Should we Give Naloxone in Cardiac Arrest? Insights From the Authors of Three Key Studies

The Poison Lab

Finally, the journal club to rule ALL journal clubs.

In this episode of The Poison Lab, we tackle one of the biggest topics in emergency medicine and toxicology: Should naloxone be given during opioid-associated cardiac arrest? With three fantastic studies published in 2024, we’re diving into the data and hearing directly from the authors themselves.

Join host Ryan Feldman as he interviews Dr. Eric Quinn, Dr. Joshua Lupton, and Dr. David Dillon, some of the minds behind the latest research exploring the role of naloxone in out-of-hospital cardiac arrest (OHCA). With perspectives ranging from clinical outcomes to practical implementation, this episode offers a deep dive into what these studies tell us—and what remains unanswered.

But that’s not all! Featuring special guests Spencer Oliver and Chris Pfingston from EMS 2020, this roundtable discussion incorporates the real-world insights of prehospital EMS professionals who face these decisions every day. Together, the panel unpacks:

• Conflicting evidence on naloxone’s impact on ROSC and survival.
• The challenges of interpreting retrospective studies in a high-stakes setting.
• Ethical dilemmas surrounding randomized trials for naloxone.
• Practical considerations for paramedics and emergency physicians in the field.

Whether you’re a toxicologist, EMS professional, or just curious about the intersection of drugs, overdose, and resuscitation, this episode is packed with actionable insights, expert opinions, and engaging discussions.

Tune in now to explore the science, controversy, and future directions for naloxone in cardiac arrest care!

Studies discussed in the show

• Outcomes of Out-of-Hospital Cardiac Arrest Patients Who Receive Naloxone in an EMS System with a High Prevalence of Opioid Overdose – Dr. Eric Quinn.
• Association of Early Naloxone Use with Outcomes in Nonshockable Out-of-Hospital Cardiac Arrest – Dr. Joshua Lupton.
• Naloxone and Patient Outcomes in Out-of-Hospital Cardiac Arrest in Northern California – Dr. David Dillon.

Studies and guidelines mentioned

• Editorial by Dr. Lavonas on Dr. Lupton's study
• AHA 2023 Guidelines for poisoning cardiac arrest
• AHA 2021 Position statement on opioid overdose out of hospital cardiac arrest
• Study of opioid overdose death after bystander naloxone training mentioned by Toxo

Shows mentioned

• Chris and Spencer's excellent EMS show
• Ryan's Interview on Poisoning Cardiac Arrest Guidelines with Dr. Eric Lavonas
• Journal club with Ryan and Dr. Dillon

Timestamps and chapters

Introduction (0:00–12:25)

• Podcast Introduction
• Overview of The Poison Lab and this episode’s focus.
• Introduction of the Topic
• Exploring naloxone use during out-of-hospital cardiac arrest (OHCA).
• Introduction of Guests
• Drs. Eric Quinn, Joshua Lupton, and David Dillon: authors of 2024 studies on naloxone in OHCA.
• Spencer Oliver and Chris Phingston: paramedics and co-hosts of EMS 2020.

Background (12:26–26:08)

Rationale for Studying Naloxone in OHCA

• Addressing the lack of evidence for naloxone use.
• High prevalence of opioid overdoses in study regions.
• EMS provider questions about naloxone’s role in suspected opioid-associated OHCA.

Overview of Existing Guidelines and Research

• 2021 AHA guidelines and scientific statement on opioid-associated OHCA.

Challenges in Determining Opioid Overdose as the Cause of OHCA

• Difficulties with pulse checks and drug testing limitations.

Summary of the Three 2024 Studies

• Dr. Quinn’s study: No significant benefit of naloxone.
• Dr. Lupton’s study: Benefit in early naloxone use for non-shockable rhythms vs no or late naloxone.
• Dr. Dillon’s study: Benefits of Naloxone in OOHCA, even in presumed non-drug-related OHCA cases.

Discussion (26:09–48:31)

Identifying Potential Opioid Overdose

• Importance of scene cues and patient history.

Study Methodologies and Confounding Factors

• Age as a significant confounder.
• Techniques used to control confounding (logistic regression, propensity score matching).

Potential Benefits and Harms of Naloxone in OHCA

• Risks of administering naloxone unnecessarily.
• Ethical concerns about withholding naloxone in trials.
• Broader physiological effects of naloxone.
• Challenges with current CPR ventilation techniques and naloxone’s potential role in improving respiratory drive.

Review of Current Guidelines

• AHA: Consider naloxone for high-risk cases.
• ILCOR: Does not recommend naloxone due to insufficient evidence.

Future Directions and Conclusion (48:32–55:00)

Need for a Randomized Controlled Trial (RCT)

• Importance of defining naloxone’s role in OHCA.
• Challenges in RCT design, including ethical concerns and patient selection.

Final Takeaways

• Cautious optimism, but more research needed.
• Emphasis on standard ACLS protocols while awaiting further evidence.