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

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

    .

    Dextrose 10% in the Treatment of Out-of-Hospital Hypoglycemia

    ResearchBlogging.org
     

    Is 50% dextrose as good as 10% dextrose for treating symptomatic hypoglycemia?

    If the patient is disoriented, but becomes oriented before the full dose of dextrose is given, is it appropriate to continue to treat the patient as if the patient were still disoriented? If your protocols require you to keep giving dextrose, do the same protocols require you to keep giving opioids after the pain is relieved? Is there really any difference?

    50% dextrose has problems.
     

    Animal models have demonstrated the toxic effect of glucose infusions in the settings of cardiac arrest and stroke.2 Experimental data suggests that hyperglycemia is neurotoxic to patients in the setting of acute illness.1,3 [1]

     

    Furthermore, extravasation can cause necrosis.
     


    Image credit.[2]
     

    I expect juries to look at this kind of image and say, Somebody has to take one for the 50% dextrose team. We can’t expect EMS to change.

    Is 10% dextrose practical?
     

    Won’t giving less concentrated dextrose delay treatment?
     

    The median initial field blood glucose was 38 mg/dL (IQR = 28 mg/dL – 47 mg/dL), with subsequent blood glucose median of 98 mg/dL (IQR = 70 mg/dL – 135 mg/dL). Elapsed time after D10 administration before recheck was not uniform, with a median time to recheck of eight minutes (IQR = 5 minutes – 12 minutes).[1]

     

    If that is going to slow your system down, is it because you are transporting patients before they wake up?

    Did anyone require more than 10 grams of 10% dextrose, as opposed to 25 grams of 50% dextrose?
     

    Of 164 patients, 29 (18%) received an additional dose of intravenous D10 solution in the field due to persistent or recurrent hypoglycemia, and one patient required a third dose.[1]

     

    18% received a second dose, which is 20 grams of dextrose and still less than the total dose of 25 grams of dextrose given according to EMS protocols that still use 50% dextrose.

    Only one patient, out of 164 patients, required a third dose. That is 30 grams of dextrose.

    Only one patient, out of 164 patients, received as much as we would give according to the typical EMS protocol, which should be a thing of the past. If we are routinely giving too much to our patients, is that a good thing? Why?
     

    Maybe the blood sugars were not that low to begin with.
     


     

    The average was 38 mg/dL, which is not high.
     

    Maybe the change in blood sugar was small after just 10 grams of dextrose, rather than 25 grams.
     


     

    The average (mean) change was 67 mg/dL, which is enough to get a patient with a blood sugar of 3 up to 70.
     

    Maybe the blood sugar was not high enough after just 10 grams of dextrose, rather than 25 grams.
     


     

    The average (mean) repeat blood sugar was 106 mg/dL, which is more than enough.
     

    Maybe it took a long time to treat patients this way.
     


     

    The average (mean) time was 9 minutes, which is not a lot of time.
     

    Is this perfect?
     

    Three patients had a drop in blood glucose after D10 administration: one patient had a drop of 1 mg/dL; one patient had a drop of 10 mg/dL; and one patient had a drop of 19 mg/dL.[1]

     

    All patients, even the three with initial drops in blood sugar (one had an insulin pump still pumping while being treated) had normal blood sugars at the end of EMS contact.

    10% dextrose is cheaper, just as fast, probably less likely to cause hyperglycemia, probably less likely to cause rebound hypoglycemia, probably less likely to cause problems with extravasation, less of a problem with drug shortages, . . . .

    Why are we still resisting switching to 10% dextrose?
     

    Other articles on 10% dextrose.

    Footnotes:

    [1] Dextrose 10% in the treatment of out-of-hospital hypoglycemia.
    Kiefer MV, Gene Hern H, Alter HJ, Barger JB.
    Prehosp Disaster Med. 2014 Apr;29(2):190-4. doi: 10.1017/S1049023X14000284. Epub 2014 Apr 15.
    PMID: 24735872 [PubMed – indexed for MEDLINE]

    [2] Images in emergency medicine. Dextrose extravasation causing skin necrosis.
    Levy SB, Rosh AJ.
    Ann Emerg Med. 2006 Sep;48(3):236, 239. Epub 2006 Feb 17. No abstract available.
    PMID: 16934641 [PubMed – indexed for MEDLINE]

    Kiefer MV, Gene Hern H, Alter HJ, & Barger JB (2014). Dextrose 10% in the treatment of out-of-hospital hypoglycemia. Prehospital and disaster medicine, 29 (2), 190-4 PMID: 24735872

    Levy SB, & Rosh AJ (2006). Images in emergency medicine. Dextrose extravasation causing skin necrosis. Annals of emergency medicine, 48 (3) PMID: 16934641

    .

    The Controversy of Admitting ‘We Do Not Know What Works’

    ResearchBlogging.org

     

    There are several news articles today criticizing a study because the patients might be deprived of a drug that has not been adequately studied in humans. This criticism is coming from journalists – the people who publicized the fraudulent vaccines research by Andrew Wakefield, who was trying to sell his competing vaccine and was being paid to produce negative research by lawyers suing the vaccine companies.[1]

    The real controversy is that this untested drug became the standard of care with no evidence that it improves outcomes that matter.

    Is it controversial to give a placebo, rather than a drug not yet adequately tested in humans?

    No.

    We are not informing patients that there is no evidence that the standard treatment is effective. We are not obtaining consent to give the unproven drug – epinephrine (Adrenaline in Commonwealth countries). How are the ethics different when we substitute a placebo for a mystery medicine?

    What is less ethical than continuing the tradition of giving an inadequately studied drug to people who cannot consent to treatment?

    Are we depriving patients of effective medicine or are we depriving them of witchcraft?

    If you think that epinephrine is effective medicine at improving survival to discharge, provide the evidence and stop this study. The reason the study is being done is that evidence of benefit does not exist.
     

    Click on image to make it larger.[2] The studies are in the footnotes.[3],[4],[5],[6],[7],[8],[9],[10]
     

    Is Adrenaline beneficial in cardiac arrest?

    Probably, but only for some patients and we do not know which patients benefit.

    Is Adrenaline harmful in cardiac arrest?

    Probably, but only for some patients and we do not know which patients are harmed.

    What is the right dose of Adrenaline in cardiac arrest?

    Pick a number – any number. We do not know the right dose.
     

     

    Even the patients who only received the minimum dose – 1 mg – had worse outcomes.[11]

    Wrong timing? Wrong dose? Wrong drug?

    We do not know.
     

    We have used this untested treatment for half a century and not bothered to find out if it works. A recent study shows that epinephrine produces worse outcomes when given by EMS later,[12] but that does not mean that the outcomes are good when epinephrine is given early. The study had no placebo group, so like a study comparing different doses of cyanide, just because one dose is not as bad as another dose, the results do not suggest that cyanide is beneficial.
     


     

    This is comparing three different treatments HDE (High-Dose Epinephrine), SDE (Standard-Dose Epinephrine), and NE (NorEpinephrine). The lines for the HDE and NE are so close to each other, that you may not be able to see the gold line.[13] Other studies produce similar results.[3],[14],[15],[16],[17] Only one study showed better ROSC with standard dose epinephrine.[18]
     

    Epinephrine does produce more ROSC (Return Of Spontaneous Circulation – at least a temporary pulse) than placebo, but high dose epinephrine produces even more ROSC than standard dose epinephrine, so why do we give the standard dose that only produces middling ROSC?

    Is ROSC the goal? No.

    For the guidelines (ACLS and ILCOR), ROSC is the basis for giving standard dose epinephrine, but it would make more sense to give high dose epinephrine if the goal is ROSC. More ROSC, but no more survivors leaving the hospital. If all we want is put the patient in a coma long enough to run up a big hospital bill, then the drugs are great.

    If we want people to leave the hospital alive, then We Do Not Know What Works.
     

    The guidelines are based on wishful thinking and rationalization. They are not based on improved survival. A lot of research is cited (hundreds of papers), but the research does not show improved survival with any drug(s).

    Will the guidelines be revised to remove epinephrine? Maybe.
     

    The exciting development is that these data create equipoise about the current standard of resuscitation care. The best available observational evidence indicates that epinephrine may be harmful to patients during cardiac arrest, and there are plausible biological reasons to support this observation. However, observational studies cannot establish causal relationships in the way that randomized trials can.[19]

     

    Some cocktails have produced better results than epinephrine in tiny studies. It is too probably too early to tell if these are just statistical aberrations. I will write about them later.

    Continued in Does a Placebo vs. Adrenaline Study Deprive Patients of Necessary Care According to the Resuscitation Guidelines?

    Footnotes:

    [1] “Piltdown medicine” and Andrew Wakefield’s MMR vaccine fraud
    Science-Based Medicine
    Posted by David Gorski
    January 6, 2011
    Article
     

    In a mere decade and a half, several decades of progress in controlling this scourge had been unravelled like a thread hanging off a cheap dress, all thanks to Andrew Wakefield and scandal mongers in the British press.

    [2] 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.

    [3] High dose and standard dose adrenaline do not alter survival, compared with placebo, in cardiac arrest.
    Woodhouse SP, Cox S, Boyd P, Case C, Weber M.
    Resuscitation. 1995 Dec;30(3):243-9.
    PMID: 8867714 [PubMed – indexed for MEDLINE]

    [4] Adrenaline in out-of-hospital ventricular fibrillation. Does it make any difference?
    Herlitz J, Ekström L, Wennerblom B, Axelsson A, Bång A, Holmberg S.
    Resuscitation. 1995 Jun;29(3):195-201.
    PMID: 7667549 [PubMed – indexed for MEDLINE]

    [5] Survival outcomes with the introduction of intravenous epinephrine in the management of out-of-hospital cardiac arrest.
    Ong ME, Tan EH, Ng FS, Panchalingham A, Lim SH, Manning PG, Ong VY, Lim SH, Yap S, Tham LP, Ng KS, Venkataraman A; Cardiac Arrest and Resuscitation Epidemiology Study Group.
    Ann Emerg Med. 2007 Dec;50(6):635-42. Epub 2007 May 23.
    PMID: 17509730 [PubMed – indexed for MEDLINE]

    Free Full Text Download in PDF format from prdupl02.ynet.co.il

    [6] Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.
    Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L.
    JAMA. 2009 Nov 25;302(20):2222-9.
    PMID: 19934423 [PubMed – indexed for MEDLINE]

    Free Full Text from JAMA

    [7] Outcome when adrenaline (epinephrine) was actually given vs. not given – post hoc analysis of a randomized clinical trial.
    Olasveengen TM, Wik L, Sunde K, Steen PA.
    Resuscitation. 2011 Nov 22. [Epub ahead of print]
    PMID: 22115931 [PubMed – as supplied by publisher]

    [8] 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.

     

    [9] Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest.
    Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S.
    JAMA. 2012 Mar 21;307(11):1161-8. doi: 10.1001/jama.2012.294.
    PMID: 22436956 [PubMed – indexed for MEDLINE]

    Free Full Text from JAMA.

    [10] Impact of early intravenous epinephrine administration on outcomes following out-of-hospital cardiac arrest.
    Hayashi Y, Iwami T, Kitamura T, Nishiuchi T, Kajino K, Sakai T, Nishiyama C, Nitta M, Hiraide A, Kai T.
    Circ J. 2012;76(7):1639-45. Epub 2012 Apr 5.
    PMID: 22481099 [PubMed – indexed for MEDLINE]

    Free Full Text from Circulation Japan.

    [11] Wide variability in drug use in out-of-hospital cardiac arrest: A report from the resuscitation outcomes consortium.
    Glover BM, Brown SP, Morrison L, Davis D, Kudenchuk PJ, Van Ottingham L, Vaillancourt C, Cheskes S, Atkins DL, Dorian P; Resuscitation Outcomes Consortium Investigators.
    Resuscitation. 2012 Nov;83(11):1324-30. doi: 10.1016/j.resuscitation.2012.07.008. Epub 2012 Jul 31.
    PMID: 22858552 [PubMed – indexed for MEDLINE]

    Free Full Text from PubMed Central.

    [12] 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.

    [13] A randomized clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest.
    Callaham M, Madsen CD, Barton CW, Saunders CE, Pointer J.
    JAMA. 1992 Nov 18;268(19):2667-72.
    PMID: 1433686 [PubMed – indexed for MEDLINE]

    [14] A comparison of standard-dose and high-dose epinephrine in cardiac arrest outside the hospital. The Multicenter High-Dose Epinephrine Study Group.
    Brown CG, Martin DR, Pepe PE, Stueven H, Cummins RO, Gonzalez E, Jastremski M.
    N Engl J Med. 1992 Oct 8;327(15):1051-5.
    PMID: 1522841 [PubMed – indexed for MEDLINE]

    Free Full Text from NEJM.

    [15] Standard doses versus repeated high doses of epinephrine in cardiac arrest outside the hospital.
    Choux C, Gueugniaud PY, Barbieux A, Pham E, Lae C, Dubien PY, Petit P.
    Resuscitation. 1995 Feb;29(1):3-9.
    PMID: 7784720 [PubMed – indexed for MEDLINE]

    [16] A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. European Epinephrine Study Group.
    Gueugniaud PY, Mols P, Goldstein P, Pham E, Dubien PY, Deweerdt C, Vergnion M, Petit P, Carli P.
    N Engl J Med. 1998 Nov 26;339(22):1595-601.
    PMID: 9828247 [PubMed – indexed for MEDLINE]

    Free Full Text from NEJM.

    [17] High dose versus standard dose epinephrine in cardiac arrest – a meta-analysis.
    Vandycke C, Martens P.
    Resuscitation. 2000 Aug 1;45(3):161-6.
    PMID: 10959014 [PubMed – indexed for MEDLINE]

    [18] High-dose epinephrine in adult cardiac arrest.
    Stiell IG, Hebert PC, Weitzman BN, Wells GA, Raman S, Stark RM, Higginson LA, Ahuja J, Dickinson GE.
    N Engl J Med. 1992 Oct 8;327(15):1045-50.
    PMID: 1522840 [PubMed – indexed for MEDLINE]

    Free Full Text from NEJM.

    [19] Questioning the use of epinephrine to treat cardiac arrest.
    Callaway CW.
    JAMA. 2012 Mar 21;307(11):1198-200. doi: 10.1001/jama.2012.313. No abstract available.
    PMID: 22436961 [PubMed – indexed for MEDLINE]

    Link to a free 6 1/2 minute recording of an interview with Dr. Callaway about this paper.

    On the right side of the page, to the right of the First Page Preview, is a section with the title Multimedia Related by Topic. Below that is Author Interview. Below that is some information about the edition, . . . , and below that is an embedded recording of the interview. Press on the arrow to play. That has the recording of the interview with Dr. Callaway.

    The interview with Dr. Callaway is definitely worth listening to.

    Larabee TM, Liu KY, Campbell JA, & Little CM (2012). Vasopressors in cardiac arrest: a systematic review. Resuscitation, 83 (8), 932-9 PMID: 22425731

    Woodhouse SP, Cox S, Boyd P, Case C, & Weber M (1995). High dose and standard dose adrenaline do not alter survival, compared with placebo, in cardiac arrest. Resuscitation, 30 (3), 243-9 PMID: 8867714

    Herlitz J, Ekström L, Wennerblom B, Axelsson A, Bång A, & Holmberg S (1995). Adrenaline in out-of-hospital ventricular fibrillation. Does it make any difference? Resuscitation, 29 (3), 195-201 PMID: 7667549

    Ong ME, Tan EH, Ng FS, Panchalingham A, Lim SH, Manning PG, Ong VY, Lim SH, Yap S, Tham LP, Ng KS, Venkataraman A, & Cardiac Arrest and Resuscitation Epidemiology Study Group (2007). Survival outcomes with the introduction of intravenous epinephrine in the management of out-of-hospital cardiac arrest. Annals of emergency medicine, 50 (6), 635-42 PMID: 17509730

    Olasveengen, T., Sunde, K., Brunborg, C., Thowsen, J., Steen, P., & Wik, L. (2009). Intravenous Drug Administration During Out-of-Hospital Cardiac Arrest: A Randomized Trial JAMA: The Journal of the American Medical Association, 302 (20), 2222-2229 DOI: 10.1001/jama.2009.1729

    Olasveengen TM, Wik L, Sunde K, & Steen PA (2011). Outcome when adrenaline (epinephrine) was actually given vs. not given – post hoc analysis of a randomized clinical trial. Resuscitation PMID: 22115931

    Jacobs IG, Finn JC, Jelinek GA, Oxer HF, & Thompson PL (2011). Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation, 82 (9), 1138-43 PMID: 21745533

    Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, & Miyazaki S (2012). Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA : the journal of the American Medical Association, 307 (11), 1161-8 PMID: 22436956

    Hayashi Y, Iwami T, Kitamura T, Nishiuchi T, Kajino K, Sakai T, Nishiyama C, Nitta M, Hiraide A, & Kai T (2012). Impact of early intravenous epinephrine administration on outcomes following out-of-hospital cardiac arrest. Circulation journal : official journal of the Japanese Circulation Society, 76 (7), 1639-45 PMID: 22481099

    Glover BM, Brown SP, Morrison L, Davis D, Kudenchuk PJ, Van Ottingham L, Vaillancourt C, Cheskes S, Atkins DL, Dorian P, & the Resuscitation Outcomes Consortium Investigators (2012). Wide variability in drug use in out-of-hospital cardiac arrest: A report from the resuscitation outcomes consortium. Resuscitation PMID: 22858552

    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

    Callaham M, Madsen CD, Barton CW, Saunders CE, & Pointer J (1992). A randomized clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest. JAMA : the journal of the American Medical Association, 268 (19), 2667-72 PMID: 1433686

    Brown CG, Martin DR, Pepe PE, Stueven H, Cummins RO, Gonzalez E, & Jastremski M (1992). A comparison of standard-dose and high-dose epinephrine in cardiac arrest outside the hospital. The Multicenter High-Dose Epinephrine Study Group. The New England journal of medicine, 327 (15), 1051-5 PMID: 1522841

    Choux C, Gueugniaud PY, Barbieux A, Pham E, Lae C, Dubien PY, & Petit P (1995). Standard doses versus repeated high doses of epinephrine in cardiac arrest outside the hospital. Resuscitation, 29 (1), 3-9 PMID: 7784720

    Gueugniaud PY, Mols P, Goldstein P, Pham E, Dubien PY, Deweerdt C, Vergnion M, Petit P, & Carli P (1998). A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. European Epinephrine Study Group. The New England journal of medicine, 339 (22), 1595-601 PMID: 9828247

    Vandycke C, & Martens P (2000). High dose versus standard dose epinephrine in cardiac arrest – a meta-analysis. Resuscitation, 45 (3), 161-6 PMID: 10959014

    Stiell IG, Hebert PC, Weitzman BN, Wells GA, Raman S, Stark RM, Higginson LA, Ahuja J, & Dickinson GE (1992). High-dose epinephrine in adult cardiac arrest. The New England journal of medicine, 327 (15), 1045-50 PMID: 1522840

    Callaway, C. (2012). Questioning the Use of Epinephrine to Treat Cardiac Arrest JAMA: The Journal of the American Medical Association, 307 (11) DOI: 10.1001/jama.2012.313

    .