Summary of Key Issues and Major Changes

Opioid Overdose Education and Naloxone Training and Distribution

2015 (New): It is reasonable to provide opioid overdose response education, either alone or coupled with naloxone distribution and training, to persons at risk for opioid overdose (or those living with or in frequent contact with such persons). It is reasonable to base this training on first aid and non-HCP BLS recommendations rather than on more advanced practices intended for HCPs.

Opioid Overdose Treatment

2015 (New): Empiric administration of IM or IN naloxone to all unresponsive victims of possible opioid-associated life-threatening emergency may be reasonable as an adjunct to standard first aid and non-HCP BLS protocols. For patients with known or suspected opioid overdose who have a definite pulse but no normal breathing or only gasping (ie, a respiratory arrest), in addition to providing standard care, it is reasonable for appropriately trained rescuers to administer IM or IN naloxone to patients with an opioid-associated respiratory emergency (Figure 1). Responders
should not delay access to more advanced medical services while awaiting the patient’s response to naloxone or other interventions.

Empiric administration of IM or IN naloxone to all unresponsive opioid-associated resuscitative emergency patients may be reasonable as an adjunct to standard first aid and non-HCP BLS protocols. Standard resuscitation procedures, including EMS activation, should not be delayed for naloxone administration.

Figure 1: Opioid-Associated Life-Threatening Emergency (Adult) Algorithm

Cardiac Arrest in Patients With Known or Suspected Opioid Overdose

2015 (New): Patients with no definite pulse may be in cardiac arrest or may have an undetected weak or slow pulse. These patients should be managed as cardiac arrest patients. Standard resuscitative measures should take priority over naloxone administration, with a focus on high-quality CPR (compressions plus ventilation). It may be reasonable to administer IM or IN naloxone based on the possibility that the patient is in respiratory arrest, not in cardiac arrest. Responders should not delay access to more-advanced medical services while awaiting the patient’s response to naloxone or other interventions.

Why: Naloxone administration has not previously been recommended for first aid providers, non-HCPs, or BLS providers. However, naloxone administration devices intended for use by lay rescuers are now approved and available for use in the United States, and the successful implementation of lay rescuer naloxone programs has been highlighted by the Centers for Disease Control.1 While it is not expected that naloxone is beneficial in cardiac arrest, whether or not the cause is opioid overdose, it is recognized that it may be difficult to distinguish cardiac arrest from severe respiratory depression in victims of opioid overdose. While there is no evidence that administration of naloxone will help a patient in cardiac arrest, the provision of naloxone may help an unresponsive patient with severe respiratory depression who only appears to be in cardiac arrest (ie, it is difficult to determine if a pulse is present).

Intravenous Lipid Emulsion

2015 (Updated): It may be reasonable to administer ILE, concomitant with standard resuscitative care, to patients who have premonitory neurotoxicity or cardiac arrest due to local anesthetic toxicity. It may be reasonable to administer ILE to patients with other forms of drug toxicity who are failing standard resuscitative measures.

2010 (Old): It may be reasonable to consider ILE for local anesthetic toxicity.

Why: Since 2010, published animal studies and human case reports have examined the use of ILE for patients with drug toxicity that is not the result of local anesthetic infusion. Although the results of these studies and reports are mixed, there may be clinical improvement after ILE administration. As the prognosis of patients who are failing standard resuscitative measures is very poor, empiric administration of ILE in this situation may be reasonable despite the very weak and conflicting evidence.

Cardiac Arrest in Pregnancy: Provision of CPR

2015 (Updated): Priorities for the pregnant woman in cardiac arrest are provision of high-quality CPR and relief of aortocaval compression. If the fundus height is at or above the level of the umbilicus, manual left uterine displacement can be beneficial in relieving aortocaval compression during chest compressions.

2010 (Old): To relieve aortocaval compression during chest compressions and optimize the quality of CPR, it is reasonable to perform manual left uterine displacement in the supine position first. If this technique is unsuccessful, and an appropriate wedge is readily available, then providers may consider placing the patient in a left lateral tilt of 27° to 30°, using a firm wedge to support the pelvis and thorax.

Why: Recognition of the critical importance of high-quality CPR and the incompatibility of the lateral tilt with high-quality CPR has prompted the elimination of the recommendation for using the lateral tilt and the strengthening of the recommendation for lateral uterine displacement.

Cardiac Arrest in Pregnancy: Emergency Cesarean Delivery

2015 (Updated): In situations such as nonsurvivable maternal trauma or prolonged maternal pulselessness, in which maternal resuscitative efforts are obviously futile, there is no reason to delay performing perimortem cesarean delivery (PMCD). PMCD should be considered at 4 minutes after onset of maternal cardiac arrest or resuscitative efforts (for the unwitnessed arrest) if there is no maternal ROSC. The clinical decision to perform a PMCD—and its timing with respect to maternal cardiac arrest—is complex because of the variability in level of practitioner and team training, patient factors (eg, etiology of arrest, gestational age of the fetus), and system resources.

2010 (Old): Emergency cesarean delivery may be considered at 4 minutes after onset of maternal cardiac arrest if there is no ROSC.

Why: PMCD provides the opportunity for separate resuscitation of the potentially viable fetus and the ultimate relief of aortocaval compression, which may improve maternal resuscitation outcomes. The clinical scenario and circumstances of the arrest should inform the ultimate decision around the timing of emergency cesarean delivery.

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  1. Wheeler E, Jones TS, Gilbert MK, Davidson PJ. Opioid overdose prevention programs providing naloxone to laypersons—United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(23): 631-635.
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