Epinephrine in PEA...

[VentJockey]

I am curious about the ACLS algorithm for PEA. We only give epi every 3 to 5 minutes. It seems to me that this is a little too spread out. Why don't we give it every 2 minutes right after pulse checks? 2 minutes should be enough time for it to work, and if they are still pulseless after 2 minutes it makes sense to me that they should get another hit of epi. Is there some rationale for only giving it every 3 to 5 minutes? Every time I run a code w/ PEA I'm always itching to push more epi because it my experience it is the only thing that's going to get me ROSC. I'm not worried about the tips of their fingers at this point. Anybody have any thoughts on this? Any data? Right now my practice is to give it every 3 minutes on the dot, but if I had some data to back me up I'd be giving it every 2 minutes instead.

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[jdh71]

I don't think there is really any good data for even using epi.

Chest compressions is about as good as it gets and after most nonVfib/tach or other rhythm arrests if you don't correct what is wrong fast your chance if getting anyone back is super low so any code for PEA that you think you're getting improved outcomes from epi more often is probably all random confirmation bias.

 

[Instatewaiter]

I am curious about the ACLS algorithm for PEA. We only give epi every 3 to 5 minutes. It seems to me that this is a little too spread out. Why don't we give it every 2 minutes right after pulse checks? 2 minutes should be enough time for it to work, and if they are still pulseless after 2 minutes it makes sense to me that they should get another hit of epi. Is there some rationale for only giving it every 3 to 5 minutes? Every time I run a code w/ PEA I'm always itching to push more epi because it my experience it is the only thing that's going to get me ROSC. I'm not worried about the tips of their fingers at this point. Anybody have any thoughts on this? Any data? Right now my practice is to give it every 3 minutes on the dot, but if I had some data to back me up I'd be giving it every 2 minutes instead.

First, there's really no good evidence for epi improving outcomes, leading to improved survival or hospital discharge. So not only are you going to struggle for something saying epi more often improves outcomes, you're going to struggle finding evidence that any epi does anything for outcomes. If anything, there is some evidence that it is associated with worse outcomes.

Second, If you've ever given epi to someone as a push prior to true loss of pulse, you'd see that its effects last for quite a while- minutes. Add to that the fact that there's basically no cardiac output and 3-5 minutes seems about right.

 

[deleted547339]

In PEA, you're much better off doing whatever you can to fix the problem. I've heard lectures from some real guru's who are pretty iffy on even giving chest compressions. Obviously, that's way off from standard of care, but when you think about it, it makes sense. Are chest compressions going to move blood through a heart blocked off by a tension PTX or a massive PTE? No. Are chest compressions going to increase preload in a tamponade arrest? Probably not much? Increase O2 in a hypoxic PEA? Probably not much.

Epi dosing isn't the problem. Epi MAY have a minuscule survival benefit (yet to be proven), but it isn't where you should focus your time.

 

[DrAwesomo]

I don't think there is really any good data for even using epi.

Chest compressions is about as good as it gets and after most nonVfib/tach or other rhythm arrests if you don't correct what is wrong fast your chance if getting anyone back is super low so any code for PEA that you think you're getting improved outcomes from epi more often is probably all random confirmation bias.

I respectfully disagree. Chest compressions just pumps blood (fixes the mechanical defect temporarily). Epi in my experiences tends to revitalize the myocardium. How? I don't have a clue. I guess the massive infusion of epi stimulates all the receptors simultaneously and forces the myocardium to beat against the odds and sometimes that's all you need.

 

[jdh71]

I respectfully disagree. Chest compressions just pumps blood (fixes the mechanical defect temporarily). Epi in my experiences tends to revitalize the myocardium. How? I don't have a clue. I guess the massive infusion of epi stimulates all the receptors simultaneously and forces the myocardium to beat against the odds and sometimes that's all you need.

Sounds like magic gnomes then.

Get back to me when you have an actual mechanism of action and demonstrated real survival benefit.