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

- Rogue Medic

Most Survive with Mystery Treatment for Cardiac Arrest – Comments from Christopher

In response to my post, Most Survive with Mystery Treatment for Cardiac Arrest, there are a lot of comments. all of them raise some important points, but here I am going to respond to one from Christopher, who writes My Variables Only Have 6 Letters.

Christopher starts out referring to earlier comments on this post, referring to the wide range of doses given to patients surviving cardiac arrest in the study, which I will abbreviate.

I had written –

There are reports of patients who have been resuscitated after several hundred milligrams of epinephrine. So, the dose range is not unrealistic for something approved for use in cardiac arrest, for which Drug X is not approved, but epinephrine is approved – epinephrine is almost required.

Christopher responded –

Wouldn’t your normal phrasing be something like:

There are reports of patients who have been resuscitated after in spite of several hundred milligrams of epinephrine.

I replied –

I try to make is clear what my opinion is and what the evidence is. I may not always succeed.

And I went into a bit more detail. Christopher’s most recent comment is below, with my responses mixed in –

I think we’re on the same page,

I agree.

I was hinting to the fact that if you leave the dosing range open-ended it is a bit harder to tell whether or not the 101st milligram of Epi did the trick, or if all 101mg did absolutely nothing.

This is true. The research should address the larger groups, the groups that are easier to randomize, the groups that are resuscitated much more quickly.

How would we have a large enough study to examine prolonged resuscitation, when we do not even have large enough studies to examine much more common, much more optimistic situation of a resuscitation that lasts less than 10 minutes?

Does epinephrine improve resuscitation outcomes?

Maybe. Maybe not.

Since this appears to be a Yes/No question, the guess of the AHA (American Heart Association) is no better than flipping a coin, or asking Madame la Charlatan, Psychic Extraordinaire.

The guess opinion of the AHA is that this improved ROSC (Return Of Spontaneous Circulation) is important – as long as we cannot prove that it is harmful.

To believe that ROSC might not always be a good thing, you would have to believe in reperfusion injury, oxidative stress, and all sorts of other crazy things.

That’s just not possible. Is it?

Although epinephrine has been used universally in resuscitation, there is a paucity of evidence to show that it improves survival in humans. Both beneficial and toxic physiologic effects of epinephrine administration during CPR have been shown in animal and human studies.44–50 [1]

Post-Cardiac Arrest: Here, too, the evidence is too scant to tell. We do know that virtually all current therapies for cardiac arrest (drugs, airway) are of little, if any, benefit. The primary therapies remain CPR (often with limited ventilation initially) and defibrillation followed by induced hypothermia. The whole purpose of induced hypothermia is to prevent the detrimental effects of oxidative stress and the other harmful effects of reperfusion injury.[2]

Maybe, in 5 – 10 years, we will have evidence to determine whether epinephrine improves resuscitation outcomes. Maybe. On the other hand, the question of prolonged resuscitation is not likely to be answered by a randomized placebo controlled study.

You would need to test with cohorts receiving dosages in fixed intervals of some sort otherwise you could only make retrospective guesses as to if it really WAS the high dosages of Epi that did the trick. The trouble with resuscitations is we get into the “throw the kitchen sink at the problem” and most likely confound ourselves as to what actually “brought the patient back.”

Kitchen sink? It is almost as if you do not think that the problem with resuscitation is something other than More cowbell. (Don’t Fear) The Reaper – more cowbell. (Keeping People Away From) The Reaper – more epinephrine. It is a sign from Saturday Night Live. What more evidence do we need?

We are not much different from primitive humans in our assessment of cause and effect.

Whatever most closely preceded an event is presumed to be the cause of resuscitation.


The most favored treatment is presumed to be the cause of resuscitation.

That is, if the most favored treatment has been given at any point. Since it is the most favored treatment, everyone will have received the most favored treatment, except when patients are resuscitated too quickly.

Why don’t those darned fools wait for the most favored treatment?

It is as if they don’t really want to be cured by magic the most favored treatment.

Almost all resuscitations follow administration of the most favored treatment. Therefore, almost all resuscitations follow are caused by administration of the most favored treatment.

What could be more obvious to a primitive human?

Likely nothing but CPR and defibrillation, but we wouldn’t know!

We generally ignore evidence that does not support our beliefs.

Many of us seem to be quite comfortable with that ignorance.

I gave the most favored treatment. Then the patient got better. It must have been because of the most favored treatment.

The patient couldn’t have gotten better in spite of the most favored treatment. EMS patients never get better in spite of what EMS does to them!

Footnotes –

[1] Management of Cardiac Arrest
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Medications for Arrest Rhythms

[2] The Oxygen Myth?
Bryan E. Bledsoe, DO, FACEP
JEMS.com Another Perspective
2009 Mar 5
Article at EMT City

There is some unintentional comedy from those posting negative comments at EMT City. Often, there will be people who ignore what Dr. Bledsoe actually wrote, they then create some imaginary argument to replace what Dr. Bledsoe wrote, and they attack this made up argument – an argument that Dr. Bledsoe never made.

This is known as a straw man argument. A straw man is used mainly for 2 reasons. 1. The person truly does not have a clue what he is responding to. 2. The person is intentionally attempting to mislead others. Misunderstanding and/or misleading.

This sort of “reasoning” is fallacious, because attacking a distorted version of a position fails to constitute an attack on the actual position.



  1. Hah, I’m going to be thinking “more cowbell” from now on when somebody starts pulling the random drugs during a code. It is crazy how after 10 minutes people go into a “let’s try anything” mode! Why? We have pretty dismal resuscitation rates with that sort of mentality…It’s almost like they feel like they’re giving up if they’re not doing “something”.

    The really successful departments have almost moved to a minimalist protocol (Wake County comes to mind) and send enough people home from the hospital to call Mom about it.

  2. But think how much more fun and how much cooler it would be to have Will Ferrell running our codes. And it’s all about fun and how good the hospital feels about themselves……right?


  1. […] This post was mentioned on Twitter by Shelly Wilcoxson and Chronicles of EMS, EMS Blogs. EMS Blogs said: From #RogueMedic: Most Survive with Mystery Treatment for Cardiac Arrest – Comments from Christopher http://bit.ly/aIGi5I #EMS #Blogs […]

  2. […] Is Giving Up! Tue, 14 Sep 2010 14:10:30 +0000 By Rogue Medic Leave a Comment In the comments to Most Survive with Mystery Treatment for Cardiac Arrest – Comments from Christopher, there is an essential point made by the very same Christopher, who writes My Variables Only Have 6 […]

  3. […] 14 Sep 2010 14:45:25 +0000 By Rogue Medic Leave a Comment I am still feeling inspired by that last comment, but the second paragraph, by Christopher of My Variables Only Have 6 Letters. The really […]