JUST SAY NO? THE LATEST LOOK AT ACLS MEDICATIONS BRIDGETTE SVANCAREK, MD

OBJECTIVES Review the progression of the American Heart Association s ACLS cardiac arrest medication guidelines Identify the latest research on the use of epinephrine in cardiac arrest and how this may change how we currently use it Compare and contrast the use of amiodarone and lidocaine for ventricular fibrillation and future implications

ACLS 2005 LIPPINCOTT WILLIAMS & WILKINS CIRCULATION. 2005;112:IV-58-IV-66

Neumar R W et al. Circulation. 2010;122: S729-S767 ACLS 2010

ATROPINE

ACLS 2010 Stiell, et al. Acad of Emerg Med 1995 529 cardiac arrest patients Atropine, lidocaine, bicarbonate, calcium had no effect on survival to hospital discharge

ACLS 2010 Engdahl, et al. Am J Cardiology 2000 1,635 patients with asystole Survivors were less likely to have received atropine prehospital

GOOD-BYE ATROPINE

EPINEPHRINE

ACLS 2010 Herlitz, Resuscitation 1995 1203 V. fib cardiac arrests 417 received epinephrine pre-hospital Higher rates of ROSC No difference in survival to hospital discharge

Michael, et al. Circulation 1984 Epinephrine increases cerebral perfusion pressure 29 mmhg with epi 3 mmhg without epi Epinephrine increases myocardial perfusion pressure 71 mmhg with epi 58 mmhg without epi ACLS 2010

ACLS 2010 Ristagno, et al. Crit Care Med 2009 Epinephrine significantly decreased cerebral microvascular blood flow in pigs

ACLS 2010 Epinephrine 1mg every 3-5 min Vasopressin 40 units in place of 1 st or 2 nd dose IV or IO

AMIODARONE AND LIDOCAINE

ACLS 2010 Dorian, et al. NEJM 2002 347 V. fib arrest patients 167 received lidocaine 180 received amiodarone Increased survival to hospital admission in patients who got amiodarone vs. lidocaine 22.8% vs. 12.0%

ACLS 2010 Amiodarone is first line agent for ventricular fibrillation/ventricular tachycardia 300mg IV/IO first dose, followed by one dose of 150mg Lidocaine may be considered if amiodarone is unavailable 1-1.5mg/kg first dose followed by 0.5-0.75mg/kg every 5 minutes Max dose of 3mg/kg

SINCE 2010

EPINEPHRINE

EPINEPHRINE Jacobs et al, Resuscitation 2011 262 patients placebo vs. 272 epinephrine Higher rates of ROSC with epi but no difference in survival to hospital discharge

EPINEPHRINE Hagihara et al, JAMA 2012 417,188 cardiac arrests Higher rates of ROSC with prehospital epi but decreased 1 month survival with good neuro outcome 2.36x more likely to get ROSC if received epi 2.17x more likely to survive at 1 month with good neuro outcome if NO epi

EPINEPHRINE Kosick, et al. Resuscitation 2013 686 cardiac arrests 155 received early epi 911 call to epi administration 10 min or less Early epi results in higher ROSC but not survival to discharge

TIME TO GET RID OF EPINEPHRINE FOR CARDIAC ARREST?

NOT SO FAST

EPINEPHRINE Mentzelopoulos, et al. JAMA 07/17/13 In-hospital cardiac arrest 130 patients treated with vasopressin, epi, and steroids 138 patients treated with epi and placebo Vasopressin/epi/steroid group had improved neuro intact survival to hospital discharge 13.9% vs. 5.1%

EPINEPHRINE Donnino, et al. BMJ May 2014 Analysis of prospectively collected data in get with the guidelinesresuscitation database Analyzed 25,095 in hospital cardiac arrest with asystole or PEA as initial rhythm Survival to discharge and neuro intact survival decreased with increasing interval of time to epi

EPINEPHRINE Donnino, et al. BMJ May 2014 Survival to discharge and neuro intact survival decreased with increasing interval of time to epi Compared to patients receiving epi at 1-3 min Survival 9% lower if 4-6 min Survival 26% lower if 7-9 min Survival 37% lower if >9 min

STAY TUNED Study underway in UK Cardiac arrest patients randomized to receive epinephrine or placebo

VASOPRESSIN

VASOPRESSIN Menztelopoulos, et al. Resuscitation 2012 Meta-analysis of 6 randomized controlled trials comparing vasopressin and epinephrine alone Overall no difference in long-term survival Higher 1 month survival in asystole patients who received vasopressin 1.8 x higher

AMIODARONE VS. LIDOCAINE

AMIODARONE VS. LIDOCAINE Dorian, et al. NEJM 2002 Increased survival to hospital admission in patients who got amiodarone vs. lidocaine

AMIODARONE VS. LIDOCAINE Piccini, et al. Critical Care Med. 2011 1, 126 STEMI patients that developed VF/VT Increased 30 day and 6 month mortality in STEMI patients who received amiodarone vs. lidocaine 1.7 x more like to die by 30 days 1.9 x more likely to die by 6 months

STAY TUNED Study under way in the US and Canada VF/VT arrest patients randomized to receive amiodarone, lidocaine, placebo

SUMMARY Epinephrine/vasopressin may be beneficial in certain situations Early in PEA/asystole A cocktail of epinephrine + vasopressin + solumedrol Concern that epinephrine may cause cerebral ischemia Unclear which is better when comparing amidoarone and lidocaine Whether amiodarone or lidocaine improves or hurts survival is still to be determined Stay tuned for the ACLS 2015 guidelines and other studies

THANK YOU!!!!

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RESOURCES ENGDAHL, ET AL. CAN WE DEFINE PATIENTS WITH NO AND THOSE WITH SOME CHANCE OF SURVIVAL WHEN FOUND IN ASYSTOLE OUT OF HOSPITAL? AM J CARDIOL. 2000 SEP 15;86(6):610-4. MICHAEL, ET AL. MECHANISMS BY WHICH EPINEPHRINE AUGMENTS CEREBRAL AND MYOCARDIAL PERFUSION DURING CARDIOPULMONARY RESUSCITATION IN DOGS. CIRCULATION. 1984 APR;69(4):822-35 HERLITZ, ET AL. LIDOCAINE IN OUT-OF-HOSPITAL VENTRICULAR FIBRILLATION. DOES IT IMPROVE SURVIVAL? RESUSCITATION. 1997 JAN;33(3):199-205. KUDENCHUK, ET AL. AMIODARONE FOR RESUSCITATION AFTER OUT-OF-HOSPITAL CARDIAC ARREST DUE TO VENTRICULAR FIBRILLATION. N ENGL J MED. 1999 SEP 16;341(12):871-8.

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