Epi in V-Fib arrest...

LACoGurneyjockey

LACoGurneyjockey

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So I work as an EMT on an ALS truck. The other day we ran an arrest, patient found by PD in his parked car, pulseless and apneic, they began CPR until our arrival. We had a fairly smooth transition from the parking lot to the gurney to the truck. I start bagging with PD continuing CPR. Now for some reason, my partner decided to start an IO, push Epi, and then realized he didn't have the patient on the monitor. At this point FD is arriving, takes over BLS, and I get the patient on the monitor revealing VF. Shocked once into polymorphic VT.
At this point we continue our VF/VT protocol, transport the patient (that's a different discussion) and he's called by the ER doc within 15 minutes.
Now my question in all of this: what is the impact of Epinephrine in a VF/VT arrest?
 
There is, to my knowledge, no evidence that adrenaline increases ROSC and certainly no evidence that it increases neurological intactness at discharge.

Adrenaline is used because it has always been used and there is not (yet) enough evidence that it is harmful for it to be removed.

And your partner is a muppet, vascular access and drugs are way down the priority list in a primary cardiac arrest.
 
LACoGurneyjockey said:
So I work as an EMT on an ALS truck. The other day we ran an arrest, patient found by PD in his parked car, pulseless and apneic, they began CPR until our arrival. We had a fairly smooth transition from the parking lot to the gurney to the truck. I start bagging with PD continuing CPR. Now for some reason, my partner decided to start an IO, push Epi, and then realized he didn't have the patient on the monitor. At this point FD is arriving, takes over BLS, and I get the patient on the monitor revealing VF. Shocked once into polymorphic VT.
At this point we continue our VF/VT protocol, transport the patient (that's a different discussion) and he's called by the ER doc within 15 minutes.
Now my question in all of this: what is the impact of Epinephrine in a VF/VT arrest?
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Epi has no impact in a VF/VT arrest. We just give it so we can bill for more things, and so it looks like we're doing something to make pt families feel better.
http://www.ncbi.nlm.nih.gov/pubmed/23196774

Did PD have an AED hooked up? If not, it seems to me that your partner botched this pretty horrendously.
 
No AED, no monitor, and a *censored* up list of priorities. Homie definitely botched it in hindsight.
I realize Epi is fairly useless even in asystole, and I'm very aware of the link to brain damage in long term outcomes.
But is there anything specific (good, bad, just interesting) that epi will do to for VF?
 
Remi said:
In theory, it improves coronary and cerebral perfusion pressures.
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This.

Until Epi is removed from ACLS algorithm it will still be used in all full arrests (unless an area doesn't follow ACLS)
 
LACoGurneyjockey said:
So I work as an EMT on an ALS truck. The other day we ran an arrest, patient found by PD in his parked car, pulseless and apneic, they began CPR until our arrival. We had a fairly smooth transition from the parking lot to the gurney to the truck. I start bagging with PD continuing CPR. Now for some reason, my partner decided to start an IO, push Epi, and then realized he didn't have the patient on the monitor. At this point FD is arriving, takes over BLS, and I get the patient on the monitor revealing VF. Shocked once into polymorphic VT.
At this point we continue our VF/VT protocol, transport the patient (that's a different discussion) and he's called by the ER doc within 15 minutes.
Now my question in all of this: what is the impact of Epinephrine in a VF/VT arrest?
Click to expand...

Sounds like a supervisor needs to be filled in on your partners tactics for this call haha. Sounds like he got a little to jumpy and just began doing what popped into his head.
 
Hmm, I had it in my undereducated EMT head that Epi was only in our asystole protocol, but turns out after re reading our protocols its the first drug in our VF/VT as well. So in hindsight there should have been earlier defibrillation with Epi and Amio coming later. He still ****ed up, and I still don't think we should be giving Epi without any solid evidence of its efficacy, but I had thought there was no indication for it in V fib. I has edumacated ma self, thank yall very much.
 
LACoGurneyjockey said:
Hmm, I had it in my undereducated EMT head that Epi was only in our asystole protocol, but turns out after re reading our protocols its the first drug in our VF/VT as well. So in hindsight there should have been earlier defibrillation with Epi and Amio coming later. He still ****ed up, and I still don't think we should be giving Epi without any solid evidence of its efficacy, but I had thought there was no indication for it in V fib. I has edumacated ma self, thank yall very much.
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For ACLS Epi is the first line drug for every arrest (asystole, PEA, VT, VF).
 
LACoGurneyjockey said:
Hmm, I had it in my undereducated EMT head that Epi was only in our asystole protocol, but turns out after re reading our protocols its the first drug in our VF/VT as well. So in hindsight there should have been earlier defibrillation with Epi and Amio coming later. He still ****ed up, and I still don't think we should be giving Epi without any solid evidence of its efficacy, but I had thought there was no indication for it in V fib. I has edumacated ma self, thank yall very much.
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Electricity is much more effective in VF/VT than epi. easier to deliver too
 
DrParasite said:
Electricity is much more effective in VF/VT than epi. easier to deliver too
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And more personnel are able to deliver a shock than Epi.

I think even with the controversy surrounding Epi aside, the Pt needs to be on the monitor before any medication is pushed. If its VF/VT, then shocking will (hopefully) make your job easier. If its not, then you need the monitor anyway to find out what rhythm to treat.
 
LACoGurneyjockey said:
Hmm, I had it in my undereducated EMT head that Epi was only in our asystole protocol, but turns out after re reading our protocols its the first drug in our VF/VT as well. So in hindsight there should have been earlier defibrillation with Epi and Amio coming later. He still ****ed up, and I still don't think we should be giving Epi without any solid evidence of its efficacy, but I had thought there was no indication for it in V fib. I has edumacated ma self, thank yall very much.
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A couple of things that you as an EMT should be thinking/ doing in these cases. First, if you are going to call out your partner on here for "****ing up" you should be willing to have a conversation with him, find out what he was thinking, and find out what the two of you could do in the future to provide better service. I would strongly recommend this as it doesn't sound like he intentionally provided poor care, but rather did a poor job of running a significant call with a new EMT partner as well as PD instead of more EMT trained personnel. Second, as stated multiple times already Epi is in the ACLS algorithms, good or bad, as it in theory may provide for better resuscitation of patients. Though you haven't been trained in this, remember a Paramedic has a far greater scope of practice and therefore more on his mind. Again I would advise you to speak with him and make a plan for these types of calls.

I work as a firefighter/paramedic and it is instilled in us from day one the value of good communication with your partner and crew. These conversations can at first be difficult to bring up with the individual, however you will be amazed at how much you and your partner will grow from these talks and experiences. Good luck!
 
J B said:
Epi has no impact in a VF/VT arrest. We just give it so we can bill for more things, and so it looks like we're doing something to make pt families feel better.
http://www.ncbi.nlm.nih.gov/pubmed/23196774

Did PD have an AED hooked up? If not, it seems to me that your partner botched this pretty horrendously.
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Mostly in response to the cited article more than anything else. The problem that I have with the article and the studies which it cites, is that it does not tell you how many patients would have gotten ROSC without the Epi? It is telling you that epi helps achieve ROSC, but that it decreases survival to discharge with neurologically intact functions. However, it does not tell you how many of those that did not have a neurologically intact survival would have achieved ROSC without administration of the Epi? Therefore, it leads me as a reader to think, do I want a dead person now who might survive without impairment, or do I want a person with a pulse who may not be intact.

The dilemma here is that it does not give you the numbers/data for Epi ROSC vs non-Epi ROSC vs. their respective intact survival rates. For example, if there are 20 survivors (out of 100) with no Epi and 10 of them are neurologically intact to d/c, you have a theoretical 50% intactness rate. However, if there are 50 survivors (out of 100) with Epi and 15 of them are neurologically intact to d/c, then you have only have a 30% intactness rate [calculated with neurologically intact from all who get ROSC]. However, even though there is a lower percentage of theoretical neurological intact to d/c, you save more people by pushing Epi (15-10). All though I have no clue if this is true, I believe that this is feasible since the cited article states that more retain ROSC with Epi than without.

At least, that is how I interpreted the study. I may very well be wrong, and I stand ready to be corrected.
 
Simple answer is even if it was VF/VT per ACLS Epi is the first line.

I don't agree with it but that's what the AHA and most protocols say.

I won't parrot what others have already said.
 
DesertEMT66 said:
...(unless an area doesn't follow ACLS)
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Except the guidelines state, "It is reasonable to consider..." So, if your service considered to not do so, it would still fall within the guideline.

Underoath87 said:
^^ Hopefully the looming epi study in London will clear this up for us.
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The PARAMEDIC-2 trial won't answer the "why", nor is it powered to answer the question of which rhythms are appropriate.

It is actually only trying to answer, "is 1mg epinephrine given every 5 minutes IV/IO more effective than placebo in adult cardiac arrest at the primary end point of survival to 30 days post event." They haven't even set a CPC score for their primary end point.

Now, they have secondary endpoints including "Neurological outcome at hospital discharge, 3 and 6 months." But again, this is not a primary endpoint.

Consider this: what if the study showed clinical equipose? That is, no difference between epi and placebo in outcomes. What now? Do you remove epi altogether?

Is it actually unhelpful or was it the dose? Timing? Drug? Rhythms? Perhaps they can dig the data to generate hypotheses as to which subgroup may benefit and which may not. More studies!

Handsome Robb said:
Simple answer is even if it was VF/VT per ACLS Epi is the first line.
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In all rhythms epinephrine is not first line: CPR is, then oxygen, then monitor/defibrillator, then Check Rhythm, then Shock if Appropriate, then drug therapy.

gotshirtz001 said:
I am faced with this question: Why are u trying to buddy f@ck ur partner?
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What does this even mean? This is healthcare, not Las Vegas. QA/QI is paramount in cardiac arrest management.
 
Christopher said:
In all rhythms epinephrine is not first line: CPR is, then oxygen, then monitor/defibrillator, then Check Rhythm, then Shock if Appropriate, then drug therapy.
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Fair enough. It's still the first recommended pharmacological intervention besides oxygen. I don't necessarily agree with it.
 
MonkeyArrow said:
Again, not claiming to be an expert in any way, shape, or form, but I found this study that claims to state that no Epi according to current ACLS guidelines helps to increase neurologically intact survival.

http://jama.jamanetwork.com/article.aspx?articleid=1105081
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The Higihara study is very interesting, although it serves only as a "hypothesis generating" study. The Japanese model of EMS does not really relate well to the US. My takeaway has been that indiscriminate usage of unstudied medications can adversely affect survival.
 
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