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cardio.post-arrest.opioid-overdose.v1PRODUCTION
cardio.post-arrest.opioid-overdose.v1

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

cardiologyacuteadult
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12/12 authored

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

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Detailed

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

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opioid etiology + co-ingestant screen + initial rhythm documented

Patient inputs (21)

Older patients have higher hypoxic-ischemic encephalopathy risk and worse neurologic recovery; informs prognosis discussion + ICU-care intensity

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

Mixed OD common — sympathomimetic (cocaine/meth) → post-reversal agitation; benzo → flumazenil CONTRAINDICATED in mixed OD; alcohol → withdrawal management; gabapentinoid → additive sedation

Prolonged down-time → rhabdomyolysis from positional injury + worse hypoxic-ischemic encephalopathy + lower ROSC sustainability

Witnessed + bystander CPR + low-flow time → favorable neuro prognosis (AHA 2020); CAHP/OHCA score inputs

PEA / asystole most common with opioid OD (asphyxial mechanism); shockable rhythm uncommon and suggests primary cardiac etiology rather than direct opioid arrest

CPR duration → ECPR eligibility (ARREST PMID 33308475 — <60 min low-flow); neuro prognosis weighting

Bradypnea or apnea is the prearrest opioid signature; post-ROSC spontaneous rate informs extubation timing + naloxone redosing

AKI risk from rhabdomyolysis + post-arrest hypoperfusion; KDIGO 2012 staging

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

Hypoxic myocardial injury post-arrest produces troponin elevation; rule out concurrent type-1 MI as precipitant in patients with cardiac history

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

Down-time + positional injury → rhabdomyolysis → myoglobinuric AKI; CK >5000 high-risk threshold (Bosch 2009 PMID 19571284)

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

Severe respiratory + metabolic acidosis typical given prolonged hypoventilation; pH <7.0 + lactate >10 → grim prognosis

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

MAP ≥65 target post-ROSC; hypotension common from hypoxic myocardial stunning + acidosis

TTM target 33–37.5 °C × 24h (TTM2 PMID 34133859); HYPERION PMID 31532382 supports TTM in non-shockable arrest as is typical here

Avoid hyperoxia: SpO2 92–98% (AHA 2020 Class IIa); aspiration + NCPE may complicate oxygenation requiring ARDSnet vent

Prior overdose → highest risk for repeat OD-related death; existing OUD diagnosis informs MAT bridge initiation; documents pattern of substance use

LV/RV function for post-arrest stunning; rule out concurrent ischemic precipitant if ECG concern

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Severity triggers (5)

5 need judgement
  • informationallife_threateningrecurrent_arrest_after_naloxone_wears_off
    Re-arrest or recurrent severe respiratory depression as administered naloxone wears off (15–90 min t½) before opioid (especially fentanyl/methadone) is fully eliminated
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsevere_aspiration_or_ncpe_with_refractory_hypoxemia
    Aspiration pneumonitis or non-cardiogenic pulmonary edema with PaO2/FiO2 <100 despite ARDSnet vent in opioid OD post-ROSC patient
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresuspected_fentanyl_or_carfentanyl_high_dose_naloxone_required
    Cumulative naloxone >4 mg required for reversal OR persistent respiratory depression despite standard naloxone dosing — suggests fentanyl analogue or non-opioid co-toxin
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremat_bridge_failure_or_buprenorphine_precipitated_withdrawal
    Failed initial buprenorphine induction with precipitated withdrawal (worsening symptoms after first dose) OR patient declines MAT bridge despite counseling
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereopioid_withdrawal_during_post_rosc_sedation_unmasked
    Severe opioid withdrawal symptoms (COWS > 12) emerging as ICU sedation is weaned in known OUD patient
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Opioid-overdose post-arrest phenotype — naloxone-titration resuscitation + post-ROSC standard bundle + OUD bridge MAT (AHA 2020 + ACMT 2024 + SAMHSA Bridge Clinic + Thom 2021)
axis: opioid_overdose_post_arrest_phenotype
Selected axis "Opioid-overdose post-arrest phenotype — naloxone-titration resuscitation + post-ROSC standard bundle + OUD bridge MAT (AHA 2020 + ACMT 2024 + SAMHSA Bridge Clinic + Thom 2021)" by default fallback (first axis)
  • naloxone
    first line
    opioid_antagonist
    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
    triggers: opioid_overdose_arrest, post_rosc_re_arrest_risk, fentanyl_analogue_exposure
    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
    rxcui 7242
  • norepinephrine
    first line
    vasopressor_alpha1_beta1
    0.05–0.5 µg/kg/min titrate MAP ≥65 • IV • continuous
    triggers: post_rosc_vasoplegia, hypoxic_myocardial_stunning
    SOAP-II PMID 20200382; first-line post-ROSC vasoactive
    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
    rxcui 3992
  • propofol
    first line
    sedative_iv_anesthetic
    5–50 µg/kg/min • IV • continuous; titrate RASS
    triggers: post_rosc_intubation_ttm
    PADIS 2018
    rxcui 8782
  • fentanyl
    second line
    opioid_analgesic
    25–100 µg/h (use cautiously given the OD context — consider non-opioid analgesia where possible) • IV • continuous; titrated
    triggers: post_rosc_intubation_ttm_with_pain, shivering_control
    PADIS 2018 — analgesia + shivering suppression for TTM; in OD context favor lower doses + shorter courses + early de-escalation; document OUD context for transition planning
    rxcui 4337
  • buprenorphine
    first line
    partial_mu_opioid_agonist
    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
    triggers: oud_diagnosis_with_post_overdose_bridge, cows_score_above_8_in_inpatient_setting
    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
    rxcui 1819
  • methadone
    second line
    long_acting_mu_opioid_agonist
    20–30 mg PO daily with day-3 OTP referral • PO • daily; OTP supervision
    triggers: oud_with_buprenorphine_intolerance, patient_preference_methadone_bridge
    Berg J Addict Med 2024 — ED methadone bridge reduces mortality; use with monitored ECG (QTc surveillance) given methadone QT effects
    rxcui 6813
  • naltrexone XR-IM
    second line
    opioid_antagonist_long_acting
    380 mg IM q4 weeks AFTER ≥7-d opioid-free interval • IM • monthly
    triggers: oud_with_opioid_free_period_documented, patient_preference_antagonist_strategy
    XR-NTX vs buprenorphine — alternative MAT pathway; only use after confirmed opioid-free interval to avoid precipitated withdrawal
    rxcui 7243
  • lactated_ringers
    first line
    crystalloid_resuscitation_fluid
    1–1.5 L bolus then 200–500 mL/h titrate UOP 1–2 mL/kg/h • IV • continuous
    triggers: rhabdomyolysis_from_down_time, shock_with_perfusion_deficit
    KDIGO 2012 §5.4 + Bosch 2009 PMID 19571284 — aggressive crystalloid prevents myoglobinuric AKI in rhabdo
  • dextrose 50%
    add on
    iv_dextrose_concentrated
    25 g IV • IV • one-time
    triggers: hypoglycemia_during_post_rosc
    AHA 2020 — correct hypoglycemia immediately; common in malnourished IV-drug-use patients
    rxcui 4850
  • thiamine
    add on
    b_complex_vitamin
    500 mg IV TID × 3 d then 100 mg PO daily • IV/PO • TID then daily
    triggers: malnutrition_with_iv_drug_use, wernicke_encephalopathy_risk
    Empiric thiamine before glucose in malnourished IV-drug-use patients to prevent Wernicke’s encephalopathy
    rxcui 10454

outpatient playbook — drug actions (2)

  1. 1. continue MAT (buprenorphine or methadone)
    rxcui 352384
    per addiction medicine maintenance • SL/PO • daily
    trigger: long-term OUD
    SAMHSA TIP 63 — long-term MAT reduces all-cause mortality + OD mortality
  2. 2. continue HIV/HCV regimen if applicable
    rxcui 83367
    per ID specialist • PO • as scheduled
    trigger: HIV/HCV positive
    DHHS + AASLD

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ROSC after opioid-overdose cardiac arrest — typically PEA / asystole rhythm reflecting asphyxial mechanism (AHA 2020 §opioid); 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.

Objective

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

Assessment

**Post-cardiac-arrest care — opioid-overdose-induced arrest** (cardio.post-arrest.opioid-overdose.v1).
Phenotype framing: 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
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **Opioid-overdose post-arrest phenotype — naloxone-titration resuscitation + post-ROSC standard bundle + OUD bridge MAT (AHA 2020 + ACMT 2024 + SAMHSA Bridge Clinic + Thom 2021)**.
1. 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 (opioid_antagonist, first line) — 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
2. norepinephrine 0.05–0.5 µg/kg/min titrate MAP ≥65 IV continuous (vasopressor_alpha1_beta1, first line) — SOAP-II PMID 20200382; first-line post-ROSC vasoactive
3. epinephrine 1 mg IV q3–5 min during arrest IV standard ACLS (inotrope_chronotrope_vasopressor, first line) — AHA 2020 ACLS
4. propofol 5–50 µg/kg/min IV continuous; titrate RASS (sedative_iv_anesthetic, first line) — PADIS 2018
5. fentanyl 25–100 µg/h (use cautiously given the OD context — consider non-opioid analgesia where possible) IV continuous; titrated (opioid_analgesic, second line) — PADIS 2018 — analgesia + shivering suppression for TTM; in OD context favor lower doses + shorter courses + early de-escalation; document OUD context for transition planning
6. 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 (partial_mu_opioid_agonist, first line) — 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
7. methadone 20–30 mg PO daily with day-3 OTP referral PO daily; OTP supervision (long_acting_mu_opioid_agonist, second line) — Berg J Addict Med 2024 — ED methadone bridge reduces mortality; use with monitored ECG (QTc surveillance) given methadone QT effects
8. naltrexone XR-IM 380 mg IM q4 weeks AFTER ≥7-d opioid-free interval IM monthly (opioid_antagonist_long_acting, second line) — XR-NTX vs buprenorphine — alternative MAT pathway; only use after confirmed opioid-free interval to avoid precipitated withdrawal
9. lactated_ringers 1–1.5 L bolus then 200–500 mL/h titrate UOP 1–2 mL/kg/h IV continuous (crystalloid_resuscitation_fluid, first line) — KDIGO 2012 §5.4 + Bosch 2009 PMID 19571284 — aggressive crystalloid prevents myoglobinuric AKI in rhabdo
10. dextrose 50% 25 g IV IV one-time (iv_dextrose_concentrated, add on) — AHA 2020 — correct hypoglycemia immediately; common in malnourished IV-drug-use patients
11. thiamine 500 mg IV TID × 3 d then 100 mg PO daily IV/PO TID then daily (b_complex_vitamin, add on) — Empiric thiamine before glucose in malnourished IV-drug-use patients to prevent Wernicke’s encephalopathy

Setting playbook (outpatient) — Long-term addiction medicine + primary care + mental health surveillance; MAT continuation; harm reduction; HIV/HCV management; mental health long-term; cardiology surveillance only if residual structural cardiac concern
12. continue MAT (buprenorphine or methadone) per addiction medicine maintenance SL/PO daily — long-term OUD (SAMHSA TIP 63 — long-term MAT reduces all-cause mortality + OD mortality)
13. continue HIV/HCV regimen if applicable per ID specialist PO as scheduled — HIV/HCV positive (DHHS + AASLD)

Non-pharmacologic actions:
- Take-home naloxone refill annually
- Harm reduction service engagement long-term
- Mental health long-term
- Primary care for chronic disease management
- Family CPR/AED + naloxone maintenance

AVOID / contraindication checks:
- Flumazenil_AVOID_in_mixed_overdose_with_benzo_dependence (seizure risk)
- Naltrexone_AVOID_within_7_days_of_opioid_use (precipitated withdrawal)
- Buprenorphine_AVOID_until_moderate_withdrawal_present (precipitated withdrawal if given in early withdrawal or active intoxication)
- Methadone_AVOID_qtc_above_500 (torsades risk)
- Beta_blocker_avoid_acute_cardiogenic_shock (AHA 2020)
- Nephrotoxic_drug_avoid_evolving_aki (KDIGO 2012)

Monitoring

Regimen monitoring:
- continuous ecg telemetry x 24h for re arrest and qtc (AHA 2020)
- serial ecg q4-6h x 24h for qtc evolution if methadone or loperamide (cardiology consensus)
- serial troponin q3-6h x 24h (4th UDMI 2018)
- CK q6h until peak then q12h until downtrending (Bosch 2009 PMID 19571284)
- BMP q6h + K + Mg + Ca + bicarb (rhabdo + AKI electrolyte derangement)
- urine output hourly target 1-2 mL/kg/h (KDIGO 2012 §5.4)
- continuous core temp via bladder or esophageal probe during TTM (TTM2)
- continuous EEG for 24-48h (Sandroni 2021)
- NSE at 24h 48h 72h (Sandroni 2021)
- lactate q2-4h until normalized (SCAI 2022)
- naloxone re dosing protocol at bedside x 24h or duration of opioid (ACMT 2024)
- COWS q4h for OUD bridge timing (SAMHSA Bridge Clinic)

Setting (outpatient) monitoring:
- Quarterly addiction medicine visits
- Annual labs — BMP + HIV/HCV + lipid + A1c + LFTs
- Annual ECG if methadone

Follow-up plan: 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)
- Close-out criterion: addiction medicine + harm reduction + mental health + primary care + naloxone Rx booked

Monitoring phase: 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

Disposition

Current setting: outpatient — Long-term addiction medicine + primary care + mental health surveillance; MAT continuation; harm reduction; HIV/HCV management; mental health long-term; cardiology surveillance only if residual structural cardiac concern

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 only for residual chronic HFrEF; otherwise primary care + addiction medicine + mental health long-term home

Escalation triggers (move to higher acuity):
- Repeat OD → ED + escalated case management
- MAT discontinuation request → addiction medicine + mental health discussion
- Mental health deterioration → urgent psychiatry

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Re-arrest or recurrent severe respiratory depression as administered naloxone wears off (15–90 min t½) before opioid (especially fentanyl/methadone) is fully eliminated
- [LIFE_THREATENING] Aspiration pneumonitis or non-cardiogenic pulmonary edema with PaO2/FiO2 <100 despite ARDSnet vent in opioid OD post-ROSC patient
- [SEVERE] Cumulative naloxone >4 mg required for reversal OR persistent respiratory depression despite standard naloxone dosing — suggests fentanyl analogue or non-opioid co-toxin

Citations

- 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 [PMID:33081530](https://pubmed.ncbi.nlm.nih.gov/33081530/)
- Cited evidence (PMID 34516947) [PMID:34516947](https://pubmed.ncbi.nlm.nih.gov/34516947/)
- Cited evidence (PMID 34133859) [PMID:34133859](https://pubmed.ncbi.nlm.nih.gov/34133859/)
- Cited evidence (PMID 31532382) [PMID:31532382](https://pubmed.ncbi.nlm.nih.gov/31532382/)
- Cited evidence (PMID 33745427) [PMID:33745427](https://pubmed.ncbi.nlm.nih.gov/33745427/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 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 — PMID:33081530
  • Cited evidence (PMID 34516947) — PMID:34516947
  • Cited evidence (PMID 34133859) — PMID:34133859
  • Cited evidence (PMID 31532382) — PMID:31532382
  • Cited evidence (PMID 33745427) — PMID:33745427