ALPS Study

[PotatoMedic]

And it is out! Here is the long awaited ALPS study. What do you all think?

http://www.nejm.org/doi/full/10.1056/NEJMoa1514204#t=article

 

[Summit]

This borders on comedic:

"Nonetheless, the suggestion that survival was improved by drug treatment in patients with witnessed out-of-hospital cardiac arrest, without evidence of harm in those with unwitnessed arrest, merits thoughtful consideration."

"point estimates of the survival rates in the placebo group and the amiodarone group differed less than anticipated when the trial was designed, which suggests that the trial may have been underpowered. If amiodarone has a true treatment effect of 3 percentage points ... 1800 additional lives could be saved each year in North America"

"In conclusion, in this randomized trial, we found that overall neither amiodarone nor lidocaine resulted in a significantly higher rate of survival to hospital discharge or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia."

Allow me to summarize: CONCLUSIVE, BUT NOT CONCLUSIVE ENOUGH TO REMOVE AMIO FROM ACLS

 

[Carlos Danger]

This borders on comedic:

"Nonetheless, the suggestion that survival was improved by drug treatment in patients with witnessed out-of-hospital cardiac arrest, without evidence of harm in those with unwitnessed arrest, merits thoughtful consideration."

"point estimates of the survival rates in the placebo group and the amiodarone group differed less than anticipated when the trial was designed, which suggests that the trial may have been underpowered. If amiodarone has a true treatment effect of 3 percentage points ... 1800 additional lives could be saved each year in North America"

"In conclusion, in this randomized trial, we found that overall neither amiodarone nor lidocaine resulted in a significantly higher rate of survival to hospital discharge or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia."

Allow me to summarize: CONCLUSIVE, BUT NOT CONCLUSIVE ENOUGH TO CHANGE PROTOCOLS

Yep. Reminds me of pretty much any study pertaining to prehospital airway management.

"The research is clear, but not clear enough for us to stop doing things the way we want to do them".

 

[MonkeyArrow]

Very interesting results. Especially, the point that while administering Amiodarone or Lidocaine only marginally improves survival to discharge, it significantly reduces total code time, number of defibrillations needed, amount of drugs infused, etc. Completely counterintuitive, but science doesn't lie.

 

[Bullets]

I couldnt be less surprised. Considering the history of Amio i assumed this would show that its no better than lido. I hoped it would show that the placebo is just as good. I doubt that AHA will ever remove epi or amio/lido from the algorithm

 

[PotatoMedic]

All I know is king county is using this to say amio is the best and it needs to be used.

 

[medicsb]

I do not think this is at all definitive in its conclusion. This should be the start, not the end. (That is not to say that one would not be justified in stopping the use of anti-arrhythmics in most situations.)

There were trends that lead me to believe that the "not significant" findings may not be due to chance. Sub-group analysis did show a significant association with survival for amiodarone, particularly for the bystander and EMS witnessed patients. With benefit for some, and no clear evidence of harm, it is not unreasonable to keep using it as it already is. For sure, it would be unreasonable to stop using it in cases of bystander or EMS witnessed VF/VT arrest.

 

[Bullets]

I do not think this is at all definitive in its conclusion. This should be the start, not the end. (That is not to say that one would not be justified in stopping the use of anti-arrhythmics in most situations.)

There were trends that lead me to believe that the "not significant" findings may not be due to chance. Sub-group analysis did show a significant association with survival for amiodarone, particularly for the bystander and EMS witnessed patients. With benefit for some, and no clear evidence of harm, it is not unreasonable to keep using it as it already is. For sure, it would be unreasonable to stop using it in cases of bystander or EMS witnessed VF/VT arrest.

When i read that, i questioned whether positive survival was because of the amio or rather because of the fact that it was witnessed and the patient received the early CPR and early defibrillation that we pretty much know is what truly matters. Ideally there needs to be a study done of BLS vs ALS arrests and outcomes, but i dont see that happening for ethical or political reasons.

King County wants to use this the validate their use of Amio, but they also want to attribute the high survival rate in southern King County and Seattle to 70% of arrests getting bystander CPR. So which is really helping the patient? Our medical director prefers lidocaine for a number of reasons and i expect him to move lido up in our protocols. With it also being the far cheaper options, i know management will go for it.

 

[NomadicMedic]

My guess is the high rate of bystander CPR is saving more lives in King County then amiodarone

 

[medicsb]

When i read that, i questioned whether positive survival was because of the amio or rather because of the fact that it was witnessed and the patient received the early CPR and early defibrillation that we pretty much know is what truly matters. Ideally there needs to be a study done of BLS vs ALS arrests and outcomes, but i dont see that happening for ethical or political reasons.

King County wants to use this the validate their use of Amio, but they also want to attribute the high survival rate in southern King County and Seattle to 70% of arrests getting bystander CPR. So which is really helping the patient? Our medical director prefers lidocaine for a number of reasons and i expect him to move lido up in our protocols. With it also being the far cheaper options, i know management will go for it.

The amio+bystanderCPR was compared to Lido+bystanderCPR and placebo+bystanderCPR. So, it is possible to say with confidence that the difference was due to amiodarone (or lidocaine, as they were equivalent). Amiodarone fared better than lidocaine for EMS witnessed patients, so I think that could be a justification for adoption of amiodarone. While amiodarone is somewhere around 10 times more expensive than lidocaine (though its no longer 1$/mg like it once was), it is still far cheaper than glucagon, adenosine, or narcan these days (or supra glottic airways or EZ-IO needles).

Also, lets not forget that there were 9 other EMS systems involved in this study. This was not all done in Seattle/King Co. Anyways, lidocaine would be a fine choice if a system finds it cost prohibitive.

My guess is the high rate of bystander CPR is saving more lives in King County then amiodarone

You guess?

I think they understand (not guess) this more than anyone else, which is why there are so few medics as opposed to almost every other system in the US. It's also why they've been training bystanders in CPR since the 70s. (And also why they trained EMTs to defibrillate prior to AEDs, and why they were one of the first to promote AED use by bystanders).

 

[ExpatMedic0]

I think it shows that our friends in pharmaceutical sciences need to work on a better recipe...