From the Guidelines
For a patient who experienced cardiac arrest due to opioid overdose, a comprehensive workup including cardiac enzymes, ECG, echocardiogram, and basic metabolic panel is necessary before discharge to assess for end-organ damage, and cardiology consultation is recommended, especially if there are abnormal cardiac findings or evidence of structural heart damage. This approach is supported by the 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1, which emphasize the importance of early recognition and management of opioid-associated resuscitative emergencies.
When considering the workup, the following elements should be included:
- Cardiac enzymes (troponin series) to assess for myocardial injury
- ECG to evaluate for arrhythmias or ischemic changes
- Echocardiogram to assess for structural heart damage
- Basic metabolic panel to evaluate for electrolyte imbalances or renal injury
Additionally, substance use assessment and connection with addiction services are crucial, as well as providing naloxone kits with education on use and arranging close follow-up within 1-2 weeks. Consideration of medication for opioid use disorder, such as buprenorphine or methadone, may also be necessary. Cardiac monitoring for at least 24-48 hours post-arrest is important to detect potential myocardial injury or arrhythmias resulting from hypoxic events during overdose. Evaluation for other complications like aspiration pneumonia, rhabdomyolysis, or neurological deficits should also be performed. This comprehensive approach addresses both the acute cardiac event and the underlying substance use disorder to reduce the risk of recurrence, as highlighted in the guidelines 1.
From the Research
Workup Before Discharge
Before discharge, a patient who experienced cardiac arrest due to opioid overdose should undergo a comprehensive workup, including:
- Electrocardiogram (EKG) to assess cardiac rhythm and identify potential arrhythmias 2
- Laboratory tests to evaluate for underlying conditions that may have contributed to the cardiac arrest, such as electrolyte imbalances or cardiac biomarkers
- Imaging studies, such as chest X-rays or echocardiograms, to assess cardiac function and structure
- Toxicology screening to confirm the presence of opioids and other substances
Cardiology Consultation
Cardiology consultation is necessary to:
- Evaluate the patient's cardiac function and structure
- Assess the risk of future cardiac events
- Develop a plan for ongoing cardiac care and monitoring
- Consider implantable cardioverter-defibrillator (ICD) placement if indicated 3, 4, 5
- Patients with opioid-associated out-of-hospital cardiac arrest (OA-OHCA) may have distinctive clinical features, such as polysubstance toxidromes, asphyxial death, and prolonged hypoxemia, which require specialized cardiac care 3
Opioid-Associated Out-of-Hospital Cardiac Arrest
Opioid-associated out-of-hospital cardiac arrest (OA-OHCA) requires specific consideration, including:
- Recognition of the potential for opioid overdose and cardiac arrest
- Prompt administration of naloxone, an opioid antagonist, to reverse opioid effects 2, 3, 6
- Effective ventilation and compressions during cardiopulmonary resuscitation (CPR)
- Consideration of secondary prevention measures, such as counseling, opioid overdose education, and medication for opioid use disorder 3