# BLS Epi in cardiac arrest?



## blindsideflank (Jul 18, 2013)

Are there any BLS services out there giving epi Q5 for all cardiac arrests (while continuing the AED analyze and shock every 5 cycles).

I know there is controversy regarding epi in cardiac arrest but it is the standard in ALS and ED codes. Perhaps amio/lido and bicarb etc. are too much for BLS but what are your thoughts on BLS crews doing 5 cycles, analyze, shock or dont then epi Q5?

I put this in the ALS forum to stimulate a better discussion but if it truly belongs in the BLS section then please move it.


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## STXmedic (Jul 18, 2013)

Well you'd have to have a route to administer it. EMTs with IV capabilities has been discussed ad nauseum here. IOs in a full arrest could be a potential. How long is your normal wait for ALS to arrive on scene?


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## blindsideflank (Jul 19, 2013)

no ALS in this area (my old job) and this is how it is in all rural areas in british columbia. Also, almost every PCP here has IV endorsement. If you cant get a line then continue with the current status quo? (5 cycles of CPR and after 3 no shocks you transport? sorry i dont remember the BLS "protocol")

i didnt know it was common that EMT's cant perform IV's


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## Medic Tim (Jul 19, 2013)

blindsideflank said:


> no ALS in this area (my old job) and this is how it is in all rural areas in british columbia. Also, almost every PCP here has IV endorsement. If you cant get a line then continue with the current status quo? (5 cycles of CPR and after 3 no shocks you transport? sorry i dont remember the BLS "protocol")
> 
> i didnt know it was common that EMT's cant perform IV's



The emt in the usa is closer to our emr or the ofa3 than pcp. 
I don't see pcps getting epi 1:10000 anytime soon. The effectiveness of it has been questioned for years.


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## Mariemt (Jul 19, 2013)

Could stab um with an epi pen:rofl:


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## Handsome Robb (Jul 19, 2013)

Mariemt said:


> Could stab um with an epi pen:rofl:



Minus the whole lack of blood flow that's required to absorb IM meds.

Epi bristojets are dummyproof but like someone said, without a route to administer it what's the point unless you plan on dumping it down the KING airway but that's an even worse idea.


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## NomadicMedic (Jul 19, 2013)

I've removed off topic posts.


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## WBExpatMedic (Jul 19, 2013)

No disrespect intended, but what's the point of having different levels of providers if we allow basic's or it's equivalent to provide ALS care. As a basic I was frustrated with not being able to provide a higher level of care so I went to medic school. We need to have the education to back up the decisions we are making.


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## hogdweeb (Jul 19, 2013)

WBExpatMedic said:


> No disrespect intended, but what's the point of having different levels of providers if we allow basic's or it's equivalent to provide ALS care. As a basic I was frustrated with not being able to provide a higher level of care so I went to medic school. We need to have the education to back up the decisions we are making.


this. exactly why im starting medic school next fall. I hate providing oxygen, comfort and ASA to patients and thinking im helping them.


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## Carlos Danger (Jul 19, 2013)

Mariemt said:


> Could stab um with an epi pen:rofl:



Actually, it would probably work as well as IV epi.....




hogdweeb said:


> this. exactly why im starting medic school next fall. I hate providing *oxygen, comfort and ASA to patients and thinking im helping them.*



Do you really not think that oxygen, comfort, and ASA help your patients? 

Nothing wrong at all with wanting to advance your level of practice, but don't sell yourself short as "just a basic". In many (if not most) cases, the interventions that are provided by a good EMT-B are the only ones that have actually been proven to have a positive impact. 

With the exception of a few specific scenarios, I would honestly just as soon have my family taken care of by a good basic as by a paramedic.


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## Mariemt (Jul 19, 2013)

hogdweeb said:


> this. exactly why im starting medic school next fall. I hate providing oxygen, comfort and ASA to patients and thinking im helping them.



These are also very important treatments.
As is sometimes listening to your suicidal psyche patient, talking to your dementia patient who doesn't even understand and letting them know you are there to help with your bls skills


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## broken stretcher (Jul 19, 2013)

hogdweeb said:


> this. exactly why im starting medic school next fall. I hate providing oxygen, comfort and ASA to patients and thinking im helping them.



dumb statement. im a better PROVIDER than most medics i work with and I'm a basic. EMS before ALS. if the patients cared for and comforted in their time of need and i can get them to more definitive care than that is a job well done. thats the problem with SOME ALS providers. they forget about the pt's and just go robo-medic through their protocols and forget that they have a person to care for and comfort. and its not all their fault. a lot of them are scared that some doctor is gonna widen their :censored: if they :censored::censored::censored::censored: up so they focus on the protocols and not the pt.


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## Mariemt (Jul 19, 2013)

broken stretcher said:


> EMS before ALS.


 ALS is EMS


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## Handsome Robb (Jul 19, 2013)

broken stretcher said:


> dumb statement. im a better PROVIDER than most medics i work with and I'm a basic. EMS before ALS. if the patients cared for and comforted in their time of need and i can get them to more definitive care than that is a job well done. thats the problem with SOME ALS providers. they forget about the pt's and just go robo-medic through their protocols and forget that they have a person to care for and comfort. and its not all their fault. a lot of them are scared that some doctor is gonna widen their :censored: if they :censored::censored::censored::censored: up so they focus on the protocols and not the pt.



Because EMTs never make this mistake. Only paramedics with our ALS skills can have a poor bedside manner 

Honestly, us rather have a competent medic who's an :censored::censored::censored::censored::censored::censored::censored: but knows their stuff inside and out than a sub par medic who makes me feel all warm and fuzzy. I'm sure there are many out there that agree with me.


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## chaz90 (Jul 19, 2013)

Robb said:


> Honestly, us rather have a competent medic who's an :censored::censored::censored::censored::censored::censored::censored: but knows their stuff inside and out than a sub par medic who makes me feel all warm and fuzzy. I'm sure there are many out there that agree with me.



Oh, I've said before that given those two options, the competent jerk would be my preference as well. Given the general populace however, we're in the minority. Most people don't know if they were treated with good medicine. All they notice or remember is how they were treated as a person. The good point made earlier though was "Why not have both?" Fortunately, the real world doesn't separate it with only those choices available.


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## Wheel (Jul 19, 2013)

Mariemt said:


> ALS is EMS



Yeah I'm not sure what they meant by this statement. Probably BLS before ALS, which wouldn't be a lot better.


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## Mariemt (Jul 20, 2013)

Robb said:


> Because EMTs never make this mistake. Only paramedics with our ALS skills can have a poor bedside manner
> 
> Honestly, us rather have a competent medic who's an :censored::censored::censored::censored::censored::censored::censored: but knows their stuff inside and out than a sub par medic who makes me feel all warm and fuzzy. I'm sure there are many out there that agree with me.


Well you know there is no such thing as a nice medic or a jerky EMT


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## Bullets (Jul 20, 2013)

hogdweeb said:


> this. exactly why im starting medic school next fall. I hate providing oxygen, comfort and ASA to patients and thinking im helping them.



The vast majority of your patients probably only need that, if that much

If someone can show a benefit of Epi in cardiac arrest then there may be room for conversation, but even then, how would BLS administer the medication?

I dont see a need for it


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## Medic Tim (Jul 20, 2013)

Bullets said:


> The vast majority of your patients probably only need that, if that much
> 
> If someone can show a benefit of Epi in cardiac arrest then there may be room for conversation, but even then, how would BLS administer the medication?
> 
> I dont see a need for it



I agree. If there was evidence showing that epi actually led to better outcomes I would be all for it. 

Also keep in mind the BLS being refered to here are like AEMTs in the us. They already do IVs and several meds.


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## omak42 (Jul 20, 2013)

Halothane said:


> Actually, it would probably work as well as IV epi.....
> 
> 
> 
> ...



That last statement is a pit fall of the systems you have seen apparently. The area I work, as well as myself, strive to ensure paramedics continue to provide great bls care while adding als....I know its an issue all across the country (probably world) and sadly its a training/mindset issue


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## Mariemt (Jul 20, 2013)

omak42 said:


> That last statement is a pit fall of the systems you have seen apparently. The area I work, as well as myself, strive to ensure paramedics continue to provide great bls care while adding als....I know its an issue all across the country (probably world) and sadly its a training/mindset issue



Well it all depends on the situation. I know good basics can handle a variety of issues. Many times a medic isn't necessary, however medics can offer things a basic can not and knowing what I know,  I would be perfectly happy with a basic caring for my family for a basic type call... but there are those calls that are not basic calls


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## STXmedic (Jul 20, 2013)

omak42 said:


> That last statement is a pit fall of the systems you have seen apparently. The area I work, as well as myself, strive to ensure paramedics continue to provide great bls care while adding als....I know its an issue all across the country (probably world) and sadly its a training/mindset issue



I don't think he's referring to poor paramedics as much as the lack of evidence for reduction of morbidity/mortality that many of the paramedic skills are supposed to provide; for example,  cardiac meds and RSI/ETI.* Again, not poor execution, but lack of verifiable benefit.

*Sentence structure sucks. Don't want to change it.


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## WBExpatMedic (Jul 20, 2013)

hogdweeb said:


> this. exactly why im starting medic school next fall. I hate providing oxygen, comfort and ASA to patients and thinking im helping them.



hogdweeb you've gotten kind of beat up over your views. I felt similar when I was an EMT and there is nothing wrong with wanting to do more for your patients. BLS can and does save lives, but the key to being excellent at any level of EMT is to never stop learning and I applaud you for wanting to continue your education.

Most of the EMT's that want to* trash* medic's do it for a couple of reasons. 1 They failed out of medic school or 2 They are afraid to tray.


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## omak42 (Jul 20, 2013)

Mariemt said:


> Well it all depends on the situation. I know good basics can handle a variety of issues. Many times a medic isn't necessary, however medics can offer things a basic can not and knowing what I know,  I would be perfectly happy with a basic caring for my family for a basic type call... but there are those calls that are not basic calls



Sorry, I guess I just misread your statement


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## Mariemt (Jul 20, 2013)

omak42 said:


> Sorry, I guess I just misread your statement


It wasn't my statement you read. Lol


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## Mariemt (Jul 20, 2013)

WBExpatMedic said:


> hogdweeb you've gotten kind of beat up over your views. I felt similar when I was an EMT and there is nothing wrong with wanting to do more for your patients. BLS can and does save lives, but the key to being excellent at any level of EMT is to never stop learning and I applaud you for wanting to continue your education.
> 
> Most of the EMT's that want to* trash* medic's do it for a couple of reasons. 1 They failed out of medic school or 2 They are afraid to tray.


Unfortunately I see more medics trash EMTs. Just online, here more than anywhere .

I believe there is a place for both in the system. Medics are an absolute necessity, so I can't understand the friction. 
EMTs that bash medics? Um why? 
Maybe it is because in our system we get along very well. I mean our medic will tell us nice job, couldn't do iT without you etc etc . Because we all know our role, job and do it like a well greased wheel

The ems world needs medics, EMTs have no right to bash medics and really, medics should respect their EMTs


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## Tigger (Jul 20, 2013)

Let's try and keep this thread on topic, which is _BLS Epi in Cardiac Arrest_ if you have forgotten.


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## Wheel (Jul 20, 2013)

I would say that we shouldn't have it. While Epi in cardiac arrest has no evidence that it harms, it really has no evidence it helps either. I think we shouldn't be adding treatments just to add them, without a good clinical reason to do so. Also, epi is not free. It's going to cost someone some money, and for what clinical benefit?


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## hogdweeb (Jul 20, 2013)

WBExpatMedic said:


> hogdweeb you've gotten kind of beat up over your views. I felt similar when I was an EMT and there is nothing wrong with wanting to do more for your patients. BLS can and does save lives, but the key to being excellent at any level of EMT is to never stop learning and I applaud you for wanting to continue your education.
> 
> Most of the EMT's that want to* trash* medic's do it for a couple of reasons. 1 They failed out of medic school or 2 They are afraid to tray.


youre completely right. Medics save lives, Basics save medics. I've never heard a basic trash a medic thoughunless the medic treats his basics like POS'. Work with couple I's that work with medics... and some medics dont wont let them spike their bags cause they dont feel they are "competent" to do it at another service.

Back on topic, as Wheel said. no harm, no good, why do it?


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## blindsideflank (Jul 20, 2013)

^^^^ Thanks tigger
here are my thoughts on the issues that have been discussed so far.

1. EMT's shouldnt have their scope expanded. Just go do your medic.
In BC (canada) where I work, there are very few ALS practitioners, none rurally, and there is no push to change this.

2. Epi doesnt have a proven benefit. 
True, but it is a standard of care for emerg/ALS and all other hospital departments. (sometimes not ie: ive seen protocols post heart surgery, stack 3 shocks then crack the chest but this is special situations )
I dont necessarily disagree with this though

3. EMT's dont do IV's.
They do here. And if they fail to get an IV then they run a code like they normally would.

4. cost
no commment. its always a factor

5. ALS vs BLS
i hate this term. ALS should be synonomous with starting from the top (including BLS skills). I hate the turf war involved in this. Also, the comments regarding some ALS interventions not being proven to help annoy me.
As with all of EMS education, this is another saying that gets thrown around by most practitioners (refer back to BLS before ALS). "Referencing the research" is the new way of saying I am too smart to follow protocols. I agree with it but sometimes people dont understand the limitations od said research. There is so much that has not been researched that saying something isnt proven to work is NOT synonomous with proving it doesnt work. It may just mean it has not been researched well (or at all). In this case, sound clinical judgment is the reason these treatments exist.

Has oxygen in a hypoxic patient with partial airway obstruction been proven to work in the PREHOSPITAL setting? Probably not. (who would do that research?). Our profession is also so young that even where we need research, it simply hasnt happened yet.

***note, im not saying epi works. this last rant was general. Im just saying that we need to understand the limitations when we reference studies or the lack of them.



I thought there would be discussion regarding altering the standard of care to fit EMT's. That a code would get the epi part of it but not amio/lido, bicarb etc.


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## blindsideflank (Jul 20, 2013)

I did hear a quote once regarding ACLS drugs. it was to the effect that
"they arent proven to work, but they are proven to get ROSC. and you cant survive if you dont get ROSC"

with the addition of hypothermic therapy, which shows great benefits, maybe ROSC IS the short term goal of EMS and we should leave neurologocal survival to the hospital...


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## Carlos Danger (Jul 20, 2013)

blindsideflank said:


> I did hear a quote once regarding ACLS drugs. it was to the effect that
> "they arent proven to work, but they are proven to get ROSC. and you cant survive if you dont get ROSC"
> 
> with the addition of hypothermic therapy, which shows great benefits, maybe ROSC IS the short term goal of EMS and *we should leave neurologocal survival to the hospital...*



This is a tempting point of view, but it isn't the right way to look at it.

Getting pulses back with high-dose epi is like starting an old car with a clogged up fuel system by spraying some starter fluid into the intake manifold. You might get it to turn over and catch and run for a few seconds, but you haven't fixed the car at all, or really even done anything to benefit the situation.  

When you bring a post-arrest patient to the ED with pulses, all you've done most of the time is spray some starter fluid into the intake. The patient has suffered a a fatal and irreversible injury.

So the question is, why do we bother continuing to spray fuel into the intake and then claim success just because the engine runs for a few minutes?

IMO, it is time for resuscitation science to stop trying to raise everyone from the dead, and start focusing on identifying those few who can benefit from resuscitation.


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## hogdweeb (Jul 20, 2013)

Halothane said:


> This is a tempting point of view, but it isn't the
> IMO, it is time for resuscitation science to stop trying to raise everyone from the dead, and start focusing on identifying those few who can benefit from resuscitation.


The way I am reading this is, pick and choose through a series of questions and expierence to determine who is likely to have the best outcome...but unfortunately you wont know until after the fact. 

Unless i am reading it wrong....


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## Carlos Danger (Jul 20, 2013)

PoeticInjustice said:


> omak42 said:
> 
> 
> > That last statement is a pit fall of the systems you have seen apparently. The area I work, as well as myself, strive to ensure paramedics continue to provide great bls care while adding als....I know its an issue all across the country (probably world) and sadly its a training/mindset issue
> ...



Exactly, poetic.

Though omak is right that tunnel-vision towards ALS therapies when BLS ones are important is a common and sometimes serious problem among paramedics, I think, and isn't an issue with EMT-B'S.


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## blindsideflank (Jul 20, 2013)

Halothane said:


> When you bring a post-arrest patient to the ED with pulses, all you've done most of the time is spray some starter fluid into the intake. The patient has suffered a a fatal and irreversible injury.



hard to disagree with your other points but for the above do you think its would be better to have high quality CPR and no pulse upon ED arrival. Ive never seen any study on this but it would be interesting.


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## Carlos Danger (Jul 21, 2013)

blindsideflank said:


> hard to disagree with your other points but for the above do you think its would be better to have high quality CPR and no pulse upon ED arrival. Ive never seen any study on this but it would be interesting.



I don't really think it matters. If a person in poor health is down for more than a few minutes without high-quality CPR, they are dead. Period. Nothing that has been tried in decades of research and constantly evolving recommendations has had much impact on that. 

Epi sure hasn't helped. In fact some theorize that epi makes resuscitation even less likely.

I'd just like to see the focus shift towards stressing the use of the few things that we know are helpful, applied only to those who have a reasonable chance of surviving.


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## Medic Tim (Jul 21, 2013)

Instead of changing the protocol or process or treatment guidelines to add this medication why not focus on what has been proven to work. good cpr and defib. Hunkering down on scene and working it there instead of in the back of a moving truck. It is not possible to perform good high quality cpr in a moving ambulance. One of the places I used to work, we had to transport just about every code, now we only transport if we have rosc +10 min or if there are "special circumstances" 

I am not sure what your criteria is for calling the pt in the field or what your resources are but I certainly hope you are not transporting these pt's...risking the safety of the crew and public, just to have the doc call it the minute you get to the er.

not saying this pertains to the op, just one of my soapboxes.


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## blindsideflank (Jul 22, 2013)

Hey thanks everyone for all the good discussions. Before I let this thread die off I have one more thing to say.
A lot of the discussion regarding survivability of  arrests is based off of experience (our patients aren't surviving). This is pretty logical but we are assuming the permanent damage being done is from the initial lack of perfusion (probably true) but we aren't really taking reperfusion injury into consideration. Some of these patients we are writing off  (or wishing we could write off) may be salvageable in the future with increased understanding of reperfusion injury.


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## Christopher (Jul 24, 2013)

Wheel said:


> I would say that we shouldn't have it. While Epi in cardiac arrest has no evidence that it harms, it really has no evidence it helps either. I think we shouldn't be adding treatments just to add them, without a good clinical reason to do so. Also, epi is not free. It's going to cost someone some money, and for what clinical benefit?



Actually, epi has evidence of harm and little if any evidence of benefit.

If 1mg IVP of 1:10,000 or 1:1,000 epinephrine would be unbelievably detrimental to any living person...why would 1mg every 3-5 minutes be helpful?

There is most likely a time and place for epi in cardiac arrest, we just have no idea when and how much we should give. We do know that we are most likely not helping people with our current protocols. Thankfully folks are actually starting to study this stuff now.


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## blindsideflank (Jul 25, 2013)

Christopher said:


> Actually, epi has evidence of harm and little if any evidence of benefit.


 
Source?


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## Rialaigh (Jul 25, 2013)

Halothane said:


> This is a tempting point of view, but it isn't the right way to look at it.
> 
> Getting pulses back with high-dose epi is like starting an old car with a clogged up fuel system by spraying some starter fluid into the intake manifold. You might get it to turn over and catch and run for a few seconds, but you haven't fixed the car at all, or really even done anything to benefit the situation.
> 
> ...





This

But also

It is time for resuscitation science to stop trying to raise everyone from the dead and work on educating providers on humanely NOT trying to raise MOST of the cardiac arrests we see from the dead...

IMO it is more important and ethical to know when NOT to work a code than to have to deal with making the decision on when to call a code...


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## Handsome Robb (Jul 25, 2013)

blindsideflank said:


> Source?



http://www.ncbi.nlm.nih.gov/m/pubmed/22436956/

First google result searching "efficacy of epinephrine in cardiac arrest"


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## Carlos Danger (Jul 25, 2013)

blindsideflank said:


> Source?



I replied to you a few posts up with a link to a meta-analysis that indicates as much. They've actually been saying this for decades.

Also, keep in mind that it is the responsibility of the _intervention_ to prove it's worth, not the other way around. Very important thing to remember.


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## Christopher (Jul 25, 2013)

blindsideflank said:


> Source?



Holmberg 2002, Ong 2007, Jacobs 2010, and Higihara 2013 all come to mind.

Causal harm? Not proven. Associated harm? Possibly.

Causal benefit? Not proven. Associated benefit? Possibly.


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## blindsideflank (Jul 26, 2013)

Robb said:


> http://www.ncbi.nlm.nih.gov/m/pubmed/22436956/
> 
> First google result searching "efficacy of epinephrine in cardiac arrest"



btw, when i said source, i hope i didnt come off as rude. i truly would like to see the studies. i am also not disagreeing with you guys, simply playing the devils advocate.

i will read the whole study when i can, but what this tells me is
epi is better for rosc, but of those resuscitated, a higher percent dont survive

so the more salvageable pts (that can be resuscitated without epi) have a higher chance of survival 

but did epi save a few that they wouldnt have gotten back without epi? would epi have hurt those they got back without it?

i will read the others tomorrow. my point still stands that post resus care/research may change who we deem as not worth working


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