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I thought we were working on
So did I. There I was, just minding my own business, when all of a sudden, out of nowhere SumdoodTM opens this can of worms. I'm completely innocent, I tell you.
OK, now that I have
What is state of the art resuscitation?
Even the answer to that is not as simple as it would seem. Several people have mentioned that the use of epinephrine, amiodarone, lidocaine, et cetera, remains in the ACLS (Advanced Cardiac Life Support) guidelines. These critics point out that being in the guidelines is evidence that these treatments have a scientific basis. Surely the AHA (American Heart Association) would not come up with these treatments without a rigorous scientific basis.
Exactly! The AHA wouldn't do that!
Would they?
There is very little high-level evidence for resuscitation therapies, and many traditional treatment recommendations such as the use of epinephrine/adrenaline, are based on animal studies and reluctance to change an existing treatment recommendation until it is proven ineffective or less effective than a novel therapy.[1]
During cardiac arrest, basic CPR and early defibrillation are of primary importance, and drug administration is of secondary importance. Few drugs used in the treatment of cardiac arrest are supported by strong evidence. After beginning CPR and attempting defibrillation, rescuers can establish intravenous (IV) access, consider drug therapy, and insert an advanced airway.[2]
Let me just change what you focus on in reading this paragraph. I am not changing any of the words. People seem to think this paragraph is telling them that the ALS is important. It is not. In stead, look at it this way.
During cardiac arrest, basic CPR and early defibrillation are of primary importance,[2]
What does primary mean in this case?
Primary = more than any other treatment.
and drug administration is of secondary importance.[2]
What does secondary mean in this case?
Secondary = a whole category below any treatment of primary importance.
Few drugs used in the treatment of cardiac arrest are supported by strong evidence.[2]
Surely epinephrine is supported by strong evidence.
No. I'll get to that in a minute. First the change in emphasis.
After beginning CPR and attempting defibrillation, rescuers can establish intravenous (IV) access, consider drug therapy, and insert an advanced airway.[2]
These are so important that they are only things you can do, things you may consider, in addition to the stuff you can consider you may add an advanced airway.
See, they want you to intubate.
The advanced airway can be any alternative airway. The important thing to notice is that this is after you have taken care of the important stuff - continuous compressions and defibrillation. This should never interrupt compressions.
typical ACLS therapies, such as insertion of advanced airways and pharmacologic support of the circulation, have not been shown to increase rate of survival to hospital discharge.[3]
To date no placebo-controlled trials have shown that administration of any vasopressor agent at any stage during management of pulseless VT, VF, PEA, or asystole increases the rate of neurologically intact survival to hospital discharge. There is evidence, however, that the use of vasopressor agents favors initial ROSC.[4]
See! There is evidence, however, that the use of vasopressor agents favors initial ROSC (Return Of Spontaneous Circulation). That is a good thing. If you don't get pulses back, you can't resuscitate the patient.
It is true, that if you do not get pulses back, you will not resuscitate patients. If we stopped when we got pulses back, declared victory, and paid no attention to what happened after, then epinephrine would be a success.
Epinephrine leads to no real improvement. Epinephrine is a short term fix.
Epinephrine is like cocaine. Cocaine may make the person feel better in the short term, but that is not a good justification for the use of cocaine.
Epinephrine allows a bunch of whackers to high five each other when they get pulses back, even though they are decreasing the chances of long term survival for the patient.
Decreasing the chances for long term survival for the patient?
More patients with pulse, but no more patients surviving, probably means more patients dying in the hospital due to something bad from the epinephrine.
Let's go back to that first quote . . .
The first quote was not from ACLS. Why did you start with that?
Actually, it is. I do not know why it is not included with the rest of the 2005 links.
So, back to that first quote. This shows a big problem with the approach of the people involved.
There is very little high-level evidence for resuscitation therapies, and many traditional treatment recommendations such as the use of epinephrine/adrenaline, are based on animal studies and reluctance to change an existing treatment recommendation until it is proven ineffective or less effective than a novel therapy.[5]
until it is proven ineffective or less effective than a novel therapy.
How much effort is being put into even finding out if it is effective? There is a huge bias toward accepting the traditional treatment. There is no need to provide evidence that epinephrine works. Epinephrine is the traditional treatment.
Traditional means that it has been around a while and is better than the alternative.
No.
Traditional treatments include leeches to remove blood, because medieval doctors were trying to balance the humours in the body. Eventually, people realized that bleeding people to death with the traditional treatment had nothing to do with being effective or with being safe, never mind being both effective and safe.
Until we have evidence that a treatment is both effective and safe, we should not be encouraging widespread use of that treatment.
In cardiac arrest, epinephrine has not been shown to be effective. In cardiac arrest, epinephrine has not been shown to be safe. The presumption of the experts is that epinephrine needs to be shown to be ineffective or less effective than a new treatment. They don't even seem to consider the possibility that epinephrine could be harmful. This kind of bias is inappropriate.
I'm not even getting started on the problems with the typical antiarrhythmic placebos and their significant toxic effects (amiodarone and lidocaine). At least, not yet.
Footnotes:
^ TM Sumdood
An often sighted, never captured, never photographed denizen of the world of Ambulance Driver. As with Big Foot, his existence a subject of controversy and exaggeration.
Sumdood: Evil Criminal Mastermind
^ 1 Controversial Topics from the 2005 International Consensus Conference on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations.
Nolan JP, Hazinski MF, Steen PA, Becker LB.
Resuscitation. 2005 Nov-Dec;67(2-3):175-9. No abstract available.
PMID: 16324986 [PubMed - indexed for MEDLINE]
^ 2 Circulation. 2005;112:IV-58 – IV-66.
© 2005 American Heart Association, Inc.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Access for Medications: Correct Priorities
^ 3 Circulation. 2005;112:IV-58 – IV-66.
© 2005 American Heart Association, Inc.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Introduction
^ 4 Circulation. 2005;112:IV-58 – IV-66.
© 2005 American Heart Association, Inc.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Medications for Arrest Rhythms
^ 5 Controversial Topics from the 2005 International Consensus Conference on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations.
Nolan JP, Hazinski MF, Steen PA, Becker LB.
Resuscitation. 2005 Nov-Dec;67(2-3):175-9. No abstract available.
PMID: 16324986 [PubMed - indexed for MEDLINE]
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Good information. I won't get all bent out of shape over it, either :-)
ReplyDeleteAs with everything else, we spend quite a bit of time on ACLS, Mega Code etc. learning which drugs to push and when - but even in class we're told that basically they don't work. Even more importantly, without good CPR those drugs won't GO anywhere. Emphasis even in ACLS is still very much on good quality CPR with minimal interruption - BLS before ALS...
One question. The sole purpose of Epi during arrest is to act as a peripheral vasoconstrictor, thus increasing preload - correct ?
One question. The sole purpose of Epi during arrest is to act as a peripheral vasoconstrictor, thus increasing preload - correct ?
ReplyDeleteAnd afterload, and automaticity. Along with oxygen demand and overall workload which aren't too desired in a dead person.
Anonymous,
ReplyDeleteGood information. I won't get all bent out of shape over it, either :-)
Thank you.
I didn't mean to be singling you out for criticism. I was pointing out that it is not always clear what will stir up controversy. It is good to clear up disagreements, or at least get to the point of agreeing to disagree on a topic, before progressing to less agreed upon material.
As with everything else, we spend quite a bit of time on ACLS, Mega Code etc. learning which drugs to push and when - but even in class we're told that basically they don't work.
It is good that the instructors are pointing out the problems with the treatments.
Even more importantly, without good CPR those drugs won't GO anywhere.
It still amazes me when I see somebody eagerly push a drug, during a long pause in CPR, but they fail to resume the compressions. As if they are waiting for Fed X to show up and deliver the drug to the heart.
Emphasis even in ACLS is still very much on good quality CPR with minimal interruption - BLS before ALS...
I think we should demand that these treatments be supported by better evidence before we make them a part of the guidelines. At the time, we did not have enough research to go on, but now, we don't have enough research to justify continuing to use them, except in large randomized placebo controlled well designed studies that are powered to show a difference in survival with good neurological function.
One question. The sole purpose of Epi during arrest is to act as a peripheral vasoconstrictor, thus increasing preload - correct ?
Adam has mentioned that there is more to the theory behind epinephrine use than just vasoconstriction, but the theory is based on what drug was chosen to be included in ACLS.
I responded to this last question in Narrative Fallacy II.