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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 05:06.

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