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cardio.post-arrest.opioid-overdose.v1

Post-cardiac-arrest care — opioid-overdose-induced arrest

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.post-arrest.core.v1 — narrowed to opioid-overdose-induced cardiac arrest cohort. Asphyxial mechanism (opioid → respiratory depression → hypoxia → PEA/asystole) makes cardiac etiology UNCOMMON. Critical resuscitation modifications: EARLY + REPEATED naloxone 0.4–2 mg q2–3 min PRN with high-dose (4–10 mg+) for fentanyl/carfentanyl; infusion at 2/3 reversal-dose/h for prolonged opioid exposures or methadone; airway secured early + standard post-ROSC bundle; TTM 33–37.5 °C × 24h still indicated if comatose. Post-ROSC complications dominated by: re-arrest as naloxone wears off, non-cardiogenic pulmonary edema (NCPE), aspiration pneumonitis, rhabdomyolysis from down-time, hypoxic-ischemic encephalopathy. OUD bridge MAT initiated from ED: buprenorphine 4–8 mg SL when COWS ≥ 8 (SAMHSA Bridge Clinic; Edwards 2020); methadone alternative; warm handoff to outpatient bridge clinic / OTP within 7 d (Thom 2021 PMID 34516947). Inherits manifest + design-brief pointer from parent. 5 setting playbooks (ed, icu, inpatient, transition, outpatient). 5 severity triggers: re-arrest after naloxone wears off, suspected fentanyl/carfentanyl high-dose naloxone, MAT bridge failure or buprenorphine-precipitated withdrawal, opioid withdrawal during sedation weaning, severe aspiration/NCPE with refractory hypoxemia. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute Phase E wave 11.

Entry points (4)

  • symptom
    ROSC after opioid-overdose cardiac arrest — typically PEA / asystole rhythm reflecting asphyxial mechanism (AHA 2020 §opioid)
    rosc_after_opioid_overdose_arrest
  • history
    Witnessed opioid use / found-down with paraphernalia / track-marks + bradypnea–to-asystole progression
    witnessed_opioid_overdose_with_arrest
  • history
    Suspected fentanyl / carfentanyl / nitazene exposure — high-dose / prolonged naloxone requirement; tissue redistribution
    fentanyl_analogue_exposure_with_arrest
  • symptom
    Initial ROSC with naloxone but RE-ARREST as naloxone wears off (15–90 min t½ vs longer opioid t½)
    recurrent_arrest_after_initial_naloxone_response

Required inputs (21)

  • agerequired
    demographic • used at CONTEXT
    Older patients have higher hypoxic-ischemic encephalopathy risk and worse neurologic recovery; informs prognosis discussion + ICU-care intensity
  • opioid_type_suspectedrequired
    history • used at CONTEXT
    Fentanyl analogues (fentanyl, carfentanyl, nitazenes) require higher / longer naloxone dosing due to lipophilicity + tissue redistribution; methadone has prolonged half-life requiring infusion; heroin has shorter duration
  • co_ingestantsrequired
    history • used at CONTEXT
    Mixed OD common — sympathomimetic (cocaine/meth) → post-reversal agitation; benzo → flumazenil CONTRAINDICATED in mixed OD; alcohol → withdrawal management; gabapentinoid → additive sedation
  • down_time_minrequired
    history • used at CONTEXT
    Prolonged down-time → rhabdomyolysis from positional injury + worse hypoxic-ischemic encephalopathy + lower ROSC sustainability
  • arrest_witnessedrequired
    history • used at CONTEXT
    Witnessed + bystander CPR + low-flow time → favorable neuro prognosis (AHA 2020); CAHP/OHCA score inputs
  • initial_rhythmrequired
    history • used at CONTEXT
    PEA / asystole most common with opioid OD (asphyxial mechanism); shockable rhythm uncommon and suggests primary cardiac etiology rather than direct opioid arrest
  • low_flow_time_minrequired
    history • used at CONTEXT
    CPR duration → ECPR eligibility (ARREST PMID 33308475 — <60 min low-flow); neuro prognosis weighting
  • prior_overdose_or_oud
    history • used at CONTEXT
    Prior overdose → highest risk for repeat OD-related death; existing OUD diagnosis informs MAT bridge initiation; documents pattern of substance use
  • sbprequired
    vital • used at TREATMENT
    MAP ≥65 target post-ROSC; hypotension common from hypoxic myocardial stunning + acidosis
  • core_temprequired
    vital • used at TREATMENT
    TTM target 33–37.5 °C × 24h (TTM2 PMID 34133859); HYPERION PMID 31532382 supports TTM in non-shockable arrest as is typical here
  • spo2required
    vital • used at TREATMENT
    Avoid hyperoxia: SpO2 92–98% (AHA 2020 Class IIa); aspiration + NCPE may complicate oxygenation requiring ARDSnet vent
  • rrrequired
    vital • used at CONTEXT
    Bradypnea or apnea is the prearrest opioid signature; post-ROSC spontaneous rate informs extubation timing + naloxone redosing
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    Generally non-ischemic post-arrest opioid OD; QTc prolongation possible with methadone (cardiac arrest from torsades) and loperamide misuse; baseline + serial ECG for arrhythmia surveillance
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Hypoxic myocardial injury post-arrest produces troponin elevation; rule out concurrent type-1 MI as precipitant in patients with cardiac history
  • urine_drug_screenrequired
    lab • used at INITIAL_WORKUP
    Confirms opioid + identifies co-ingestants; note that fentanyl + many analogues are NOT detected on standard immunoassay UDS — clinical correlation primary; serum LC-MS for confirmatory if needed
  • ck_with_mbrequired
    lab • used at INITIAL_WORKUP
    Down-time + positional injury → rhabdomyolysis → myoglobinuric AKI; CK >5000 high-risk threshold (Bosch 2009 PMID 19571284)
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Tissue hypoperfusion + post-arrest perfusion debt; clearance trajectory drives prognosis (SCAI 2022 PMID 35718438)
  • creatininerequired
    lab • used at CONTEXT
    AKI risk from rhabdomyolysis + post-arrest hypoperfusion; KDIGO 2012 staging
  • abgrequired
    lab • used at INITIAL_WORKUP
    Severe respiratory + metabolic acidosis typical given prolonged hypoventilation; pH <7.0 + lactate >10 → grim prognosis
  • cxr_post_opioid_arrestrequired
    imaging • used at INITIAL_WORKUP
    Aspiration pneumonitis + non-cardiogenic pulmonary edema (NCPE; opioid-overdose-induced negative-pressure pulmonary edema, onset 0–24 h per Sterrett 2003); pneumothorax from CPR; baseline for ARDS evolution
  • echo_post_rosc
    imaging • used at INITIAL_WORKUP
    LV/RV function for post-arrest stunning; rule out concurrent ischemic precipitant if ECG concern

12-phase flow (12)

  1. 1FRAME
    Opioid-overdose cardiac arrest — asphyxial mechanism produces PEA/asystole most often (cardiac etiology UNCOMMON); post-ROSC dominated by aspiration, NCPE, rhabdomyolysis, hypoxic-ischemic encephalopathy, and re-arrest risk as naloxone wears off; route to parent cardio.post-arrest.core.v1 for TTM + neuroprog and integrate OUD bridge from ED
    inputs: opioid_type_suspected, initial_rhythm
    advance: opioid etiology + co-ingestant screen + initial rhythm documented
  2. 2ENTRY
    Standard ACLS with EARLY + REPEATED naloxone 0.4–2 mg IV/IM/IN q2–3 min PRN; do not delay airway pending naloxone response in arrest patient; secure airway / ventilate / treat reversible causes
    inputs: age, arrest_witnessed, down_time_min
    advance: ACLS + naloxone + airway secured
  3. 3CONTEXT
    Opioid type, co-ingestants, prior overdose / OUD, witnessed status, down-time, social history (housing, employment, treatment readiness), allergies, prior cardiac history, Q-T-prolonging meds (methadone history)
    inputs: co_ingestants, low_flow_time_min, sbp, core_temp, spo2, rr, creatinine
    advance: context + GOC + family + harm-reduction screening initiated
  4. 4RED_FLAGS
    Re-arrest from naloxone wearing off; severe hypoxemic respiratory failure / NCPE; rhabdomyolysis with rising CK; refractory hyperkalemia; concurrent ACS as the precipitant (pre-OD chest pain / known CAD with new ECG changes); aspiration pneumonitis with ARDS evolution; mixed-OD complications (benzo seizures from flumazenil; agitation from sympathomimetic co-use)
    inputs: ck_with_mb, creatinine, sbp, ecg_12_lead, cxr_post_opioid_arrest
    actions: cardiogenic_shock
    advance: red flags screened + escalations triggered
  5. 5INITIAL_WORKUP
    ECG + serial troponin + CK ± myoglobin + BMP + ABG + lactate + CBC + coags + UA + UDS (note: fentanyl often NOT detected on routine UDS) + acetaminophen + salicylate + ethanol levels for occult co-ingestion + CXR + bedside echo + CT head if AMS unresolved
    inputs: ecg_12_lead, troponin, urine_drug_screen, ck_with_mb, lactate, abg, cxr_post_opioid_arrest
    actions: post_arrest_care, panel.cardiac, panel.renal
    advance: workup complete + AKI risk + cardiac injury + NCPE assessed
  6. 6BRANCHING_WORKUP
    STEMI on post-ROSC ECG → cath; severe NCPE → ARDSnet vent; severe rhabdo → IVF + nephrology; QTc prolongation (methadone, loperamide) → torsades workup; refractory shock → MCS / SCAI staging
    actions: acs_pathway
    advance: cardiac vs pulmonary vs renal vs metabolic branching decided
  7. 7DIFFERENTIAL
    Pure opioid arrest (asphyxial PEA/asystole) vs opioid + concurrent ACS (independent precipitant) vs methadone-related QT-torsades (loperamide misuse mimic) vs mixed OD (sympathomimetic-driven cardiac arrest with opioid co-use confounding) vs septic / hypovolemic precipitants
    advance: primary mechanism + co-precipitants established
  8. 8RISK_STRATIFICATION
    CAHP/OHCA scores; CK trend + AKI stage; SCAI shock stage; severity of hypoxemic respiratory failure (PaO2/FiO2); GCS off sedation if delayed neuroprog window; OUD severity (DSM-5) for MAT planning
    inputs: initial_rhythm, low_flow_time_min, sbp, lactate, ck_with_mb, creatinine
    actions: calc.map, calc.heart, calc.ckd_epi_2021, calc.cha2ds2vasc
    advance: risk class + AKI + respiratory severity + neuro prognosis + OUD severity documented
  9. 9TREATMENT
    Continue naloxone titration (consider infusion at 2/3 reversal-dose/h if multiple boluses needed or fentanyl/methadone exposure); aggressive ARDSnet vent for NCPE if PaO2/FiO2 <300; aggressive IVF + UOP target 1–2 mL/kg/h if rhabdo; TTM 33–37.5 °C × 24h once stable; standard post-ROSC bundle (vasopressor → MAP ≥65, lung-protective vent, sedation); cath if STEMI suspected as concurrent precipitant; INITIATE OUD BRIDGE: buprenorphine 4–8 mg SL once moderate withdrawal develops (SAMHSA Bridge Clinic) OR methadone 20–30 mg PO daily with d-3 OTP referral (Berg 2024)
    inputs: sbp, core_temp, spo2, creatinine, ck_with_mb
    actions: protocol.cardiogenic_shock
    advance: naloxone strategy + post-ROSC bundle + OUD bridge plan documented
  10. 10DISPOSITION
    CICU vs MICU per predominant problem (cardiac concern → CICU; respiratory/metabolic predominant → MICU; psychiatric/social factors → ED hold-bed if appropriate, with floor admit + addiction medicine consult); multidisciplinary team — addiction medicine + critical care + cardiology + nephrology + social work + harm-reduction services
    advance: unit + service-line ownership + addiction medicine consult booked
  11. 11MONITORING
    Continuous telemetry (capture re-arrest + QTc + arrhythmia) + arterial line + central line + Foley with hourly UOP target 1–2 mL/kg/h; re-arrest protocol — naloxone available at bedside × 24h or duration of suspected opioid; CK q6h until peak documented + downtrending; serial troponin + ABG; multimodal neuroprog ≥72h post-rewarm (Sandroni 2021 PMID 33745427); COWS (Clinical Opiate Withdrawal Scale) q4h for OUD bridge timing
    inputs: ck_with_mb, creatinine
    actions: panel.renal, panel.cardiac
    advance: monitoring + re-arrest protocol + OUD bridge timeline documented
  12. 12FOLLOWUP
    Critical cardiology / EP follow-up if cardiac concern; addiction medicine outpatient (warm handoff to bridge clinic / OTP within 7 d per Thom 2021 PMID 34516947); harm reduction (take-home naloxone × 2, fentanyl test strips, needle exchange); mental health (PTSD + depression high-risk); social work (housing, employment, legal); family education on overdose recognition + naloxone use; primary care for HIV/HCV screening if IV use; post-discharge MAT continuation (buprenorphine refill at d/c, methadone OTP appointment)
    advance: addiction medicine + harm reduction + mental health + primary care + naloxone Rx booked