Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Lidocaine for Cardiac Arrest in the 2010 ACLS – Part III

Continued from Lidocaine for Cardiac Arrest in the 2010 ACLS – Part I and from Lidocaine for Cardiac Arrest in the 2010 ACLS – Part II This is what we are told about lidocaine in the new AHA (American Heart Association) ACLS (Advanced Cardiac Life Support) guidelines?

2010

Lidocaine is an alternative antiarrhythmic of long-standing and widespread familiarity with fewer immediate side effects than may be encountered with other antiarrhythmics. Lidocaine, however, has no proven short- or long-term efficacy in cardiac arrest. Lidocaine may be considered if amiodarone is not available (Class IIb, LOE B). The initial dose is 1 to 1.5 mg/kg IV.[1]

Class IIb

LOE B

OK. How is this different from what lidocaine was in the 2005 ACLS Guidelines?

2005

In summary, lidocaine is an alternative antiarrhythmic of long standing and widespread familiarity with fewer immediate side effects than may be encountered with other antiarrhythmics. Lidocaine, however, has no proven short-term or long-term efficacy in cardiac arrest. Lidocaine should be considered an alternative treatment to amiodarone (Class Indeterminate). The initial dose is 1 to 1.5 mg/kg IV.[2]

Class Indeterminate?

Lidocaine, however, has no proven short-term or long-term efficacy in cardiac arrest.

2005

In summary, Eye of Newt is an alternative antiarrhythmic of long standing and widespread familiarity with fewer immediate side effects than may be encountered with other antiarrhythmics. Eye of Newt, however, has no proven short-term or long-term efficacy in cardiac arrest. Eye of Newt should be considered an alternative treatment to amiodarone (Class Indeterminate). The initial dose is 1 to 1.5 mg/kg IV.[2]

2010

Eye of Newt is an alternative antiarrhythmic of long-standing and widespread familiarity with fewer immediate side effects than may be encountered with other antiarrhythmics. Eye of Newt, however, has no proven short- or long-term efficacy in cardiac arrest. Eye of Newt may be considered if amiodarone is not available (Class IIb, LOE B). The initial dose is 1 to 1.5 mg/kg IV.[1]

2005Eye of Newt should be considered an alternative treatment to amiodarone (Class Indeterminate).

vs.

2010Eye of Newt may be considered if amiodarone is not available (Class IIb, LOE B).

Why is the dose important?

Even though we don’t have any reason to expect any benefit from lidocaine, we do need to avoid toxicity.

Toxic effects of lidocaine include seizures.

Seizure Management
Whether there is any disease-specific management of seizures after cardiac arrest remains unknown and the true incidence of post–cardiac arrest electrographic seizures may be higher as the clinical diagnosis of seizures may not be readily apparent. It is accepted in other settings that prolonged, untreated seizures are detrimental to the brain, and seizures are common after ROSC, occurring in 5% to 20% of comatose cardiac arrest survivors with or without therapeutic hypothermia.11,196,197[3]

Seizures are no big deal. Not looking busy is a very big deal.

and seizures are common after ROSC, occurring in 5% to 20% of comatose cardiac arrest survivors

We are giving a drug that predisposes patients to seizures. The dose required to produce seizures is very close to the therapeutic dose. However, we do not expect any benefit, other than some ego massage for doctors, nurses, and paramedics.

Nothing has changed, except for the wording and the lack of a safe place (Class Indeterminate) to hide Eye of Newt lidocaine.

Those of us who do not use amiodarone need to have a bone thrown to us. It would be beyond politically incorrect to make those of us without amiodarone feel as if we are not doing all we can. Rah! Rah! Rah!

At least we took care of that awkwardness.

Footnotes:

[1] Lidocaine
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 8.2: Management of Cardiac Arrest
Medications for Arrest Rhythms
Antiarrhythmics
Free Full Text Article with links to Free Full Text PDF download

[2] Lidocaine
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Medications for Arrest Rhythms
Antiarrhythmics
Free Full Text Article with links to Free Full Text PDF download

[3] Seizure Management
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 9: Post–Cardiac Arrest Care
Central Nervous System
Free Full Text Article with links to Free Full Text PDF download

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