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Thread: Epinephrine in cardiac arrest (paramedics, anesthetists, and ED Docs, get in here)

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    Epinephrine in cardiac arrest (paramedics, anesthetists, and ED Docs, get in here)

    I’ve been studying epinephrine in cardiac arrest with a critical eye since vasopressin was the next big thing. Numerous studies have been published on this. The most impactful has been PARAMEDIC II, in which 8,000 or so patients were enrolled.

    http://rebelem.com/wp-content/upload...pi-765x499.png

    Many studies have shown that epinephrine (adrenaline) can increase the rate of ROSC, like vasopressin. Vasopressin was nixed because of a lack of favorable long term outcomes vs epinephrine, despite ROSC advantages. But a better primary endpoint is intact neurologic survival, in my opinion. Another consideration is that epinephrine 1mg IV is known to cause ventricular tachycardia, yet we use it to treat... ventricular tachycardia.

    In the PARAMEDIC II trial, for the first time in human history, we have a large, prospective, randomly controlled, double blinded study of epinephrine (epi, from here on) in cardiac arrest. The findings are in conflict with our goals. Again, my opinion. Some previous studies support this, including one that found that more epi, more often, worsened outcomes. In the PARAMEDIC II trial, it was found that the number needed to treat (NNT) to see a benefit to epi vs saline placebo was 112. In some EMS systems, that is a year worth of calls for service for cardiac arrest. In many EDs, that is a few months. And we’re only talking about ROSC here, not survival or neurologically intact outcomes. In the severe neurologic impairment data, we have 31% with epi, and 17.8% with placebo. That is nearly double the negative outcomes with epi vs placebo.

    Given this data, I posit that we should prioritize compressions and defibrillation and only use drugs as appropriate for the rhythm at hand. In the case of epi, that means to me PEA (especially pulseless bradycardias) and asystole. Additionally, we should practice cognitive offloading during a code and reduce the epi roller coaster of the AHA recommended (it is reasonable to consider epinephrine, level IIb, weak evidence, benefit greater or equal than risk) dose of 1mg q3-5 minutes. To that end, I would consider 1-3mg epi in the 1L bag used for bolus as a continuous infusion, that can also be used to support circulation post ROSC. Protocolize this and pre work the math.

    I am not an epi nihilist, however, the way that we currently use it is theatre.
    Last edited by 1168; 09-15-19 at 06:06.

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    Here is my first question, which obviously we are just getting a snap shot, do we have full access to the study? I don’t have any luck on google.

    My second question, which likely is in the full study, are they using a single dose of epi or is each additional dose statistically separate in the study? I think the answer to that could really muddy the waters in applicable conclusions which we can draw. Ultimately, NHA ACLS governs what I can and cannot do within my role.


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    I see you edited your post while I was typing. You make great points which I have thought myself during AARs.


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    Quote Originally Posted by lsllc View Post
    Here is my first question, which obviously we are just getting a snap shot, do we have full access to the study? I don’t have any luck on google.

    My second question, which likely is in the full study, are they using a single dose of epi or is each additional dose statistically separate in the study? I think the answer to that could really muddy the waters in applicable conclusions which we can draw. Ultimately, NHA ACLS governs what I can and cannot do within my role.


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    https://www.nejm.org/doi/full/10.1056/NEJMoa1806842

    There is also lots of discussion on FOAMed blogs on this topic, curated by MDs.

    In PARAMEDIC II, we’re talking multiple doses, as appropriate to the timeline, of epi vs placebo. I don’t see that the number of doses is a factor in the study.

    Here is a study on high-dose epi: https://www.nejm.org/doi/full/10.105...99210083271502

    And another on dosing: https://www.ncbi.nlm.nih.gov/pubmed/29305926/

    Unfortunately I am not able to find, at this moment the study that showed less favorable outcomes, in a statistically significant way, for increasing doses of epi.
    RLTW

    “That is why there isn't an AK chart.” -SteyrAUG
    “They eat tide pods also so what's your point?” Retrorevolver77

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    Quote Originally Posted by lsllc View Post
    I see you edited your post while I was typing. You make great points which I have thought myself during AARs.


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    Yeah, I accidentally hit post while writing.
    RLTW

    “That is why there isn't an AK chart.” -SteyrAUG
    “They eat tide pods also so what's your point?” Retrorevolver77

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    Quote Originally Posted by 1168 View Post
    https://www.nejm.org/doi/full/10.1056/NEJMoa1806842

    There is also lots of discussion on FOAMed blogs on this topic, curated by MDs.

    In PARAMEDIC II, we’re talking multiple doses, as appropriate to the timeline, of epi vs placebo. I don’t see that the number of doses is a factor in the study.

    Here is a study on high-dose epi: https://www.nejm.org/doi/full/10.105...99210083271502

    And another on dosing: https://www.ncbi.nlm.nih.gov/pubmed/29305926/

    Unfortunately I am not able to find, at this moment the study that showed less favorable outcomes, in a statistically significant way, for increasing doses of epi.
    Gotcha. I will take a look. My first thought is in cases which multiple doses are given it is futile, and as you say, theatrics at that point.

    Additionally, seems multiple doses are more likely to be given in field scenarios and unwitnessed arrests. I guess this is just me thinking out loud.


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    Quote Originally Posted by lsllc View Post
    Gotcha. I will take a look. My first thought is in cases which multiple doses are given it is futile, and as you say, theatrics at that point.

    Additionally, seems multiple doses are more likely to be given in field scenarios and unwitnessed arrests. I guess this is just me thinking out loud.


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    On the subject of witnessed arrests, a potential confound is that we are more likely to shock/do compressions immediately, and get ROSC before epi 1mg IV/IO q3-5min is considered.

    I have not often given that dose of epi to a patient that I witnessed to arrest, but I have had unbelievably good luck on quick ROSC with them, before getting to epi in the algorithm.
    RLTW

    “That is why there isn't an AK chart.” -SteyrAUG
    “They eat tide pods also so what's your point?” Retrorevolver77

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    Quote Originally Posted by 1168 View Post
    On the subject of witnessed arrests, a potential confound is that we are more likely to shock/do compressions immediately, and get ROSC before epi 1mg IV/IO q3-5min is considered.

    I have not often given that dose of epi to a patient that I witnessed to arrest, but I have had unbelievably good luck on quick ROSC with them, before getting to epi in the algorithm.
    Yep totally can see that. We’re using epi on the cases that are less likely to have positive outcomes anyway.


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    Didn't have time to read the link yet and I'm tipsy, but...

    Compressions. Compressions. Compressions.

    You must continue QUALITY compressions to maintain an adequate MAP. If they're interrupted outside of a pulse check, that MAP is going to drop; and you're back to square one.

    Defib with biphasic 200J if shockable rhythm.

    Epi is cool if you have it. Vaso is meh. Have someone prepare a bag of Epi ASAP, if possible.

    Bicarb ain't gonna help. However, there is at least anecdotal evidence that some pressors may not be efficacious if too acidotic.

    Bag mask. If you're able to ventilate, and getting decent ETCO2 - continue. Tube if you can without stopping compressions, but it ain't gonna save 'em.

    I work in a hospital though so YMMV.

    Edit: I can probably get the full study, if desired. PM me.
    Last edited by scooter22; 09-13-19 at 22:23.

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    Quote Originally Posted by scooter22 View Post
    Bicarb ain't gonna help. However, there is at least anecdotal evidence that some pressors may not be efficacious if too acidotic.
    .
    Dopamine comes to mind. I suspect that Bicarb in arrest is theater, also.
    RLTW

    “That is why there isn't an AK chart.” -SteyrAUG
    “They eat tide pods also so what's your point?” Retrorevolver77

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