Epinephrine

Resuscitation drug adrenaline research in cardiac arrest study

http://www.bbc.com/news/health-28770885


A story on the BBC website brings up a lot of good discussion points.

1. Is epinephrine the right thing to give during a cardiac arrest?

This comes up quite a bit in discussions I have with other MDs. It is unknown. There is some evidence that sooner is better, some that less is better than more. We went away from the high doses we gave in the 90's, so it is realistic that we could move away from it altogether. I am not sure what will be the deciding point.Likely it will be a rogue system that decides to do without it and then shows their survival rates.

2. How can you figure these things out with patients who can not consent to participate in research?

To really know what works in cardiac arrest you need many patients. then you need them to consent to be part of the study.

So I ask the reader Knowing what you know, if you arrested, would you want epinephrine or not?

In the environment of patient safety, you need permission from a patient or family to put them in a study. The scene of a cardiac arrest is not optimal for any consent process.
So it falls to the IRB and community to decide if they are going to support doing the research without traditional consent. IRBs are going to approach it very differently and you may have extensive requirements to do it, like have community forums for people to ask questions.


3. Who would pay for it?

All of this comes at a cost, and then think about how many patients you would need to enroll. There is precious little funding for something like all of this. epinephrine is not a new drug that has a strong upside of success driving investors.



I think it is going to come down to someone deciding to go against the AHA guidelines, and current community (herd) practice and stop using it. If they doing everything else in the arrest the same, any change in survival would be a crude representation of the effects of epinephrine.
It would be a leap for any service.

 

Calcium, Oh Calcium. Why do you come in 2 forms?

( If you are in a hurry, skip to the red sentences.)

We had a recent caller from the north metro request a clarification about calcium, specifically for the magnesium toxicity prooblem you may see when transporting a patient with pre-term labor.

The background is that magnesium relaxes smooth muscle. This is great when the smooth muscles of the uterus are contracting, or, in theory, the smooth muscles of your lungs are tightening during an asthma attack.

It follows that too much magnesium can make other smooth muscles stop working. This would include your diaphragm ( a smooth or involuntary muscle) and the muscles that run your reflexes ( also smooth or involuntary muscles.) So too much magnesium makes your breathing slow down and you reflexes go away, that is how you measure toxicity.

If you decide your patient on a magnesium drip is getting toxic, you should first turn off the magnesium drip. Then you should give calcium as an anti-dote.

And that is where we run into trouble. The ALS trucks carry calcium chloride for the purposes of cardiac arrests and elevated potassium. This is a fine medication for use in magnesium toxicity. Just put the whole ampule (1 gram) in over 10 minutes.

If you happen to get a calcium gluconate from the hospital, use it the same way, the whole ampule in 10 minutes.

Yes, the two have different amounts of elemental calcium in them. If you ask a chemist, they will sat that 1 ampule of calcium chloride has 272 mgs of calcium in it, while 1 ampule of calcium gluconate has 90 mgs of elemental calcium in it.

For medical use, we are only concerned about the clinical effects and 1 ampule of either will have the same effect

The only reason I can figure why gluconate is preferred over chloride when a magnesium drip is the problem is this:

Calcium Chloride will combine with magnesium and form a solid when used in the same IV line.

If you use the Calcium chloride, you have to use another line.

It is not an issue with calcium gluconate.

New Study shows the importance of following guidelines in cardiac arrest management

Anyone who works in pre-hospital care has to know that THE hot topic for the past 3-5 years has been cardiac arrest. New science is coming out every month. This is helping us rapidly refine the best practice for managing a cardiac arrest outside of the hospital.

Ahhh, outside of the hospital. What about in-hospital cardiac arrest? A NEJM article published in 2012 puts the survival rate at 22%. That is much better than out-of-hospital rates which are often quoted as below 10%. It seems logical that the survival rate would be better in a hospital, what better place to have and arrest than in the hospital.But, even if you are in a hospital, there may be some room for improvement.

Consider an article published right now in Resuscitation.Title:

The effect of adherence to ACLS protocols on survival of event in the setting of in-hospital cardiac arrest.

The article says that when a person arrests in the hospital, they have a greater chance of ROSC if ACLS guidelines are followed. They make the point that omitting interventions, or adding in your own that are not part of the protocol, leads to ROSC less often.

This is the key. Managing a cardiac arrest is not a free for all. It needs to be done via a plan that everyone knows, agrees to and understands. It is not a time to be unprepared, random and unpredictable.

 

I want your opinion

I have a question and really want to hear from all of you.

Currently, the state of Minnesota defines a health officer as:

Health officer.

"Health officer" means:

(1) a licensed physician;
(2) a licensed psychologist;
(3) a licensed social worker;
(4) a registered nurse working in an emergency room of a hospital;
(5) a psychiatric or public health nurse as defined in section 145A.02, subdivision 18;
(6) an advanced practice registered nurse (APRN) as defined in section 148.171, subdivision 3;
(7) a mental health professional providing mental health mobile crisis intervention services as described under section 256B.0624; or
(8) a formally designated member of a prepetition screening unit established by section 253B.07.

I have been of the opinion that the list should also include paramedics.
That would facilitate the medic writing a transport hold on scene and taking the patient to a hospital. There have been some concerns about the MD's agreeing over the phone, because then you need to ensure that the patient is seen by that MD. Triage and bed space in a large ED with multiple providers doesn't always make that realistic. And some MD are unsure if it is appropriate to agree to a hold over the phone without really seeing the patient.

So, would it make an impact in your job if paramedics could sign the hold form? How?
On your first day of work, would you have been able to make that decision?
Recognizing that much of the state is served by EMS providers trained to the EMT level, should they be included in the definition?
Remember, I am not governor so I am not making any campaign promises, I just want to know what you think.
Paul

Best Practice

This is the button to avoid!!

I think we all agree the Lucas 2 is an upgrade from the previous version. I understand it is top-heavy, but the auto adjusting is nice and I have been told it is much more quiet.

One new option it gives us is the choice between continuous compressions and 30:2.

Dr. Lick and I think the patients have the best circulation when the compressions are uninterrupted, even when you are only using a basic airway. This is contradictory to the current AHA recommendations, but the science is ahead of the 2010 AHA guidelines.

So, avoid the 30:2 button, use only continuous compressions regardless of what airway you use.

Watch out, it's graphic!

A little on the gory side, but it is a good demonstration of ventilating lungs.

We were using this at a training day for a different group. In the video, you can see the lungs expand with each breath. If you watch the deflation period, it is much quicker when the PEEP valve is off. When the PEEP valve is in place, the lungs deflate to a certain point but hold some volume. Think of this as maintaining open alveoli that would normally collapse. These are then ready to accept now, oxygenated air with the next ventilation.

If you watch, you can see blebs forming on the right lung, among other places. This is because we have caused injury to the lungs by over-inflating them at times.

This is also a good exercise to watch the effects of hyperventilation on lungs and how they lungs are affected when we ventilate rapidly without giving enough time for them to deflate normally.

Something to think about

For the past 2 years, the Twin Cities and the surrounding communities have been leaders in cardiac arrest survival. The innovation coming from this community is setting the tone for cardiac arrest care around the world. Overall survival from cardiac arrest in Hennepin County is 14.5%. This is almost twice the national average of 7.9% survival of all victims of cardiac arrest.

There is a special segment of the data set that is pulled out and compared so that people can be sure they are comparing similar data points. This is called the Utstein data set. This only includes people who have a witnessed cardiac arrest and are found in a shockable rhythm. In Hennepin county, the survival for these patients is a nation leading 43% compared to a 31.5%  average for the rest of the country.

 

Believe it or not, there is room for improvement.

 

Where?

 

In our community, victims of cardiac arrest only get bystander CPR 28% of the time. To be clear, bystander CPR is defined as someone other than a member of the EMS response, not the firefighters and law enforcement members who provide first responder services as part of our EMS system. The national average for bystander CPR is 36%.

 

In the Cares data set for Hennepin county, if the Utstein group was limited to those with a witnessed arrest, who were found in a shockable rhythm AND had bystander CPR, their survival rate when up 4.5% to 47.5%. 

 

Bystander CPR is very important and makes a big difference. It is something that can add to our success if we can improve our community participation.

I urge you, as the experts in cardiac arrest care, to encourage others to get invovled, learn CPR and perform it when an arrest happens.

There are CPR classes happening all over the community. It is simple to learn and poses minimal risk to the patient with the potential for great benefit.