Cadet133

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During a code blue ,Assuming you follow ACLS and administer epi per protocols, how often do you come to a point where you just start throwing meds for sake of trial like bicarb or even atropine more as a last ditch effort. Or should that be avoided. Is it typically frowned upon? I just feel like if youve tried everything inside the box, sometimes it becomes necessary to step outside the box before declaring a patient
 
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jdh71

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Sort of depends on the case but sure, If you think there is a reasonable reason in play to try something out of the box in a situation that seems like fair play. But just throwing a bunch of random drugs at a PEA arrest loses you cool points in my book. Call it when it needs called. Know the difference between saving a life, prolonging a life, and prolonging the DYING process inappropriately.
 

MedicineZ0Z

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Bicarb is a fair choice. Mg is another you can throw in. Calcium at a renal patient. Not sure why you'd use atropine?
 
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Cadet133

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It was in 2010 acls before they removed it and i believe studies show it had not been proven to be effective nor harmful

Bicarb is a fair choice. Mg is another you can throw in. Calcium at a renal patient. Not sure why you'd use atropine?
 

TimesNewRoman

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Bicarb is a fair choice. Mg is another you can throw in. Calcium at a renal patient. Not sure why you'd use atropine?
Bicarb is voodoo.

I wish I could find that video about using crystals in cardiac arrest...
 
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MedicineZ0Z

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That's a general point of us doing stuff in ACLS which historically has not always been evidence-based especially in the context of walking out the hospital neurologically intact (which is what really counts).
 

CCM-MD

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That's a general point of us doing stuff in ACLS which historically has not always been evidence-based especially in the context of walking out the hospital neurologically intact (which is what really counts).
Some things have more evidence than others.
 

MedicineZ0Z

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Some things have more evidence than others.
And really the stuff with less evidence is done cause "why not, can't hurt." Calcium in renal patients is somewhat intuitive. Mg is always a good adjunct for everything. Bicarb increases intravascular volume as a side benefit.

Unlikely to have an impact on anything but makes us feel good to do it.
 

Siggy

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Unlikely to have an impact on anything but makes us feel good to do it.
I think this is the real problem with ACLS. I remember when atropine was removed and everyone cried because, "what else will we give besides epinephrine?" When someone suggests that epi should be removed, people come out of the woodwork saying, "But if we don't give epi, then what will we do?" I mean... nothing is better than giving something that hasn't been shown to improve meaningful outcomes.
 

CCM-MD

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And really the stuff with less evidence is done cause "why not, can't hurt." Calcium in renal patients is somewhat intuitive. Mg is always a good adjunct for everything. Bicarb increases intravascular volume as a side benefit.

Just because we don’t know something can hurt now, doesn’t mean it does not hurt. It just means we don’t know that it does. There are things that have been done historically and made physiological sense that have turned out to cause harm when studied. If you’re going to go by your rationale, you might as well start giving every patient who codes vitamin C, thiamine, a B12 shot in their gluteus, and rub some CBD oil on their chest... cuz why not? It can’t hurt? And it makes us feel good that we did something. A lot of times in critical care, the right thing to do is not do anything at all. As the saying goes, “don’t just do stuff, stand there”.
 

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Long after evidence came out that hyperoxia can increase infarct size and worsen MI and CVA, we were still taught in EMT and paramedic school to "give all patients high flow oxygen, it can't hurt!"

People like to do stuff vs not do stuff.
 
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MedicineZ0Z

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Just because we don’t know something can hurt now, doesn’t mean it does not hurt. It just means we don’t know that it does. There are things that have been done historically and made physiological sense that have turned out to cause harm when studied. If you’re going to go by your rationale, you might as well start giving every patient who codes vitamin C, thiamine, a B12 shot in their gluteus, and rub some CBD oil on their chest... cuz why not? It can’t hurt? And it makes us feel good that we did something. A lot of times in critical care, the right thing to do is not do anything at all. As the saying goes, “don’t just do stuff, stand there”.
I didn't mean that we apply the "can't hurt" idealogy in a broad sense to everything. I meant it in regards to the specifics I pointed out.
Physiologically, it just isn't feasible that those few things could be in any way harmful. And there's a theoretical case for their utility.
 

CCM-MD

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I didn't mean that we apply the "can't hurt" idealogy in a broad sense to everything. I meant it in regards to the specifics I pointed out.
Physiologically, it just isn't feasible that those few things could be in any way harmful. And there's a theoretical case for their utility.
That’s simply not true. You just may not know that it’s harmful or how harmful it is. For example, you mentioned calcium “can’t hurt”, when neurotoxicity associated with it is quite well described.
 

ShockIndex

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The problem with cardiac arrest is that it’s a symptom, not a cause and there are a myriad of causes. What is good for the goose is not necessarily good for the gander. ACLS makes a lot of sense for the relatively healthy person who is less than 65 and has a witnessed cardiac arrest event. If your initial impression is, “wow, I wonder why this 50-year old guy V-fib arrested,” then you are probably doing the right thing spending a few minutes doing some ACLS. For the chronically ill or advanced age, it makes very little sense unless an immediately reversible cause is known.

So, the best way to improve cardiac arrest outcomes is not to look for a last ditch drug, but instead to stop offering mechanical circulatory support (i.e. CPR) to people with no reasonable chance of survival. These people are not in cardiac arrest, they are simply dead. Discussing or otherwise offering a “code status” with family members of those with severe dementia, widely metastatic cancer, or otherwise already slowly deteriorating in the ICU is stupid. Offering a brain transplant makes more sense.

So, rather than flagellate yourself trying to find a “last ditch” medical therapy for someone who is dead, do your patient a favor and just turn off the monitor.
 
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MedicineZ0Z

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That’s simply not true. You just may not know that it’s harmful or how harmful it is. For example, you mentioned calcium “can’t hurt”, when neurotoxicity associated with it is quite well described.
For a renal patient (which is where I highlighted its use), you don't think the benefits of using it outweigh the risk you described?
 

TimesNewRoman

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Don't disagree. The point was it is incorrect to equate the evidence for administering epinephrine to administering bicarb.
You’re right. One does nothing. The other increases your odds of being trached/pegged and in an LTACH.
 

Siggy

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Have you stopped administering epinephrine during codes?
After the first or second round I don't really care, and even then I don't care enough to discuss the matter when the nurse recording excitedly called out that it's time for epi. The second you suggest that more epi isn't going to help there's always at least one person who shoots a look like you just killed their dog.
 
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TimesNewRoman

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Have you stopped administering epinephrine during codes?
I don’t do it until the nurse says “do you want to give Epi” unless I think it may help in a specific instance.
 

SpacemanSpifff

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During a code blue ,Assuming you follow ACLS and administer epi per protocols, how often do you come to a point where you just start throwing meds for sake of trial like bicarb or even atropine more as a last ditch effort. Or should that be avoided. Is it typically frowned upon? I just feel like if youve tried everything inside the box, sometimes it becomes necessary to step outside the box before declaring a patient
ACLS is for dentists. Resuscitation based specialties (anesthesia, EM, CCM) should not be applying this protocol in all code situations, we should be aiming to temporize/correct the underlying cause of arrest. Sometimes that’s epi, other times blood products, tPA, thoracostomy, etc. Flogging someone blindly with random meds is a waste of your team’s time.
 
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economycian

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The evidence for worse neurooutcomes with Epi is in out of hospital cardiac arrest where there is significant delay until commencement of effective CPR.

This is entirely different from the in hospital arrest.
 
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MedicineZ0Z

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The evidence for worse neurooutcomes with Epi is in out of hospital cardiac arrest where there is significant delay until commencement of effective CPR.

This is entirely different from the in hospital arrest.
How about evidence for better neuro outcomes for in-hospital arrest?
 

economycian

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How about evidence for better neuro outcomes for in-hospital arrest?
I’m not sure there is any.

For me it stands to reason that if you produce greater survival but your survivors are neurologically fried in the out of hospital setting, then taking the time without CPR out of the equation in an in hospital setting has a good chance of producing good survival.

That said I have turned up to a floor code on someone in rigor mortis...
 

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TimesNewRoman

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The evidence for worse neurooutcomes with Epi is in out of hospital cardiac arrest where there is significant delay until commencement of effective CPR.

This is entirely different from the in hospital arrest.
Meh. I ran a code today in the icu and didn’t give Epi.
 

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I ran a 28 minute code with no Epi recently. Patient came in with a STEMI and VFed in front of me. Remained in refractory VF, and I wasn’t about to go excite that myocardium more with mega dose epi. Got some weird glances from the nurses but I sounded convincing enough that I knew what I was doing.

Walked out of the hospital neuro intact.
 
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Siggy

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I ran a 28 minute code with no Epi recently. Patient came in with a STEMI and VFed in front of me. Remained in refractory VF, and I wasn’t about to go excite that myocardium more with mega dose epi. Got some weird glances from the nurses but I sounded convincing enough that I knew what I was doing.

Walked out of the hospital neuro intact.
I think the weirdest look I ever got was in a refractory v-tach/electrical storm code in the cath lab when I called for Metoprolol 5mg. Both the cardiologist any my attending gave a WTF? followed by a ¯\_(ツ)_/¯ as we were well over 30 defibrillations at that point. Got ROSC, but the patient still expired a few hours later. No more v-tach though.
 

MedicineZ0Z

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I ran a 28 minute code with no Epi recently. Patient came in with a STEMI and VFed in front of me. Remained in refractory VF, and I wasn’t about to go excite that myocardium more with mega dose epi. Got some weird glances from the nurses but I sounded convincing enough that I knew what I was doing.

Walked out of the hospital neuro intact.
What did you use besides amio etc ?
 

leviathan

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There are two RCTs showing neuro intact survival with vaso, steroids, epi for in hospital arrest. As others said, cardiac arrest is not a disease, it's a symptom of a very heterogeneous population. Some of them will benefit from epi. Others will be harmed. The majority it will do nothing for, realistically.
 
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