to sternal rub.

Per EMS and wallet ID — 29-year-old male with no documented medical history at this facility. A friend who was located states he has a known history of heroin use and recently obtained what he believed was heroin from a new source. He had reportedly been in a treatment program 6 months ago and had a period of abstinence, which may have significantly reduced his tolerance.

BP 88/58 mmHg, HR 56 bpm, RR 6 breaths/min (agonal, shallow), SpO2 76% — BVM ventilation initiated by EMS now providing SpO2 88%. Temp 35.8°C (hypothermic from environmental exposure). GCS 5 (E1 V1 M3). Pupils bilaterally pinpoint (1mm), non-reactive to light. Skin pale, cyanotic peripherally, track marks visible on both antecubital fossae.

Classic opioid toxidrome: pinpoint pupils, respiratory depression, and decreased level of consciousness. BVM ventilation continued. Second dose of naloxone 2mg IV given — patient becomes more responsive within 90 seconds, GCS improves to 10, and respiratory rate increases to 14 breaths/min. Oropharynx suctioned. Patient placed in recovery position. Naloxone infusion started (two-thirds of the effective reversal dose per hour) given the prolonged half-life of synthetic opioids such as fentanyl. Aspiration pneumonia precautions initiated.

Urine drug screen: positive for opiates and fentanyl. Blood alcohol level: 0.03% (trace). Serum glucose: 82 mg/dL. ABG pre-naloxone: pH 7.18, PaCO2 78 mmHg, PaO2 42 mmHg, HCO3 28 — severe combined respiratory acidosis with hypoxia. ABG post-naloxone: pH 7.34, PaCO2 46 mmHg, PaO2 88 mmHg on supplemental O2. Troponin 0.9 ng/mL (hypoxic demand ischemia). Chest X-ray: bilateral basilar infiltrates consistent with aspiration.