We are there for the good of the patient, not for the good of the protocol, not for the good of the medical director, and not for the good of the company.

- Rogue Medic

Details on NIPPV for CHF Works, ACLS Algorithms Do Not at the 1-Union-801 Podcast

 

I have forgotten to post about a podcast that was kind enough to have me as a guest on the topic of CPAP (which works) and ACLS (Advanced Cardiac Life Support) drugs (which don’t work).

John Broyles, the host of 1-Union-801, had me on back in October.[1] This was about something I wrote reviewing an article by Dr. David Newman.[2],[3]

What is NIPPV – Non-Invasive Positive Pressure Ventilation?

What is CPAP?

Is there evidence that CPAP improves outcomes?

What are contraindications to CPAP?

The real problem with disoriented patients using CPAP is that they may not be able to trigger a breath by taking a deep enough breath.

CPAP should be a BLS skill everywhere.

CPAP is required BLS equipment in Pennsylvania.[4]

Et cetera.
 

What do we do for cardiac arrest according to ACLS that is based on evidence?

What do we do for cardiac arrest according to ACLS that is not based on evidence?

Where is the evidence that ACLS drugs improve any outcome that matters?
 

ACLS Medications for Cardiac Arrest[5]
 

What does the epinephrine research show?
 

 

I added the two most recent studies to this, since they were not yet published when the review of vasopressors was published.[6] The quality and outcome of the added studies is my interpretation, but I think that others will rank them similarly.
 

If your idea of a good outcome is a temporary pulse in a patient who lives in a coma for a few seconds, or minutes, or hours, or days, then your priorities are screwed up.

My idea of a good outcome is the ability to wake up and talk with the people I care about.

ACLS drugs DO get pulses back more often than not using drugs, but the drugs decrease the chances that these patients will wake and be able to think.
 

Why do we poison our patients’ brains just to get some temporary pulses?
 

Because we are giving the drugs for the satisfaction of getting a pulse back, not for bringing a living, thinking human back.

We value a zombie resuscitation over resuscitation of a thinking patient.

If the patient could walk, and talk, and make sense before the cardiac arrest, not being able to walk, and talk, and make sense after the cardiac arrest is not a good outcome.
 

Any standard of care that does not have evidence of survival benefit needs to have an expiration date.
 

If your idea of a good outcome is to be one of The Walking Dead, but without the walking, then you will want epinephrine for your cardiac arrest.
 

Go listen to the podcast.

I apologize for not being more lively during the podcast, but part of the reason is that there were people sleeping near by.

Footnotes:

[1] NIPPV with CHF works…ACLS does not
by 1 Union 801 TheWebcast
Sat. October 13, 2012
Podcast

[2] NIPPV for CHF Works, ACLS Algorithms Do Not
by David Newman, MD
September 26, 2012
Emergency Physicians Monthly
Article

[3] NIPPV for CHF Works, ACLS Algorithms Do Not
Thu, 04 Oct 2012
Rogue Medic
Article

[4] Required Ground and Air Ambulance Equipment and Supplies
[39 Pa.B. 6167]
[Saturday, October 17, 2009]
Web Page.

Required Equipment and Supplies

 Approved equipment and supplies shall be carried and readily available in working order for use on both ground and air ambulances. Some patients and crewmembers of an ambulance service may have allergies to latex. Latex free supplies are recommended, where possible. The following equipment and supplies must be carried on each ground and air ambulance, as indicated.

EQUIPMENT/ SUPPLIES AMBULANCE TYPE
BLS   ALS MOBILE CARE   ALS SQUAD  
62. CPAP Ventilation-portable equipment X X X

[5] ACLS Medications for Cardiac Arrest
August 19, 2010
The NNT
Article

[6] Vasopressors in cardiac arrest: a systematic review.
Larabee TM, Liu KY, Campbell JA, Little CM.
Resuscitation. 2012 Aug;83(8):932-9. Epub 2012 Mar 15.
PMID: 22425731 [PubMed - in process]

CONCLUSION: There are few studies that compare vasopressors to placebo in resuscitation from cardiac arrest. Epinephrine is associated with improvement in short term survival outcomes as compared to placebo, but no long-term survival benefit has been demonstrated. Vasopressin is equivalent for use as an initial vasopressor when compared to epinephrine during resuscitation from cardiac arrest. There is a short-term, but no long-term, survival benefit when using high dose vs. standard dose epinephrine during resuscitation from cardiac arrest. There are no alternative vasopressors that provide a long-term survival benefit when compared to epinephrine. There is limited data on the use of vasopressors in the pediatric population.

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Comments

  1. I have found many side effects a CPAP.. sleep folks don’t like them posted. I’m unemployed after using cpap 10/1/12. I had a seizure. Was an over the road driver. sleepwalked 6/8/12 after putting cpap mask on.
    Wife was driving about 60 when I got out of truck like it was parked. NO seizures or sleep walking before cpap usage.

  2. Rogue,

    What do you think about a situation in which someone who was allergic to bees got stung and started to pass out, but ephinephrine was used to bring her back to consciousness? I don’t have much info. On the matter and am attempting to understand the situation. Are you suggesting ephinephrine isn’t even needed?

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