pre-hospital epi: associated with a lower chance of survival (new issue of JACC)

[repititionition]

New issue of JACC:

Conclusions: In this large cohort of patients who achieved ROSC, pre-hospital use of epinephrine was consistently associated with a lower chance of survival, an association that showed a dose effect and persisted despite post-resuscitation interventions.

http://content.onlinejacc.org/article.aspx?articleID=2020181

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[pianoman511]

The findings are consistent with previous studies in JAMA 2009 - http://www.ncbi.nlm.nih.gov/pubmed/19934423 and NEJM 2004 http://www.ncbi.nlm.nih.gov/pubmed/15306666 both of which looked at prehospital use of ACLS and survival to discharge and found no difference with ACLS interventions. theNNT.com has a good synopsis.

 

[deleted6669]

an australian study a few years ago showed no benefit in cardiac arrest for any intervention but cpr and defibrillation.

 

[TheDudeMD]

I'm not buying any of this until someone actually does a prospective RCT (granted, might never happen).

To me, I look at this study and say "of course the patients who got more epi had worse outcomes, they were deader-looking than the patients who got less epi." Selection bias.

 

[da8s0859q]

I look at this study and say "of course the patients who got more epi had worse outcomes, they were deader-looking than the patients who got less epi."

Definitely just had that one scene from The Rock -- "Like what, kill him again?" -- flash through my head.

 

[TheDudeMD]

Definitely just had that one scene from The Rock -- "Like what, kill him again?" -- flash through my head.

If I remember correctly, The Rock had the greatest intracardiac injection scene of all time (was it atropine I think?). Pulp Fiction had that great intracardiac injection scene too.

Ah to practice emergency medicine in 90s movies...

 

[Arcan57]

Out of hospital epi is a tool for keeping paramedics from having to wait around for the coroner and for poor souls with anaphylactic reactions. Any other use is off-label and only supported by poor quality anecdotal evidence.

 

[rwmedic906]

Hopefully this study will provide the ultimate answer http://www.isrctn.com/ISRCTN73485024
As for my personal opinion, I think the focus on surrogates such as coronary perfusion pressure have perpetuated its use without a true understanding of the physiology involved, because it made us feel like we were doing something productive. "we must get the CPP above 15 to obtain ROSC!" We've lost sight of the trees thanks to the forest of surrogate endpoints. I'm happy to see resuscitation science begin to question the dogma.

 

[link2swim06]

Even if it does have poor evidence....they are dead, it is cheap, what's the harm. I haven't seen any randomized studies showing epi worsens outcomes. As long as it is not interfering with high quality CPR and defibrillation it doesn't matter imo.

Furthermore, even if they never regain function, resuscitating with certain medications may make them survive long enough to let their families have some closure and donate their organs.

 

[racerwad]

I'm not buying any of this until someone actually does a prospective RCT (granted, might never happen).

To me, I look at this study and say "of course the patients who got more epi had worse outcomes, they were deader-looking than the patients who got less epi." Selection bias.

Even if it does have poor evidence....they are dead, it is cheap, what's the harm. I haven't seen any randomized studies showing epi worsens outcomes. As long as it is not interfering with high quality CPR and defibrillation it doesn't matter imo.

Furthermore, even if they never regain function, resuscitating with certain medications may make them survive long enough to let their families have some closure and donate their organs.

Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation. 2011;82(9):1138-43.

Ong ME, Tiah L, Leong BS, et al. A randomised, double-blind, multi-centre trial comparing vasopressin and adrenaline in patients with cardiac arrest presenting to or in the Emergency Department. Resuscitation. 2012;83(8):953-60.

For the FOAM-only folks: Weingart and Swaminathan have talked about the topic, as have the fine folks at EM:RAP (<-requires a subscription and is very similar to Dr. Swaminathan's other talk, with a little more context).

 

[TheDudeMD]

Even if it does have poor evidence....they are dead, it is cheap, what's the harm. I haven't seen any randomized studies showing epi worsens outcomes. As long as it is not interfering with high quality CPR and defibrillation it doesn't matter imo.

Furthermore, even if they never regain function, resuscitating with certain medications may make them survive long enough to let their families have some closure and donate their organs.

Just playing devil's advocate, you could argue the "harm" is that when these patients getting epi do survive, they apparently have bad neuro outcomes with high risk of ending up as vegetables, putting increased financial and emotional burden on the family and hospital. I think there's evidence supporting that.

Not saying I agree/disagree with that argument, just throwing it out there.

 

[Birdstrike]

This is a very difficult, if not impossible question to answer with level I evidence. It comes down to this: If I or my family member have a cardiac arrest am I okay with someone trying epi in a reasonable time frame?

Yes, I am.

You're never going to get your randomized double blind placebo controlled trial to answer this question.

 

[alpinism]

Even if it does have poor evidence....they are dead, it is cheap, what's the harm. I haven't seen any randomized studies showing epi worsens outcomes. As long as it is not interfering with high quality CPR and defibrillation it doesn't matter imo.

Furthermore, even if they never regain function, resuscitating with certain medications may make them survive long enough to let their families have some closure and donate their organs.

Just playing devil's advocate, you could argue the "harm" is that when these patients getting epi do survive, they apparently have bad neuro outcomes with high risk of ending up as vegetables, putting increased financial and emotional burden on the family and hospital. I think there's evidence supporting that.

Not saying I agree/disagree with that argument, just throwing it out there.

Also, it indirectly "harms" patients due to the opportunity cost of continuing to use epi instead of researching other agents that might at least have some benefit.

 

[alpinism]

I'm not buying any of this until someone actually does a prospective RCT (granted, might never happen).

To me, I look at this study and say "of course the patients who got more epi had worse outcomes, they were deader-looking than the patients who got less epi." Selection bias.

When I was a medic (at least in my experience), the younger/healthier patients were usually more likely to get epi (and more of it) while having the proverbial "kitchen sink" thrown at them.

If we had a patient who was down for 15+ minutes or was older/unhealthier we usually just did compressions and tried to shock without opening the drug box.

 

[link2swim06]

Also, it indirectly "harms" patients due to the opportunity cost of continuing to use epi instead of researching other agents that might at least have some benefit.

Ehh I don't buy this. Amio got pushed into into the ACLS algorithm while lidocaine was the standard. Granted I don't really know if there is any quality research to show amio is better than lido for v fib arrest, but regardless lido clearly didn't limit the develop and implementation of amio. If something better came along it would be worth a ton of money, the research would easily change the algorithm.

Just playing devil's advocate, you could argue the "harm" is that when these patients getting epi do survive, they apparently have bad neuro outcomes with high risk of ending up as vegetables, putting increased financial and emotional burden on the family and hospital. I think there's evidence supporting that.

Not saying I agree/disagree with that argument, just throwing it out there.

I hear what you are saying but from my brief resuscitation experience (maybe 30 codes), it seems that the family appreciates seeing the patient "alive" and get some closure before they are "dead." I have seen codes extended solely to wait for the family to drive to hospital before we quit pushing on their loved ones chest.

I agree it adds costs...but it's worth it if 1/3 of these patients is able to donate their organs.

 

[TheDudeMD]

When I was a medic (at least in my experience), the younger/healthier patients were usually more likely to get epi (and more of it) while having the proverbial "kitchen sink" thrown at them.

If we had a patient who was down for 15+ minutes or was older/unhealthier we usually just did compressions and tried to shock without opening the drug box.

Now that you mention this, you're totally right. Deader-looking patients actually do get less epi in most codes. It's one of those unique cases in medicine where the worst cases probably get less intensive care (because it's futile). I stand corrected

 

[deleted547339]

Everyone on here should listen to the SMART:EM podcast on ACLS drugs if you want to have a more informed conversation. He goes through all the big papers on the subject. Very enlightening.

 

[Old_Mil]

2050 ACLS Algorithm:

Cardiac Arrest? If no, no intervention. If yes, shock.
ROSC? If yes, no intervention. If no, shock again.
ROSC? If yes, no intervention. If no, shovel.

We'll get there eventually.

 

[EMIM2011]

You're never going to get your randomized double blind placebo controlled trial to answer this question.

http://www.ncbi.nlm.nih.gov/pubmed/21745533

 

[Birdstrike]

http://www.ncbi.nlm.nih.gov/pubmed/21745533

Okay. "Never say, never." I should have prefaced that with "in the United States" since it's kind of hard to consent someone in cardiac arrest and jump through all the ethical hoops here (giving placebo in place of a potentially life saving treatment), as that study was done on Australia. (Watch him go find one done in the US now. Lol). But I stand corrected. Still a very hard thing to study properly (resuscitation in general) and get good study design with, control and match the populations, etc, and repeat in identical fashion. But I'll defer to the research experts on here, as I am not one. I am not a researcher. I am, and I say it proudly, a working stiff.

 

[gman33]

Ehh I don't buy this. Amio got pushed into into the ACLS algorithm while lidocaine was the standard. Granted I don't really know if there is any quality research to show amio is better than lido for v fib arrest, but regardless lido clearly didn't limit the develop and implementation of amio. If something better came along it would be worth a ton of money, the research would easily change the algorithm.

Amio got in there because it was a new, expensive drug being pushed by industry

 

[Mad Jack]

I'm not buying any of this until someone actually does a prospective RCT (granted, might never happen).

To me, I look at this study and say "of course the patients who got more epi had worse outcomes, they were deader-looking than the patients who got less epi." Selection bias.

Pretty much this. The people that are getting epi pushed in the field are going to be those that are already ****ed from the start. A lot of them will have substantial downtime to begin with.

The only way we could determine if prehospital epi was actually being used ineffectively is if we compared known downtime of prehospital patients with those treated exclusively in the hospital, which is damn near impossible, as witnesses to cardiac arrests tend to suffer from severe subjective time dilation.

 

[Raryn]

Amio got in there because it was a new, expensive drug being pushed by industry

Huh?

Amio was discovered 40+ years ago and FDA approved for use in the US in the 80s. The pill version is $10 for a month supply of the generic, and I can't imagine the IV one is that much more expensive.

 

[CajunMedic]

If I remember correctly, The Rock had the greatest intracardiac injection scene of all time (was it atropine I think?). Pulp Fiction had that great intracardiac injection scene too.

Ah to practice emergency medicine in 90s movies...

I love that scene "YOU WANT ME TO STICK THIS IN MY HEART, ARE YOU F&*(&(&(ING NUTS!!!"