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Chiba T, Otaka S, Igeta R, Burns MM, Ikeda S, Shiga T. Epidemiology and clinical outcomes of poisoning-induced cardiac arrest in Japan: Retrospective analysis of a nationwide registry. Resuscitation 2022; 180:52-58. [PMID: 36185034 DOI: 10.1016/j.resuscitation.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Poisoning is an important cause of out-of-hospital cardiac arrest which can be challenging to manage. Neurological outcomes after poisoning-induced out-of-hospital cardiac arrest (POHCA) are yet to be fully elucidated. This retrospective cohort study sought to describe the characteristics of POHCA, and identify factors associated with favourable neurologic outcomes. METHODS Cardiac arrests recorded in the "All Japan Utstein Registry" from 1 January 2012 to 31 December 2017 were included. A descriptive analysis of the characteristics of POHCA and non-POHCA patients was performed. Neurological outcomes were compared between the POHCA and non-POHCA groups using logistic regression analysis. Subgroup analysis was performed for patients who underwent prolonged resuscitation. RESULTS Compared to non-POHCA patients (n = 665,262), POHCA patients (n = 1,868) were younger (median age, 80 vs 51 years) and had a lower likelihood of having a witness, bystander cardiopulmonary resuscitation, and an initial shockable rhythm. Multivariable logistic regression analysis showed that POHCA was associated with favourable neurologic outcomes (odds ratio 1.54, 95 % confidence interval 1.19-2.01, p = 0.001). Among patients who received > 30 min of resuscitation, neurologic outcomes were similar in those with POHCA and non-POHCA (favourable neurologic outcome, 1.03 % vs 0.98 %, p = 0.87). CONCLUSIONS POHCA is associated with favourable neurological outcomes and requires aggressive resuscitation. However, in patients who required prolonged resuscitation, the outcomes of POHCA were not different from those of non-POHCA. The decision to perform prolonged resuscitation should be guided on a case-by-case basis based on a range of factors.
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Affiliation(s)
- Takuyo Chiba
- Department of Emergency Medicine, International University of Health and Welfare, Narita, Chiba, Japan; Graduate School of Medicine, International University of Health and Welfare, Minatoku, Tokyo, Japan.
| | - Shunichi Otaka
- Department of Emergency Medicine, International University of Health and Welfare, Narita, Chiba, Japan; Graduate School of Medicine, International University of Health and Welfare, Minatoku, Tokyo, Japan
| | - Ryuhei Igeta
- Department of Emergency Medicine, International University of Health and Welfare, Narita, Chiba, Japan; Graduate School of Medicine, International University of Health and Welfare, Minatoku, Tokyo, Japan
| | - Michele M Burns
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Shunya Ikeda
- Graduate School of Medicine, International University of Health and Welfare, Minatoku, Tokyo, Japan
| | - Takashi Shiga
- Department of Emergency Medicine, International University of Health and Welfare, Narita, Chiba, Japan; Graduate School of Medicine, International University of Health and Welfare, Minatoku, Tokyo, Japan
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2
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Hüser C, Baumgärtel M, Ristau P, Wnent J, Suárez V, Hackl MJ, Gräsner JT, Seewald S. Higher chance of survival in patients with out-of-hospital cardiac arrest attributed to poisoning. Resuscitation 2022; 175:96-104. [PMID: 35288163 DOI: 10.1016/j.resuscitation.2022.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 01/31/2023]
Abstract
AIM OF THE STUDY Description and comparison of cohort characteristics and outcome of adult patients with out-of-hospital cardiac arrest (OHCA) attributed to poisoning (P-OHCA) versus patients with OHCA attributed to other medical causes (NP-OHCA). METHODS We included all patients who received cardiopulmonary resuscitation after OHCA between January 2011 and December 2020 from German emergency medical services with good data quality in the German Resuscitation Registry. EXCLUSION CRITERIA patients < 18 years of age or OHCA attributed to trauma, drowning, intracranial bleeding or exsanguination. RESULTS Patients with P-OHCA (n = 574) were significantly younger compared to NP-OHCA (n = 40,146) (median age of 43 (35-54) years vs. 73 (62-82) years; p < 0.001). Cardiac arrest in P-OHCA patients was significantly less often witnessed by bystanders (41.8 % vs. 66.2 %, p < 0.001). Asystole was the predominant initial rhythm in P-OHCA patients (73.5% vs. 53.7%, p < 0.001) while ventricular fibrillation (VF) and pulseless electrical activity (PEA) were less common (9.2% vs. 25.1% and 16.2 % vs. 20.5%, p < 0.001). P-OHCA had a higher chance of survival with good neurological outcome at hospital discharge (15.2 vs. 8.8 % p < 0.001) and poisoning was an independent protective prognostic factor in multivariate analysis (OR 2.47, 95%-CI [1.71-3.57]). P-OHCA patients with initial PEA survival with good neurological outcome was comparable to initial VF (34.3 % vs. 37.7%). CONCLUSION Patients in the P-OHCA group had a significantly higher chance of survival with good neurological outcome and PEA as initial rhythm was as favourable as initial VF. Therefore, in P-OHCA patients resuscitation efforts should be extended.
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Affiliation(s)
- Christoph Hüser
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937 Cologne, Germany; Emergency Department, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Matthias Baumgärtel
- Department of Pulmonology, Intensive Care Medicine, Paracelsus Medical University, Hospital Nuremberg, Prof.-Ernst-Nathan-Straße 1, 90419 Nuremberg, Germany
| | - Patrick Ristau
- Institute for Emergency Medicine, University Hospital Schleswig-Holstein, Arnold-Heller-Straße 3, Building 404, 24105 Kiel, Germany
| | - Jan Wnent
- Institute for Emergency Medicine, University Hospital Schleswig-Holstein, Arnold-Heller-Straße 3, Building 404, 24105 Kiel, Germany; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Building R3, 24105 Kiel, Germany
| | - Victor Suárez
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937 Cologne, Germany; Emergency Department, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Matthias Johannes Hackl
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937 Cologne, Germany; Emergency Department, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Jan-Thorsten Gräsner
- Institute for Emergency Medicine, University Hospital Schleswig-Holstein, Arnold-Heller-Straße 3, Building 404, 24105 Kiel, Germany; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Building R3, 24105 Kiel, Germany
| | - Stephan Seewald
- Institute for Emergency Medicine, University Hospital Schleswig-Holstein, Arnold-Heller-Straße 3, Building 404, 24105 Kiel, Germany; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Building R3, 24105 Kiel, Germany.
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3
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Lacoste-Palasset T, Megarbane B, Deye N. Poisoning-related cardiac arrest: why prognosis should be better? Resuscitation 2022; 175:77-80. [PMID: 35489520 DOI: 10.1016/j.resuscitation.2022.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 04/15/2022] [Accepted: 04/18/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Thomas Lacoste-Palasset
- Réanimation Médicale et Toxicologique, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France
| | - Bruno Megarbane
- Réanimation Médicale et Toxicologique, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France; INSERM UMRS-1144, Université de Paris, Paris, France
| | - Nicolas Deye
- Réanimation Médicale et Toxicologique, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France; INSERM UMRS-942, MASCOT, Paris, France
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4
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Naïm G, Lacoste-Palasset T, M'Rad A, Sutterlin L, Pépin-Lehalleur A, Grant C, Ekhérian JM, Deye N, Malissin I, Voicu S, Mégarbane B. Factors associated with prolonged intensive care stay among self-poisoned patients. Clin Toxicol (Phila) 2022; 60:997-1005. [PMID: 35451892 DOI: 10.1080/15563650.2022.2064870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
CONTEXT Since recovery or death is generally observed within a few days after intensive care unit (ICU) admission of self-poisoned patients in the developed countries, reasons for the prolonged ICU stay are of interest as they have been poorly investigated. We aimed to identify the characteristics, risk factors, outcome, and predictors of death in self-poisoned patients requiring prolonged ICU management. METHODS We conducted an eight-year single-center cohort study including all self-poisoned patients who stayed at least seven days in the ICU. Patients admitted with drug adverse events and chronic overdoses were excluded. Using multivariate analyses, we investigated risk factors for prolonged ICU stay in comparison with a group of similar size of self-poisoned patients with <7day-ICU stay and studied risk factors for death. RESULTS Among 2,963 poisoned patients admitted in the ICU during the study period, the number who stayed beyond seven days was small (398/2,963, 13.1%), including 239 self-poisoned patients (125 F/114M; age, 51 years [38-65] (median [25th-75th percentiles]); SAPSII, 56 [43-69]). Involved toxicants included psychotropic drugs (59%), cardiotoxicants (31%), opioids (15%) and street drugs (13%). When compared with patients who stayed <7days in the ICU, acute kidney injury (odds ratio (OR), 3.15; 95% confidence interval (1.36-7.39); p = .008), multiorgan failure (OR, 8.06 (3.43-19.9); p < .001), aspiration pneumonia (OR, 8.48 (4.28-17.3); p < .001), and delayed awakening related to the persistent toxicant effects, hypoxic encephalopathy and/or oversedation (OR, 8.64 (2.58-40.7); p = .002) were independently associated with prolonged ICU stay. In-hospital mortality rate was 9%. Cardiac arrest occurring in the prehospital setting and during the first hours of ICU management (OR, 27.31 (8.99-158.76); p < .001) and delayed awakening (OR, 14.94 (6.27-117.44); p < .001) were independently associated with increased risk of death, whereas exposure to psychotropic drugs (OR, 0.08 (0.02-0.36); p = .002) was independently associated with reduced risk of death. CONCLUSION Self-poisoned patients with prolonged ICU stay of ≥7days are characterized by concerning high rates of morbidities and poisoning-attributed complications. Acute kidney injury, multiorgan failure, aspiration pneumonia, and delayed awakening are associated with ICU stay prolongation. Cardiac arrest occurrence and delayed awakening are predictive of death. Further studies should focus on the role of early goal-directed therapy and patient-targeted sedation in reducing ICU length of stay among self-poisoned patients.
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Affiliation(s)
- Giulia Naïm
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France.,Paris University, Paris, France
| | - Thomas Lacoste-Palasset
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France.,Paris University, Paris, France
| | - Aymen M'Rad
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France
| | - Laetitia Sutterlin
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France.,Paris University, Paris, France
| | - Adrien Pépin-Lehalleur
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France.,Paris University, Paris, France
| | - Caroline Grant
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France
| | - Jean-Michel Ekhérian
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France
| | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France
| | - Isabelle Malissin
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France.,INSERM UMRS-1144, Paris University, Paris, France
| | - Sebastian Voicu
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France.,INSERM UMRS-1144, Paris University, Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière hospital, Federation of Toxicology, APHP, Paris, France.,Paris University, Paris, France.,INSERM UMRS-1144, Paris University, Paris, France
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Kulpanowski AM, Copen WA, Hancock BL, Rosenthal ES, Schoenfeld DA, Dodelson JA, Edlow BL, Kimberly WT, Amorim E, Westover MB, Ning MM, Schaefer PW, Malhotra R, Giacino JT, Greer DM, Wu O. Severe cerebral edema in substance-related cardiac arrest patients. Resuscitation 2022; 173:103-111. [PMID: 35149137 PMCID: PMC9282938 DOI: 10.1016/j.resuscitation.2022.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 01/01/2022] [Accepted: 01/31/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Studies of neurologic outcomes have found conflicting results regarding differences between patients with substance-related cardiac arrests (SRCA) and non-SRCA. We investigate the effects of SRCA on severe cerebral edema development, a neuroimaging intermediate endpoint for neurologic injury. METHODS 327 out-of-hospital comatose cardiac arrest patients were retrospectively analyzed. Demographics and baseline clinical characteristics were examined. SRCA categorization was based on admission toxicology screens. Severe cerebral edema classification was based on radiology reports. Poor clinical outcomes were defined as discharge Cerebral Performance Category scores > 3. RESULTS SRCA patients (N = 86) were younger (P < 0.001), and more likely to have non-shockable rhythms (P < 0.001), be unwitnessed (P < 0.001), lower Glasgow Coma Scale scores (P < 0.001), absent brainstem reflexes (P < 0.05) and develop severe cerebral edema (P < 0.001) than non-SRCA patients (N = 241). Multivariable analyses found younger age (P < 0.001), female sex (P = 0.008), non-shockable rhythm (P = 0.01) and SRCA (P = 0.05) to be predictors of severe cerebral edema development. Older age (P < 0.001), non-shockable rhythm (P = 0.02), severe cerebral edema (P < 0.001), and absent pupillary light reflexes (P = 0.004) were predictors of poor outcomes. SRCA patients had higher proportion of brain deaths (P < 0.001) compared to non-SRCA patients. CONCLUSIONS SRCA results in higher rates of severe cerebral edema development and brain death. The absence of statistically significant differences in discharge outcomes or survival between SRCA and non-SRCA patients may be related to the higher rate of withdrawal of life-sustaining treatment (WLST) in the non-SRCA group. Future neuroprognostic studies may opt to include neuroimaging markers as intermediate measures of neurologic injury which are not influenced by WLST decisions.
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Affiliation(s)
- Annelise M Kulpanowski
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, United States
| | - William A Copen
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Brandon L Hancock
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, United States
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - David A Schoenfeld
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, United States
| | - Jacob A Dodelson
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, United States
| | - Brian L Edlow
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - W Taylor Kimberly
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Edilberto Amorim
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Ming Ming Ning
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Pamela W Schaefer
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Rajeev Malhotra
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, United States
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States
| | - David M Greer
- Department of Neurology, Boston University and Boston Medical Center, Boston, MA, United States
| | - Ona Wu
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, United States.
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6
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Winstanley EL, Mahoney JJ, Castillo F, Comer SD. Neurocognitive impairments and brain abnormalities resulting from opioid-related overdoses: A systematic review. Drug Alcohol Depend 2021; 226:108838. [PMID: 34271512 PMCID: PMC8889511 DOI: 10.1016/j.drugalcdep.2021.108838] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Non-fatal opioid-related overdoses have increased significantly over the past two decades and there have been increasing reports of brain injuries and/or neurocognitive impairments following overdose events. Limited preclinical research suggests that opioid overdoses may cause brain injury; however, little is known about such injuries in humans. The purpose this systematic review is to summarize existing studies on neurocognitive impairments and/or brain abnormalities associated with an opioid-related overdose in humans. METHODS PubMed, Web of Science, Ovid MEDLINE and PsyINFO were searched, without year restrictions, and identified 3099 articles. An additional 24 articles were identified by reviewing references. Articles were included if they were published in English, reported study findings in humans, included individuals 18 years of age or older, and reported an objective measure of neurocognitive impairments and/or brain abnormalities resulting from an opioid-related overdose. Six domains of bias (selection, performance, attrition, detection (two dimensions) and reporting were evaluated and themes were summarized. RESULTS Seventy-nine journal articles, published between 1973-2020, were included in the review. More than half of the articles were case reports (n = 44) and there were 11 cohort studies, 18 case series, and 6 case-control studies. All of the studies were categorized as at-risk of bias, few controlled for confounding factors, and methodological differences made direct comparisons difficult. Less than half of the studies reported toxicology results confirming an opioid-related overdose; 64.6 % reported brain MRI results and 27.8 % reported results of neuropsychological testing. Only two studies had within subject comparative data to document changes in the brain possibly associated with an overdose. Despite these limitations, existing publications suggest that brain injuries and neurocognitive impairments are associated with opioid overdose. Additional research is needed to establish the incidence of overdose-related brain injuries and the potential impact on functioning, as well as engagement in treatment of substance use disorders. CONCLUSIONS Respiratory depression is a defining characteristic of opioid overdose and prolonged cerebral hypoxia may cause brain injuries and/or neurocognitive impairments. The onset, characteristics, and duration of such injuries is variable and additional research is needed to understand their clinical implications.
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Affiliation(s)
- Erin L. Winstanley
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA,Department of Neuroscience, West Virginia University, Morgantown, WV, USA,Corresponding author at: West Virginia University, School of Medicine, Rockefeller Neuroscience Institute, Department of Behavioral Medicine and Psychiatry, 930 Chestnut Ridge Road, Morgantown, WV 26505, USA. (E.L. Winstanley)
| | - James J. Mahoney
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA,Department of Neuroscience, West Virginia University, Morgantown, WV, USA
| | - Felipe Castillo
- Columbia University, Department of Psychiatry and New York State Psychiatric Institute, New York, NY, USA
| | - Sandra D. Comer
- Columbia University, Department of Psychiatry and New York State Psychiatric Institute, New York, NY, USA
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Dezfulian C, Orkin AM, Maron BA, Elmer J, Girotra S, Gladwin MT, Merchant RM, Panchal AR, Perman SM, Starks MA, van Diepen S, Lavonas EJ. Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e836-e870. [PMID: 33682423 DOI: 10.1161/cir.0000000000000958] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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.
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