Following a lengthy discussion in the comments of EMCrit Wee – Abandon Epinephrine?, where I am suggesting that we should abandon epinephrine (adrenaline in Commonwealth countries) and he is suggesting that we should not, Dr. Minh LeCong invited me to discuss this on his podcast –
PHARM is PreHospital And Retrieval Medicine, the blog of Dr. Minh LeCong of the Royal Flying Doctor Service, Queensland Section, in Cairns. That is in the northeast of Australia. He describes his blog as –
In many ways the philosophy espoused will be that of prehospital critical care. Whereas EMCrit brings upstairs care, downstairs; I aim to bring it out of the hospital. Many prehospital providers are doing this already.
- What works, what does not?
- What is the evidence base and who cares?
I would modify that a bit for the US, but I am discussing EMS provided by paramedics, while he is discussing EMS provided by doctors. I think that paramedics should be providing more aggressive treatment (because it can be shown that paramedics can safely deliver a lot of more aggressive treatments) than what is typical in the US. There is still a big difference between what doctors can do safely and what paramedics can do safely.
Excellent, high-quality patient care is less about the skills, than about when to do something. It is even more important to know when not to do something.
The important points that I think we need to understand about resuscitation are these –
We still do not have any evidence that epinephrine improves outcomes that matter.
We still do not have any evidence that amiodarone improves outcomes that matter.
We still do not have any evidence that lidocaine improves outcomes that matter.
We still do not have any evidence that ventilations improves outcomes that matter.
We need very good studies that control for all of these variables. We cannot really know what the effects of epinephrine are – until we study without all of the unproven treatments that eventually will probably be proven to be harmful (amiodarone, lidocaine, and early ventilations).
Some of the advocates of epinephrine as Standard Of Care will always be able to respond to criticism of epinephrine (an unproven treatment), that it was being used with poor quality CPR, or with amiodarone, or with lidocaine, or with a lot of ventilations, to claim that we need to keep using it until there is so much obvious harm that people will look back at us and call us barbarians for giving epinephrine.
We do not need to prove that treatments are harmful to stop using them.
We need to provide good evidence that treatments improve survival in order to start using them outside of controlled trials.
Eventually, we may find a group of patients that benefit from epinephrine in cardiac arrest, but giving it routinely to everyone dead long enough for us to give them epinephrine is not the way to improve survival.