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cardio.post-arrest.brugada-channelopathy.v1PRODUCTION
cardio.post-arrest.brugada-channelopathy.v1

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

cardiologyacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Detailed

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

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Brugada high pretest probability confirmed + structural disease screen initiated

Patient inputs (24)

Brugada most often manifests age 30–50 y; informs ICD device-size considerations + cascade-testing prioritization for younger relatives

Male predominance ~8:1 (testosterone effect on Ito); informs counseling + risk stratification + prioritized cascade screening of male relatives

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

CPR within 1 min dramatically improves outcome; CAHP/OHCA score input

AED within 3 min → 50%+ survival; venue AED program presence is dominant prognostic factor

VF most common in Brugada (~95%); polymorphic VT degenerating to VF is the classic mechanism; informs storm-suppression bridge planning

Family history of SCD <45 y or known Brugada in first-degree relative is a critical input — drives SCN5A panel + cascade screening priority

Prior nocturnal syncope suggests Brugada substrate; recent Na-channel-blocker exposure (lidocaine, procainamide, flecainide, propafenone, cocaine, TCA) suggests acquired or unmasked Brugada phenotype

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

eGFR for quinidine dose adjustment (renal + hepatic clearance); target quinidine level 2-5 µg/mL

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

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

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

Often modestly elevated from arrest + CPR; rise pattern helps differentiate from ACS-mediated arrest; primary Brugada arrest typically negative or modest

Tissue hypoperfusion + post-arrest perfusion debt; clearance trajectory drives prognosis (SCAI 2022 PMID 35718438; CardShock PMID 26333869)

K target ≥4.0 — hypokalemia worsens Brugada storm; aggressive replacement

Mg target ≥2.0 supportive; replace standard polymorphic VT supportive therapy

Rib fractures from CPR; pneumothorax; aspiration; baseline for ICD lead placement planning

MAP ≥65 target post-ROSC; SCAI staging if shock; cautious vasopressor dosing (α-agonists OK in Brugada, unlike β-blockers acutely)

Bradycardia / vagal triggers may have unmasked Brugada substrate; isoproterenol storm-suppression target HR 90–110 if recurrence

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

Avoid hyperoxia: SpO2 92-98% (AHA 2020 Class IIa)

Cocaine has Na-channel blocking effect that can unmask Brugada substrate; cannabis may also contribute; lifestyle counseling input

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

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningrecurrent_vf_storm_post_rosc_brugada_bridge
    Recurrent VF / polymorphic VT post-ROSC suggests ongoing Brugada storm physiology — isoproterenol 1-3 µg/min IV bridge (paradoxical β-1 augments ICa-L); quinidine load 1-2 g/d PO; aggressive antipyresis any temperature elevation; STOP all Na-channel blockers + propofol; route to sister cardio.cardiogenic-shock.brugada-storm.v1 for mid-storm management; consider RVOT ablation referral if refractory
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninginadvertent_na_channel_blocker_or_propofol_administered_post_rosc
    Inadvertent administration of Na-channel-blocker (lidocaine, procainamide, flecainide, propafenone, cocaine, TCA) or propofol (during diagnostic confirmation phase) post-ROSC in confirmed or suspected Brugada — STOP drug + isoproterenol bridge if storm develops + escalate to EP + chart audit + nursing handoff review; substitute with INa-neutral alternative (midazolam + fentanyl + dexmedetomidine for sedation)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefever_mitigation_protocol_breach_post_rosc_brugada
    Fever (T > 37.5 °C) post-ROSC in confirmed or suspected Brugada — aggressive antipyresis acetaminophen 650-1000 mg q4-6 h + surface cooling; if T > 38.5 °C consider isoproterenol bridge if storm develops; lifelong fever mitigation protocol education for patient + family
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereicd_eligibility_evaluation_brugada_post_arrest
    Sustained VT/VF survivor by definition meets HRS 2017 Class I ICD criteria — implant pre-discharge or schedule within 1 wk; subcutaneous ICD considered if no pacing indication; WCD bridge if ICD deferred for stabilization
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecascade_family_screening_referral_required_brugada
    Confirmed Brugada (or strongly suspected pending genetic / provocation results) triggers mandatory cascade screening of first-degree relatives — ECG + SCN5A genetic testing at proband mutation; genetic counseling referral; provocation challenge (ajmaline 1 mg/kg IV preferred; or flecainide 2 mg/kg IV up to 150 mg) in genetics center under EP supervision only for SCN5A-positive relatives with non-diagnostic baseline ECG
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

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
axis: brugada_post_arrest_phenotype
Selected axis "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" by default fallback (first axis)
  • acetaminophen
    first line
    antipyretic_analgesic
    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
    triggers: fever_in_brugada_patient_post_rosc, temperature_above_37.5c_lifelong
    HRS 2017 PMID 28219760 — fever is the MOST COMMON modifiable Brugada storm trigger; aggressive antipyresis + surface cooling mandatory; lifelong fever mitigation protocol
    rxcui 161
  • potassium chloride
    first line
    electrolyte
    20-40 mEq IV/PO until K ≥4.0 in Brugada post-arrest • IV/PO • PRN until target sustained
    triggers: k_below_4_in_brugada_post_arrest, recurrent_polymorphic_vt
    Hypokalemia worsens Brugada storm; K ≥4.0 target supportive
    rxcui 8591
  • magnesium sulfate
    first line
    electrolyte
    2 g IV bolus then 2 g/h infusion if any polymorphic VT recurrence; target Mg ≥2.0 • IV • continuous if storm
    triggers: polymorphic_vt_post_rosc, mg_below_2_in_brugada_post_arrest
    Standard polymorphic VT supportive therapy; safer than additional antiarrhythmics in Brugada
    rxcui 6585
  • norepinephrine
    first line
    vasopressor_alpha1_beta1
    0.05-0.5 µg/kg/min titrate MAP ≥65; α-agonists OK in Brugada (β-blockers AVOIDED acutely) • IV • continuous
    triggers: post_rosc_vasoplegia
    SOAP-II PMID 20200382 — first-line in CS; α-1 effect supports MAP without adversely affecting Brugada substrate
    rxcui 7512
  • epinephrine
    first line
    inotrope_chronotrope_vasopressor
    1 mg IV q3-5 min during arrest • IV • standard ACLS
    triggers: cardiac_arrest, pea_asystole_during_index_arrest
    AHA 2020 ACLS — standard arrest pathway
    rxcui 3992
  • midazolam
    first line
    benzodiazepine_sedative
    1-2 mg IV bolus PRN; 0.02-0.1 mg/kg/h infusion if needed • IV • PRN / continuous
    triggers: post_rosc_sedation_substitute_for_propofol_during_brugada_diagnostic_phase
    PADIS 2018; substitute for propofol during Brugada diagnostic confirmation phase (propofol can accentuate Type 1 Brugada pattern — Brugada Phenocopy from propofol)
    rxcui 6960
  • fentanyl
    first line
    opioid_analgesic
    25-200 µg/h • IV • continuous
    triggers: post_rosc_intubation_ttm, analgesia
    PADIS 2018; INa-neutral; preferred over methadone
    rxcui 4337
  • dexmedetomidine
    first line
    alpha2_agonist_sedative
    0.2-1.4 µg/kg/h; no bolus • IV • continuous
    triggers: post_rosc_delirium_prevention, avoidance_of_propofol_during_brugada_diagnostic_phase
    PADIS 2018; preferred for ICU delirium in Brugada cohort because INa-neutral and substitutes for propofol; Class IIa AHA delirium prevention
    rxcui 48937
  • quinidine
    comorbidity specific
    class_ia_antiarrhythmic_with_ito_blockade
    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
    triggers: confirmed_brugada_post_arrest_long_term_storm_prevention, recurrent_icd_shocks_bridge_to_ablation
    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
    rxcui 9068
  • isoproterenol
    rescue
    beta1_agonist
    1-3 µg/min IV titrate to HR 90-110 + storm suppression • IV • continuous
    triggers: recurrent_brugada_storm_post_rosc
    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
    rxcui 6054

outpatient playbook — drug actions (4)

  1. 1. continue quinidine maintenance lifelong if storm-prone
    rxcui 9068
    600-1200 mg/d (level 2-5 µg/mL) • PO • q6h; lifelong
    trigger: storm-prone phenotype or post-arrest Brugada
    Belhassen registry + HRS 2017 IIa long-term storm prevention
  2. 2. consider catheter ablation if storm-prone despite quinidine (Nademanee RVOT epicardial substrate technique)
    EP referral • n/a • one-time procedure
    trigger: recurrent storm despite quinidine
    Nademanee 2011 PMID 21571989 — RVOT epicardial substrate ablation suppresses storm in 75-80% of refractory cases
  3. 3. continue lifelong avoidance of all Na-channel blockers (www.brugadadrugs.org)
    patient education + curated drug list • n/a • lifelong
    trigger: Brugada diagnosis
    HRS 2017
  4. 4. lifelong fever mitigation protocol
    rxcui 161
    acetaminophen any T > 37.5 °C; ED visit any T > 38.5 °C • PO • PRN
    trigger: T > 37.5 °C
    Lifelong protocol

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: 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); 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.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Post-cardiac-arrest care — Brugada syndrome channelopathy (SCN5A type 1 ECG; sleep / fever-triggered VF)** (cardio.post-arrest.brugada-channelopathy.v1).
Phenotype framing: 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
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **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**.
1. 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 (antipyretic_analgesic, first line) — HRS 2017 PMID 28219760 — fever is the MOST COMMON modifiable Brugada storm trigger; aggressive antipyresis + surface cooling mandatory; lifelong fever mitigation protocol
2. potassium chloride 20-40 mEq IV/PO until K ≥4.0 in Brugada post-arrest IV/PO PRN until target sustained (electrolyte, first line) — Hypokalemia worsens Brugada storm; K ≥4.0 target supportive
3. magnesium sulfate 2 g IV bolus then 2 g/h infusion if any polymorphic VT recurrence; target Mg ≥2.0 IV continuous if storm (electrolyte, first line) — Standard polymorphic VT supportive therapy; safer than additional antiarrhythmics in Brugada
4. norepinephrine 0.05-0.5 µg/kg/min titrate MAP ≥65; α-agonists OK in Brugada (β-blockers AVOIDED acutely) IV continuous (vasopressor_alpha1_beta1, first line) — SOAP-II PMID 20200382 — first-line in CS; α-1 effect supports MAP without adversely affecting Brugada substrate
5. epinephrine 1 mg IV q3-5 min during arrest IV standard ACLS (inotrope_chronotrope_vasopressor, first line) — AHA 2020 ACLS — standard arrest pathway
6. midazolam 1-2 mg IV bolus PRN; 0.02-0.1 mg/kg/h infusion if needed IV PRN / continuous (benzodiazepine_sedative, first line) — PADIS 2018; substitute for propofol during Brugada diagnostic confirmation phase (propofol can accentuate Type 1 Brugada pattern — Brugada Phenocopy from propofol)
7. fentanyl 25-200 µg/h IV continuous (opioid_analgesic, first line) — PADIS 2018; INa-neutral; preferred over methadone
8. dexmedetomidine 0.2-1.4 µg/kg/h; no bolus IV continuous (alpha2_agonist_sedative, first line) — PADIS 2018; preferred for ICU delirium in Brugada cohort because INa-neutral and substitutes for propofol; Class IIa AHA delirium prevention
9. 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 (class_ia_antiarrhythmic_with_ito_blockade, comorbidity specific) — 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
10. isoproterenol 1-3 µg/min IV titrate to HR 90-110 + storm suppression IV continuous (beta1_agonist, rescue) — 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

Setting playbook (outpatient) — Long-term EP / inherited-arrhythmia clinic surveillance; ICD interrogation q3 mo; quinidine maintenance + level monitoring; consider catheter ablation for storm-prone phenotype (Nademanee technique); family cascade testing completion + ongoing identification of newly recognised relatives; lifelong drug-avoidance + fever mitigation education + lifestyle modifications; annual mental health screen
11. continue quinidine maintenance lifelong if storm-prone 600-1200 mg/d (level 2-5 µg/mL) PO q6h; lifelong — storm-prone phenotype or post-arrest Brugada (Belhassen registry + HRS 2017 IIa long-term storm prevention)
12. consider catheter ablation if storm-prone despite quinidine (Nademanee RVOT epicardial substrate technique) EP referral n/a one-time procedure — recurrent storm despite quinidine (Nademanee 2011 PMID 21571989 — RVOT epicardial substrate ablation suppresses storm in 75-80% of refractory cases)
13. continue lifelong avoidance of all Na-channel blockers (www.brugadadrugs.org) patient education + curated drug list n/a lifelong — Brugada diagnosis (HRS 2017)
14. lifelong fever mitigation protocol acetaminophen any T > 37.5 °C; ED visit any T > 38.5 °C PO PRN — T > 37.5 °C (Lifelong protocol)

Non-pharmacologic actions:
- EP / inherited-arrhythmia clinic q3 mo lifelong
- ICD generator / lead surveillance per device clinic; replacement at end-of-service
- Family genetic counseling + first-degree relative ECG screening + genetic testing at proband mutation; provocation challenge (ajmaline/flecainide) in genetics center under EP supervision only for SCN5A-positive with non-diagnostic baseline ECG
- Lifestyle: aggressive fever management; avoid large meals (vagal trigger); moderate alcohol; lifelong avoidance of cocaine + cannabis; medic-alert bracelet
- Vaccinations brought current to reduce future febrile illness triggers
- Mental health long-term

AVOID / contraindication checks:
- Lidocaine_AVOID_in_brugada_post_arrest (Na channel blocker — paradoxically arrhythmogenic at therapeutic dose; diagnostic at low dose with provocation)
- Procainamide_AVOID_in_brugada_post_arrest (Na channel blocker — PROCAMIO general algorithm does NOT apply in Brugada)
- Flecainide_AVOID_in_brugada_post_arrest (DIAGNOSTIC at low dose; LETHAL at therapeutic oral dose)
- Propafenone_AVOID_in_brugada_post_arrest (Na channel blocker — same class IC as flecainide)
- Propofol_AVOID_during_brugada_diagnostic_confirmation_phase (can accentuate Type 1 Brugada pattern; substitute midazolam + fentanyl + dexmedetomidine; acceptable low dose short duration after diagnosis confirmed)
- Cocaine_and_cannabis_AVOID_in_brugada (Na channel blocking effect; can trigger storm; lifelong avoidance)
- Amiodarone_relative_AVOID_in_brugada (variable / unproven benefit; can prolong QT further)
- Beta_blocker_AVOID_acute_brugada_post_arrest (removes β 1 stabilization; opposite of LQT pharmacology)
- Tricyclic_antidepressants_amitriptyline_AVOID_in_brugada (Na channel blocking effect)
- Lifelong_avoidance_na_channel_blockers_per_brugadadrugs_org (international curated avoid list)
- Icd_indicated_HRS_2017_class_i_post_brugada_arrest (sustained VT/VF survivor by definition)
- Fever_mitigation_protocol_lifelong (any T > 37.5 °C aggressive acetaminophen + cooling; ED visit any T > 38.5 °C)

Monitoring

Regimen monitoring:
- continuous ecg telemetry x 48-72h with HIGH V1 V2 lead placement 2nd 3rd ICS (Brugada-sensitive lead positioning; HRS 2017)
- serial ECG q4-6h initially then q6-8h x 48-72h (track ST evolution + Type 1 unmasking)
- ECG re evaluation 48-72h after defervescence (fever masks pattern; resolution unmasks Type 1)
- core temp q1h aggressive antipyresis any elevation target under 37 (fever is top trigger lifelong)
- BMP q4-6h until K above 4 and Mg above 2 sustained
- serial troponin q3-6h x 24h (4th UDMI 2018)
- continuous core temp via bladder or esophageal probe during TTM (TTM2 PMID 34133859)
- continuous EEG for 24-48h (Sandroni 2021 PMID 33745427)
- NSE at 24h 48h 72h (Sandroni 2021)
- lactate q2-4h until normalized (SCAI 2022 PMID 35718438)
- daily medication audit against brugadadrugs org (lifelong drug avoidance)
- genetic panel scn5a core then expanded if negative (HRS 2017)
- cardiac MRI at 4-6 wk (rule out ARVC overlap)
- first degree relative ecg screening referral (cascade testing; consider provocation challenge for SCN5A-positive relatives with non-diagnostic baseline)
- quinidine level q24h target 2-5 mcg per mL once started (therapeutic window)

Setting (outpatient) monitoring:
- q3 mo ICD interrogation + quinidine level lifelong
- Annual ECG with high V1-V2 placement
- Family cascade testing progress documentation
- Lifelong drug audit at every clinic visit (www.brugadadrugs.org)

Follow-up plan: 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
- Close-out criterion: 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

Monitoring phase: 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

Disposition

Current setting: outpatient — Long-term EP / inherited-arrhythmia clinic surveillance; ICD interrogation q3 mo; quinidine maintenance + level monitoring; consider catheter ablation for storm-prone phenotype (Nademanee technique); family cascade testing completion + ongoing identification of newly recognised relatives; lifelong drug-avoidance + fever mitigation education + lifestyle modifications; annual mental health screen

Disposition criteria:
- Long-term continuation lifelong; ICD + quinidine + RVOT ablation if storm-prone + lifelong drug avoidance + fever mitigation + lifestyle modifications + family cascade testing operational

Escalation triggers (move to higher acuity):
- Recurrent ICD shocks → emergent EP + RVOT ablation evaluation
- New arrhythmia (AF, VT) → EP for programming + drug review (AVOID Class IC + III antiarrhythmics for AF in Brugada)
- Quinidine intolerance / toxicity → ablation pathway
- Family member positive screening → cascade testing extended + EP referral
- Mental health crisis → psychiatry

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Recurrent VF / polymorphic VT post-ROSC suggests ongoing Brugada storm physiology — isoproterenol 1-3 µg/min IV bridge (paradoxical β-1 augments ICa-L); quinidine load 1-2 g/d PO; aggressive antipyresis any temperature elevation; STOP all Na-channel blockers + propofol; route to sister cardio.cardiogenic-shock.brugada-storm.v1 for mid-storm management; consider RVOT ablation referral if refractory
- [LIFE_THREATENING] Inadvertent administration of Na-channel-blocker (lidocaine, procainamide, flecainide, propafenone, cocaine, TCA) or propofol (during diagnostic confirmation phase) post-ROSC in confirmed or suspected Brugada — STOP drug + isoproterenol bridge if storm develops + escalate to EP + chart audit + nursing handoff review; substitute with INa-neutral alternative (midazolam + fentanyl + dexmedetomidine for sedation)
- [SEVERE] Fever (T > 37.5 °C) post-ROSC in confirmed or suspected Brugada — aggressive antipyresis acetaminophen 650-1000 mg q4-6 h + surface cooling; if T > 38.5 °C consider isoproterenol bridge if storm develops; lifelong fever mitigation protocol education for patient + family

Citations

- 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) [PMID:28219760](https://pubmed.ncbi.nlm.nih.gov/28219760/)
- Cited evidence (PMID 24251382) [PMID:24251382](https://pubmed.ncbi.nlm.nih.gov/24251382/)
- Cited evidence (PMID 20805107) [PMID:20805107](https://pubmed.ncbi.nlm.nih.gov/20805107/)
- Cited evidence (PMID 15007110) [PMID:15007110](https://pubmed.ncbi.nlm.nih.gov/15007110/)
- Cited evidence (PMID 21571989) [PMID:21571989](https://pubmed.ncbi.nlm.nih.gov/21571989/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 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) — PMID:28219760
  • Cited evidence (PMID 24251382) — PMID:24251382
  • Cited evidence (PMID 20805107) — PMID:20805107
  • Cited evidence (PMID 15007110) — PMID:15007110
  • Cited evidence (PMID 21571989) — PMID:21571989