ACLS - Epi in VF/pulseless VT

Discussion in 'Anesthesiology' started by whiteorgo, May 11, 2018.

  1. whiteorgo

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    During our recent ACLS training, we were told that epinephrine shouldn't be given right away during CPR if the patient is in VF/pulseless VT - but 2 cycles of defibrillations should be done before that?

    I've been in situations where epi is given right away no matter the rhythm in ACLS, so I just wanted to ask what you guys do? Do you really avoid epi and wait for the defibrillator and just keep doing chest compressions during these situations???
     
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  3. anbuitachi

    anbuitachi ASA Member

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    who trained you and what was their reasoning for it?
     
  4. NITRAS

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    The explanation I was given was that lots of cardiac arrest are arrhythmia related and they need electricity more than a epinephrine, and a mega dose of pressor might complicate their post-arrest course. Personally, I'd give it as soon as I had an IV and I knew it wasn't VT/VF. . . . . but I don't run to many codes.
     
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  5. whiteorgo

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    It was a MICU attending who gave us the course. Her reasoning for avoiding epi in V-fib/pVT was that it would cause more harm in terms of exciting the cardiac function in the midst of already tachy/defribrillating myocytes
     
  6. pgg

    pgg Laugh at me, will they?
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    Depends

    If you think they're likely to shock back into a viable rhythm and you deliver it promptly, epi may just make them super hypertensive when a perfusing rhythm is restored.

    Remember that ACLS is a protocol made from data coming from mostly unwitnessed out-of-hospital obstructed coronary arrests. That's not the case for most in hospital codes. We can and should use our doctor educations and judgment.

    A vfib or pulseless vtach arrest in the OR usually doesn't need a full mg of IV epi and it may be best to hold off entirely until a shock is given.
     
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  7. FFP

    FFP Grunt, body, pompous ass, pissant, buzzkill, jaded
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    ACLS is for the general healthcare worker, or whenever your thinking drops to that level in the heat of the moment. It's something to fall back to, for lack of better ideas.

    Ideally, the person running a code should be a VERY experienced intensivist, anesthesiologist, cardiologist or EM doc. He should maintain a cool head, and think through it. (This concept that anybody could properly run a code is idiotic. The same way anesthesiology has an intubation pager, EM or CCM should go to the codes and run them. There should be malpractice immunity for anything a physician does in a code that's not egregious; patients would get much better care than from quasi-amateurs. There should be a constant code team that trains weekly TOGETHER.)

    Once the patient is getting EFFICIENT CPR, trying to figure out the exact cause of the arrest can improve survival (and for intra-hospital arrests there is the clinical history that can put some things very high on the list). That's why there's been talk of giving smaller doses of epi in the beginning, of postponing intubation etc. As with any critical patient, knee-jerk solutions can knock out some teeth and kill patients. First do no harm.

    Imagine how nice it is to give 1 mg of epi bolus to a patient with severe hypokalemia, for example. Or torsades (it prolongs QT). Or MI.
     
    #6 FFP, May 11, 2018
    Last edited: May 11, 2018
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  8. Psai

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    Witnessed vfib or v tach = shock right away

    I think epi is overused, if you're giving a mg and it doesn't help, the patient is probably hosed anyway. I give it in 20-30 mcg boluses.
     
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  9. drmwvr

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    Big difference between giving a warm, oxygenated, non acidemic patient (ie, witnessed, in-house arrest) a mg of adrenalin and one that is cold, blue and acidotic (ie dragged through the back doors of the ER)
     
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  10. anbuitachi

    anbuitachi ASA Member

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    20-30 mcg boluses in a ACLS? thats a bit low
     
  11. Psai

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    Initial goal is around 100-150 within 3 minutes or so. We've had a few cases where they pound in a mg of epi, then next thing you know the patient is 280/150 and they're pulling out the nitroglycerin to treat iatrogenic hypertension. I don't want to make my patient bleed out their eyeballs.
     
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  12. pgg

    pgg Laugh at me, will they?
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    Again though it depends.

    Say you're doing a lap something and the surgeon puts a hole in the diaphragm and a tension pneumo develops. PEA ensues.

    Or you're doing a VATS pleurodesis for a 20 yo who had a spontaneous pneumo. Surgeon mechanically tickles the heart and the patient goes into VT.

    Neither of these people need any epi despite what ACLS says. 10-50 mcg hits are reasonable.
     
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  13. T-burglar

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    massive doses of epinephrine are a joke among veteran resuscitationists and have been for decades. Small doses can help a patient with low CV reserve pull through some other insult like a PTX or tamponade. But large doses only serve to create dangerous hypertension once you fix the problem, or if you fail to diagnose and rescue, then mammoth doses of epi are just causing harmful intense vasoconstriction.

    I see shamefully run codes frequently, even by intensivists. Massive epinephrine doses with no real attempt at diagnosis. I also continue to recieve requests for intubation without even a single line of past medical history.
     
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  14. dhb

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    Except for anaphylactic reactions.
     
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  15. FFP

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    The worst thing one can do in an anaphylactic reaction is to push 1 mg of epi IV. I have heard of people who got a STEMI from that dose. The correct starting dose is actually 0.3-0.5 mg IM. For IV, start at even lower doses.
     
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  17. Psai

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    You only need about 100-200 mcg of epi iv in anaphylaxis to see significant effect.
     
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  18. zizzer

    zizzer ASA Member

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    I recall this being addressed in one of my TrueLearn ITE questions this year. For shockable rhythms, I think there was some retrospective evidence of worsened outcomes with early epinephrine. However, delayed epinephrine in non shockable rhythms resulted in worsened outcomes. 95% sure of this. If I run across it again I'll share sources.



    EDIT: I actually had it readily available.

    Donnino MW, et al. Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry. BMJ. 2014 May 20;348:g3028.

    -Shows better outcomes (ROSC) when epi administered within 1-3 minutes rather than later

    and...

    Andersen LW, et al. Early administration of epinephrine (adrenaline) in patients with cardiac arrest with initial shockable rhythm in hospital: propensity score matched analysis. BMJ. 2016 Apr 6;353:i1577.

    -Showed worsened outcomes (ROSC, in-hospital mortality) when epinephrine administered within the first 2 minutes in VF/Vtach

    Therefore, the new guidelines (2015) state "There is insufficient evidence to make a recommendation as to the optimal timing of epinephrine, particularly in relation to defibrillation, when cardiac arrest is due to a shockable rhythm".

    Link MS, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S444-64.
     
    #16 zizzer, May 13, 2018
    Last edited: May 13, 2018
  19. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay

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    1mg Epi is reserved for dead people. A shockable rhythm I only consider 1/2 dead.
     
  20. dhb

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    We've had a thread about this, i know of one case that needed 17mg to bring the patient back.
     
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  21. eikenhein

    eikenhein my cat is awesome, his name is bandit
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    In divided doses????

    Yes, sometimes with anaphylaxis they see some improvement then their pressures tank again necessitating further doses.

    Same reason why some people need multiple epipens
     
  22. Psai

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    That's insane. I guess it depends on the patient's immune response and how much histamine, bradykinin etc they're pumping out and for how long but damn that is an huge amount.
     
  23. Arch Guillotti

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    It isn't all that insane if you have ever seen full blown life threatening anaphylaxis.
     
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  24. Cryc_to_the_point

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    In my paramedic days I treated a pt that presented to a derm clinic with anaphylactoid symptoms. 1mg later I was called. When I arrived she had her medical assistant drawing up a second dose...
     
  25. pgg

    pgg Laugh at me, will they?
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    :)

    Titrate to effect, but don't start with a mg IV.
     
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  26. drmwvr

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    and don't forget protamine reactions
     
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  27. somedumbDO

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    Anaphylactoid rxns tend to need multiple higher dose epi boluses (had one pt w reaction to local needed 6mg it wasn't LAST...) Whereas anaphylactic rxns tend to respond to much lower doses. The hard part sometimes is trying to figure out which one you are treating.
     
  28. Cryc_to_the_point

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    I'll call it inappropriate when the patient is breathing great, super anxious, hypertensive, and tachycardic...
     
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  29. chessknt87

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    I would be worried about going off acls and losing someone in a code. You can make all the physiology arguments you want but the hospital probably requires you to be acls certified and for you to intentionally ignore it would look bad to a jury especially if the hospital bylaws require training and adherence to it. And having someone die is probably the highest risk event of a lawsuit.

    I personally have not seen an in hospital code go off book from acls for this very reason although the argument s presented here are interesting.
     
  30. Psai

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    If you're doing acls, you already lost them. You're just trying to bring them back and your chances are pretty bad.
     
  31. eikenhein

    eikenhein my cat is awesome, his name is bandit
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    at my hospital (large academic medical center and level 1 trauma), it is a requirement for the nurses and anesthesiology residents to be ACLS certified -- however it is not a requirement for the anesthesiology attendings. i keep up to date with my ACLS certification but recognize that it is meant for very different circumstances than witnessed intraop arrest
     
  32. FFP

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    You have not seen a code go off book because you have not seen a good ACLS resus yet. ;)

    I had a patient go VTach on me in the ICU a few months ago. I ordered Amio to be given over 10 minutes. After like 3-5 minutes, the VTach got under control but the heart rate started dropping really fast towards towards 50. I stopped the Amio at less than half-dose, and waited. The surgeon kept insisting to give the rest of the "full" dose; I ignored him. The patient did fine. First do no harm.

    Do what's right for your patient and his physiology, assuming you know his physiology (as you should). Don't just CYA. The most saddening thing I see in the hospital, day in and day out, are docs (including anesthesiologists), who do everything the same way for all of their patients, as if by protocol, and know crap about their patients' individual physiologies. One doesn't need physicians for that.
     
    #30 FFP, May 14, 2018
    Last edited: May 14, 2018
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  33. Newtwo

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    Why is it?
     
  34. Newtwo

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    I've been saying this for years. We're killing people with epi and acls. It's fecking crazy.

    1 bloody milligram of epi iv is insane.
    Repeated 5 or 6 times it's actually criminal.

    You can have your rosc all you want, you've almost definitely killed the poor guys brain. Is that better? And it wasnt the 8th mg of epi that did it. It was probably luck, or he always had a pulse you just couldn't feel it, or fluids or who knows what

    I don't know how ACLS is allowed survive. No evidence for most of it other than 'expert opinion' or retrospect. How often do we chew papers to pieces here with far better evidence than acls

    Snotty medical residents coming in shouting 'im the leader'

    Give me a break
     
    #32 Newtwo, May 14, 2018
    Last edited: May 14, 2018
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  35. Robotic Wis-Hipple

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    Yet they removed atropine and Vaso due to lack of evidence....

    And as far as LAST goes, ASRA has guidelines stating NOT to use 1mg Epi but instead to start with 1mcg/kg which I think is great. Throwing Epi at someone without actually thinking about the diagnosis/cause is essentially like defibrillating without assessing the rhythm and determining if it’s shockable.
     
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  36. Robotic Wis-Hipple

    Robotic Wis-Hipple ASA Member

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    This is why we need actual physicians involved in policy making at the hospital level.

    You know how many times I’ve seen ACLS performed in the actual OR? Maybe a handful. We aren’t arriving to a bedside without any info on the Pt, we know their comorbid condition, volume status, lyte status (usually), dialysis requirement and last run, we consider how plausible it is that the Pt threw a massive PE, or to have tamponade, etc. We also know what has been occurring in the preceding moments (as Pgg described). We also typically have the defibrillator much more readily available than the average floor code. It’s never made any sense to me to hit a malignant arrhythmia with a huge dose of an arrhythmogenic medication when electricity is the treatment. And if the shocks don’t work, guess what, it’s probably not Epi that’s going to fix the underlying issue regardless.

    But per the original question by the OP, if you look at the ACLS algorithm it actually doesn’t call for Epi in the shockable VT/Vfib pathway until after a couple rounds of “shock” anyway so imo we can argue we are following ACLS per their own algorithms. Good CPR, acquisition of the defibrillator and no delay in delivering the shock, and patient specific diagnostics should be the priorities. Epi is a crutch to try to stimulate some red numbers while you buy time and that’s pretty much it.
     
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  37. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay

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    Wait, is nobody doing precordial thumps anymore???
     
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  38. pgg

    pgg Laugh at me, will they?
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    This is taking defensive medicine way too far, to the point where it's an actual hazard to patients. In any case I don't agree that the legal risk is elevated by straying from the guidelines when circumstances demand it. Do the right thing and document the what and why.

    The further away from the OR and a witnessed obvious etiology arrest you are, the closer one will be to ACLS. It provides time to figure things out in a framework of doing something when you know little or nothing. The patient found down on the ward during a q4h vital check is worlds different than anything witnessed in the OR.

    I won't go so far as go call strict adherence to the letter of ACLS for most in-OR arrests outright malpractice, but that's only because the local standard of care is likely to be low enough that ACLS is all some people have got.

    If the jury is scrutinizing the conduct of the code, you'll probably still burn because the code and the death were your fault in the first place.

    You can always say you're following ACLS perfectly by skipping ahead to the "Hs and Ts" and addressing the root cause. :)
     
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  39. Psai

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    We actually did a pericardial thump recently. It worked reasonably well.
     
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  40. FFP

    FFP Grunt, body, pompous ass, pissant, buzzkill, jaded
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    All the time!

    [​IMG]
     
  41. drmwvr

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    Why not do a precordial thump? In the time it takes to get the pads on, its compressions any way, which serves as a thump of sorts. Patients convert from witnessed ventricular dysrythmias with chest compressions too.
     
  42. RoyBasch

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    The utility of epi in VT/VF seems particularly questionable as emerging case reports support the use of beta blockers like esmolol in the setting of refractory VF or VT Storm.
     
  43. Psai

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    We did try shocking but patient didn't convert into sinus. Hard to do chest compressions with a median sternotomy though.
     
  44. dchz

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    EXACTLY THIS.

    I don't know where you all practice, but all of our codes are giving mg bolus of epi at a time. The best reason to do this is to protect the hospital and the medical license medical-legally. It has nothing to do with what is best for the patient. I remember discussing this with people during ACLS training, citing that we as anes should be way better at rescue than a protocol, specially if we know the pt. But i was shot down left and right saying there is no way i know better than a protocol created by a SOCIETY of cardiologists...
     
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  45. dchz

    dchz Avoiding the Dunning-Kruger
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    Easy for you to say, veterans don't die and the navy will never fire you...

    But that line about H&Ts is good. I'm gonna use that as my excuse to go off book ;)
     
  46. T-burglar

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    You’re not going to lose your license if you give less than a milligram of adrenaline in cardiac arrest...
     
  47. drmwvr

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    pericardial...missed that. Long nite...
     
  48. Psai

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    Dude we are anesthesiologists. A protocol is for people who don't know what they're doing. It doesn't apply to us. We know much more about human physiology and resuscitation than a freaking acls instructor. Please.
     
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  49. Newtwo

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    I don't think you would either but I am certain it could create a massive headache for yourself.

    Picture some fresh resident leading the code with an Entourage of people who 'know' ACLS in the room on a medical ward and you suggest any dose other than the dogma these people have been brainwashed. Their own innocence will lead them to believe you incompetent...
    They could write you up! Especially if things are heated as we all know arrests can become...

    It's all well and good if you're pushing the drugs in an arrest in your own or but let's be honest how often does that happen? 3 times in 7 years for me...
     
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  50. Psai

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    I don't suggest doses. I order them. If people don't feel like doing what I say, I tube if it's warranted then I leave.
     

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