Should epi be used in cardiac arrests?

[zzyzx]

I know there's been a lot of discussion on this site about the use of epi and other ACLS drugs in cardiac arrest. If you want to listen to an excellent 2-hr long discussion looking at many past studies of epi's use in cardiac arrest, check out the Smart EM podcast on this topic.

smartem.org

This is the most comprehensive discussion of this topic that I've come across.

 

[bstone]

I hate the fact that you are getting me to listen to this informative, well spoken, excellently researched podcast on my day off!

 

[zzyzx]

I hate the fact that you are getting me to listen to this informative, well spoken, excellently researched podcast on my day off!

Ha ha! Yeah, sorry about that.

It really is impressive how excellently these two research their topics. It's also pretty hard to argue with their conclusions when they lay out ALL the evidence for you.

 

[DPM]

Good post, thanks for sharing!

 

[bstone]

They pretty much demonstrate how all the ACLS drugs are useless, that even if you get ROSC back they almost never make it to discharge with intact neurological functioning. They mentioned the possible use of low dose epi over a longer period of time, but it's all theory at this point.

 

[DPM]

I've heard it a few times, "If you give a rock enough EPI you'll get ROSC".

Haven't had a listen, do they talk about the Japanese study? IIRC they found high dose Epi achieved ROSC but proportionately less PTs survived to discharge / with intact Neuro function Vs those that don't.

Quick google:

Conclusion Among patients with OHCA in Japan, use of prehospital epinephrine was significantly associated with increased chance of return of spontaneous circulation before hospital arrival but decreased chance of survival and good functional outcomes 1 month after the event.

http://jama.jamanetwork.com/article.aspx?articleid=1105081

 

[bstone]

I've heard it a few times, "If you give a rock enough EPI you'll get ROSC".

Haven't had a listen, do they talk about the Japanese study? IIRC they found high dose Epi achieved ROSC but proportionately less PTs survived to discharge / with intact Neuro function Vs those that don't.

Quick google:



http://jama.jamanetwork.com/article.aspx?articleid=1105081

Don't recall a mention of the JP study, but they did talk about an AUS study, in addition to several US studies. All found that CPR and defibrillation were the only main factors in surviving neurologically intact. There was talk of removing epi from the ACLS protocols entirely, as well as atropine, calcium, sodium bicarb, etc.

 

[Melclin]

Pretty sure they did this show before the jap study.

I know I personally listened to the this podcast a long while before I became aware of the jap study.

Scott Weingart did an EMCRIT Wee on it.

http://emcrit.org/wee/abandon-epinephrine/


An interesting review of pressors (not in cardiac arrests pts, just thought I'd add it in):

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003709.pub3/pdf

 

[DPM]

I'm listening to the SMART pod-cast now... Just got to the 'ACLS drugs show no statistical improvement in survival to discharge'... :blink:

 

[VFlutter]

Pretty sure they did this show before the jap study.

I know I personally listened to the this podcast a long while before I became aware of the jap study.

Scott Weingart did an EMCRIT Wee on it.

http://emcrit.org/wee/abandon-epinephrine/


An interesting review of pressors (not in cardiac arrests pts, just thought I'd add it in):

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003709.pub3/pdf

+1 on the Emcrit, i believe he did a full podcast on the topic that was very insightful.

 

[EpiEMS]

It almost seems like much of ACLS is without any empirical backing...other than the BLS skills and a few other sundries. We know CPR (at least, the compressions component) makes a difference, as does early defibrillation. Can't quite say the same about lots of the drugs.

Of the drugs, do any of them have evidence-based backing?

 

[bstone]

It almost seems like much of ACLS is without any empirical backing...other than the BLS skills and a few other sundries. We know CPR (at least, the compressions component) makes a difference, as does early defibrillation. Can't quite say the same about lots of the drugs.

Of the drugs, do any of them have evidence-based backing?

Not really. The studies have shown no better outcomes with the use of ACLS drugs than without. The podcast goes into great detail and they basically say that in the case of a true MI (not an MI secondary to another issue) that the best one can do is compressions and early defibrillation.

 

[Christopher]

Scott Weingart did an EMCRIT Wee on it.[/url]

Dr. Weingart has stated on some other episodes that they place fem lines and monitor IVC pressures to determine when to add more epinephrine!

 

[Dwindlin]

Dr. Weingart has stated on some other episodes that they place fem lines and monitor IVC pressures to determine when to add more epinephrine!

Believe he was talking about this in relation to shock states and when to use pressors in general and not specifically for cardiac arrest.

 

[Christopher]

Believe he was talking about this in relation to shock states and when to use pressors in general and not specifically for cardiac arrest.

This was from podcast 31 where he talks about intra-arrest management. He references:

If the arterial relaxation “diastolic” pressure is <20 mm Hg, it is reasonable to consider trying to improve quality of CPR by optimizing chest compression parameters or giving a vasopressor or both.

I believe in this case they were using fem A-lines, so apologies on the IVC reference.

 

[bstone]

If anything this article gives strength to the argument that we should all be investing in and using chest-compression devices. They do the number and depth of compressions that are necessary for a person to have the best chance of survival.