I’m sure you’ve seen summary articles from various sources regarding updates to the ACLS algorithm for 2010. The change in the BLS component from an A-B-C to a C-A-B with a focus on providing high-quality compression-only CPR is well-publicized.
On EM:RAP – an educational resource I simply cannot recommend highly enough as a way to mix entertainment with CME – Mel Herbert issued the challenge to submit proof of the “epinephrine-free code”. They made this hypothetical challenge based on a close reading of the new ACLS guidelines for PEA/asystole – which, if you look closely, reflect a tacit acknowledgement of the futility of ACLS medications. Between atropine, bicarbonate, epinephrine, and calcium – various pieces of the kitchen sink available in the code cart – only epinephrine still has a role in the guidelines, but the level of evidence has decayed to IIb, which is at the “expert opinion or consensus” level.
There are a couple large studies with limitations from Scandinavia that show associations of epinephrine with poorer outcomes, or no improvement in survival with ACLS medication administration pre-hospital. And, if you consider the vasoactive properties of epinephrine – sure it increases CPP, but its effects on the oxygen-debt of the peripheral vascular bed, the effect on subendocardial perfusion and infarct size – imagine giving epinephrine to a STEMI patient. We’re injuring the most important organ system of interest in cardiac arrest. I am more than willing to take up the challenge of epinephrine-free resuscitation – I just need to find some evidence to support something else to give in the meantime so I’m not reported to the Chief of Staff so it looks like I’m trying. Anyone have anything in mind?
http://circ.ahajournals.org/content/vol122/18_suppl_3/
http://www.ncbi.nlm.nih.gov/pubmed/12104107
http://www.ncbi.nlm.nih.gov/pubmed/19934423
I found you a something to push instead of epi: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2737804/
Very interesting! There does seem to be a role for nitroglycerin and sodium nitroprusside in some cases – need to find some animal studies demonstrating the physiologic effects during cardiac arrest/CPR to justify attempting it in an RCT in humans.
Indeed! I finally finished catching up on your earlier posts and just saw the one on the nitroprusside-during-cpr article that I hadn't encountered before. Thanks for this great blog, it's a wonderful resource.
Thanks for the encouragement! I've only been doing this a few months, and it's nice to hear if people are interested in it.