This handout is for post-cardiac-arrest care — brugada syndrome channelopathy (scn5a type 1 ecg; sleep / fever-triggered vf). Your care team identified this based on: 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).
Other reasons your team may use this plan: 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; 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; 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.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| acetaminophen | 650-1000 mg PO/PR/IV q4-6 h scheduled at any T > 37.5 °C; aggressive antipyresis mandatory | PO/PR/IV | q4-6 h scheduled while temperature elevated | HRS 2017 PMID 28219760 — fever is the MOST COMMON modifiable Brugada storm trigger; aggressive antipyresis + surface cooling mandatory; lifelong fever mitigation protocol |
| potassium chloride | 20-40 mEq IV/PO until K ≥4.0 in Brugada post-arrest | IV/PO | PRN until target sustained | Hypokalemia worsens Brugada storm; K ≥4.0 target supportive |
| magnesium sulfate | 2 g IV bolus then 2 g/h infusion if any polymorphic VT recurrence; target Mg ≥2.0 | IV | continuous if storm | Standard polymorphic VT supportive therapy; safer than additional antiarrhythmics in Brugada |
| norepinephrine | 0.05-0.5 µg/kg/min titrate MAP ≥65; α-agonists OK in Brugada (β-blockers AVOIDED acutely) | IV | continuous | SOAP-II PMID 20200382 — first-line in CS; α-1 effect supports MAP without adversely affecting Brugada substrate |
| epinephrine | 1 mg IV q3-5 min during arrest | IV | standard ACLS | AHA 2020 ACLS — standard arrest pathway |
| midazolam | 1-2 mg IV bolus PRN; 0.02-0.1 mg/kg/h infusion if needed | IV | PRN / continuous | PADIS 2018; substitute for propofol during Brugada diagnostic confirmation phase (propofol can accentuate Type 1 Brugada pattern — Brugada Phenocopy from propofol) |
| fentanyl | 25-200 µg/h | IV | continuous | PADIS 2018; INa-neutral; preferred over methadone |
| dexmedetomidine | 0.2-1.4 µg/kg/h; no bolus | IV | continuous | PADIS 2018; preferred for ICU delirium in Brugada cohort because INa-neutral and substitutes for propofol; Class IIa AHA delirium prevention |
| quinidine | BRUGADA long-term: 1-2 g/d PO loading then 600-1200 mg/d maintenance (target level 2-5 µg/mL) | PO | q6h after load; lifelong if storm-prone | Belhassen quinidine registry (representative PMID 15007110) + HRS 2017 PMID 28219760 IIa — the ONLY Na-channel blocker that helps in Brugada because it ALSO blocks Ito (transient outward K current); reduces phase-2 dispersion driving reentry; long-term storm prevention + bridge to ablation |
| isoproterenol | 1-3 µg/min IV titrate to HR 90-110 + storm suppression | IV | continuous | HRS 2017 PMID 28219760 — paradoxical β-1 agonist that suppresses Brugada storm by augmenting L-type Ca current (ICa-L); FIRST-LINE storm-suppression bridge when storm recurs post-ROSC; route to sister cardio.cardiogenic-shock.brugada-storm.v1 for sustained storm |
Plan: Brugada syndrome post-arrest phenotype — standard post-ROSC bundle (NO propofol during diagnostic phase) + fever mitigation + Na-channel-blocker avoidance + long-term quinidine + ICD pathway (HRS 2017 Class I) + cascade family screening
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
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
Guideline: HRS 2017 Inherited Arrhythmia Syndromes Expert Consensus (Al-Khatib PMID 28219760) + AHA 2020 ACLS / Post-Cardiac-Arrest Care + TTM2 + Sandroni 2021 ERC-ESICM neuroprog + Brugada P 2014 review + Belhassen quinidine registry + Nademanee RVOT epicardial substrate ablation + BrugadaDrugs.org international curated avoid-list (Postema)