In an unconscious patient with suspected overdose, in what order should you administer thiamine, glucose, and naloxone?

• A. Glucose → Thiamine → Naloxone
• B. Naloxone → Glucose → Thiamine
• C. Thiamine → Naloxone → Glucose
• D. Thiamine → Glucose → Naloxone

Answer: (D)

The crucial idea is to prevent precipitating a thiamine-deficiency–related brain complication while you fix immediate metabolic problems. In an unconscious patient who might have malnutrition or chronic alcohol use, giving glucose before thiamine can trigger or worsen Wernicke's encephalopathy because the brain needs thiamine to effectively use the sugar you’re giving. So you give thiamine first to replenish that essential cofactor.

After thiamine is started, you can safely administer glucose if hypoglycemia is a concern, to correct the energy deficit that can keep someone unconscious or coma-like. Only then do you address possible opioid toxicity with naloxone if there’s clinical suspicion, since reversing a potential opioid overdose can improve respiration and consciousness once basic metabolic needs are being managed.

Thus, thiamine first, then glucose, then naloxone aligns with protecting against Wernicke’s while still treating hypoglycemia and potential opioid-induced respiratory depression.