Why do we keep paying attention to studies that only look at ROSC (Return Of Spontaneous Circulation)?
It is true that ROSC is associated with survival to discharge, but as we use treatments to increase ROSC, we only seem to increase the rate of death in the hospital.
We do not increase the rate of survival.
Epinephrine (Adrenaline) produces a lot more ROSC, but appears to produce worse survival.
What is it about epinephrine that causes so many more people to die before they wake up from a coma?
Why do we keep trying to put people in short-term comas, before admitting that they are dead?
Why are we still using a treatment that only causes a brief pulse, when what we want is a treatment that increases the rate of survival to discharge with a working brain?
Even ventilations seem to dramatically decrease survival.
Patients had dramatically better survival without ventilations.
Don’t change the subject. What about the epi?
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.
Compare that chart of HDE, SDE, and NE with this chart comparing Epinephrine and No Epinephrine.
More ROSC, but fewer survivors.
Shouldn’t the standard of care improve outcomes?
Even the patients who only received the minimum dose – 1 mg – had worse outcomes.
It is possible that there is a subgroup that does benefit from epinephrine – perhaps patients who have ROSC, but remain very bradycardic and lose pulses again. However, there appears to be no attempt to identify any patients who actually may benefit.
This binary, all or nothing, approach is dangerous and nothing new. Five centuries ago Paracelsus gave important advice that we continue to ignore.
All things are poison and nothing is without poison, only the dose permits something not to be poisonous. – Paracelsus.
Dr. David Newman at The NNT reviewed ACLS medications and concluded that there is no evidence of benefit.
The patients who receive epinephrine are those who remain dead long enough to be treated with epinephrine.
Why do we assume that their outcomes would be any worse without epinephrine?
This is the arrogance of ignorance. We don’t know and we don’t want to know.
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