This handout is for post-cardiac-arrest care — opioid-overdose-induced arrest. Your care team identified this based on: rosc after opioid-overdose cardiac arrest — typically pea / asystole rhythm reflecting asphyxial mechanism (aha 2020 §opioid).
Other reasons your team may use this plan: witnessed opioid use / found-down with paraphernalia / track-marks + bradypnea–to-asystole progression; suspected fentanyl / carfentanyl / nitazene exposure — high-dose / prolonged naloxone requirement; tissue redistribution; initial rosc with naloxone but re-arrest as naloxone wears off (15–90 min t½ vs longer opioid t½).
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 |
|---|---|---|---|---|
| naloxone | 0.4–2 mg IV/IM/IN q2–3 min PRN; consider 4–10 mg total (or more) for fentanyl/carfentanyl; infusion at 2/3 reversal-dose/h if multiple boluses required | IV/IM/IN | PRN q2–3 min then continuous infusion | AHA 2020 §opioid overdose ACLS PMID 33081530 + ACMT 2024 high-dose for synthetic opioid exposures; infusion to bridge naloxone half-life vs longer opioid duration |
| norepinephrine | 0.05–0.5 µg/kg/min titrate MAP ≥65 | IV | continuous | SOAP-II PMID 20200382; first-line post-ROSC vasoactive |
| epinephrine | 1 mg IV q3–5 min during arrest | IV | standard ACLS | AHA 2020 ACLS |
| propofol | 5–50 µg/kg/min | IV | continuous; titrate RASS | PADIS 2018 |
| fentanyl | 25–100 µg/h (use cautiously given the OD context — consider non-opioid analgesia where possible) | IV | continuous; titrated | PADIS 2018 — analgesia + shivering suppression for TTM; in OD context favor lower doses + shorter courses + early de-escalation; document OUD context for transition planning |
| buprenorphine | 4–8 mg SL once moderate withdrawal (COWS ≥ 8) develops; may give 16–24 mg/d divided over 24 h | SL | daily; titrate to suppress withdrawal + craving | SAMHSA Bridge Clinic protocol + Edwards Ann Emerg Med 2020 — ED-initiated buprenorphine reduces 30-d mortality + improves OUD treatment retention; key step in MAT bridge after opioid OD |
| methadone | 20–30 mg PO daily with day-3 OTP referral | PO | daily; OTP supervision | Berg J Addict Med 2024 — ED methadone bridge reduces mortality; use with monitored ECG (QTc surveillance) given methadone QT effects |
| naltrexone XR-IM | 380 mg IM q4 weeks AFTER ≥7-d opioid-free interval | IM | monthly | XR-NTX vs buprenorphine — alternative MAT pathway; only use after confirmed opioid-free interval to avoid precipitated withdrawal |
| lactated_ringers | 1–1.5 L bolus then 200–500 mL/h titrate UOP 1–2 mL/kg/h | IV | continuous | KDIGO 2012 §5.4 + Bosch 2009 PMID 19571284 — aggressive crystalloid prevents myoglobinuric AKI in rhabdo |
| dextrose 50% | 25 g IV | IV | one-time | AHA 2020 — correct hypoglycemia immediately; common in malnourished IV-drug-use patients |
| thiamine | 500 mg IV TID × 3 d then 100 mg PO daily | IV/PO | TID then daily | Empiric thiamine before glucose in malnourished IV-drug-use patients to prevent Wernicke’s encephalopathy |
Plan: Opioid-overdose post-arrest phenotype — naloxone-titration resuscitation + post-ROSC standard bundle + OUD bridge MAT (AHA 2020 + ACMT 2024 + SAMHSA Bridge Clinic + Thom 2021)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
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)
Guideline: AHA 2020 ACLS / Post-Cardiac-Arrest Care opioid overdose § + ACMT 2024 fentanyl management consensus + SAMHSA Bridge Clinic + SAMHSA TIP 63 (2023) + KDIGO 2012 AKI + TTM2 + HYPERION + Sandroni 2021 neuroprog