Abstract
Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans. The epidemiology of opioid-associated out-of-hospital cardiac arrest in the United States is changing rapidly, with exponential increases in death resulting from synthetic opioids and linear increases in heroin deaths more than offsetting modest reductions in deaths from prescription opioids. The pathophysiology of polysubstance toxidromes involving opioids, asphyxial death, and prolonged hypoxemia leading to global ischemia (cardiac arrest) differs from that of sudden cardiac arrest. People who use opioids may also develop bacteremia, central nervous system vasculitis and leukoencephalopathy, torsades de pointes, pulmonary vasculopathy, and pulmonary edema. Emergency management of opioid poisoning requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled to compressions in the setting of opioid-associated out-of-hospital cardiac arrest. Effective ventilation is challenging to teach, whereas naloxone, an opioid antagonist, can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest. Opioid education and naloxone distributions programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions, and perform rescue breathing. Current American Heart Association recommendations call for laypeople and others who cannot reliably establish the presence of a pulse to initiate cardiopulmonary resuscitation in any individual who is unconscious and not breathing normally; if opioid overdose is suspected, naloxone should also be administered. Secondary prevention, including counseling, opioid overdose education with take-home naloxone, and medication for opioid use disorder, is important to prevent recurrent opioid overdose.
Highlights
Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans
Our group felt that the highestpriority items for future research in OA-OHCA included studying how naloxone should be used during resuscitation, defining novel brain injury pathways and protective agents, defining the risks and benefits of compression-only versus conventional cardiopulmonary resuscitation (CPR), determining optimal education and implementation, studying the best interventions, and establishing policies for preventing subsequent mortality after opioid poisoning
The present opioid epidemic has increased OA-OHCA, which is distinct in pathophysiology from cardiac-type OHCA
Summary
All deaths resulting 4.3 from drug overdose Deaths averted by EMS response EMS-treated OHCA 0.7. This minimizes adverse effects such as agitation and pulmonary edema.[154] In the era of potent synthetic opioids such as fentanyl, predicting the optimal dose may be challenging, with higher doses necessitated in some cases.[249,250] Whereas providing assisted ventilation, starting with a low dose of naloxone, and titrating repeat naloxone doses to restoration of protective airway reflexes and adequate spontaneous respirations is the ideal treatment in the EMS or ED setting, this approach is not practical for lay rescuers For this reason, presentations of naloxone intended for intramuscular or intranasal administration by the lay public incorporate a 2-mg dose, which is more than the initial recommended intravenous dose for health care professionals.[7,251] In the prehospital setting, the need to rapidly reverse hypoventilation may take priority over avoiding precipitated withdrawal. Our group felt that the highestpriority items for future research in OA-OHCA included studying how naloxone should be used during resuscitation, defining novel brain injury pathways and protective agents, defining the risks and benefits of compression-only versus conventional CPR, determining optimal education and implementation, studying the best interventions, and establishing policies for preventing subsequent mortality after opioid poisoning
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