Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Every Drug in the Box

The problem of using every relevant, but perhaps not necessary, drug is something medics, nurses, and doctors are bad at. The major exceptions to this are sedation and pain management. Then the problem is getting the doctor to allow the box to be opened. Both demonstrate a lack of understanding of pharmacology and assessment.

I was discussing, with some doctors, a journal article about an anaphylactic patient, who received about a dozen different medications. I suggested that some of the problems the patient experienced were probably from all of the drugs being pushed.

“Horse feathers. There is nothing wrong with giving all of the potentially indicated drugs to the patient.” OK, not the exact wording of the doctors, but it seems to capture the sentiment.

Potentially indicated and indicated are worlds apart.

It isn’t as if there is any research on the administration of all of these medications combined. There are far too many variables to control for, much too small an incidence of anaphylaxis that does not respond to standard treatments, and apparently not enough interest in questioning the just dump the box into the patient philosophy demonstrated.

In cardiac arrest algorithms, it is nice to be moving away from the let’s get rid of all of the expiring drugs approach. We still have a long way to go in recognition of the lack of benefit of ALS (Advanced Life Support) treatment of dead people. It is a start.

Currently, the AHA (American Heart Association) does not feel that an IV is that important. They have been gradually moving in this direction over the past couple of decades. Eventually, they will probably only recommend medications specifically indicated for potentially reversible causes, rather than everybody dead gets epi – and/or vasopressin.

For victims of witnessed VF arrest, prompt bystander CPR and early defibrillation can significantly increase the chance for survival to hospital discharge. In comparison, typical ACLS therapies, such as insertion of advanced airways and pharmacologic support of the circulation, have not been shown to increase rate of survival to hospital discharge.

After beginning CPR and attempting defibrillation, rescuers can establish intravenous (IV) access, consider drug therapy, and insert an advanced airway.

One of the problems with research, on a bunch of drugs given to the same patient, is that there are so many variables involved. This does not only affect the research, but the administration, too. When patient presentation changes, how do you know what the likely cause was?

Is it the effect of medication?

Is it a side effect?

Is it spontaneous remission?

Is it an erroneous assessment?

Is it the last medication given?

The first?

The third?

Is it a combination of the medications?

We do not know. How do most people deal with this? They act as if it must be the most recently given medication.

Is there a reason to believe that this is the correct approach?

No.

Here is the logic that is applied by those, who insist that the drugs are essential:

1. Successful resuscitation is having the patient leave the hospital in about the same condition as they were before the cardiac arrest.

2. Having a pulse is necessary for a successful resuscitation.

3. Therefore, anything that leads to pulses is good, or one step closer to #1.

Unfortunately, things are not that simple. While it is hard to resist the I’m going to Disneyland! response at this point. The most common outcome for patients who have a return of a pulse is that the pulse goes away again. At some point during the resuscitation, the pulse usually goes away permanently.

Getting a pulse back is the almost immediate response that is similar to what a crack addict feels – a rush. There is a need to replicate that, and it is easy, you give enough epi to a corpse and you often get a pulse.

There is a quote above supporting the focus on excellent chest compressions and rapid defibrillation. It is immediately followed by a quote that points out the futility of the mistaken, but persistent, focus on ALS in cardiac arrest. I include both sentences together, now. the italics are mine.

For victims of witnessed VF arrest, prompt bystander CPR and early defibrillation can significantly increase the chance for survival to hospital discharge. In comparison, typical ACLS therapies, such as insertion of advanced airways and pharmacologic support of the circulation, have not been shown to increase rate of survival to hospital discharge.

If the patients who never get drugs are leaving the hospital (with an intact brain) at least at the same rate as the patients who received drugs, then maybe the drugs do not help.

If we only focused on things that produce a pulse, would we include defibrillation?

Defibrillation produces a pulse.

No. Defibrillation produces asystole. During the asystole, it is hoped that the patient’s heart has at least one pacemaker that initiates an organized rhythm. It is further hoped that the rhythm does produce a pulse.

Resuscitation is about resuscitating the heart and the brain, not about giving enough drugs to get a pulse.

Perhaps cerebral resuscitation is about a little bit more.

And the medic, with his medic-feet ice-cold in the snow,
Stood puzzling and puzzling:

How could it be so?

It came without drugs! It came without tubes!
It came without gadgets, IVs or drips!

And he puzzled three hours, till his puzzler was sore.
Then the medic thought of something he hadn’t before!

Maybe Resuscitation,

he thought

doesn’t come from a drug store.
Maybe Resuscitation… perhaps… means a little bit more!

And what happened then…? Well… in BLS-ville they say
That the medic’s understanding grew three sizes that day!

And the minute the patient’s heart didn’t feel quite so tight
He whizzed with his load away from the bright dying light

He brought back the brain! And the heart for the pulse!

And he…HE HIMSELF!

The medic got a real save!

To paraphrase a great doctor.

Adapted from How the Grinch Stole Christmas.

Theodor Seuss Geisel, better known as Dr. Seuss.

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Comments

  1. It’s getting harder to know what works and what doesn’t. It’s also far less clear than it used to be who is a good candidate for resuscitation and who isn’t. Which, as you know isn’t as simple a question as it would appear to be. Some of our long cherished treatments not only don’t seem to help, but now appear to hurt. Two years ago if you had told me that room air ventilation for cardiac arrest victims is potentially better than Oxygen I probably would have laughed at you. We knew that hyperventilation with Oxygen was bad, but who could have guessed that ventilation with 21% Oxygen might, just might, be better in terms of survival to discharge?Obviously someone did, since they decided to test the theory. Sometimes it seems that the whole medicine thing in EMS gets forgotten.

  2. I’m working on a longer response to this as a post, rather than a comment, but I keep getting distracted. You make some excellent points, as usual.

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