There are plenty who … claim to be competent at intubation even though their last intubation was months ago on the third attempt and if the patient had not already been dead – that would have finished the patient off …

- Rogue Medic

The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia

ResearchBlogging.org
 

This is a very interesting trial that may surprise the many outspoken amiodarone advocates, but it should not surprise anyone who pays attention to research.

ALPS showed that we should stop giving amiodarone for unwitnessed shockable cardiac arrest. The lead researcher is still trying to spin amiodarone for witnessed shockable cardiac arrest, even though the results do not show improvement in the one outcome that matters – leaving the hospital with a brain that still works.[1],[2],[3]

There is an excellent discussion of the study on the podcast by Dr. Salim Rezaie and Dr. Anand Swaminathan REBELCast: The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia.

One problem with the study that they do not address on the podcast is that the patients in the study appear to have had time to watch Casablanca before treatment started. Here’s looking at you, while we’re waiting, kid. This is apparently unintentional one way of doing a placebo washout. If we wait long enough . . . .
 

Time from arrival to start of infusion was 87 ± 21 min for procainamide and 115 ± 36 min for amiodarone patients (P = 0.58).[4]

 

If nothing else, this demonstrates how little we need to worry about immediately pushing drugs for stable monomorphic VT (V Tach or Ventricular Tachycardia). Should we expect much from antiarrhythmic treatment?

Research shows that for stable monomorphic VT (V Tach or Ventricular Tachycardia) amiodarone is not very likely to be followed by an improvement. Only 29%[5] or only 25%[6] or only 15% within 20 minutes, but if we don’t mind waiting an hour it can be as much as 29%.[7] For those of you who are not good at math, that means amiodarone is about the same as doing nothing, only it comes in a syringe. Even though these poor outcomes ignore the side effects, they are the best evidence in favor of amiodarone, so what Kool-Aid are the advocates drinking?

Adenosine, yes adenosine the SVT (SupraVentricular Tachycardia) drug, appears to be more effective at treating ventricular tachycardia than amiodarone – and adenosine is faster and safer than amiodarone.[8]

What if the patient becomes unstable? First start an IV (IntraVenous) line. Then sedate the patient. Then apply defibrillator pads. After the patient is adequately sedated, then cardiovert. We do not need the pads on the patient first. If it takes a while to put the pads on, that is a problem with the ability of the doctors and nurses, not a medical problem.

It does not appear as if any patient received amiodarone or procainamide until after waiting in the ED (Emergency Department) for over an hour. Were some patients cardioverted in well under an hour? Probably. The important consideration is that the doctors and nurses be able to apply the defibrillator pads properly and quickly and deliver a synchronized cardioversion in less than a minute. If the patient has not yet been sedated, the cardioversion should be delayed until after the patient is adequately sedated, so the intervention that depends most on time is the sedation of the patient.
 

VT + Amiodarone Cardioversion
 

Is there a better treatment than amiodarone? Sedate the patient before the patient becomes unstable, then cardiovert. How do the MACEs (Major Adverse Cardiac Events) compare with sedation and cardioversion vs. antiarrhythmic treatment.
 

5.4 Proarrhythmia
Amiodarone may cause a worsening of existing arrhythmias or precipitate a new arrhythmia. Proarrhythmia, primarily torsade de pointes (TdP), has been associated with prolongation, by intravenous amiodarone, of the QTc interval to 500 ms or greater. Although QTc prolongation occurred frequently in patients receiving intravenous amiodarone, TdP or new-onset VF occurred infrequently (less than 2%). Monitor patients for QTc prolongation during infusion with amiodarone. Reserve the combination of amiodarone with other antiarrhythmic therapies that prolong the QTc to patients with life-threatening ventricular arrhythmias who are incompletely responsive to a single agent.
[9]

 

All antiarrhythmic drugs can cause arrhythmias. In the absence of information about a specific problem that is best addressed by a specific drug (amiodarone is the opposite of specific), we should avoid treatments that have such a high potential for harm.

Amiodarone doesn’t even do a good job of preventing arrhythmias.
 

Intravenous amiodarone did not prevent induction of sustained ventricular tachycardia in any of five patients inducible at baseline. Of six patients with non-sustained ventricular tachycardia, five had sustained ventricular tachycardia or fibrillation induced after amiodarone infusion.[10]

 

Is anything worse than amiodarone? Even epinephrine, yes epinephrine the inadequately tested cardiac arrest drug, has been followed by improved outcomes from V Tach after amiodarone failed.[11]
 

What is best for the patient?

Sedation, search for reversible causes, apply defibrillator pads, and be prepared to cardiovert.

Maybe sedation isn’t that important? This is by Dr. Peter Kowey, one of the top cardiologists in the world.
 

The man’s very first utterance was, “If it happens again, just let me die.”

As I discovered, the reason for this patient’s terror was that he had been cardioverted in an awake state. Ventricular tachycardia had been relatively slow, he had not lost consciousness, and the physicians, in the heat of the moment, had not administered adequate anesthesia. Although the 5 mg of intravenous diazepam had made him a bit drowsy, he felt the electric current on his chest and remembered the event clearly.

The patient’s mental state complicated the case considerably.[12]

 

How unimportant is sedation? How unimportant is consent?

For sedation, I would recommend ketamine, but etomidate was recommended in the podcast. Both work quickly and the most important obstacle to immediate treatment of a patient who suddenly deteriorates is the time to effect of sedation. Neither drug is expected to interfere with perfusion, which is the main excuse given for avoiding sedation for cardioversion.

This study is very small (not the fault of the authors), but it adds to the evidence that amiodarone is not a good first treatment for the patient.
 

Go listen to the podcast by Dr. Salim Rezaie and Dr. Anand Swaminathan REBELCast: The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia

 

Over the years, I have written a bit about cardioversion and the importance of sedation –

Cardioversion – I’m not doing that, you do it! – Mon, 24 Mar 2008

Cardioversion – 2010 ACLS – Part I – Mon, 25 Oct 2010

Cardioversion – 2010 ACLS – Part II – Sun, 31 Oct 2010

Cardioversion – 2010 ACLS – Part III – Thu, 11 Nov 2010

On the relative wisdom of synchronized cardioversion without sedation – Part I – Thu, 11 Nov 2010

On the relative wisdom of synchronized cardioversion without sedation – Part II – Fri, 12 Nov 2010

Synchronized Cardioversion Without Sedation – Part II Scallywag’s Response – Sun, 14 Nov 2010

On the relative wisdom of synchronized cardioversion without sedation – Part III – Tue, 16 Nov 2010

On the relative wisdom of synchronized cardioversion without sedation – Part IV – Wed, 24 Nov 2010

Comments on Cardioversion – 2010 ACLS – Part II – Mon, 16 Apr 2012
 

I have also written a bit about amiodarone –

Merit Badge Courses, Amiodarone, and tPA – Fri, 17 Sep 2010

Amiodarone for Cardiac Arrest in the 2010 ACLS – Part I – Wed, 01 Dec 2010

Amiodarone for Cardiac Arrest in the 2010 ACLS – Part II – Fri, 03 Dec 2010

Is Nexterone the Next Amiodarone? – Sat, 04 Dec 2010

Amiodarone for Cardiac Arrest in the 2010 ACLS – Part III – Mon, 06 Dec 2010

Where are the Black Box Warnings on These Drugs – I – Mon, 05 Dec 2011

Where are the Black Box Warnings on These Drugs – II – Sun, 11 Dec 2011

Is Amiodarone the Best Drug for Stable Ventricular Tachycardia – Wed, 14 Dec 2011

V Tach Storm – Part I – Wed, 28 Dec 2011

V Tach Storm – Part II – Thu, 29 Dec 2011

Nifekalant versus lidocaine for in-hospital shock-resistant ventricular fibrillation or tachycardia – Wed, 04 Jan 2012

NIH launches trials to evaluate CPR and drugs after sudden cardiac arrest – Sun, 29 Jan 2012

What Will Be the Next Standard Of Care We Eliminate – Wed, 28 Mar 2012

Happy Adenosine Day – Tue, 12 Jun 2012

Too Much Medicine and Evidence-Based Guidelines – Part I – Tue, 26 Jun 2012

Too Much Medicine and Evidence-Based Guidelines – Part II – Tue, 03 Jul 2012

Ondansetron (Zofran) Warning for QT Prolongation – is Amiodarone next? – Part I – Mon, 02 Jul 2012

Ondansetron (Zofran) Warning for QT Prolongation – is Amiodarone next? – Part II – Thu, 05 Jul 2012

Wide variability in drug use in out-of-hospital cardiac arrest: A report from the resuscitation outcomes consortium – Part I – Mon, 17 Sep 2012

Wide variability in drug use in out-of-hospital cardiac arrest: A report from the resuscitation outcomes consortium – Part II – Tue, 18 Sep 2012

How do we measure the QT segment when there are prominent U waves? – Thu, 13 Dec 2012

Woman with Risks for Torsades de Pointes Dying within Hours of Leaving the Emergency Department – Wed, 02 Jan 2013

Examples of Ventricular Tachycardia Caused by Amiodarone – Part I – Tue, 28 May 2013

Publication Bias – The Lit Whisperers – Tue, 11 Jun 2013

Standards Of Care – Ventricular Tachycardia – Wed, 31 Jul 2013

Footnotes:

[1] Dr. Kudenchuk is Misrepresenting ALPS as ‘Significant’
Tue, 12 Apr 2016
Rogue Medic
Article

[2] Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest
Mon, 04 Apr 2016
Rogue Medic
Article

[3] Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest.
Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, Leroux B, Vaillancourt C, Wittwer L, Callaway CW, Christenson J, Egan D, Ornato JP, Weisfeldt ML, Stiell IG, Idris AH, Aufderheide TP, Dunford JV, Colella MR, Vilke GM, Brienza AM, Desvigne-Nickens P, Gray PC, Gray R, Seals N, Straight R, Dorian P; Resuscitation Outcomes Consortium Investigators.
N Engl J Med. 2016 May 5;374(18):1711-22. doi: 10.1056/NEJMoa1514204. Epub 2016 Apr 4.
PMID: 27043165

CONCLUSIONS
Overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia.

[4] Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study.
Ortiz M, Martín A, Arribas F, Coll-Vinent B, Del Arco C, Peinado R, Almendral J; PROCAMIO Study Investigators.
Eur Heart J. 2016 Jun 28. pii: ehw230. [Epub ahead of print]
PMID: 27354046

Free Full Text from European Heart Journal.

[5] Amiodarone or procainamide for the termination of sustained stable ventricular tachycardia: an historical multicenter comparison.
Marill KA, deSouza IS, Nishijima DK, Senecal EL, Setnik GS, Stair TO, Ruskin JN, Ellinor PT.
Acad Emerg Med. 2010 Mar;17(3):297-306.
PMID: 20370763 [PubMed – indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.

[6] Amiodarone is poorly effective for the acute termination of ventricular tachycardia.
Marill KA, deSouza IS, Nishijima DK, Stair TO, Setnik GS, Ruskin JN.
Ann Emerg Med. 2006 Mar;47(3):217-24. Epub 2005 Nov 21.
PMID: 16492484 [PubMed – indexed for MEDLINE]

[7] Intravenous amiodarone for the pharmacological termination of haemodynamically-tolerated sustained ventricular tachycardia: is bolus dose amiodarone an appropriate first-line treatment?
Tomlinson DR, Cherian P, Betts TR, Bashir Y.
Emerg Med J. 2008 Jan;25(1):15-8.
PMID: 18156531 [PubMed – indexed for MEDLINE]

[8] Adenosine for wide-complex tachycardia – diagnostic?
Thu, 23 Aug 2012
Rogue Medic
Article

[9] AMIODARONE HYDROCHLORIDE- amiodarone hydrochloride injection, solution
DailyMed
5 WARNINGS AND PRECAUTIONS
FDA Label

[10] Effects of intravenous amiodarone on ventricular refractoriness, intraventricular conduction, and ventricular tachycardia induction.
Kułakowski P, Karczmarewicz S, Karpiński G, Soszyńska M, Ceremuzyński L.
Europace. 2000 Jul;2(3):207-15.
PMID: 11227590 [PubMed – indexed for MEDLINE]

Free Full Text PDF + HTML from Europace

[11] Low doses of intravenous epinephrine for refractory sustained monomorphic ventricular tachycardia.
Bonny A, De Sisti A, Márquez MF, Megbemado R, Hidden-Lucet F, Fontaine G.
World J Cardiol. 2012 Oct 26;4(10):296-301. doi: 10.4330/wjc.v4.i10.296.
PMID: 23110246 [PubMed]

Free Full Text from PubMed Central.

[12] The calamity of cardioversion of conscious patients.
Kowey PR.
Am J Cardiol. 1988 May 1;61(13):1106-7. No abstract available.
PMID: 3364364

Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, Leroux B, Vaillancourt C, Wittwer L, Callaway CW, Christenson J, Egan D, Ornato JP, Weisfeldt ML, Stiell IG, Idris AH, Aufderheide TP, Dunford JV, Colella MR, Vilke GM, Brienza AM, Desvigne-Nickens P, Gray PC, Gray R, Seals N, Straight R, Dorian P, & Resuscitation Outcomes Consortium Investigators (2016). Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. The New England journal of medicine, 374 (18), 1711-22 PMID: 27043165

Ortiz M, Martín A, Arribas F, Coll-Vinent B, Del Arco C, Peinado R, Almendral J, & PROCAMIO Study Investigators (2016). Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. European heart journal PMID: 27354046

Marill KA, deSouza IS, Nishijima DK, Senecal EL, Setnik GS, Stair TO, Ruskin JN, & Ellinor PT (2010). Amiodarone or procainamide for the termination of sustained stable ventricular tachycardia: an historical multicenter comparison. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 17 (3), 297-306 PMID: 20370763

Marill KA, deSouza IS, Nishijima DK, Stair TO, Setnik GS, & Ruskin JN (2006). Amiodarone is poorly effective for the acute termination of ventricular tachycardia. Annals of emergency medicine, 47 (3), 217-24 PMID: 16492484

Tomlinson DR, Cherian P, Betts TR, & Bashir Y (2008). Intravenous amiodarone for the pharmacological termination of haemodynamically-tolerated sustained ventricular tachycardia: is bolus dose amiodarone an appropriate first-line treatment? Emergency medicine journal : EMJ, 25 (1), 15-8 PMID: 18156531

Kułakowski P, Karczmarewicz S, Karpiński G, Soszyńska M, & Ceremuzyński L (2000). Effects of intravenous amiodarone on ventricular refractoriness, intraventricular conduction, and ventricular tachycardia induction. Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology, 2 (3), 207-15 PMID: 11227590

Bonny A, De Sisti A, Márquez MF, Megbemado R, Hidden-Lucet F, & Fontaine G (2012). Low doses of intravenous epinephrine for refractory sustained monomorphic ventricular tachycardia. World journal of cardiology, 4 (10), 296-301 PMID: 23110246

Kowey PR (1988). The calamity of cardioversion of conscious patients. The American journal of cardiology, 61 (13), 1106-7 PMID: 3364364

.

Is EMS a Trade or a Profession?

 

In the current issue of JEMS, there is an article by Dr. Bryan Bledsoe that does an excellent job of identifying many of the problems with low standards in EMS – at least if the quality of care is important.
 

Also, if you will note, the welding curriculum was revised in 2011.

The paramedic curriculum was last revised in 2009. Which trades would you say have had the most changes in the last eight to 10 years? Certainly changes in EMS have occurred much more frequently and are much more significant than those that have occurred in welding.[1]

 
trade vs profession 1

 
In some places, EMS has been more aggressive in changing treatment guidelines/protocols to improve the care delivered to patients. In other places, change has been resisted.

Backboards are rarely used in the places that have admitted that we do not have any valid evidence that backboards improve outcomes, while we do have good evidence that backboards cause harm. Even more important is the evidence that manipulating the patient’s spine in order to stabilize the spine is wishful thinking that encourages us to do exactly what we claim to be trying to prevent.

High dose NTG (NiTroGlycerin – GTN GlycerylTriNitrate in Commonwealth countries) is becoming much more widely used for acute CHF/ADHF (Acute Decompensated Heart Failure), because high dose NTG dramatically improves survival and decreases the perceived need for aggressive airway manipulation.

Likewise, furosemide is being eliminated from the CHF/ADHF guidelines/protocols, because furosemide does not do what it is supposed to do and furosemide causes harm that it is not supposed to cause.

Ketamine is becoming the drug for many indications. Ketamine may be the best sedative, best analgesic, best agitated delirium treatment available to EMS.

How do we know that we have been harming patients?

Enough people stopped listening to the old timers, the QA/QI/CYA people who don’t understand quality, the brand new if it were dangerous, it wouldn’t be in the protocol people, and other opponents of quality care.

People are paying more attention to the evience, rather than making excuses for the absence of evidence.
 

What is important is whether or not the graduating paramedic is competent and ready to assume the important role of prehospital care.[1]

 

Many states use the NREMT (National Registry of EMTs) test to determine if a paramedic is ready to become a new hire paramedic with no experience, some day to be able to work without a supervisor present. Some states continue to require this babe in the woods test of outdated material as their goal for even experienced paramedics.

The NREMT is holding EMS back.
 

It is time for the national standard curriculum to go away. We must meet and decide what the core competencies of a paramedic will be. We must validate these core competencies through scientific study. Then, we should leave it up to the educators to determine how best to educate their students in these core competencies.[1]

 

The paramedic curriculum, revered by the NREMT, harms patients.

Why are we protecting a curriculum that harms patients?

Footnotes:

[1] Is EMS a Trade or a Profession?
Thu, Jul 28, 2016
ByBryan Bledsoe, DO, FACEP, FAAEM, EMT-P
JEMS Editorial Board member
Journal of EMS (JEMS)
Article

.

Deja vu all over again in segregation

 

I was just a little kid when Alabama Governor George Wallace gave his famous inauguration speech announcing segregation now, segregation tomorrow, and segregation forever.[1] I had hoped that we, in America, had matured and improved our morality in the last half century.
 


 

Alabama Supreme Court Chief Justice Roy Moore wants to prove that segregation, and other immoral acts, still get votes in Alabama.[2] The Alabama Supreme Court is elected and today the Chief Justice demonstrated that he will continue to pander to the immorality of voters. He was removed from office in 2003 for idolatry, but the voters support idolatry – as long as it is their version of the golden calf. Because tradition has arbitrarily limited the rights of some Americans, some Americans think that immoral tradition should continue.

These defenders of immorality claim that they are defending Biblical marriage. With so many forms of God-endorsed Biblical marriage, why do they defend only one form? Why not the polygamy that God approved of in the Bible? Why not the selling of a daughter into sexual slavery that God approved of in the Bible? Why do they leave out the parts of the Bible that they find embarrassing?
 

7 “If a man sells his daughter as a female slave, she is not to [a]go free as the male slaves [b]do. 8 If she is [c]displeasing in the eyes of her master [d]who designated her for himself, then he shall let her be redeemed. He does not have authority to sell her to a foreign people because of his [e]unfairness to her. 9 If he designates her for his son, he shall deal with her according to the custom of daughters. 10 If he takes to himself another woman, he may not reduce her [f]food, her clothing, or her conjugal rights. 11 If he will not do these three things for her, then she shall go out for nothing, without payment of money. Exodus 21:7-11[3]

 

What about all of the other forms of Biblical marriage that the God of the Bible endorses?
 

biblical marriages
Image credit.
 

Fortunately, we live in America, so these examples of Biblical immorality are prohibited.

Justifications of slavery are rooted in the Bible and an economic system that is so obscene that it is used as a metaphor for other, less bad economic systems, such as communism and Nazism. We had to defend America against a rebellion by those who wanted to expand slavery. It took half a million deaths in a war to end this Biblical immorality.
 

Justifications of laws prohibiting contraception are rooted in the Bible. Struck down by the American Supreme Court in Griswold v. Connecticut in 1965.[4]
 

Justifications of laws prohibiting interracial marriage are rooted in the Bible. Struck down by the American Supreme Court in Loving v. Virginia in 1967.[5]
 

Justifications of laws prohibiting marriage equality are rooted in the Bible. Struck down by the American Supreme Court in Obergefell v. Hodges in 2015.[6]
 

To paraphrase what has been written elsewhere, The fact that I can no longer sell my daughter as a sex slave means that we have already redefined marriage. It is just one of many parts of eternal and unchanging laws of the God of the Bible that are illegal in civilized countries.

On the other hand, maybe these Christians are right. Maybe we should return to Biblical marriage. I don’t make much money as a paramedic and my daughter got her looks from her mother. The bidding starts at . . . well, make me an offer. It is the moral thing to do, according to the Bible.

When will we stop listening to Bible thumpers promoting immorality in the name of their interpretation of their Bible?

The American Constitution is in conflict with the Bible, because the Founding Fathers were more interested in fair play than in promoting persecution by the religious. The Founding Fathers could have limited the vote (and political office) to Protestants, but they explicitly forbade such discrimination.[7]

So many of these segregationists claim to disapprove of big government, but demand a big government to enforce their rules of watered down sharia. Hypocrisy seems to be required to defend such blatant immorality.

Footnotes:

[1] George Wallace’s 1963 Inaugural Address
Wikipedia
Article

[2] The Quixotic Adventures of Roy Moore – Alabama’s chief justice issued an order on Wednesday to keep the state’s same-sex marriage ban intact despite the Supreme Court’s landmark ruling last year.
The Atlantic
Matt Ford
5:15 PM ET
Article
 

Alabama Supreme Court Chief Justice Roy Moore issued an administrative order Wednesday that effectively banned same-sex marriages in the state, less than seven months after the U.S. Supreme Court ruled that same-sex marriage bans violated the Constitution.

 

[3] Exodus 21:7-11
New American Standard Bible (NASB)
Bible Gateway – A Christian site that allows you to use any other version if you like.
God
Link to these holy words of the God of the Bible

[4] Griswold v. Connecticut
U.S. Supreme Court
Decided: June 7, 1965
FindLaw
Transcript

[5] Loving v. Virginia
U.S. Supreme Court
Decided: June 12, 1967
Cornell University Law School
Transcript

[6] Obergefell v. Hodges
U.S. Supreme Court
Decided: June 26 2015
SCOTUSblog
Transcript

[7] Article VI Section 3
U.S. Constitution
Transcript
 

The Senators and Representatives before mentioned, and the Members of the several State Legislatures, and all executive and judicial Officers, both of the United States and of the several States, shall be bound by Oath or Affirmation, to support this Constitution; but no religious Test shall ever be required as a Qualification to any Office or public Trust under the United States.

 

Highlighting is mine.
 

.

2015 In Review – Superstitious Standards of Care Suffer Small Losses, But Continue to be Favorites

 

What changed, or almost changed in 2015?

Withholding epinephrine (adrenaline in Commonwealth countries) in cardiac arrest is still heresy. This use of epinephrine is not based on evidence of improved outcomes that matter to patients – unless the patient is a pig/dog/rat with no heart disease having an artificially produced cardiac arrest.

The Jacobs trial ways sabotaged by politicians, the media, and other opponents of science claiming that depriving patients of the standard witchcraft is unethical.[1] Using inadequately tested hunches on uninformed patients, as long as everyone else is doing it, appears to be their idea of ethical behavior. However, the Paramedic2 trial has been underway for about a year and should provide results in 2018.[2]
 

paramedic2_logo
 

There probably is some benefit for cardiac arrest patients who are not having heart attacks, but we do not currently try to identify them. We also do not know what dose or frequency is best or when to give epinephrine. Paramedic2 will only be able to answer some of those questions.
 

Withholding ventilation is a less defended heresy, at least in Pennsylvania.
 

AVOID endotracheal intubation and patient packaging during initial 10 minutes

Ventilation Options6:

  • No Ventilation
  • 1 ventilation every 10-15 compressions8 (Monitor Perfusion with Capnography[3]
  •  

    However, the AHA (American Heart Association) and ILCOR (International Liaison Committee On Resuscitation) 2015 resuscitation guidelines double down on baseless fears –
     

    2015 Evidence Review
    There is concern that delivery of chest compressions without assisted ventilation for prolonged periods could be less effective than conventional CPR (compressions plus breaths) because the arterial oxygen content will decrease as CPR duration increases.
    [4]

     

    There is no evidence to support this fear, but using reason against irrational beliefs is often unsuccessful, since the irrational appeals to emotion and avoids reason.
     

    Medical directors have been recognizing that backboards were used because of irrational fear and assumptions of benefit that were based on hunches. Therefore many medical directors now recognize the absurdity of the use of this malpractice device and discourage the use of backboards.
     

    Pennsylvania has also removed chilled IV fluid from protocols following the failure of the treatment to improve outcomes for cardiac arrest patients, when given by EMS.

    Chilled IV fluid therapeutic hypothermia does work in the hospital, but not when provided by EMS.

    This is one of the reasons EMS should not automatically adopt treatments that work in the hospital. It is difficult for many in EMS to understand, but many in EMS still think that occasionally intubating a patient makes a paramedic as good as an anesthesiologist.
     

    In general, the state of EMS is best summed up by this statement by Prachi Sanghavi –

    Our current ambulance system is based on little scientific evidence.

    The scary thing for patients is that many in EMS are proud of our ignorance.
     

    Elsewhere in medicine in 2015.

    Thousands of Americans travel to regions with outbreaks of Ebola and help to stop the spread of infection. This was in spite of the panic being encouraged by the scientifically illiterate. We should have welcomed them home as we welcome home out military. Both of these groups of Americans risk their lives to protect others and should be treated better. They are far more ethical than our isolationist politicians.

    We learned that we need to add rats to the growing list of the non-human animals that exhibit empathy and will sacrifice to help others.[5] It appears that comparing those who opposed sending Americans to rats is unfair to the rats.
     

    Finally, 2015 was the 100th anniversary of Albert Einstein explaining that Isaac Newton was wrong about gravity, but that is the way science improves.
     

    PS – We also had push dose pressors added to the Pennsylvania protocols in 2015.

    Footnotes:

    [1] 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.

     

    [2] Paramedic2 – The Adrenaline Trial
    Warwick Medical School
    About

    [3] General Cardiac Arrest – Adult
    3031A – ALS – Adult
    Pennsylvania Emergency Health Services Council
    PA ALS Protocols in PDF format

    [4] 2015 Evidence Review
    2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
    Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality
    Adult BLS Sequence—Updated
    2015 Evidence Review

    [5] Rats forsake chocolate to save a drowning companion
    Science Magazine
    By Emily Underwood
    12 May 2015
    Article

    .

    Pennsylvania Eliminating Backboards for Potential Spinal Injuries

     
    Medical directors should already have every EMS provider in Pennsylvania following the new Statewide BLS Protocols, but the procrastinators have until July 1, 2015 to get everyone to aggressively avoid using backboards.

    We should not be manipulating the potentially injured spines of patients to get them onto backboards for no known benefit, while possibly causing permanent disabilities or other significant harms.
     

    Excessive motion of the spine may worsen spine fractures or spinal cord injuries (especially in patients with altered consciousness who can’t restrict their own spinal motion), but immobilization on a long spine board may also cause pain, agitation, respiratory compromise, and pressure ulcers. Patients with the following symptoms or mechanisms of injury should be assessed to determine whether restriction of spinal motion is required:[1]

     


     

    What are the full steps to be performed for someone suspected of having an unstable spinal injury?
     

    Restrict Spinal Motion

    Apply Rigid Cervical Collar[1]

     

    We are beginning to realize that collars are probably also not be such a great idea,[2] but this is only one step to decrease the harm we cause for no apparent benefit.
     

    If ambulatory,

    Allow patient to move to stretcher mattress with minimal spinal motion3 [1]

     

    This is just recognizing that people have been walking to stretchers without sudden onset of paralysis, so manipulating the patient’s spine onto a flat board for no known benefit was never a good idea. It was just dogma, that went unquestioned for too long.
     

    If nonambulatory,

    Use backboard, scoop/orthopedic stretcher, vacuum mattress, or other device to move patient to stretcher with minimal spinal motion4,5 [1]

     

    We could use a sheet, since manipulating the patient onto a backboard, or other device, may result in much more movement of the spine than sliding a sheet under the patient and using the sheet to lift the patient.
     

    Use CID may be used to further restrict spinal motion[1]

     

    The typo is not important, but we can consider putting some sort of blocks next to the patient’s head to keep the head of an unconscious patient from flopping around.
     

    Transport on stretcher mattress without backboard if patient ambulatory or if scoop/orthopedic stretcher can be removed with minimal patient motion.[1]

     

    Again, the use of a sheet to move the patient may be the preferred method, since the use of the sheet may produce the least manipulation of the spine. We are trying to minimize the manipulation of the spine, not trying to defend some dogma that there is only one right way of doing things, regardless of outcomes. The patients’ outcomes are what matter, not adherence to the protocol at the expense of the patients.

    The protocol clearly does not limit us to using backboards, scoops, orthopedic stretchers, or vacuum mattresses.

    Using a sheet to move the patient, so that it does not produce more manipulation that would be produced by using these other devices appears to be encouraged, if not required. We are supposed to use the method that is least likely to harm the patient, which probably makes a backboard the least acceptable method.
     

    This protocol also applies to assessment of patients before inter-facility transfer for injuries from a traumatic mechanism unless a medical command physician agrees that the patient may be transported without restriction of spinal motion.[1]

     

    Any suggestion that a patient is going to be manipulated back onto a backboard should result in a firm, No, thank you.

    I am not a lawyer, but I wouldn’t be surprised to see law suits against EMS agencies/providers who continue to cause harm with backboards, when there are less harmful alternatives available and no protocol/standard of care to defend this abuse of patients by placing them on backboards.
     


     

    Pennsylvania is the largest state (not all states have statewide protocols, so this is often only at the agency level) to do this and joins a growing list of EMS agencies that are putting patients ahead of superstition –
     
     

    Agencies/EMS Systems Minimizing Backboard use –
     

    Let me know if I should add your agency to this list.
     
     

    Alameda County
    CA
     

    Albuquerque-Bernalillo County Medical Control Board
    NM
     

    Bend Fire and Rescue
    Bend, OR
     

    Bernalillo County Fire Department
    NM
     

    CentraCare Health
    Monticello, MN
     

    Chaffee County EMS
    CO
     

    Connecticut, State of
    CT
     

    Durham County EMS
    NC
     

    Eagle County Ambulance District
    CO
     

    HealthEast Medical Transportation
    St. Paul, MN
     

    Johnson County EMS
    KS
     

    Kenosha Fire Department
    Kenosha, WI
     

    Macomb County EMS Med Control Authority
    Macomb County, MI
     

    Maryland, State of
    MD
     

    MedicWest Ambulance
    NV
     

    Milwaukee EMS
    WI
     

    North Memorial Ambulance & Aircare
    Minneapolis, MN
     

    Palm Beach County Fire Rescue
    FL
     

    Pennsylvania, Commonwealth of
    PA
     

    Pewaukee Fire Dept
    Pewaukee, WI
     

    Rio Rancho Fire Department
    NM
     

    SERTAC (Southeast Regional Trauma Advisory Council)
    WI
     

    Wichita-Sedgwick County EMS System
    KS
     

    Xenia Fire Department
    Xenia, OH
     
     

    Outside of the US –
     

    NHS (National Health Service)
    England (UK?)
     

    St. John Ambulance
    New Zealand
     

    Norway
     

    QAS
    Queensland, Australia
     
     

    Footnotes:

    [1] Spinal Care
    2015 Pennsylvania Statewide BLS Protocols
    261 – BLS – Adult/Peds
    pp 59 – 61
    Protocols in PDF Download Format.

    [2] Why EMS Should Limit the Use of Rigid Cervical Collars
    Bryan Bledsoe, DO, FACEP, FAAEM, EMT-P and Dale Carrison, DO, FACEP
    Monday, January 26, 2015
    JEMS
    Article

    .

    The Kitchen Sink Approach to Cardiac Arrest

     
    When faced with death, we can become desperate, stop thinking clearly, and just try anything.

    Alternative medicine thrives on the desperation of people who are not thinking clearly. We should be better than that, but are we?

    A recent comment on The Myth that Narcan Reverses Cardiac Arrest[1] proposes that I would suddenly give kitchen sink medicine a try, if I really care about the patient.

    Kitchen sink medicine? It’s better to do something and harm the patient, than to limit treatment to what works. Throw everything, including the kitchen sink, at the patient.

    Mike Karras writes –
     

    I will leave you with this question sir and I am interested to hear your answer. You walk in to find your 14 year old daughter that intentionally overdosed on morphine in a suicide attempt and she is in cardiac arrest. How would you treat her? Would you give her Narcan? I think you would.[2]

     

    Mike, I am thrilled to read that you do not think that I care about the outcomes of my patients, unless the patient happens to be my daughter. I am even more thrilled that you made my imaginary daughter suicidal.

    No, I would not use naloxone (Narcan).

    I would also not use homeopathy, acupuncture, sodium bicarbonate, incantations, or magic spells to treat my daughter during cardiac arrest. Voodoo only works on believers, because voodoo is just a placebo/nocebo.[3]
     


    Image credit.
     

    Does really wanting something to be true make it true? If you believe in magic, the answer is Yes, believing makes it true. If you examine the evidence for that belief, you have several choices. You can acknowledge your mistake, or you can employ a bit of cognitive dissonance, or . . . . Cognitive dissonance is the way our minds copes with the conflict, when reality and belief do not agree, and we choose to reject reality.[4]

    According to the ACLS (Advanced Cardiac Life Support) guidelines –
     

    Naloxone has no role in the management of cardiac arrest.[5]

     

    If the patient is suspected of having a cardiac arrest because of an opioid overdose (overdose of heroin, fentanyl, morphine, . . . ), the treatments should include ventilation and chest compressions. If those do not provide a response, epinephrine (Adrenaline in Commonwealth countries) is added.

    An opioid overdose can produce respiratory depression and/or vasodilation. I can counter both of those with chest compressions, ventilation, and maybe epinephrine. Naloxone works on opioid receptors. What does naloxone add?

    Does naloxone’s stimulation of an opioid receptor produce more ventilation than bagging/intubating?

    Does naloxone’s stimulation of an opioid receptor produce more oxygenation than bagging/intubating?

    Does naloxone’s stimulation of an opioid receptor produce more vasoconstriction than chest compressions and epinephrine?*

    Also –
     

    Don’t confuse post- or pre–arrest toxicologic interventions with the actual cardiac arrest event.[6]

     

    Dead people do not respond to treatments the same way living people do.
     
     

    See also –
     

    Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions – Tue, 01 Nov 2011

    Naloxone in cardiac arrest with suspected opioid overdoses – Thu, 05 Apr 2012

    The Myth that Narcan Reverses Cardiac Arrest – Wed, 12 Dec 2012

    Resuscitation characteristics and outcomes in suspected drug overdose-related out-of-hospital cardiac arrest – Sun, 03 Aug 2014
     

    * Late edit – 02/17/2015 10:52 – added the word naloxone’s to the three sentences about the relative amount of stimulus provided by standard ACLS and by the addition of naloxone. Thanks to Brian Behn for pointing out the lack of clarity.

    Footnotes:

    [1] The Myth that Narcan Reverses Cardiac Arrest
    Wed, 12 Dec 2012
    Rogue Medic
    Article

    [2] Comment by Mike Karras
    The Myth that Narcan Reverses Cardiac Arrest by Rogue Medic
    Mon, 16 Feb 2015
    Article

    [3] Nocebo
    Wikipedia
    Article

    A nocebo is an inert agent that produces negative effects. What this means is that nocebo effects are adverse placebo effects. There is no reason to believe that placebos only produce positive effects or no effects at all.

    [4] Cognitive dissonance
    Wikipedia
    Article

    [5] Opioid Toxicity
    2010 ACLS
    2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
    Part 12.7: Cardiac Arrest Associated With Toxic Ingestions
    Free Full Text from Circulation

    [6] Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions
    Emergency Medicine News:
    October 2011 – Volume 33 – Issue 10 – pp 16-18
    doi: 10.1097/01.EEM.0000406945.05619.ca
    InFocus
    Roberts, James R. MD
    Article

    Read the whole article about antidotes and cardiac arrest.

    .

    Happy Darwin Day 2015

     

    Charles Darwin is one of the greatest scientists of all time. We should celebrate the tremendous work that he has done, but it is considered politically incorrect to point out that evolution is real and that we use science to learn about reality.

    To celebrate Darwin Day, Ken Ham has decided to do even more to embarrass himself. You remember him. He is the guy who debated Bill Nye.
     


     

    What would it take to change your mind?
    Bill Nye – Evidence.
    Ken Ham – Nothing.

    Nothing? If God were to tell Ken Ham that evolution is true, that would not change Ken Ham’s mind, because his mind is made up? Or is Ken Ham telling us that he does not believe that God exists?
     

    Ken Ham claims to understand science, but the scientists he employs are required to sign a statement that what Ken Ham believes sets a limit their science. Ken Ham is celebrating today as Darwin was wrong Day.[1]
     

    The 66 books of the Bible are the written Word of God. The Bible is divinely inspired and inerrant throughout. Its assertions are factually true in all the original autographs. It is the supreme authority in everything it teaches. Its authority is not limited to spiritual, religious, or redemptive themes but includes its assertions in such fields as history and science.[2]

     

    Ken Ham tells us that only his interpretation of the Bible is the truth. Science encourages us to look everywhere for the truth.

    If you do not sign a Statement of Faith, you cannot work for Ken Ham. You only have to read the Bible to see that even the description of Creation has irreconcilable contradictions if Genesis is to be interpreted as science, rather than metaphor.
     

    24 Then God said, “Let the earth bring forth living creatures after [ag]their kind: cattle and creeping things and beasts of the earth after [ah]their kind”; and it was so. 25 God made the beasts of the earth after [ai]their kind, and the cattle after [aj]their kind, and everything that creeps on the ground after its kind; and God saw that it was good.

    26 Then God said, “Let Us make man in Our image, according to Our likeness; and let them rule over the fish of the sea and over the birds of the [ak]sky and over the cattle and over all the earth, and over every creeping thing that creeps on the earth.” 27 God created man in His own image, in the image of God He created him; male and female He created them.[3]

     
     

    God made Adam and Eve after making the animals.
     
     

    18 Then the Lord God said, “It is not good for the man to be alone; I will make him a helper [a]suitable for him.” 19 Out of the ground the Lord God formed every beast of the field and every bird of the [b]sky, and brought them to the man to see what he would call them; and whatever the man called a living creature, that was its name.[4]

     
     

    God made Adam and Eve before making the animals.
     
     

    It doesn’t matter which came first, if this is a metaphor, but if this is supposed to be literally true and accurate, then it does matter which came first.

    Is your God incapable of telling the difference between before and after? Ken Ham’s God can’t seem to tell the difference. Ken Ham seems to prefer to mock his God.

    Is your God limited by the restrictions Ken Ham arrogantly places on God?

    Is your God capable of using metaphors?

    Are there other places where your God uses metaphors in the Bible?
     


     

    Footnotes:

    [1] #DarwinWasWrongDay
    AiG (Answers in Genesis)
    Ken Ham’s Twitter hashtag encouraging rejection of evolution
    Page at AiG

    [2] Statement of Faith
    AiG (Answers in Genesis)
    Section 2: Basics
    Updated: December 12, 2012
    Accessed on February 12, 2015
    Page at AiG

    [3] Genesis 1:24-27
    New American Standard Bible (NASB)
    Bible Gateway (a Christian site)
    Passage

    Pick up a printed Bible. Look at whatever version of the Bible you like. You can look up one verse at a time to compare among versions.

    [4] Genesis 2:18-19
    New American Standard Bible (NASB)
    Bible Gateway (a Christian site)
    Passage

    .

    The Media are Just As Bad at Ethics As They are at Science

     
    There is another article about the adrenaline (epinephrine in non-Commonwealth countries) vs. placebo in cardiac arrest trial that is about to start in England.[1] Media sites no longer seem to want to spend money to get valid information on science or ethics. Forbes provides another example of the writer completely missing the obvious.
     

    It’s one thing to treat an incapacitated emergency patient without consent, when you’re administering a standard therapy already proven to be beneficial.[2]

     

    Nobody is being deprived of anything that has been adequately tested on humans. Why assume that the untested and unknown standard treatment is beneficial?

    The active drug (adrenaline) is an unknown. There is no good evidence that adrenaline improves outcomes.

    If you disagree, provide some evidence that shows that adrenaline is better than placebo at anything that matters.

    Adrenaline is an unknown because it has never been adequately studied. The only study that has tried to compare it to placebo was limited by politicians and the media – the people who know the least about how science works.

    This is like being told that you will be put in a room with either a killer or a mannequin. Which one do you want. Except that we do not know if adrenaline is a killer. We do not have enough information. The only way to find out is to study it.

    The research so far is negative. Is that because the adrenaline is given too late? Is that because too much adrenaline is given? Is that because we give it to everyone still dead after a few minutes?

    We do not know.

    We treat adrenaline like snake oil – Able to cure all kinds of cardiac arrest. Step right up and get your magic elixir. Cures baldness, too!
     


    Image credit.
     

    When the sales pitch is that the drug fixes everything, we should be very suspicious.

    Cardiac arrest due to blood loss?   Give adrenaline.

    Cardiac arrest due to slow heart rate?   Give adrenaline.

    Cardiac arrest due to fast heart rate?   Give adrenaline.

    Cardiac arrest due to irritated heart?   Give adrenaline.

    Cardiac arrest due to not enough stimulus to the heart?   Give adrenaline.

    Cardiac arrest due to drug over-dose?   Give adrenaline.

    Cardiac arrest due to drug under-dose?   Give adrenaline.

    Cardiac arrest due to diabetes problem?   Give adrenaline.

    Cardiac arrest due to infectious disease?   Give adrenaline.

    Cardiac arrest due to lightning strike?   Give adrenaline.

    Cardiac arrest due to drowning?   Give adrenaline.

    Cardiac arrest due to asthma?   Give adrenaline.

    Cardiac arrest due to stroke?   Give adrenaline.

    Cardiac arrest due to cancer?   Give adrenaline.

    Cardiac arrest due to adrenaline overdose?   Give adrenaline.

    We do not discriminate. We just give adrenaline. All of the other drugs have failed to produce a benefit, but we still believe in adrenaline without good evidence. We have been using adrenaline for over half a century on unsuspecting people and we still have no evidence that it works.
     

    However, the more important issue is what you as a patient think. Should scientists be able to enroll you in a life-or-death medical experiment without your consent?[2]

     

    Adrenaline has worked in laboratory animals, but every drug that is tested in humans is supposed to have worked in animals. Why doesn’t adrenaline work in humans? If it does work, where is the evidence?

    The standard of care is an experiment that is not controlled and not even acknowledged. The guidelines clearly state that we do not know what works and that we should only consider adrenaline, but that we do not have any good evidence that adrenaline improves outcomes for anyone.

    The ethical failure is that we have failed to find out if what we are giving is harmful.
     

    We have only improved outcomes when we have ignored the drugs and paid attention to chest compressions and defibrillation.
     

    We are lying to patients when we tell them that we know what works in cardiac arrest.

    How much worse than placebo is adrenaline? We don’t know. Failing to find out is what is unethical.

    Footnotes:

    [1] Does a Placebo vs. Adrenaline Study Deprive Patients of Necessary Care According to the Resuscitation Guidelines?
    Wed, 27 Aug 2014
    Rogue Medic
    Article

    [2] UK To Experiment on Cardiac Arrest Patients Without Their Consent
    8/27/2014 @ 3:55PM
    Paul Hsieh – Contributor
    Forbes
    Article

    .