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New Evidence of Naloxone in Cardiac Arrest? No.

Question #19

The medical cardiac arrest medical directive states “There is no clear role for routine administration of Naloxone in confirmed cardiac arrest”. With the new emerging evidence on the administration of naloxone in the setting of opioid-overdose related PEA cardiac arrest, what is CEPCP’s stance on this treatment? And can Naloxone be administered in a opioid-overdose VSA presenting in PEA as long as high quality CPR and all other priorities are being managed accordingly?

Answer:

The current stance on intra-arrest naloxone administration in opioid-related cardiac arrests remains unchanged based on the latest scientific review from ILCOR. While some emerging evidence suggests potential associations between naloxone administration and improved return of spontaneous circulation (ROSC) or survival in specific subgroups, the overall quality of evidence remains very low due to study limitations, including risk of bias and indirectness.

ILCOR’s systematic review identified mixed findings regarding intra-arrest naloxone. Some studies reported an association between naloxone administration and improved ROSC and survival in EMS-unwitnessed, non-shockable arrests (Strong et al., 2024; Dillon et al., 2024), while others found no significant benefit regarding survival to hospital discharge or neurological outcomes (Love et al., 2023; Quinn et al., 2024). Importantly, no study has demonstrated a clear survival or neurological benefit that would warrant a change in practice.

Given this, the primary management of opioid-related cardiac arrest should continue to focus on high-quality CPR, airway management, and addressing reversible causes. Intra-arrest naloxone administration is not currently recommended as a routine intervention, aligning with the existing medical cardiac arrest directive, which states: “There is no clear role for routine administration of naloxone in confirmed cardiac arrest.”

Paramedics should continue to prioritize evidence-based resuscitation interventions. If opioid toxicity is suspected, high-quality CPR and ventilation remain the cornerstone of treatment, ensuring oxygenation and perfusion while managing reversible causes appropriately.

References

  1. Strong, N., Daya, M., Neth, M., Noble, M., Jui, J., & Lupton, J. (2023). The association between naloxone administration and outcomes for out-of-hospital cardiac arrest due to suspected overdose. Circulation, 148(Suppl 1).
  2. Strong, N. H., Daya, M. R., Neth, M. R., Noble, M., Sahni, R., Jui, J., & Lupton, J. R. (2024). The association of early naloxone use with outcomes in non-shockable out-of-hospital cardiac arrest. Resuscitation, 201, 110263. https://doi.org/10.1016/j.resuscitation.2024.110263
  3. Love, C., Boivin, Z., Doko, D., Duignan, K., & She, T. (2023). Does naloxone improve outcomes in cardiac arrests related to opiate overdose? Academic Emergency Medicine, 30(Suppl 1), 260. https://doi.org/10.1111/acem.14718
  4. Dillon, D. G., Montoy, J. C. C., Nishijima, D. K., Niederberger, S., Menegazzi, J. J., Lacocque, J., Rodriguez, R. M., & Wang, R. C. (2024). Naloxone and patient outcomes in out-of-hospital cardiac arrests in California. JAMA Network Open. https://doi.org/10.1001/jamanetworkopen.2024.29154
  5. Quinn, E., Murphy, E., Du Pont, D., Comber, P., Blood, M., Shah, A., Kuc, A., Hunter, K., & Carroll, G. (2024). Outcomes of out-of-hospital cardiac arrest patients who received naloxone in an emergency medical services system with a high prevalence of opioid overdose. Journal of Emergency Medicine, 67(3), e249-e258. https://doi.org/10.1016/j.jemermed.2024.03.038
  6. Panchal, A. R., Bartos, J. A., Cabañas, J. G., Donnino, M. W., Drennan, I. R., Hirsch, K. G., Kudenchuk, P. J., Kurz, M. C., Lavonas, E. J., Morley, P. T., O’Neil, B. J., Peberdy, M. A., Rittenberger, J. C., Rodriguez, A. J., Sawyer, K. N., & Berg, K. M. (2020). Part 3: Adult basic and advanced life support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 142(16_2), S366–S468. https://doi.org/10.1161/CIR.0000000000000916
  7. Castren, M., Perkins, G., Kudenchuk, P., Mancini, M. B., Avis, B., Brooks, S., Chung, S., Considine, J., Hatanaka, T., Nishiyama, C., Ristagno, G., Semeraro, F., Smith, C., Smyth, M., Morley, P., & Olasveengen, T. M. (2020). Resuscitation care for suspected opioid-associated emergencies: Consensus on science with treatment recommendations. International Liaison Committee on Resuscitation (ILCOR). https://costr.ilcor.org/documents
  8. Dezfulian, C., Orkin, A. M., Maron, B. A., Elmer, J., Girotra, S., Gladwin, M. T., Merchant, R. M., Panchal, A. R., Perman, S. M., Starks, M. A., van Diepen, S., & Lavonas, E. J. (2021). Opioid-associated out-of-hospital cardiac arrest: Distinctive clinical features and implications for health care and public responses. Circulation, 143(16). https://doi.org/10.1161/CIR.0000000000000958
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Medical Directive Category

Cardiac Arrest

Published

13 February 2025

ALSPCS Version

5.4

Views

18

Please reference the MOST RECENT ALS PCS for updates and changes to these directives.