Drugs and pharmacology during a code

[TheTruckGuy]

Hello friends. I'm an EM resident right now, had to respond to a code on the ward the other night by myself and we got the patient back, however I did some stuff that isn't technically ACLS and was wondering if I could get some thoughts from the people that understand drugs more than me.

Here are my questions:

1) How often do you all get asked to make drips during codes? And what has been your experience with their efficacy?
2) Are these pressors' affinity for different receptors dose dependent? And how do you think the 1mg slam of epi during ACLS affects the different receptors' levels of stimulation?
3) Do you think the goal of epi in a code is to stimulate the heart? Or promote peripheral vasocontriction and subsequently coronary perfusion?
4) Anyone ever do a norepi drip prior to ROSC?
5) Do you have any out of the box drug combos you've seen used effectively during codes? I've heard adding 40mg solumedrol to the mix has shown some promise (specifically the study used vaso, solumedrol, and epi - Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. - PubMed - NCBI) But this hasn't caught on anywhere that I'm aware of.

---

Members don't see this ad.

 

[mustang sally]

1) Frequently. Though this is typically after ROSC (not during full on cardiac arrest). Not too sure about their efficacy as we are a small rural hospital and we are usually making the drips just prior to the patient being shipped out. Some people make it and some don't.
2) Yes, for sure (depending on which drug we are talking about). High dose epi = more alpha than beta
3) Both
4) Not that I can recall.
5) Not offhand. We pretty much stick with ACLS and don't use vasopressin anymore during codes since they took it out of the guidelines. I have heard of using Solu-medrol during sepsis but am not familiar with using it during cardiac arrest.

 

[TheTruckGuy]

Would you happen to know at what point we cross into the high dose epi range and start getting more alpha effects?

Also, post ROSC, I've heard of more physicians saying they hang epi drips for post ROSC hypotension. If I want more vasoconstriction and less heart stimulation, would a levo drip accomplish that? Because on this recent code, I started an epi drip before we got ROSC, after the 3rd round of code epi. She got ROSC a minute later, but her heart rate was 160+ (probably not good for a metabolically deprived heart). We cut the epi in half, but then she got really hypotense. So just curious.

 

[Truthspeaker]

About the drips, I personally don't approve of them during a code. Just compare the amounts given in the Epinephrine bolus vs. what the drip will likely be started at. Let's say you put up an Epinephrine drip up at 10 mcg/min or a high amount like 30 mcg/min. In three minutes you gave 30-90 mcg total. An Epinephrine syringe gives 1000 mcg per dose every 3 minutes in the ACLS algorithm.The drip is just a lot more work for you, the nurse & isn't even delivering anywhere near the pressor you deliver with the bolus unless you are running the drip wide open for some reason. The doctors who are asking for pressor drips on a pulseless patients are usually rookies from what I've seen. They probably didn't think about the rate of delivery vs. the ACLS protocol thoroughly enough.

 

[TimeZero]

About the drips, I personally don't approve of them during a code. Just compare the amounts given in the Epinephrine bolus vs. what the drip will likely be started at. Let's say you put up an Epinephrine drip up at 10 mcg/min or a high amount like 30 mcg/min. In three minutes you gave 30-90 mcg total. An Epinephrine syringe gives 1000 mcg per dose every 3 minutes in the ACLS algorithm.The drip is just a lot more work for you, the nurse & isn't even delivering anywhere near the pressor you deliver with the bolus unless you are running the drip wide open for some reason. The doctors who are asking for pressor drips on a pulseless patients are usually rookies from what I've seen. They probably didn't think about the rate of delivery vs. the ACLS protocol thoroughly enough.

I have the RN run the epi gtt wide open in these situations. I don't argue the appropriateness.

 

[TimeZero]

Hello friends. I'm an EM resident right now, had to respond to a code on the ward the other night by myself and we got the patient back, however I did some stuff that isn't technically ACLS and was wondering if I could get some thoughts from the people that understand drugs more than me.

Here are my questions:

1) How often do you all get asked to make drips during codes? And what has been your experience with their efficacy?
2) Are these pressors' affinity for different receptors dose dependent? And how do you think the 1mg slam of epi during ACLS affects the different receptors' levels of stimulation?
3) Do you think the goal of epi in a code is to stimulate the heart? Or promote peripheral vasocontriction and subsequently coronary perfusion?
4) Anyone ever do a norepi drip prior to ROSC?
5) Do you have any out of the box drug combos you've seen used effectively during codes? I've heard adding 40mg solumedrol to the mix has shown some promise (specifically the study used vaso, solumedrol, and epi - Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. - PubMed - NCBI) But this hasn't caught on anywhere that I'm aware of.

1-Quite often. Amio and epi are the usual requests. Efficacy really depends on the patient, rhythm, underlying cause if identifiable, etc. There really is no cure all and each situation is different. Quality CPR and electricity >>>> drugs in terms of survival. From my experience, the chance of survival when an epi drip is requested is not good.
2-Definitely. See Dopamine. Receptor saturation occurs for all drugs at some point. My personal opinion is that the huge doses of amio are epi are designed to stimulate and saturate whatever the hell they can to save the patient's life. There's a reason these kinds of push doses aren't used in any other setting.
3-All of the above. An EM doc once told me a pineapple can be given a pulse with enough epi.
4-Once or twice as last ditch effort salvage therapy.
5-We've tried pushing methylpred after everything else has failed. I recommend you check out EMcrit.org. It's run by an EM physician and there is some great content that examines the use of agents like esmolol and methylene blue (Podcast 191 - Cardiac Arrest Update).

 

[TheTruckGuy]

I'm definitely a rookie, might explain why I went for the drip. But my understanding is that epi doesn't necessarily improve neurological outcomes during CPR, hammering the heart and brain with those 1mg doses may help get a pulse back but at the expense of the brain. Everywhere I've looked I've seen only marginal evidence for epi to be included in codes. And I see mixed studies showing increased vs decreased cerebral perfusion with epi.

 

[TheTruckGuy]

I'm definitely a rookie, might explain why I went for the drip. But my understanding is that epi doesn't necessarily improve neurological outcomes during CPR, hammering the heart and brain with those 1mg doses may help get a pulse back but at the expense of the brain. Everywhere I've looked I've seen only marginal evidence for epi to be included in codes. And I see mixed studies showing increased vs decreased cerebral perfusion with epi.

Also, when I did that code with the drip, I started at 50mcg/min after round 3 of epi, which was a little more than 0.5mcg/kg/min. When we got ROSC and she started taching away at 160+, cut it to 25mcg/min and added on levo.

 

[John Detter]

I'm definitely a rookie, might explain why I went for the drip. But my understanding is that epi doesn't necessarily improve neurological outcomes during CPR, hammering the heart and brain with those 1mg doses may help get a pulse back but at the expense of the brain. Everywhere I've looked I've seen only marginal evidence for epi to be included in codes. And I see mixed studies showing increased vs decreased cerebral perfusion with epi.

Also, when I did that code with the drip, I started at 50mcg/min after round 3 of epi, which was a little more than 0.5mcg/kg/min. When we got ROSC and she started taching away at 160+, cut it to 25mcg/min and added on levo.

You're right, the evidence for any of the code medications is really crappy. Many of the outcomes look at ROSC or survival to hospital admission, but they don't guarantee that your patient won't be a vegetable afterwards. Nevertheless, it's the only data we have and designing a clinical trial to obtain more evidence would be extremely difficult. Therefore I would recommend focusing on the reversible causes of cardiac arrest instead of coming up with "creative" dosing regimens for code medications.