Does anybody want to guess what Drug X is?
To narrow things down a bit, Drug X is not homeopathy, acupuncture, epinephrine, amiodarone, lidocaine, bretylium, magnesium, atropine, or sodium bicarbonate.
Click on the image to make it larger.
I believe that this drug was used only after other treatments had failed, but I could be wrong.
Even if you were to remove the 4 not quite dead yet patients, all of whom survived, you only drop from a 59% survival rate to a 50% survival rate. Not bad.
Any ideas?
Any desire to study this as an alternative to the alternative medicine treatments listed above?
Maybe Drug X would not work, when examined in large enough randomized placebo-controlled double-blinded studies, but Drug X isn’t likely to do any worse than what we are already using.
.
OK i give whats drug x??? inquiring minds want to know. But then again we dont need a new drug that might work, we have our new LP15’s that tell us how fast to do cpr and when to bag. And our new PALS class that was way to short and didnt make anybody cry (the first PALS class that i took more years ago that i care to admit was 3 days long and made grown doctors leave crying. Are we really dumbing down EMS this much??
Raymond
You can’t give up that easily. You have to give other people a chance.
Don’t worry about not using something that medical command would permit, or having to wait until the new guidelines come out (next month?), because there is not enough research to support it.
I like having capnography. I can look at the numbers, and with a good waveform and familiarity with what the numbers have been for my patient, know if I have been subconsciously bagging too quickly or too slowly. With complicated patients, or just with the complications of moving a resuscitated patient, this can be important.
I love the ability to pass the bagging to new people and explain to them that they are supposed to keep the numbers in a certain range. They complain that they can’t bag that slowly.
Too much Ritalin?
A crying baby is a healthy baby.
Is now –
A crying PALS student is a learning PALS student.
That could be a good slogan.
You know my answer on that one.
Yes.
Unless we stop dumbing things down, it will get worse.
There are plenty of positive things happening, but it seems as if there is always somebody saying –
We can’t expect people to think about these things. What if someone makes a mistake?
Better to let people die, than to risk the much smaller possibility of causing something bad to happen. If we train/educate people well, the problem is insignificant. But I am not a bureaucrat.
Somehow I get the distinct feeling that “Drug X” isn’t a chemical compound.
Drug X is an FDA approved drug that has been around for a while.
Refrigerated saline?
Kevin G.,
Refrigerated saline is not what was used.
With a combination of continuous compressions, defibrillation, and therapeutic hypothermia (refrigerated saline), I would not be surprised if similar, or better, results could be produced in communities with a lot of bystander CPR.
While, uh, cheating to try to find the answer on Google, I was amused to see that among my search results was one with the title “Cardiac Arrest” on the wrongdiagnosis.com website… which I found disconcerting.
Still no idea what the drug is. Gotta be a vasoconstrictor of some kind, but all the well known ones I think have been pretty extensively studies. Phenylephrine?
Matt,
I don’t know how difficult it would be to find by a search engine, but I was not looking for information on cardiac arrest when I found it.
Management of Cardiac Arrest
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Medications for Arrest Rhythms
If good research ends up showing that Drug X is effective at improving survival, it will not do anything to change that quote.
For those unfamiliar with phenylephrine, it is also known as Neo-Synephrine (or just plain Neo) and dozens of other names. The over-the-counter brand is not what is being referred to.
In the ICU, and especially in the PACU (Post-Anesthesia Care Unit), phenylephrine is not uncommon. When teaching ACLS, this is the PACU identifier. People will become upset when hypotension is treated with phenylephrine. We should consider the setting and the drugs available and familiar to those who will be treating the patient. Why insist that someone use an unfamiliar drug when treating an unstable patient. If we stick with drugs we are familiar with, we are less likely to make mistakes and the patients are less likely to be harmed by mistakes that do not happen.
Wikipedia
Phenylephrine
Vasopressor
A good idea, but Drug X is not a vasopressor.
How about calcium?
nvm, dosing makes no sense, I should think before I post.
VinceD,
The dosing does not make much sense for anything.
Calcium would be a great choice if these were a bunch of hypekalemic/renal failure patients. The survival rate would probably be much higher if they were using calcium to treat hyperkalemic cardiac arrest.
Calcium is a good thought, but it is not calcium.
Knee-jerk response: aspirin?
Sarah G,
Drug X is not aspirin, but it might be interesting to see if we gave a platelet inhibitor to people who had cardiac arrest due to blockage of one, or more, coronary arteries. Identifying them would be a problem.
Oxygen? Ha ha ha. Glucagon would be neat (inotrope/chronotrope) but the dosing isn’t right. Estrogen? Progesterone? Testosterone?
1 to 48 X-units is the dosing range, which leads me to wonder why the great variability? How exactly did they correlate the dosage to the end result?
Christopher,
No, but withholding supplemental oxygen and withholding ventilation both seem to work well.
Interesting ideas, but Drug X is not a hormone.
I do not have the answer, but I think they were titrating to not dead anymore.
That is the way epinephrine is given. If you were to look at the dose of epinephrine given to cardiac arrest patients, you would find that, for everyone who did receive epinephrine, the total dose ranges from 1 mg to whatever is the largest dose given in the study.
There are reports of patients who have been resuscitated after several hundred milligrams of epinephrine. So, the dose range is not unrealistic for something approved for use in cardiac arrest, for which Drug X is not approved, but epinephrine is approved – actually almost required.
–
Management of Cardiac Arrest
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Access for Medications: Correct Priorities
consider drug therapy
Management of Cardiac Arrest
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Medications for Arrest Rhythms
There is a separate section titled Interventions Not Supported by Outcome Evidence, but it all depends on what kind of outcome we want.
If we are satisfied with ROSC, then epinephrine is a great drug.
If we are satisfied with short-term survival to hospital admission, then amiodarone is a great drug.
If we are interested in a human being with a functioning brain being discharged from the hospital, then these drugs are not only inadequate, but possibly harmful.
–
consider drug therapy?
I do consider drug therapy.
I consider drug therapy to be more of a problem, than a solution
Wouldn’t your normal phrasing be something like:
There are reports of patients who have been resuscitated
afterin spite of several hundred milligrams of epinephrine.🙂
Christopher,
I try to make is clear what my opinion is and what the evidence is. I may not always succeed.
I think that we will eventually find a subset of patients (not just anaphylactic and asthmatic patients) who do benefit from epinephrine.
I think that the routine administration of epinephrine to everyone who does not respond quickly to BLS treatments is harmful.
It may be that patients who require longer resuscitation are unlikely to respond without epinephrine.
Applying these treatments in the absence of evidence of benefit (improved survival to neurologically intact survival) is alternative medicine – which I oppose.
If we want to practice alternative medicine, we should change our names to something mystical, use a lot of incense, and claim that everything is Quantum or Qi or some other Q word.
If we are going to practice alternative medicine, we don’t need any valid evidence.
Alternative medicine – the evidence-free alternative to real medicine.
Of course, once we grow up, we realize that the Tooth Fairy is a myth.
Alternative medicine is just refusing to admit that there is no Tooth Fairy.
I think we’re on the same page, I was hinting to the fact that if you leave the dosing range open-ended it is a bit harder to tell whether or not the 101st milligram of Epi did the trick, or if all 101mg did absolutely nothing.
You would need to test with cohorts receiving dosages in fixed intervals of some sort otherwise you could only make retrospective guesses as to if it really WAS the high dosages of Epi that did the trick. The trouble with resuscitations is we get into the “throw the kitchen sink at the problem” and most likely confound ourselves as to what actually “brought the patient back.” Likely nothing but CPR and defibrillation, but we wouldn’t know!
Christopher,
My response is at Most Survive with Mystery Treatment for Cardiac Arrest – Comments from Christopher.
High dose nitro!
Adam,
As improbable as high-dose NTG seems, based on the assumptions that we have been told are requirements for resuscitation, Drug X is high-dose NTG.
We can’t give a patient NTG (even standard dose) without an IV, because What if . . . ?
Some people do have a transient hypotensive over-reaction to NTG, but almost all recover spontaneously prior to any possible responser to the treatments given.
Fluids?
In the absence of RVI (Right Ventricular Infarction), a fluid bolus is a treatment for the doctor/nurse/medic – not a treatment for the patient. The patient would do just as well, if not better, if the doctor/nurse/medic took an Ativan, rather than pushed fluids.
So what are the dosing units in this study?
How the…. what the……. WHAT?
Wait a minute….I was always told that NTG is an excellent, albeit blunt, diagnostic tool to find RVI……by many different sources…..I’m just lost.