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cardio.post-arrest.brugada-channelopathy.v1

Post-cardiac-arrest care — Brugada syndrome channelopathy (SCN5A type 1 ECG; sleep / fever-triggered VF)

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Phase E variant of cardio.post-arrest.core.v1 — narrowed to Brugada syndrome channelopathy as the etiology of the index out-of-hospital VF arrest. SCN5A loss-of-function (~20-30% of clinically diagnosed Brugada — only mutation with definitive evidence per Bezzina; remaining 70-80% polygenic / unknown substrate) → reduced cardiac Na+ current (INa) → transmural voltage gradient in RVOT epicardium → Type 1 Brugada ECG (V1-V3 coved ST ≥2 mm + T-wave inversion) and substrate for phase-2 reentry → polymorphic VT/VF. Classic presentation: previously healthy male (M:F ~8:1) age 30-50 with sleep-triggered or fever-triggered VF arrest; family history of sudden death <45 y common. Sister to cardio.cardiogenic-shock.brugada-storm.v1 — that dossier covers MID-STORM hemodynamic management (≥3 sustained VF / 24 h with shock; isoproterenol + quinidine + RVOT ablation); THIS dossier covers POST-ROSC care after the storm has terminated in arrest, with focus on ECG RE-EVALUATION 48-72 h after defervescence (fever masks ECG; resolution unmasks Type 1 pattern; high V1-V2 placement at 2nd-3rd ICS increases sensitivity from ~35% to ~65%), SODIUM-CHANNEL-BLOCKER PROVOCATION CHALLENGE (ajmaline 1 mg/kg IV over 5 min preferred; or flecainide 2 mg/kg IV up to 150 mg; or procainamide 10 mg/kg IV up to 1 g — only in genetics center under EP supervision with continuous ECG + defibrillator pads; CONTRAINDICATED if baseline already Type 1), GENETIC PANEL (SCN5A core; expanded SCN1B/SCN2B/SCN3B/SCN10A/GPD1L/KCNE3/HCN4 if family history positive), CASCADE FAMILY SCREENING, QUINIDINE long-term (Belhassen registry — only Na-channel blocker that helps in Brugada because it ALSO blocks Ito), ICD per HRS 2017 Class I (sustained VT/VF survivor by definition), RVOT epicardial substrate ablation (Nademanee 2011 PMID 21571989) for refractory storm or recurrent ICD shocks despite quinidine, FEVER MITIGATION PROTOCOL lifelong, and lifelong avoidance of Na-channel blockers per www.brugadadrugs.org curated list. Critical post-ROSC pharmacologic AVOIDS (signature departure from generic post-arrest care): LIDOCAINE (typical post-arrest stopgap antiarrhythmic — paradoxically arrhythmogenic at therapeutic dose; substitute MgSO4 + isoproterenol if recurrent VT); PROCAINAMIDE (PROCAMIO general algorithm CONTRAINDICATED in Brugada); FLECAINIDE / PROPAFENONE (Class IC — diagnostic at low dose with provocation; LETHAL at therapeutic oral dose); PROPOFOL DURING DIAGNOSTIC CONFIRMATION PHASE (can accentuate Type 1 Brugada pattern — Brugada Phenocopy from propofol described; substitute midazolam + fentanyl + dexmedetomidine; acceptable low-dose short-duration after Brugada diagnosis confirmed); AMIODARONE relative-avoid (variable / unproven benefit; can prolong QT further; reserve for refractory VT with no alternative); β-BLOCKERS acute (variable; may worsen storm by removing β-1 stabilization — opposite of LQT pharmacology); COCAINE / CANNABIS (Na-channel blocking effect; lifelong avoidance); PSYCHOTROPICS with Na-channel blocking effect (TCAs especially amitriptyline; some SSRIs at high dose; lithium ECG changes). Reference: www.brugadadrugs.org curated international avoid-list (Postema). Lifelong fever mitigation protocol: any T > 37.5 °C aggressive antipyresis acetaminophen 650-1000 mg PO q4-6 h scheduled + cooling; ED visit any T > 38.5 °C; vaccinations brought current to reduce future febrile illness triggers. Lifestyle: sleep alone caution; avoid large meals (vagal trigger); moderate alcohol; lifelong avoidance of cocaine + cannabis; medic-alert bracelet "Brugada syndrome — AVOID Na-channel blockers" mandatory. Inherits manifest + design-brief pointer from parent cardio.post-arrest.core.v1; specializes the ECG re-evaluation + provocation challenge + channelopathy workup + family screening + fever mitigation + quinidine + ICD + RVOT ablation + drug-avoidance arcs. 5 setting playbooks (ed, icu, inpatient, transition, outpatient). 5 severity triggers: recurrent VF storm bridge routing, inadvertent Na-channel-blocker or propofol administered post-ROSC (common nursing handoff failure mode), fever mitigation protocol breach (lifelong), ICD eligibility evaluation, cascade family screening referral with provocation-challenge protocol. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute Phase E wave 24.

Entry points (5)

  • symptom
    ROSC after out-of-hospital VF arrest with known Brugada syndrome (prior diagnosis, prior ICD, prior syncope, family history) or with sentinel post-ROSC ECG Type 1 pattern (V1–V3 coved ST ≥2 mm + T-wave inversion)
    rosc_after_oohca_with_known_or_suspected_brugada
  • imaging
    Post-ROSC 12-lead ECG Type 1 Brugada pattern in V1–V3 (coved ST elevation ≥2 mm + T-wave inversion); high V1–V2 placement at 2nd–3rd ICS increases sensitivity from ~35% to ~65% — critical for unmasked diagnosis
    post_rosc_ecg_type1_brugada_pattern
  • history
    Witnessed arrest during sleep (classic Brugada nocturnal trigger pattern) or during febrile illness (T > 38°C — most common modifiable trigger) in previously healthy male age 30–50; family history of sudden death <45 y common
    witnessed_arrest_during_sleep_or_fever_in_young_male
  • history
    Family history of sudden death <45 y or known Brugada syndrome in first-degree relative — Brugada high pretest probability; offer SCN5A genetic panel + cascade screening; consider provocation challenge for SCN5A-positive relatives with non-diagnostic baseline ECG
    family_history_sudden_death_under_45_or_known_brugada
  • history
    Prior unexplained nocturnal syncope or recent exposure to Na-channel-blocking drug (lidocaine, procainamide, flecainide, propafenone, cocaine, TCA) pre-arrest — informs Brugada diagnosis + acquired vs unmasked phenotype
    prior_unexplained_syncope_or_na_channel_blocker_exposure_pre_arrest

Required inputs (24)

  • agerequired
    demographic • used at CONTEXT
    Brugada most often manifests age 30–50 y; informs ICD device-size considerations + cascade-testing prioritization for younger relatives
  • sexrequired
    demographic • used at CONTEXT
    Male predominance ~8:1 (testosterone effect on Ito); informs counseling + risk stratification + prioritized cascade screening of male relatives
  • witnessed_arrest_with_brugada_trigger_patternrequired
    history • used at CONTEXT
    Trigger pattern is highly informative: sleep / nocturnal (most common — vagal-mediated); fever (most common modifiable trigger — heat further reduces INa); large meals (vagal); alcohol; cocaine — informs storm-suppression bridge planning + lifelong trigger avoidance
  • time_to_cpr_minrequired
    history • used at CONTEXT
    CPR within 1 min dramatically improves outcome; CAHP/OHCA score input
  • time_to_aed_defibrillation_minrequired
    history • used at CONTEXT
    AED within 3 min → 50%+ survival; venue AED program presence is dominant prognostic factor
  • initial_rhythmrequired
    history • used at CONTEXT
    VF most common in Brugada (~95%); polymorphic VT degenerating to VF is the classic mechanism; informs storm-suppression bridge planning
  • family_history_sudden_death_or_known_brugadarequired
    history • used at CONTEXT
    Family history of SCD <45 y or known Brugada in first-degree relative is a critical input — drives SCN5A panel + cascade screening priority
  • prior_syncope_or_na_channel_blocker_exposurerequired
    history • used at CONTEXT
    Prior nocturnal syncope suggests Brugada substrate; recent Na-channel-blocker exposure (lidocaine, procainamide, flecainide, propafenone, cocaine, TCA) suggests acquired or unmasked Brugada phenotype
  • pre_arrest_medication_list_brugada_auditrequired
    history • used at CONTEXT
    Comprehensive medication review against www.brugadadrugs.org curated list — STOP all offenders + document; informs whether arrest was triggered by Na-channel-blocker exposure on a Brugada substrate
  • sbprequired
    vital • used at TREATMENT
    MAP ≥65 target post-ROSC; SCAI staging if shock; cautious vasopressor dosing (α-agonists OK in Brugada, unlike β-blockers acutely)
  • hrrequired
    vital • used at TREATMENT
    Bradycardia / vagal triggers may have unmasked Brugada substrate; isoproterenol storm-suppression target HR 90–110 if recurrence
  • core_temprequired
    vital • used at TREATMENT
    TTM target 33–37.5 °C × 24 h (TTM2 PMID 34133859); FEVER IS MOST COMMON MODIFIABLE BRUGADA TRIGGER — aggressive antipyresis ANY temperature elevation; ECG re-evaluation 48-72 h after defervescence to define baseline pattern
  • spo2required
    vital • used at TREATMENT
    Avoid hyperoxia: SpO2 92-98% (AHA 2020 Class IIa)
  • ecg_12_lead_serial_with_high_v1_v2_placementrequired
    imaging • used at INITIAL_WORKUP
    Serial ECGs q4-6 h × 48-72 h with HIGH V1-V2 lead placement at 2nd-3rd ICS (increases sensitivity for Type 1 from ~35% to ~65%); ECG re-evaluation 48-72 h after defervescence (fever masks pattern; resolution unmasks); document Type 1/2/3 evolution
  • tte_high_resolutionrequired
    imaging • used at INITIAL_WORKUP
    Rule out structural disease (ARVC most important differential — RV-dominant cardiomyopathy with epsilon waves can mimic Brugada; HCM, anomalous coronary, infiltrative); Brugada heart is structurally normal
  • cardiac_mri_at_4_to_6_wk
    imaging • used at FOLLOWUP
    Cardiac MRI at 4-6 wk post-arrest if echo equivocal — RULE OUT ARVC overlap (key differential), infiltrative disease, scar; allows post-arrest stunning to resolve before assessment
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Often modestly elevated from arrest + CPR; rise pattern helps differentiate from ACS-mediated arrest; primary Brugada arrest typically negative or modest
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Tissue hypoperfusion + post-arrest perfusion debt; clearance trajectory drives prognosis (SCAI 2022 PMID 35718438; CardShock PMID 26333869)
  • creatininerequired
    lab • used at CONTEXT
    eGFR for quinidine dose adjustment (renal + hepatic clearance); target quinidine level 2-5 µg/mL
  • potassiumrequired
    lab • used at INITIAL_WORKUP
    K target ≥4.0 — hypokalemia worsens Brugada storm; aggressive replacement
  • magnesiumrequired
    lab • used at INITIAL_WORKUP
    Mg target ≥2.0 supportive; replace standard polymorphic VT supportive therapy
  • tox_screen_for_cocaine_and_cannabis
    lab • used at CONTEXT
    Cocaine has Na-channel blocking effect that can unmask Brugada substrate; cannabis may also contribute; lifestyle counseling input
  • genetic_panel_scn5a_expandedrequired
    lab • used at FOLLOWUP
    Targeted gene panel — SCN5A core (only mutation with definitive evidence, ~20-30% positive in clinical Brugada per Bezzina); expanded panel SCN1B/SCN2B/SCN3B/SCN10A/GPD1L/KCNE3/HCN4 if family history positive; informs prognosis + cascade testing
  • cxr_post_cprrequired
    imaging • used at INITIAL_WORKUP
    Rib fractures from CPR; pneumothorax; aspiration; baseline for ICD lead placement planning

12-phase flow (12)

  1. 1FRAME
    Recognize post-ROSC + Type 1 Brugada ECG (or strong pretest probability — sleep/fever trigger, family history, young male) + structurally normal heart as Brugada-arrest cohort; pivot from generic post-arrest care to channelopathy-specific avoidance protocol; route to parent cardio.post-arrest.core.v1 for TTM + neuroprog while specializing on ECG re-evaluation 48-72 h after defervescence + provocation challenge + family screening + fever mitigation + quinidine + ICD + RVOT ablation
    inputs: ecg_12_lead_serial_with_high_v1_v2_placement, tte_high_resolution, witnessed_arrest_with_brugada_trigger_pattern
    advance: Brugada high pretest probability confirmed + structural disease screen initiated
  2. 2ENTRY
    Standard ACLS for index arrest; immediate scene CPR + AED deployment; transport to PCI-capable + EP-capable facility; activate EP team early; STOP all Na-channel-blocker drugs from pre-arrest medication list (www.brugadadrugs.org); STOP propofol if Brugada high pretest probability (substitute midazolam + fentanyl + dexmedetomidine)
    inputs: age, time_to_cpr_min, time_to_aed_defibrillation_min, pre_arrest_medication_list_brugada_audit
    advance: ACLS + AED + transport + EP team activation + drug audit + propofol substitution initiated
  3. 3CONTEXT
    Trigger pattern (sleep / nocturnal — most common; fever — most common modifiable; large meals; alcohol; cocaine); time-to-CPR; time-to-AED; initial rhythm (VF most common); family history of SCD <45 y or known Brugada; prior nocturnal syncope; comprehensive pre-arrest medication review against www.brugadadrugs.org
    inputs: sex, initial_rhythm, family_history_sudden_death_or_known_brugada, prior_syncope_or_na_channel_blocker_exposure, sbp, hr, core_temp, spo2, creatinine, tox_screen_for_cocaine_and_cannabis
    advance: context + family history + drug audit + trigger pattern documented + Brugada vs alternative classification attempted
  4. 4RED_FLAGS
    Recurrent VF post-ROSC suggests storm physiology (route to sister cardio.cardiogenic-shock.brugada-storm.v1); fever (any temperature elevation) → aggressive antipyresis acetaminophen + cooling; inadvertent administration of Na-channel-blocker post-ROSC (lidocaine, procainamide, propofol) → STOP + reverse with isoproterenol if storm develops; ECG Type 1 pattern at high V1-V2 placement when previously not seen → confirms diagnosis + escalate
    inputs: sbp, core_temp, ecg_12_lead_serial_with_high_v1_v2_placement
    actions: cardiogenic_shock, wide_complex_tach
    advance: red flags screened + storm-bridge route decided + Na-channel-blocker drugs + propofol cleared from active orders + fever mitigation initiated
  5. 5INITIAL_WORKUP
    Serial 12-lead ECG with HIGH V1-V2 lead placement at 2nd-3rd ICS (mandatory for Brugada sensitivity); STAT echo (rule out structural disease — Brugada heart is normal; ARVC is key differential); troponin (rule out ischemic mimic); BMP + Mg + Ca; CBC; ABG; CXR; tox screen for cocaine; comprehensive medication audit against www.brugadadrugs.org
    inputs: ecg_12_lead_serial_with_high_v1_v2_placement, tte_high_resolution, troponin, lactate, potassium, magnesium, cxr_post_cpr
    actions: post_arrest_care, panel.cardiac, panel.renal
    advance: workup complete + Brugada pretest probability refined + structural / ischemic causes excluded + electrolytes optimized
  6. 6BRANCHING_WORKUP
    Genetic panel referral (SCN5A core; expanded SCN1B/SCN2B/SCN3B/SCN10A/GPD1L/KCNE3/HCN4 if family history positive); EP consult for ICD planning (sustained VT/VF survivor = HRS 2017 Class I); STEMI on post-ROSC ECG (rare in primary Brugada) → cath; recurrent VF storm → route to sister cardiogenic-shock.brugada-storm engine; ECG RE-EVALUATION at 48-72 h after defervescence — fever masks ECG; resolution unmasks Type 1 pattern; PROVOCATION CHALLENGE in genetics center for non-diagnostic baseline + high pretest probability (ajmaline 1 mg/kg IV over 5 min preferred; or flecainide 2 mg/kg IV up to 150 mg; CONTRAINDICATED if baseline already Type 1)
    inputs: ecg_12_lead_serial_with_high_v1_v2_placement
    actions: acs_pathway, wide_complex_tach
    advance: branching decisions made + genetic referral placed + ECG re-evaluation scheduled + provocation challenge planned if needed + EP plan documented
  7. 7DIFFERENTIAL
    Brugada syndrome (Type 1 ECG + sleep/fever trigger + family history + young male) vs ARVC (RV-dominant CMP with epsilon waves and structural changes on cardiac MRI — KEY differential) vs RV ischemia / RV STEMI (rare but mimic) vs early-repolarization syndrome vs Brugada Phenocopy (drug- or fever-induced transient pattern without true substrate) vs idiopathic VF — this differential drives long-term plan + family screening
    inputs: family_history_sudden_death_or_known_brugada, witnessed_arrest_with_brugada_trigger_pattern, prior_syncope_or_na_channel_blocker_exposure
    advance: Brugada vs ARVC vs alternative classification + ECG re-evaluation timing + provocation challenge plan documented
  8. 8RISK_STRATIFICATION
    CAHP/OHCA scores apply (witnessed + bystander CPR + low-flow time + initial rhythm); SCAI shock stage if hemodynamic instability; HEART score not directly applicable (Brugada cohort low ACS pretest); HRS 2017 ICD class — sustained VT/VF survivor = Class I (this population by definition meets ICD criteria); spontaneous Type 1 ECG with prior syncope and family history = Class IIa; refractoriness to quinidine flag if recurrent VF on therapy
    inputs: initial_rhythm, time_to_cpr_min, time_to_aed_defibrillation_min, sbp, lactate
    actions: calc.map, calc.sofa, calc.ckd_epi_2021, calc.cha2ds2vasc, calc.heart
    advance: risk class + ICD eligibility + structural workup status documented
  9. 9TREATMENT
    Standard post-ROSC bundle (vasopressor → MAP ≥65; lung-protective vent; sedation with MIDAZOLAM + FENTANYL + DEXMEDETOMIDINE — NOT propofol during diagnostic confirmation; TTM 33-37.5 °C × 24 h); aggressive antipyresis at any temperature elevation (acetaminophen + cooling — fever is top trigger); STOP all Na-channel-blockers (www.brugadadrugs.org); K + Mg repletion (K ≥4.0; Mg ≥2.0); cautious NE for MAP support (α-agonists OK in Brugada). LONG-TERM (initiate before discharge): QUINIDINE 1-2 g/d PO loading then 600-1200 mg/d maintenance (target level 2-5 µg/mL — only Na-channel blocker that helps in Brugada because it ALSO blocks Ito; Belhassen registry); ICD per HRS 2017 Class I (sustained VT/VF survivor). Refractory storm → route to sister cardio.cardiogenic-shock.brugada-storm.v1 for isoproterenol bridge + RVOT epicardial substrate ablation (Nademanee PMID 21571989). AVOID lidocaine, procainamide, flecainide, propafenone, propofol (during diagnostic phase), amiodarone (relative), β-blockers acute, cocaine; substitute QT/INa-neutral alternatives
    inputs: sbp, hr, core_temp, spo2, creatinine, potassium, magnesium
    actions: protocol.cardiogenic_shock
    advance: post-ROSC bundle + propofol substitution + fever mitigation + drug-avoidance protocol + long-term quinidine plan + ICD pathway documented
  10. 10DISPOSITION
    CICU at EP-capable center for cardiac surveillance + ICD planning; transfer to inherited-arrhythmia center + ablation-capable center for refractory storm or planned RVOT ablation; cardiology + EP own structural workup + ICD + long-term quinidine + ablation pathway
    advance: unit + service-line ownership assigned + EP follow-up booked + ablation-center transfer planned if needed
  11. 11MONITORING
    Continuous telemetry × 48-72 h with HIGH V1-V2 lead placement (Brugada-sensitive); A-line; multimodal neuroprog ≥72 h post-rewarm (Sandroni 2021 PMID 33745427); serial ECG q4-6 h × 24 h then q6-8 h × 48-72 h with ECG re-evaluation 48-72 h after defervescence; daily medication audit against www.brugadadrugs.org; quinidine level q24 h once started (target 2-5 µg/mL); core temp q1 h with aggressive antipyresis any elevation
    inputs: ecg_12_lead_serial_with_high_v1_v2_placement, core_temp
    actions: panel.cardiac, panel.renal
    advance: monitoring + neuroprog + ECG re-evaluation timing + drug audit cadence + fever protocol + quinidine titration documented
  12. 12FOLLOWUP
    Cardiology + EP / inherited-arrhythmia clinic at 2-4 wks; cardiac MRI at 4-6 wk (rule out ARVC overlap; allow post-stunning resolution); GENETIC PANEL completed (SCN5A core; expanded if needed); CASCADE FAMILY SCREENING — first-degree relatives ECG + genetic testing at proband mutation; provocation challenge for SCN5A-positive relatives with non-diagnostic baseline ECG (genetics center under EP supervision only); ICD interrogation q3-6 mo; oral quinidine maintenance + level monitoring; consider RVOT epicardial substrate ablation for storm-prone phenotype (Nademanee technique); FEVER MITIGATION PROTOCOL — patient + family education on aggressive antipyresis any T > 37.5 °C, ED visit any T > 38.5 °C; vaccinations brought current; lifelong drug avoidance (medic-alert bracelet "Brugada syndrome — AVOID Na-channel blockers"); avoid large meals (vagal trigger); moderate alcohol; PTSD / mental health screen
    inputs: cardiac_mri_at_4_to_6_wk, genetic_panel_scn5a_expanded
    advance: cardiology + EP follow-up + genetic panel + cascade family screening + ICD + long-term quinidine + RVOT ablation evaluation + fever mitigation + drug avoidance + lifestyle modifications + mental health all booked / documented