(1545) Ice-Cold Crisis: Prognosis Calls in Hypothermic Patients Despite Out-of-Hospital Arrests

Introduction: Synthetic opioid overdoses, such as fentanyl, have an increasing significance in public health and critical care medicine, with an exponential increase in mortality over the past decade. These potent substances cause cardiorespiratory instability and lethal cardiac arrest. This case highlights the complex management of a critically ill patient with suspected synthetic opioid overdose resulting in hypoxic arrest, hypothermia, and Acute Respiratory Distress Syndrome (ARDS), emphasizing the importance of timing the neuroprognostication.

Description: A 20-year-old male with a reported history of polysubstance use was found unresponsive and pulseless with pinpoint pupils of unknown duration. ACLS protocol was initiated by emergency personnel (EMS) with reported rhythms, including Pulseless Electrical Activity, asystole, and Torsades de Pointes. Narcan was administered. He had multiple cardiac arrests with intermittent spontaneous circulation (ROSC) prior to and after arrival at the emergency department.

After the final ROSC, he was in idioventricular rhythm at 30-40/minute, hypothermia at 78°F in the core, hypoxemia (pO2 44.5, P/F ratio 44.5), and severe high anion gap metabolic acidosis attributed to lactic acidemia (10.8) complicated by multiorgan dysfunction. Neurologically, he had a Glasgow Coma Scale of 3 with bilateral dilated non-reactive pupils. Toxicology and urine drug screens were negative. Active external and internal rewarming was added to the pressors and broad-spectrum antibiotics. The clinical course was complicated by ARDS, which improved with guideline-based management. He had complete neurological recovery after achieving normothermia.

Discussion: In this era of the opioid epidemic, complications of overdose are under-recognized in the current critical care practice. Most of the drug screen tests in the community settings do not identify synthetic opioids. Mortality reduction requires early recognition of opioid toxicity at the EMS level. Mortality trends from drug-related out of hospital cardiac arrest peaks in the fourth decade of life who have the least comorbidities. This case emphasized the critical importance of rewarming, with current recommendations to delay neuroprognostication by 72 hours after rewarming or ROSC.