The only reason we get away with giving such large doses of epinephrine to these patients is that they are already dead.

- Rogue Medic

When is a double dose of defibrillation a good idea?

 
In the comments to Double simultaneous defibrillators for refractory ventricular fibrillation, NCMedic and Ambulance Driver write that they have already begun using variations on double defibrillation.
 

That     is     excellent.

 


 

The changes in when to implement the change, as well as the vector to use, are reasons we need to have people publishing results on what is being done. Please, work with your medical directors and/or others to publish some results.

We have had epinephrine (Adrenaline in Commonwealth countries) in ACLS (Advanced Cardiac Life Support) guidelines, and our protocols, for decades, but we still do not know the best dose or even which patients benefit.

NCMedic writes –
 

Has been in our protocols for sometime now, we are finding it more beneficial sooner than later for obvious reasons, next protocol revision will most likely have it on the 4th shock with the 2nd set of pads placed A/P to cover from a different vector.

 

Epinephrine seems to be harmful when given later, or is epinephrine less beneficial later, or is epinephrine always harmful, just much more harmful later, or something else.[1]

The problem is that we do not know when, or for whom, epinephrine is indicated.

Epinephrine is probably indicated in some patients, but which patients, at what dose, and at what time? If epinephrine should be repeated all of the same questions apply to all further doses. Dr. Scott Weingart points out how little we know about the use of epinephrine, because his approach makes more sense than what ACLS recommends and the evidence is equally lacking.[2]

There are many things in the presentation to discuss, such as Dr. Weingart’s misunderstanding of what nihilism means, but that is for another time.
 

There does not appear to be any harm from double defibrillation. As we use more current more often, we should expect to learn of harms, as we do with almost every intervention. However, as NCMedic states, we may be doing harm by waiting too long to deliver the double dose.

Should it be a double dose?

What about 1 ½ times the maximum?

300 j bi-phasic or 540j mono-phasic or maybe some combination of bi-phasic and mono-phasic, and if a combination, what combination, with drugs or without, which drugs if with drugs, . . . ?

What about 3 times the maximum?

600 joules bi-phasic or 1,080 joules mono-phasic or . . . ?

Should the higher-dose defibrillation be after the fifth shock with a return to VF/pulseless VT (Ventricular Fibrillation/pulseless Ventricular Tachycardia)? After the fourth shock? After the third shock? After the second shock? After the first shock?

Is waiting longer to increase joules making it more likely that epinephrine will be given? Is epinephrine more harmful than a double shock, less harmful than a double shock, or roughly the same?

The amount we do not know is huge.

We should learn what we are doing to our patients and not arrogantly choose to remain ignorant, as we have chosen with epinephrine. That is changing, but some still defend the arrogance of ignorance at the expense of our patients.[3]

-

Footnotes:

-

[1] Does Faster Epinephrine Administration Produce Better Outcomes from PEA-Asystole?
Sun, 25 May 2014
Rogue Medic
Article

-

[2] Podcast 125 – The New Intra-Arrest from SMACCgold
EMCrit
Dr. Scott Weingart
Web page with video and show notes.

-

[3] Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial
Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL.
Resuscitation. 2011 Sep;82(9):1138-43. Epub 2011 Jul 2.
PMID: 21745533 [PubMed - in process]

Free Full Text PDF Download of In Press Uncorrected Proof from xa.yming.com
 

This study was designed as a multicentre trial involving five ambulance services in Australia and New Zealand and was accordingly powered to detect clinically important treatment effects. Despite having obtained approvals for the study from Institutional Ethics Committees, Crown Law and Guardianship Boards, the concerns of being involved in a trial in which the unproven “standard of care” was being withheld prevented four of the five ambulance services from participating.

 

In addition adverse press reports questioning the ethics of conducting this trial, which subsequently led to the involvement of politicians, further heightened these concerns. Despite the clearly demonstrated existence of clinical equipoise for adrenaline in cardiac arrest it remained impossible to change the decision not to participate.

 

.

Double simultaneous defibrillators for refractory ventricular fibrillation

 
It looks as if the next generation of defibrillators will go to 11. This patient received a double dose of defib.

Is 720 joules too much?

If your answer is Yes, please explain how 720 joules is worse than death.

What about 400 joules? Some older mono-phasic defibrillators go to 400 joules, but we might see 400 joule bi-phasic defibrillators.

Until then, there is the possibility of using two defibrillators to deliver shocks at the same time, or milliseconds apart. By the time that this is a relevant treatment, the patient has been down for several shocks and is still in a shockable rhythm, but a supervisor or second medic unit should have arrived with a second defibrillator.
 


 

It is important to not put the pads from the same defibrillator next to each other.

The paper describes a patient with a BMI (Body Mass Index) of 40, a STEMI, and an onset of VF (Ventricular Fibrillation) in the presence of EMS.

CPR (being performed by the son when EMS arrived at the ED?), 200J x 3, epi x a bunch, amio x 1 by EMS.

High-quality CPR, a bunch more epi, 200 J x 2, lido x 1, bicarb x 1 (bicarb might have been indicated by the patient’s astrological sign), then the shock at 400 joules.
 

The patient then regained a palpable pulse and blood pressure. He had another brief episode of ventricular tachycardia that responded to a second defibrillation with 400 J. The patient had a wide QRS rhythm that quickly narrowed into normal sinus.[1]

 

Maybe the patient was not told about the concerns of some people that too much is too much. If he had been told, he would have remained dead, like a good scenario patient.

Next time he can follow the approved scenario.
 

Five studies have demonstrated safety in patients receiving 720 J of monophasic energy for cardioversion of atrial fibrillation (17,22–25).[1]

 

Five papers demonstrate the safety of 720 joules in living patients with atrial fibrillation, but many in EMS will tell us that it is too dangerous to use on dead people after the failure of standard doses of energy.

Lake Sumter EMS has been providing compression-only CPR, even adding 720 joule defibrillation, and they may have the best resuscitation rates in America. The rest of us should consider catching up. I wonder how things have gone for LEMS, since I wrote about them a couple of years ago.[2]
 

 

While ROSC (Return Of Spontaneous Circulation) is not the right outcome to use to evaluate a treatment, 70% suggests that we should pay attention to what they are doing in Lake Sumter. 46% ROSC in those who could not get ROSC any other way by EMS.

You can’t be too safe is still a lie.

-

Also read –

When is a double dose of defibrillation a good idea?

-

Footnotes:

-

[1] Double simultaneous defibrillators for refractory ventricular fibrillation.
Leacock BW.
J Emerg Med. 2014 Apr;46(4):472-4. doi: 10.1016/j.jemermed.2013.09.022. Epub 2014 Jan 21.
PMID: 24462025 [PubMed - in process]

-

[2] Optimizing Outcomes in Cardiac Arrest
Mon, 10 Dec 2012
Rogue Medic
Article

.

FREE Webinar from Annals of Emergency Medicine, the AHA, Dr. Bentley Bobrow, Dr. Christopher Crowe, Dr. Ashish Kumar Aggarwal, and Mark Venuti (paramedic)

 

Do you have questions about the best way to perform CPR?

If this FREE webinar does not answer them, there will be time to ask questions at the end.

Tuesday, July 8th 2014, 1pm EST (17:00 Universal Time).
 

Register for FREE at this link.
 


 

Dr. Bobrow is one of the people who has been focusing on improving the quality of chest compressions and minimizing interruptions. Two things that we know about CPR are that improving the quality of compressions and minimizing pauses in compressions make a big difference in neurologically intact survival.

These two improvements may be responsible for most of the improvement in survival since the 2005 ACLS guidelines.

That is the difference between the old focus on ALS (Advanced Life Support) because everybody knows the paramedic/nurse/doctor makes all of the difference and the new focus on compressions and keep the paramedics/nurses/doctors from doing things that interfere with compressions.

We are still waiting for some evidence that resuscitation rates would not increase even more if we just kept the paramedics/nurses/doctors away from the patient until after ROSC (Return Of Spontaneous Compressions).

You can read the guidelines, and the protocols, and the research at any time, but there are not many times when you are able to ask the experts responsible for creating all of them.
 

Register for FREE at this link.
 

Tuesday, July 8th 2014, 1pm EST (17:00 Universal Time).
.

Emergency Cardiovascular Care Update (ECCU) 2014 Conference – What Will We Get?

 

What should we expect from the Emergency Cardiovascular Care Update (ECCU) 2014 Conference?

The brochure suggests that the next version of the guidelines will be based more on science than the current guidelines, but that is always the suggestion.
 


 

Will the AHA (American Heart Association) actually limit treatments to those that work?

Or will we get more wishful thinking-based guidelines?

There is an examination of the research that will affect the next decade of BLS (Basic Life Support) resuscitation.
 


 

There is also a session where questions are encouraged.
 


 

Will we continue to harm patients with ventilations?

There is still no evidence of benefit from ventilations prior to ROSC (Return Of Spontaneous Circulation). We would still ventilate those who arrested secondary to respiratory causes and children.
 

That format is repeated for ALS (Advanced Life Support).
 


 

And a session where questions are encouraged.
 


 

Will we still be giving eye of newt?

While eye of newt has not been shown to increase the rate of ROSC, it has not been studied, so we do not know if eye of newt does increase the rate of ROSC.

Epinephrine (Adrenaline in Commonwealth countries) is slightly more evidence-based than eye of newt, because it has been shown to increase the rate of ROSC, but who cares?

ROSC is not the goal.

Resuscitation of the heart and brain is the goal.

Epinephrine has failed to demonstrate improved resuscitation.
 

What works?

Teaching CPR effectively works.

Ventilations impair outcomes and impair education.
 


 

What can we do to improve the quality of CPR?
 


 

What can we do to improve the quality of EMS?

EMS resuscitation is not an ALS treatment.

EMS resuscitation is about keeping the medics out of the way of the people providing compressions and defibrillations.
 


 

Resuscitation does not come in a syringe, so prehospital therapeutic hypothermia is not going to be done with chilled IV fluids.

We know that does not work.
 


 

Stutter CPR looks promising, but we are not there, yet.
 


 

What do we do after ROSC?

Higher pressures seem to lead to higher resuscitation rates, but is that just an association of healthier hearts producing higher blood pressures, is it something we can improve with pressors (epinephrine, norepinephrine, phenylephrine – but probably not with dopamine), or is it something that we will make worse with pressors?
 


 

There is even a discussion of mechanical Compression devices.

Should we teach excellent chest compressions to bystanders, while we abandon quality EMS compressions to machines?

If quality is a problem, we should give the machines to bystanders and demand high quality from EMS.

Or is it possible that the machines can act as prehospital ECMO and improve outcomes? We do not know – yet.
 


 

It looks interesting.

I hope the results are a dramatic improvement over the current (2010) guidelines.

The 2005 guidelines made a big difference in compression quality and the resuscitation rates followed.

2015 could cause us to focus on what really works.

If it doesn’t work when we study it, then we were just fooling ourselves about whether it works. If it doesn’t work when we study it, it does not work.
 

Emergency Cardiovascular Care Update (ECCU) 2014 Conference

.

Does Faster Epinephrine Administration Produce Better Outcomes from PEA-Asystole?

ResearchBlogging.org
 

If we are going to give epinephrine (Adrenaline in Commonwealth countries) to patients with rhythms that are not shockable (PEA [Pulseless Electrical Activity] or Asystole), it appears that patients receiving epinephrine earlier have better outcomes than patients who receive epinephrine later in the hospital in the less acute care settings.

Does this mean that patients who receive epinephrine have better outcomes than patients who do not receive epinephrine?

We remain willfully ignorant of the answer to that question.
 

Apart from cardiopulmonary resuscitation, no intervention has been shown to be efficacious in patients with non-shockable cardiac arrest.[1]

 

Would a placebo group have had better outcomes than the patients who received epinephrine the earliest? We have no way of knowing, because we discourage asking about what we take for granted.

 

We excluded patients with cardiac arrest in the emergency department, intensive care unit, or surgical or other specialty care or procedure areas,[1]

 


 

This does show an impressive association between giving epinephrine earlier and improved outcomes.

Does this mean that we should avoid giving epinephrine (a drug not yet adequately tested in humans) after a certain amount of time?

Does this mean that we should prioritize giving epinephrine (a drug not yet adequately tested in humans) before a certain amount of time?

Until we find out how harmful/beneficial epinephrine is compared to placebo, we do not know if we are helping with epinephrine, harming with epinephrine, or which patients we might be helping and which patients we might be harming. We have a half a century of I don’t know and I don’t care.
 

Despite a strong physiologic rationale and anecdotal reports of efficacy, there are no well controlled trials of epinephrine to assess endpoints such as improved survival and neurologically intact survival. A randomized trial failed to show efficacy for advanced cardiac life support drugs, and extrapolation to the potential lack of efficacy of epinephrine has been suggested; the dose, timing, and even use of epinephrine remains controversial.15-16 [1]

 

But some of the anecdotes are really good anecdotes!

Anecdote-based treatment is just ignorance-based treatment. We assume that we know what we are doing, but we are only imitating Skinner’s pigeons in our reaction to stimuli.
 


 

We have fancier uniforms than the pigeons, but we are just as unaware of the source of our stimuli.
 

The data was prospectively obtained using specifically defined variables, but the study was a retrospective analysis of that data.
 

Because data were used primarily as the local site for quality improvement, sites were granted a waiver of informed consent under the common rule.[1]

 

Because of the way the data are entered, any errors are likely to be at time of entry and may not be capable of being detected at the time of analysis for research. The numbers are very large – 25,095 patients – so that should correct for idiosyncratic errors, but what about cultural errors?

 

In the sensitivity analyses with adjustment for delays in initiation of cardiopulmonary resuscitation, time to epinephrine administration remained independently associated with survival to hospital discharge after multivariable adjustments.[1]

 

In the context of our findings, future investigations should consider timing of epinephrine administration in design and interpretation.[1]

 

We should also consider that epinephrine, if it is beneficial, is probably only beneficial to some patients. We need to try to identify those patients. Our current method of give epinephrine to everybody and let the emergency department sort them out is not reasonable.

This study ran from 2000 to 2009, so the improvements due to the focus on chest compressions might only affect a tiny portion of patients.[2]

Does epinephrine administration – at any time – produce better outcomes from PEA-asystole?

We still have no idea.

-

Footnotes:

-

[1] Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry.
Donnino MW, Salciccioli JD, Howell MD, Cocchi MN, Giberson B, Berg K, Gautam S, Callaway C; American Heart Association’s Get With The Guidelines-Resuscitation Investigators.
BMJ. 2014 May 20;348:g3028. doi: 10.1136/bmj.g3028.
PMID: 24846323 [PubMed - in process]

Free Full Text from BMJ.

-

[2] Delayed prehospital implementation of the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiac care.
Bigham BL, Koprowicz K, Aufderheide TP, Davis DP, Donn S, Powell J, Suffoletto B, Nafziger S, Stouffer J, Idris A, Morrison LJ; ROC Investigators.
Prehosp Emerg Care. 2010 Jul-Sep;14(3):355-60.
PMID: 20388032 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central.

On December 13, 2005, the AHA published “Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”

ROC EMS agencies required an average of 416 days to implement the 2005 AHA guidelines for OHCA. Small EMS agencies, BLS-only agencies, and nontransport agencies took longer than large agencies, agencies providing ALS care, and transport agencies, respectively, to implement the guidelines.

How relevant is that to implementation in the less acute care settings studied in these hospitalized patients?

-

Bigham BL, Koprowicz K, Aufderheide TP, Davis DP, Donn S, Powell J, Suffoletto B, Nafziger S, Stouffer J, Idris A, Morrison LJ, & ROC Investigators (2010). Delayed prehospital implementation of the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiac care. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 14 (3), 355-60 PMID: 20388032

-

Donnino, M., Salciccioli, J., Howell, M., Cocchi, M., Giberson, B., Berg, K., Gautam, S., Callaway, C., & , . (2014). Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry BMJ, 348 (may20 2) DOI: 10.1136/bmj.g3028

.

Top Ten Resuscitation Headlines from Rescue Digest – Read ‘Em and Learn

 

This should catch your attention -
 

RescueDigest’s Top Picks of essential resources for critical topics in emergency services.
 

What should we be paying attention to?
 

Headline #1: EMS Saves Everyone / EMS Saves No One[1]

 

If you read the main stream media, you get one version, or the other, or even both in the same week/month/year.

Why?

If we get our science reporting from the news media, we are not getting valid science reporting.

We are probably getting a poor translation of a secondhand account of what the researcher denied was the result of the study.

Trust the media. We would never misrepresent anything!
 


Image credit.
 

This article provides evidence to explain what the truth is.
 

Does EMS save everyone?

We haven’t put the funeral homes out of business, yet – and we never will.

Does EMS save no one?

Systems that focus on excellent uninterrupted compressions and rapid defibrillation save 40% – 60% of the patients who are in a shockable rhythm when EMS arrives.

You were dead.

No pulse.

No brain function.

Dead.

Dead.

Dead.
 

But – after EMS treatment – you are alive.

This is a true improved outcome, not getting a pulse back only to die in the ICU, or to die in a few weeks/months in a nursing home without ever waking up.

Your brain is working again.

You can play with your children/grandchildren, again.

You are alive.

Only 40% to 60% of patients in shockable rhythms when EMS arrives!

Not perfect, but nothing is perfect. Less than perfect is imperfect, but everything is imperfect. Less than perfect, but better than nothing is still better than nothing. 40% to 60% are better than they would be with nothing.

The NNT (Number Needed to Treat) is a little more than two.

That makes this one of the most effective medical treatments available. Prevention of cardiac arrest is still better, but when prevention does not work, this frequently does.

Less than perfect is the best that is available from real medicine. Charlatans will promise to do better, but they will end up making excuses for failure – and they cannot resuscitate.
 

The basic trouble, you see, is that people think that “right” and “wrong” are absolute; that everything that isn’t perfectly and completely right is totally and equally wrong.[2]

 

What about the rest of the headlines?

Don’t end up like this –
 


Image credit.
 

Go read what Rommie Duckworth is writing.

Go through the slides from his presentation. If you get a chance, go to a conference where he is presenting, such as EMS Today in Washington, D.C., a little over a week from today.
 

Education
2:15PM- 3:15PM
Don’t Lose Your Cool: Dealing With Problem Students

Room: 207B
The Know-it-all. The Worrier. The Heckler. The Rambler. The Cheater. Is one rotten apple going to spoil your whole program? This program provides educators of all levels with insight into the sources of student issues as well as the mistakes that instructors commonly make that contribute to classroom unrest. Using read more…

Speaker
Rommie Duckworth
Director
N.E. Ctr. for Rescue & Emerg. Med.
Sherman, CT, United States
[3]

 

-

Footnotes:

-

[1] RescueDigest Resources: Top Ten Resuscitation Headlines
Rescue Digest
Posted on Jan 29, 2014
Rom Duckworth
Article

-

[2] The Relativity of Wrong
The Skeptical Inquirer
Fall 1989, Vol. 14, No. 1, Pp. 35-44
By Isaac Asimov
Article

Read the whole article. It is not long, but it is an excellent introduction to how science works.

-

[3] EMS Today
February 5-8, 2014
Walter E. Washington Convention Center
Washington D.C.
Information

Results of search for Rommie Duckworth in EMS Today’s schedule search.

.

Mechanical CPR as an Excuse to Just Transport


 

Dr. Keith Wesley usually takes an approach that is focused on the patient.

Dr. Wesley is one of the doctors I use as an example of doctors who truly understand about the ways EMS can improve outcomes.

But . . .

Why is he suggesting that transporting during CPR is a good idea – except when it cannot be avoided?

Did the IAFF (International Association of Fire Fighters – EMS is about speed, not patient care) kidnap someone important to Dr. Wesley?
 

The researchers had a driver cover a predesignated course in the city with typical changes in direction, railway crossings and speeds up to 78 mph.[1]

 

Because it is about the speed of transport, not about the patient.

When the patient is dead, it is a good idea to slow down and transport safely, not try to make the rest of the occupants even more dead than the patient with the mechanical pulse.
 
 

 
Avoiding patient care, because we can drive fast!

How many of the Low Information Voters of EMS will look at this ridicule of IAFF policy and be proud that they value speed more than they value their patients’ lives?[2]

 
 

Keith Wesley’s Comments
Many may be asking why I reviewed a study with such obvious results.
[1]

 

Because the IAFF took your baby away?
 

Performing chest compressions is fatiguing and the back of an ambulance rolling lights and sirens through the night is downright dangerous. So dangerous, in fact, I consider it bordering on employer negligence if condoned or even sanctioned.[1]

 

This was a study comparing negligence with machine compressions to prove that it is less negligent to use a machine during transport.

We already know that we should be resuscitating patients on scene.

Does this study provide any kind of evidence of improved outcomes from this rush to transport as compared with treating real patients on scene?

No.

Does this even attempt to demonstrate benefit?

No.
 

When you combine the poor outcome of these cardiac arrest victims receiving worthless CPR while exposing the responders to career- or life-ending injuries, I simply wonder who is reading the science at all. If this information was well-known and accepted, then every ambulance in America would be equipped with a mechanical CPR device. So why aren’t they?[1]

 

Why are apples not oranges?

Why are we putting apples on every ambulance?

Because of oranges!
 

This is EMS. We need to know if rapid transport with a machine to be resuscitated in the hospital improves survival when compared with resuscitating patients on scene.
 

Perhaps the idea of replacing a human being with a machine to save a life is unsettling.[1]

 

Allow me to rewrite that –

Perhaps the idea of replacing a human being with a machine to save a life transport a dead body is unsettling.
 

But the science doesn’t lie. If we’re going to save more victims of cardiac arrest, we have to overcome all obstacles and embrace the value—and effectiveness—of technology.[1]

 

Then show how this saves lives.

Where is the evidence of improved survival to discharge?

Surrogate endpoints lie.

This is just a surrogate endpoint paper.

This is just a lie with bad science.

What next? Scientists sat, this one trick will cure cancer.
 

Blood-letting is an excellent treatment – based on surrogate endpoints.

Should we go back to bleeding patients to death just because it makes the surrogate endpoints look good?

-

Footnotes:

-

[1] Mechanical CPR Could Save More than the Patient’s Life
Karen Wesley, NREMT-P | Keith Wesley, MD, FACEP
December 2013 Issue | Tuesday, December 10, 2013
JEMS
Article

-

[2] EMS: The low information voters of healthcare – Making decisions purely on emotion and superficial knowledge
September 02, 2013
The Ambulance Driver’s Perspective
by Kelly Grayson
EMS1.com
Article

.

What Can EMS Expect From 2014? #2 Prehospital Therapeutic Hypothermia


 

It was the sexy new EMS treatment.

The use of fluids for prehospital therapeutic hypothermia was rushed into protocols.

Now that we have evidence, was a mistake?

Some of us are now trying to defend the rush to treat before evidence.
 

CONCLUSIONS:
In unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause, hypothermia at a targeted temperature of 33°C did not confer a benefit as compared with a targeted temperature of 36°C.
[1]

 

Cooler was not better in this study.

Patients were cooler, but outcomes were slightly worse for the cooler patients.

The difference was not statistically significant.
 

Conclusion and Relevance Although use of prehospital cooling reduced core temperature by hospital arrival and reduced the time to reach a temperature of 34°C, it did not improve survival or neurological status among patients resuscitated from prehospital VF or those without VF.[2]

 

Patients were cooler, but outcomes were slightly worse for the cooled patients.

The difference was not statistically significant, but all measures trended toward worse with prehospital cooling.
 

There was one study that did trend toward improved outcomes for asystole/PEA (Pulseless Electrical Activity) patients, but the results were not statistically significant.
 

In the patients with a cardiac cause of the arrest, 8 of 47 patients (17%) who received pre-hospital cooling had a favorable outcome at hospital discharge compared with 3 of 43 (7%) in the hospital cooled group (p = .146).[3]

 

Maybe there will be some benefit shown for asystole/PEA patients with a larger study, but this is the most positive evidence and it is not statistically significant –

In other words, there is no evidence of benefit and no reason to use this treatment outside of a controlled trial.
 


 

CONCLUSIONS:
In adults who have been resuscitated from out-of-hospital cardiac arrest with an initial cardiac rhythm of ventricular fibrillation, paramedic cooling with a rapid infusion of large-volume, ice-cold intravenous fluid decreased core temperature at hospital arrival but was not shown to improve outcome at hospital discharge compared with cooling commenced in the hospital.
[4]

 

Patients were cooler, but outcomes were slightly worse for the cooled patients.

The difference was not statistically significant, but all measures trended toward worse with prehospital cooling.

There is a free editorial that is important to read accompanying this paper.

There are possible explanations for the consistent failure to improve outcomes.
 

Swine studies show that ice-cold saline delivered during cardiac arrest reduces coronary perfusion pressure (CPP).4,5 Yannopolous et al4 found that iced saline reduced CPP during CPR from 24 mm Hg to only 4 mm Hg, an alarmingly low value that makes survival unlikely.[5]

 

We rushed to implement protocols to give fluids for prehospital therapeutic hypothermia.

Because of our failure to wait for evidence, we need to get rid of these protocols.

When will we learn to wait for evidence?

When will we put our patients’ health above our need to use the new and untested?

-

Footnotes:

-

[1] Targeted temperature management at 33°C versus 36°C after cardiac arrest.
Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wise MP, Åneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Køber L, Langørgen J, Lilja G, Møller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H; TTM Trial Investigators.
N Engl J Med. 2013 Dec 5;369(23):2197-206. doi: 10.1056/NEJMoa1310519. Epub 2013 Nov 17.
PMID:24237006[PubMed - indexed for MEDLINE]

-

[2] Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac Arrest: A Randomized Clinical Trial.
Kim F, Nichol G, Maynard C, Hallstrom A, Kudenchuk PJ, Rea T, Copass MK, Carlbom D, Deem S, Longstreth WT Jr, Olsufka M, Cobb LA.
JAMA. 2013 Nov 17. doi: 10.1001/jama.2013.282173. [Epub ahead of print]
PMID: 24240712 [PubMed - as supplied by publisher]

-

[3] Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest*.
Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid Infusion of Cold Hartmanns Investigators.
Crit Care Med. 2012 Mar;40(3):747-53. doi: 10.1097/CCM.0b013e3182377038.
PMID: 22020244 [PubMed - indexed for MEDLINE]

-

[4] Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial.
Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid Infusion of Cold Hartmanns (RICH) Investigators.
Circulation. 2010 Aug 17;122(7):737-42. doi: 10.1161/CIRCULATIONAHA.109.906859. Epub 2010 Aug 2.
PMID: 20679551 [PubMed - indexed for MEDLINE]

Free Full Text from Circulation.

-

[5] Cooling heads and hearts versus cooling our heels.
Becker LB.
Circulation. 2010 Aug 17;122(7):679-81. doi: 10.1161/CIRCULATIONAHA.110.968222. Epub 2010 Aug 2. No abstract available.
PMID: 20679546 [PubMed - indexed for MEDLINE]

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