The bad news keeps getting badder

[Smash]

For epinephrine in cardiac arrest:

Hagihara, A., Hasegawa, M., Abe, T., Nagata, T., Wakata, Y., & Miyazaki, S. Prehospital Epinephrine Use and Survival Among Patients With Out-of-Hospital Cardiac Arrest. JAMA: The Journal of the American Medical Association, 307(11), 1161-1168

A large look at out of hospital cardiac arrest from Japan - over 400 000 patients, 15 000 of whom received epi. Baseline characteristics favoured those receiving epi over those not - more likely to be witnessed, more of them in VF, more likely to have bystander CPR, more likely to get a physician on the ambulance.

Epi increased survival to hospital, but was an independent predictor of of poor outcome at one month and they were less than half as likely to have favourable neurological outcomes compared to those who didn't receive epi.

There are limitations to the study, discussed on page 1167. Of note, no hypothermia was carried out when this study was done. However, it is still another nail in the coffin.

*Cue the "but if we get them to hospital doctors can work their voodoo on them and we feel good about ourselves" argument.

Yay! We get them back. Of course they sit in the corner being watered twice a day with the other pot-plants now, but still, we are heroes!


What I find really interesting is the low number of patients receiving epi, and the favourable characteristics of those patients. It seems spookily as though they are actually thinking about what they are doing, rather than just throwing everything at everyone. h34r:

 

[Aprz]

<joke>If we administer epi to ourselves, will that help?</joke>

 

[Smash]

<joke>If we administer epi to ourselves, will that help?</joke>

I've tried it halfway through a night shift. I got to scenes really quick. But then I had to go back for the ambulance I left at the station, so it didn't save much time in the end... :blink:

 

[Veneficus]

I am sure somebody can chime in with:

"But we will get sued/fired etc if we don't give it."

So who cares what it does for/to the patient?

 

[Melclin]

I'm totally on board with the idea that 1mg epi, q3 is probably not the way to go. In a few decades we might all have a giggle about it along side blowing smoke up dead arses.

I also think its a terrible shame the Jacobs et al study was not adequately powered to expand on some of the improvements it showed.

I've got the article in my figurative in tray, I'll give it a good read after I stumble upon about 19hrs of sleep.

"But we will get sued/fired etc if we don't give it."

So who cares what it does for/to the patient?

Its not a matter of who cares. Its established practice. Its still recommended in peak body guidelines. Simply omitting it from your own personal algorithm is not the way to go for most paramedics (or indeed many doctors). Making an argument to your medical director/whoever writes your guidelines is another matter.

 

[systemet]

The next ACLS guidelines update should be fun.

 

[Melclin]

I think its probably more to do with low numbers of qualified adrenaline giverer-toers on their trucks.

Anyway, despite the odd language that made my brain hurt on my last night shift, its a pretty interesting study.

I'd like to know more about how they adjusted for confounders. My statistics-fu doesn't extend that far. I might be wrong but its seems like they've adjusted for issues that other studies have suffered from in that regard, namely the selection bias involved in epi only being given to pts that failed their first DCCS.

I'd also like to know why it is that this study showed poorer neuro outcomes in those surviving than other studies.

I'm a little disappointed that it didn't break things down by arrest rhythm a bit more. What was there though was pretty interesting. It seemed to suggest what has been suggested in other studies: that adrenaline in PEA/asystole is basically reanimating corpses, in a very expensive and resource intensive way.

If I'm reading it right (and god knows I'm probably not), its basically saying that if you manage to survive the insult of being given epi in the first place, your chances of a good neuro outcome will be more then halved specifically because you got epi.

This all seems to match the evidence from other studies both in the lab and the field. Epi increases ROSC but not survival, it may have a mild detrimental effect on survival and it has a notably negative physiological affect that may bugger up a person's chances of a good neuro outcome.

So...taking bets. Will this be the last nail in the coffin come peak body guidelines season? Are there any other adrenaline studies in the works?

 

[Veneficus]

So...taking bets. Will this be the last nail in the coffin come peak body guidelines season? Are there any other adrenaline studies in the works?

Honestly, I hope I am wrong, but I do not see epi or any other drug going away.

It is hard to put on an ACLS class when the only thing left in it is CPR/AED

Edit: too eager on the "enter key"

I have noticed over the last couple of years that "guidline" groups have considerable ego in them and very rarely let new science affect thier recommendations.

Usually the only thing that gets these people to change is a nail in their own coffin and the person who replaces them.

I have also noticed that doctors who are really breaking ground never issue guidlines and you rarely hear what they have to say because they are in the hospital taking care of patients, not traveling around giving endless speeches and attending "meetings." (case in point a really great speaker I saw last year on the flaws of using bicarb in resuscitation)

There is also the issue of "the good ol' boy network." Many top journals require invitations to publish or ignore anything that opposes the popular views. So many medical scientists will never see their research published in a top tier journal no matter how good the experiment or results.

I have even seen publications that in their conclusion claim type II statistical errors. With science so bad I would be embarassed to sign my name to it. But it still gets published.

It is the reward for working on something prior and knowing somebody.

Dr. Podunk could make the most earth shattering discovery this evening and it would never see the light of day.

Consensus is by definition, people who agree with each other, not people who have the right answer.

You must also remember that these guidlines are meant for "most patients," so if all you ever do is follow these guidlines without thought or deviation, you have basically written off every patient who will not be helped by them. (which in the case of SCA, is nearly 30% of them)

It is not that guidlines are bad, they are a starting point, not a definitive answer and not an endpoint.

There is an inherent flaw when providers see these "standards" as the definitive authority.

(disclaimer, if you are not authorized to deviate from your guidlines, don't)

 

[Melclin]

I've certainly heard about that kind of culture. I've even seen it in action during the short bursts of formal academia I've stumbled upon. Although it has to be said, the ol' boys network was a force for good in this case.

I suppose I naively thought it might be different at such high levels :wacko:

Oh well, we shall have to wait and see.

 

[Arovetli]

As an aside, I work for a hospital based service who's attached hospital is attached to a medical school, although no formal academic emergency medicine program, and the attendings still want full atropinization of asystole/PEA even 2 years after it was removed from ACLS and with a whole body of evidence backing its removal. If they are that resistant to losing atropine I can't imagine the resistance to the removal of epi. Some attendings order many many many rounds of epi even when survival, not to mention any chance of a decent neuro outcome, is all gone. Last code was asystole with a downtime of 45 mins. when I hit the ER with the attending still giving 10 rounds of epi before calling it.

 

[Melclin]

Last code was asystole with a downtime of 45 mins. when I hit the ER with the attending still giving 10 rounds of epi before calling it.

That boggles the mind. I assume you don't have the ability to chose whether or not to work arrests. Thats not a code, that is just a corpse.

 

[awesomemedic]

So, I suppose it will eventually turn into a true smash and grab operation. Start CPR, defib if necessary (until they say that is detrimental which is only a matter of time), then drive code 3 to the ER. No intubation, no IV. Just CPR and diesel. Makes sense.

 

[Veneficus]

So, I suppose it will eventually turn into a true smash and grab operation. Start CPR, defib if necessary (until they say that is detrimental which is only a matter of time), then drive code 3 to the ER. No intubation, no IV. Just CPR and diesel. Makes sense.

But what if that was really the best thing to do?

It is for trauma.

 

[awesomemedic]

I actually agree. That's why I said makes sense.

 

[medicsb]

So, I suppose it will eventually turn into a true smash and grab operation. Start CPR, defib if necessary (until they say that is detrimental which is only a matter of time), then drive code 3 to the ER. No intubation, no IV. Just CPR and diesel. Makes sense.

Not at all. It will probably be: start CPR, defib PRN, establish IV or IO access. Work for 20-30 minutes, if no ROSC then pronounce. If ROSC, use the IV or IO to initiate hypothermia and sedation. Load and go is NOT beneficial, except, maybe, if you're using an automated compression device.

 

[awesomemedic]

I would like to think we could pronounce someone in the field that easily, but if I can't tell a 46 year old woman with a stubbed toe to go to the urgent care in the morning, how can I pronounce someone dead. I'm not saying we don't have the ability, I'm saying the staff won't let it happen.

And if I can't give meds (epi, atropine, etc) then why do I need an IV? And what "work" will be done? Currently we can go one round of ACLS, IV, advanced airway, and asystole in 2 leads with unknown downtime relates to calling a physician for direct med control and stopping efforts. But take away meds and airway, we're just pumping chest for however long.

 

[Veneficus]

Devil's advocate. (because even the devil needs a lawyer)

But take away meds and airway, we're just pumping chest for however long.

So what?

If they don't help why bother?

 

[medicsb]

I would like to think we could pronounce someone in the field that easily, but if I can't tell a 46 year old woman with a stubbed toe to go to the urgent care in the morning, how can I pronounce someone dead. I'm not saying we don't have the ability, I'm saying the staff won't let it happen.

And if I can't give meds (epi, atropine, etc) then why do I need an IV? And what "work" will be done? Currently we can go one round of ACLS, IV, advanced airway, and asystole in 2 leads with unknown downtime relates to calling a physician for direct med control and stopping efforts. But take away meds and airway, we're just pumping chest for however long.

I was just speculating as to what a protocol/guideline could be for CA if all drugs were removed. Certainly one could argue to wait on ROSC to initiate an IV or IO. Many would suggest that hypothermia be initiated prehospital (though there is no evidence to show it to be better than waiting for hospital arrival), so it may be useful to have an IV already established. Also, remember that just because your area doesn't do something, doesn't mean that others won't too. A lot of system have protocols for pronouncement. Additionally, there has been some intensive research in Canada (I think) into criteria for pronouncement for use by paramedics and EMTs and I think some 1 of the 2 sets of criteria has been validated.

By and large, a medical arrest is "stay and play" situation. It's hard to do good compressions while rolling a patient onto a reeves and then to the stretcher and then to the ambulance and then while the ambulance is in motion. (obviously in unsafe/hostile scene, etc. one should move the patient sooner.)

 

[Arovetli]

In lieu of epi there is some promising animal research out there on using selective alpha 2 andrenergic agonists in cardiac arrest.


http://www.ncbi.nlm.nih.gov/pubmed/12080325
http://www.ncbi.nlm.nih.gov/pubmed/12668305
http://www.ncbi.nlm.nih.gov/pubmed/11693776
http://www.ncbi.nlm.nih.gov/pubmed/12808484

 

[Medic Tim]

epi was removed from our cardiac arrest protocols in 2008.