To the Editor,
In “Naloxone Cardiac Arrest Decision Instruments (NACARDI) for targeted antidotal therapy in occult opioid overdose precipitated cardiac arrest,” Rodriguez et al. developed a decision tool to ascertain those individuals whose arrest was most likely due to opioid overdose to guide selective administration of naloxone in cardiac arrest.
1
They found that age <60 years, black or non-Latinx white, and arrest in a public place were related to increased likelihood of arrest secondary to opioid overdose.1
This is valuable information and certainly adds to the body of knowledge surrounding the epidemic of opioid related deaths, however, we are concerned that their underlying premise that naloxone in cardiac arrest is of benefit to patients is unfounded and can lead to distraction from more critical actions.Naloxone is a non-selective and competitive opioid receptor antagonist that improves outcomes in non-fatal opioid overdose by reversing opioid-induced apnea. While researchers have hypothesized that naloxone reverses myocardial depression,
2
there is no evidence to suggest that it is beneficial in humans whose overdose has already resulted in cardiac arrest.Saybolt et al. reviewed data on patients that were given naloxone in cardiac arrest, and while they did find a temporal association between naloxone administration and change in rhythm in 15 of 36 patients that received naloxone, only 4 of those patients achieved ROSC with only 1 achieving survival to hospital discharge, rates that are not significantly different from typical cardiac arrest statistics.
3
In fact, several of the patients that had change in rhythm following administration of naloxone arguably had worsening of their cardiac rhythm with PEA to asystole and ventricular fibrillation to PEA among the documented cases.3
The initial moments following cardiac arrest are critical to patient outcomes, and extensive research demonstrates that there are multiple time sensitive interventions, including early chest compressions and early defibrillation that save lives.
4
The American Heart Association does not recommend naloxone in cardiac arrest from suspected overdose for ACLS providers, with the most recent guideline update reemphasizing the importance of high-quality CPR regardless of the suspected aetiology of the arrest.4
While the proposed physiologic mechanisms of naloxone in cardiac arrest are interesting, there is no data to suggest that they are clinically meaningful in humans. We feel that a decision tool for the use of naloxone in cardiac arrest is premature and that cardiac arrest resuscitation should continue to focus on the proven basics until more evidence is uncovered.Sincerely,
Conflicts of interest
None declared.
References
- Naloxone Cardiac Arrest Decision Instruments (NACARDI) for targeted antidotal therapy in occult opioid overdose precipitated cardiac arrest.Resuscitation. 2021; 159: 69-76
- Should naloxone be prescribed in the ED management of patients with cardiac arrest? A case reports and review of the literature.Am J Emerg Med. 2008; 26: 5-8
- Naloxone in cardiac arrest with suspected opioid overdoses.Resuscitation. 2010; 81: 42-46
- Part 1: executive summary: 2020 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.Circulation. 2020; 142: S337-S357
Article info
Publication history
Published online: May 08, 2021
Received:
February 8,
2021
Identification
Copyright
© 2021 Elsevier B.V. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- NAloxone CARdiac Arrest Decision Instruments (NACARDI) for targeted antidotal therapy in occult opioid overdose precipitated cardiac arrestResuscitationVol. 159
- PreviewWe have recently demonstrated that a significant proportion of fatal out-of-hospital cardiac arrests (OHCAs) are precipitated by occult overdose, which could benefit from antidote therapy administered adjunctively with other cardiac resuscitation measures. We sought to develop simple decision instruments that EMS providers and other first responders can use to rapidly identify occult opioid overdose-associated OHCAs.
- Full-Text
- Preview
- Reply letter to: Letter to the Editor in response to “Naloxone Cardiac Arrest Decision Instruments (NACARDI) for targeted antidotal therapy in occult opioid overdose precipitated cardiac arrest”ResuscitationVol. 164
- PreviewWe thank the authors of this well-written letter and for their interest in our research. We actually agree with the general sentiment of your letter and in fact, noted most of your points throughout the manuscript. We are not at all saying that naloxone is currently of proven benefit in cardiac arrest. In the introduction, we state, “The long-term goal of this work is to determine whether naloxone improves survival in selected patients whose cardiac arrest and pre-cardiac arrest states are precipitated by occult opioid OD.” Our decision instrument development is a first step toward this goal.
- Full-Text
- Preview
