# Vasopressin/Epi question in arrest



## Rialaigh (Feb 3, 2014)

Having trouble finding some concrete answer to this (probably just looking in the wrong places). 


Lets say you have a 55 year old male witnessed arrest. You get on scene 15 minutes later, CPR is being done by first responders prior to your arrival. Cause may be cardiac, does not appear to be respiratory or anything else easily reversible in the field. patient in asystole IO placed, 1mg of epi given, 40 of vasopressin given 3 minutes later, ROSC achieved sinus rhythm of 80. load and start moving towards the hospital, patient codes about 8-10 minutes after you gave him the vasopressin....asystole

Do you give another 1mg of epi in addition to other intervention (CPR)

Lets say you do give the epi and get ROSC and then the patient codes again 8 minutes after that ROSC, do you give another epi? 


Basically if you give vasopressin can you then not give an epi period at all no matter what? Or at what point can you start giving epi's again ? 10 minutes? 20 minutes? Re arrest like described as it is a "new" arrest" ? 


Can't find anything concrete in protocols or state or AHA


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## NomadicMedic (Feb 3, 2014)

vaso replaced the 1st or 2nd Epi. Once you use the vaso, it's a one shot deal. For a patient that arrests again, it's all Epi, every 3 to 5 minutes.


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## Rialaigh (Feb 3, 2014)

DEmedic said:


> vaso replaced the 1st or 2nd Epi. Once you use the vaso, it's a one shot deal. For a patient that arrests again, it's all Epi, every 3 to 5 minutes.





I have read different things. In  a patient that arrests and you give vaso I have read that you replace the 1st or 2nd dose of epi, BUT you can continue to give epi every 3-5 after the vaso is given. Then I have read not to do that but its okay if you achieve ROSC and then the patient re arrest. 


Point is you have a patient arrest, you give epi, you give vasopressin, they get ROSC 1 minute after vaso and re arrest 5 minutes after you gave the vaso

Do you immediately slam an epi then? or do you wait another 5-15 minutes till the vaso wears off a bit?


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## NomadicMedic (Feb 3, 2014)

You go right back to the Epi.


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## Rialaigh (Feb 3, 2014)

DEmedic said:


> You go right back to the Epi.



Okay, I got into a discussion today with a medic who said that once you give the vasopressin (lets say as your 2nd dose) that it allows you a bit more time because you then don't need to, and shouldn't give another epi for 15-20 minutes until they vasopressin wears off. Basically said to just do CPR and don't administer the epi


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## NomadicMedic (Feb 3, 2014)

Well, if he was in an ACLS class or worked for my system, he'd be wrong. (If the PT rearrested, it's fair to say that the Vaso has worn off...) 

Did you ask your medical director? 

I didn't realize that Vasopressin was still a common code drug. (We don't use it in DE, and it was being downplayed at my services in WA)


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## Rialaigh (Feb 3, 2014)

DEmedic said:


> Well, if he was in an ACLS class or worked for my system, he'd be wrong. Ask your medical director.
> 
> I didn't realize that Vasopressin was still a common code drug. (We don't use it in DE, and it was being downplayed at my services in WA)



It's making a comeback down south, more services are actually thinking of introducing it. It doesn't improve survival to discharge rates as far as the research I have come across but it sure skyrocketed our field ROSC rates here...not saying that's a good thing, just what they are pushing...

I couldn't find anywhere online (from a reputable source) where it stated that you should continue to give epi every 3-5 immediately after the administration of vasopressin. Just trying to find some clarification from some sources


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## SandpitMedic (Feb 4, 2014)

Rialaigh said:


> Okay, I got into a discussion today with a medic who said that once you give the vasopressin (lets say as your 2nd dose) that it allows you a bit more time because you then don't need to, and shouldn't give another epi for 15-20 minutes until they vasopressin wears off. Basically said to just do CPR and don't administer the epi



Remediate!

Damn, can't even remember ACLS as a medic. Shoot!


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## Rialaigh (Feb 4, 2014)

SandpitMedic said:


> Remediate!
> 
> Damn, can't even remember ACLS as a medic. Shoot!



ACLS is not very clear on whether to continue giving Epi's after Vaso or not to...seems to be a personal preference kind of thing in my area


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## Carlos Danger (Feb 4, 2014)

Rialaigh said:


> ACLS is not very clear on whether to continue giving Epi's after Vaso or not to...seems to be a personal preference kind of thing in my area



And I'm pretty sure neither epi or vaso have ever been shown to improve outcomes, so I really doubt any of it matters. Any protocols are suggestions are pretty much just conjecture (err..."expert consensus").

For the past couple years I've been pretty busy with school so I haven't kept up on the research (airway and some anesthesia-related research is all that I try to stay on top of right now), so there might be some other stuff out there now but last I knew, really none of ACLS had been proven to help at all. Good CPR and early defib are the only things that really matter.

But I understand you wanting to know. It's a good question, as far as the guidelines go.

P.S. 40 units of vaso is massive. Several mg's of IV epi is nothing to sneeze at, either. I don't know if there is a conversion but it's gotta be roughly equivalent to a handful of mg's of epi. These are toxic doses of drugs that ACLS is calling for. For whatever that's worth.


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## MSDeltaFlt (Feb 4, 2014)

Rialaigh said:


> Having trouble finding some concrete answer to this (probably just looking in the wrong places).
> 
> 
> Lets say you have a 55 year old male witnessed arrest. You get on scene 15 minutes later, CPR is being done by first responders prior to your arrival. Cause may be cardiac, does not appear to be respiratory or anything else easily reversible in the field. patient in asystole IO placed, 1mg of epi given, 40 of vasopressin given 3 minutes later, ROSC achieved sinus rhythm of 80. load and start moving towards the hospital, patient codes about 8-10 minutes after you gave him the vasopressin....asystole
> ...



If your patient rearrests then your patient's status has changed.  Therefore you rewtart the epi all the while try figure out what's causing the arrests to reoccur in the first place and see if you can stop it.  Remember true ACLS is not working a code.  It's code prevention.


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## SandpitMedic (Feb 4, 2014)

Rialaigh said:


> ACLS is not very clear on whether to continue giving Epi's after Vaso or not to...seems to be a personal preference kind of thing in my area



It is very clear.

Vaso 40 units(if carried) can substitute _either_ only the first or only the second round of 1mg 1:10,000 Epi. After that, you give Epi after 3-5 minutes, and continue to give Epi every 3-5 minutes until ROSC, rhythm change, or pronoucing death. 

Very clear. 

To the point of whether it works or not is not an issue during time of resuscitation. If you are not a conglomerate involved in a medical science study or prototype testing something with you medical directors approval OR acting under on line medical control- you have a duty to act according to the best medical practice you have been taught/certified. That includes ACLS or whatever your locality uses(although, ACLS is the nationally accepted standard.)

I say this so that your post, Halothane, does not confuse the young guys out there who may just get all top-doc out there and not do what is expected of them because someone said it doesn't work or is "toxic." Not to be disrespectful, but rather to clarify that ACLS is very clear- crystal clear, and not abiding by the current standards could be considered negligence or even gross negligence. 

Until the medical community or accrediting bodies officially change the standards - which I agree needs to be done - we have to be providers of what we subscribe to.


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## unleashedfury (Feb 4, 2014)

DEmedic said:


> Well, if he was in an ACLS class or worked for my system, he'd be wrong. (If the PT rearrested, it's fair to say that the Vaso has worn off...)
> 
> Did you ask your medical director?
> 
> I didn't realize that Vasopressin was still a common code drug. (We don't use it in DE, and it was being downplayed at my services in WA)



Same here we don't carry Vasopressin, I don't know of any services that carry it. 



Rialaigh said:


> ACLS is not very clear on whether to continue giving Epi's after Vaso or not to...seems to be a personal preference kind of thing in my area



Incorrect.

ACLS states that you are allowed to substitute the 1st or 2nd round of Epi with 40 International Units of Vasopressin. But its a one time use. 

Here is the ACLS algorithm for Adult Cardiac arrest,
http://www.emed.ie/Cardiovascular/Life_Sup/ALS_BLS.php

Here is some research on the Epi vs vasopressin debate. Clearly shows an increase in positive outcomes. but only in small groups basically they are saying they need a much larger randomized study to prove their theory.

http://www.bestbets.org/bets/bet.php?id=00407


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## unleashedfury (Feb 4, 2014)

NVM Sandpit medic beat me to it. I got to learn to type faster..


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## DesertMedic66 (Feb 4, 2014)

DEmedic said:


> vaso replaced the 1st or 2nd Epi. Once you use the vaso, it's a one shot deal. For a patient that arrests again, it's all Epi, every 3 to 5 minutes.



This. We just went over this in my ACLS class today.


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## SandpitMedic (Feb 5, 2014)

Yeah I don't know... I just feel like this topic is a little rediculous. This is basic ALS provider stuff. In some places this is ILS stuff. 

I don't get the confusion. The confusion is confusing me. If that makes sense. It's not a grey area, it's cut-and-dry.


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## Rialaigh (Feb 5, 2014)

SandpitMedic said:


> Yeah I don't know... I just feel like this topic is a little rediculous. This is basic ALS provider stuff. In some places this is ILS stuff.
> 
> I don't get the confusion. The confusion is confusing me. If that makes sense. It's not a grey area, it's cut-and-dry.




I guess it was just a misunderstanding on my part. I couldn't find anywhere in the ACLS protocols or other recommendations *explicitly* stating to continue giving Epi after Vasopressin administration.



I understand the use of Vaso, I understand that is a substitute for the first or second round of Epi, and it was my understanding that you continue to give epi every 3-5 afterwards based on what I was taught. I am trying to find something that specifically states the continued use of Epi after vasopressin IS the guideline.


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## SandpitMedic (Feb 6, 2014)

Rialaigh said:


> I guess it was just a misunderstanding on my part. I couldn't find anywhere in the ACLS protocols or other recommendations *explicitly* stating to continue giving Epi after Vasopressin administration.
> 
> 
> 
> I understand the use of Vaso, I understand that is a substitute for the first or second round of Epi, and it was my understanding that you continue to give epi every 3-5 afterwards based on what I was taught. I am trying to find something that specifically states the continued use of Epi after vasopressin IS the guideline.



Well, we're all telling you. It is the guideline. And it is in print right in the ACLS book under cardiac arrest. Look in the book and you should see it. 

I believe you're reading too much into it. Seeking "unicorns" where there are not any. You should keep in mind that what is being taught to you in your ACLS class is what you need to do on scene. It is not as organized everytime like those scenario videos, but the steps are the same.


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## SandpitMedic (Feb 6, 2014)

Images removed- old algorithms.

For your viewing pleasure. Straight from the text. The bold part in box 10 is, dare I say, explicit.


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## Ridryder911 (Feb 6, 2014)

I used to be a stickler on ACLS guidelines, unfortunately looking over the past  45 + years there has not been any remarkable changes on outcome. 

A physician friend of mine that sits on the ACLS Emergency Cardiac Care Committee (ECCC) informed me truthfully we have yet found anything that really makes the difference except good old quality CPR and early defibrillation. If we were really considering outcome percentages alone and solely based upon the pharmaceuticals administered; how many of the medications would still be allowed? As he described, " _the reason most (medications) are kept in the protocols are kept is because there is nothing else really to administer (to do) and they do not reduce outcome values either" _ 

It goes back to outcomes in cardiac arrest is dismissal. Over the past few decades we have increased it a few points. With this we still need to study and try to increase but also our emphasis should also be in prevention as well. This where EMS has been instrumental in. 

R/r 911


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## Carlos Danger (Feb 6, 2014)

SandpitMedic said:


> Yeah I don't know... I just feel like this topic is a little rediculous. This is basic ALS provider stuff. In some places this is ILS stuff.
> 
> I don't get the confusion. The confusion is confusing me. If that makes sense. It's not a grey area, it's cut-and-dry.





SandpitMedic said:


> Well, we're all telling you. It is the guideline. And it is in print right in the ACLS book under cardiac arrest. Look in the book and you should see it.
> 
> I believe you're reading too much into it. Seeking "unicorns" where there are not any. You should keep in mind that what is being taught to you in your ACLS class is what you need to do on scene. It is not as organized everytime like those scenario videos, but the steps are the same.



Keep in mind ACLS is a set of guidelines, not a religion.

When I was a new paramedic, I knew ACLS _cold_. I had every line of the protocols memorized perfectly. I could draw the algorithms in my sleep. I felt like it was important to know them that well if I wanted to be a good paramedic.

Fast forward a bunch of years, and it's been quite a while since I worried so much about ACLS. The truth is, outside of EMS, codes are rarely run perfectly according to ACLS. I doubt any of the intensivists or anesthesiologist that I work with know ACLS nearly as well as most paramedics. The in-house clinicians generally adhere to the basic principles (do good CPR, shock VF/VT as soon as possible, give pressors, look for reversible causes), but are not sticklers for the protocols because, frankly, everyone knows that aside from the aforementioned basics, they are BS.

The point is, the ACLS guidelines are simply meant to provide a framework. And while we are responsible for following our protocols, maybe we shouldn't take them so seriously that we get all riled up when someone doesn't have every_single_word of the algorithms memorized perfectly.


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## Handsome Robb (Feb 6, 2014)

For what it's worth if we give vasopressin it's 40 UI x1 and that's it. Either Epi OR vasopressin. This contradicts the AHA guidelines though so don't let it confuse you.

With that said, we can only give vasopressin if we don't have any Epi...


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## Handsome Robb (Feb 6, 2014)

IU sorry phone is dumb and I didn't catch it before I couldn't edit it.


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## SandpitMedic (Feb 6, 2014)

> ...(do good CPR, shock VF/VT as soon as possible, give pressors, look for reversible causes), but are not sticklers for the protocols because, frankly, everyone knows that aside from the aforementioned basics, they are BS.



Yes, absolutely right. We all know high quality CPR/rapid defibrillation is good for business and the (proven)most effective treatment... However, going against the grain (on paper) will land you in hot water if an issue arises. You're supposed to follow those guidelines... We're not talking about the Pirates' code here. If you fail to do so you risk your Cert. Also, it is essential to be that new guy who knows every word and line and can draw algorithms in his sleep. That way when you fast forward a bunch of years you have a good base from which you came.



> .... we shouldn't take them so seriously that we get all riled up when someone doesn't have every_single_word of the algorithms memorized perfectly.



Touché. Right you are good sir.


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## SandpitMedic (Feb 6, 2014)

Of course, your local protocols trump all. That should go without saying. But I'm saying it anyways.


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## Handsome Robb (Feb 6, 2014)

SandpitMedic said:


> Of course, your local protocols trump all. That should go without saying. But I'm saying it anyways.




That's alright. Part of our protocol update this year included the phrase, "the attending paramedic assumes any and all responsibility for treatments and care rendered by their EMT partner." 

No way!!!!! Who knew!?!?!?


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## SandpitMedic (Feb 6, 2014)

Lol. Shenanigans... So I'm supposed to drive _and_ keep an eye on that guy back there... 


Don't tell that to the texting and driving snitch guy....


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## Handsome Robb (Feb 6, 2014)

Shots fired!!!


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## TheLocalMedic (Feb 6, 2014)

SandpitMedic said:


> Lol. Shenanigans... So I'm supposed to drive _and_ keep an eye on that guy back there...
> 
> 
> Don't tell that to the texting and driving snitch guy....



LOL :rofl:


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## firemedic0227 (Feb 7, 2014)

My Department protocols state that the first round of drug administration in Codes is 40U of Vaso otherwise we get wrote up on protocol Violation. After that no matter if there is ROSC and they go back into cardiac arrest it's Epi every 3-5 minutes per ACLS Guidelines!


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## WTEngel (Feb 8, 2014)

Sandpit, you need to check the date on the algorithm you posted. Not that it changes anything you said regarding this particular conversation, your answer to the OP is correct...but the posted algorithm contains incorrect info regarding asystole care. 

You posted an ECC 2005 algorithm, not the most current ECC 2010 algorithm. ECC 2015 should be out in a year and a half or so.


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## SandpitMedic (Feb 8, 2014)

WTEngel said:


> Sandpit, you need to check the date on the algorithm you posted. Not that it changes anything you said regarding this particular conversation, your answer to the OP is correct...but the posted algorithm contains incorrect info regarding asystole care.
> 
> You posted an ECC 2005 algorithm, not the most current ECC 2010 algorithm. ECC 2015 should be out in a year and a half or so.



Yes, yes. You are very right. My apologies for the old algorithm, Google images and my failure to double check it.

I soon as I looked again and saw Atropine I was like uh oh.


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## Medico (Feb 8, 2014)

Where I am at, it is another vaso. 

The reason for this, is that vaso works better in an oxygen deficient environment. 

We give vaso first round, then epi, then vaso. We rotate in that fashion until out. To ensure we have enough vaso, we carry a plano box of vaso. If the rhythm is vfib or vtach, we flush the epi or vaso with amio.


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## WTEngel (Feb 8, 2014)

Is RVA under the BREMS Council or another district?


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## Medico (Feb 8, 2014)

The greater Richmond area is under ODEMSA, however the City of Richmond has their own protocols.


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## NomadicMedic (Feb 8, 2014)

I'd like to see those protocols. Are they posted on line?


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## Medico (Feb 8, 2014)

PM your email.


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## ChrisV (Mar 3, 2014)

sandpitmedic said:


> remediate!
> 
> Damn, can't even remember acls as a medic. Shoot!



much agreed!!!


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## 18G (Mar 11, 2014)

Maybe some of the OPs question comes from the half-life of vasopressin and epinephrine. The reason we dose epinephrine every 3-5mins is due to its short half-life. It needs to be dosed at the q3-5min intervals to maintain a therapeutic level. 

Vasopressin on the other hand exerts its effects longer. So if you give vasopressin right off the bat you're good and don't need to worry about giving a vasopressor until about 20mins into the arrest. 

So if I give vasopressin right now, get ROSC, and patient arrest two minutes later. I'm gonna hold off on epinephrine for at least ten minutes or so since the vasopressin is still working. 

Does it really matter? Doubt it. But its a good question to ask.


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## bmedic1681 (Mar 14, 2014)

If the pt codes after first round of EPI and Vaso its right back to EPI…..


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## Handsome Robb (Mar 14, 2014)

aust10n said:


> Where I am at, it is another vaso.
> 
> The reason for this, is that vaso works better in an oxygen deficient environment.
> 
> We give vaso first round, then epi, then vaso. We rotate in that fashion until out. To ensure we have enough vaso, we carry a plano box of vaso. If the rhythm is vfib or vtach, we flush the epi or vaso with amio.




That's really interesting. I was under the impression that vaso was q20 like other people have mentioned.

I'm gonna go have to do some reading.


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