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

This treatment seems to worth looking at more closely.

Does anybody want to guess what Drug X is?

To narrow things down a bit, Drug X is not homeopathy, acupuncture, epinephrine, amiodarone, lidocaine, bretylium, magnesium, atropine, or sodium bicarbonate.


Click on the image to make it larger.

I believe that this drug was used only after other treatments had failed, but I could be wrong.

Even if you were to remove the 4 not quite dead yet patients, all of whom survived, you only drop from a 59% survival rate to a 50% survival rate. Not bad.

Any ideas?

Any desire to study this as an alternative to the alternative medicine treatments listed above?

Maybe Drug X would not work, when examined in large enough randomized placebo-controlled double-blinded studies, but Drug X isn’t likely to do any worse than what we are already using.

.

Comments

  1. OK i give whats drug x??? inquiring minds want to know. But then again we dont need a new drug that might work, we have our new LP15’s that tell us how fast to do cpr and when to bag. And our new PALS class that was way to short and didnt make anybody cry (the first PALS class that i took more years ago that i care to admit was 3 days long and made grown doctors leave crying. Are we really dumbing down EMS this much??

    • Raymond

      OK I give whats drug x???

      You can’t give up that easily. You have to give other people a chance.

      Don’t worry about not using something that medical command would permit, or having to wait until the new guidelines come out (next month?), because there is not enough research to support it.

      we have our new LP15’s that tell us how fast to do cpr and when to bag.

      I like having capnography. I can look at the numbers, and with a good waveform and familiarity with what the numbers have been for my patient, know if I have been subconsciously bagging too quickly or too slowly. With complicated patients, or just with the complications of moving a resuscitated patient, this can be important.

      I love the ability to pass the bagging to new people and explain to them that they are supposed to keep the numbers in a certain range. They complain that they can’t bag that slowly.

      Too much Ritalin?

      And our new PALS class that was way to short and didnt make anybody cry (the first PALS class that I took more years ago that I care to admit was 3 days long and made grown doctors leave crying.

      A crying baby is a healthy baby.

      Is now –

      A crying PALS student is a learning PALS student.

      That could be a good slogan.

      Are we really dumbing down EMS this much??

      You know my answer on that one.

      Yes.

      Unless we stop dumbing things down, it will get worse.

      There are plenty of positive things happening, but it seems as if there is always somebody saying –

      We can’t expect people to think about these things. What if someone makes a mistake?

      Better to let people die, than to risk the much smaller possibility of causing something bad to happen. If we train/educate people well, the problem is insignificant. But I am not a bureaucrat.

  2. Somehow I get the distinct feeling that “Drug X” isn’t a chemical compound.

  3. Refrigerated saline?

  4. While, uh, cheating to try to find the answer on Google, I was amused to see that among my search results was one with the title “Cardiac Arrest” on the wrongdiagnosis.com website… which I found disconcerting.

    Still no idea what the drug is. Gotta be a vasoconstrictor of some kind, but all the well known ones I think have been pretty extensively studies. Phenylephrine?

    • Matt,

      I don’t know how difficult it would be to find by a search engine, but I was not looking for information on cardiac arrest when I found it.

      Vasopressors
      To date no placebo-controlled trials have shown that administration of any vasopressor agent at any stage during management of pulseless VT, VF, PEA, or asystole increases the rate of neurologically intact survival to hospital discharge. There is evidence, however, that the use of vasopressor agents favors initial ROSC.

      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

      If good research ends up showing that Drug X is effective at improving survival, it will not do anything to change that quote.

      For those unfamiliar with phenylephrine, it is also known as Neo-Synephrine (or just plain Neo) and dozens of other names. The over-the-counter brand is not what is being referred to.

      In the ICU, and especially in the PACU (Post-Anesthesia Care Unit), phenylephrine is not uncommon. When teaching ACLS, this is the PACU identifier. People will become upset when hypotension is treated with phenylephrine. We should consider the setting and the drugs available and familiar to those who will be treating the patient. Why insist that someone use an unfamiliar drug when treating an unstable patient. If we stick with drugs we are familiar with, we are less likely to make mistakes and the patients are less likely to be harmed by mistakes that do not happen.

      Vasopressor
      Phenylephrine is sometimes used as a vasopressor to increase the blood pressure in unstable patients with hypotension. Such use is more common in anesthesia or critical-care practices; phenylephrine is especially useful in counteracting the hypotensive effect of epidural and subarachnoid anesthetics. It also has the advantage of not being inotropic or chronotropic, and so it strictly elevates the blood pressure without increasing the heart rate or contractility (reflex bradycardia may result from the blood pressure increase, however). This is especially useful if the heart is already tachycardic and/or has a cardiomyopathy. The elimination half life of phenylephrine is about 2.5 to 3 hours.

      Wikipedia
      Phenylephrine
      Vasopressor

      A good idea, but Drug X is not a vasopressor.

  5. How about calcium?

  6. Knee-jerk response: aspirin?

  7. Oxygen? Ha ha ha. Glucagon would be neat (inotrope/chronotrope) but the dosing isn’t right. Estrogen? Progesterone? Testosterone?

    1 to 48 X-units is the dosing range, which leads me to wonder why the great variability? How exactly did they correlate the dosage to the end result?

    • Christopher,

      Oxygen? Ha ha ha.

      No, but withholding supplemental oxygen and withholding ventilation both seem to work well.

      Glucagon would be neat (inotrope/chronotrope) but the dosing isn’t right. Estrogen? Progesterone? Testosterone?

      Interesting ideas, but Drug X is not a hormone.

      1 to 48 X-units is the dosing range, which leads me to wonder why the great variability? How exactly did they correlate the dosage to the end result?

      I do not have the answer, but I think they were titrating to not dead anymore.

      That is the way epinephrine is given. If you were to look at the dose of epinephrine given to cardiac arrest patients, you would find that, for everyone who did receive epinephrine, the total dose ranges from 1 mg to whatever is the largest dose given in the study.

      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 – actually almost required.

      During cardiac arrest, basic CPR and early defibrillation are of primary importance, and drug administration is of secondary importance. Few drugs used in the treatment of cardiac arrest are supported by strong evidence. After beginning CPR and attempting defibrillation, rescuers can establish intravenous (IV) access, consider drug therapy, and insert an advanced airway.

      Management of Cardiac Arrest
      2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
      Part 7.2: Management of Cardiac Arrest
      Access for Medications: Correct Priorities

      consider drug therapy

      Vasopressors
      To date no placebo-controlled trials have shown that administration of any vasopressor agent at any stage during management of pulseless VT, VF, PEA, or asystole increases the rate of neurologically intact survival to hospital discharge. There is evidence, however, that the use of vasopressor agents favors initial ROSC.

      Antiarrhythmics
      There is no evidence that any antiarrhythmic drug given routinely during human cardiac arrest increases survival to hospital discharge. Amiodarone, however, has been shown to increase short-term survival to hospital admission when compared with placebo or lidocaine.

      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

      There is a separate section titled Interventions Not Supported by Outcome Evidence, but it all depends on what kind of outcome we want.

      If we are satisfied with ROSC, then epinephrine is a great drug.

      If we are satisfied with short-term survival to hospital admission, then amiodarone is a great drug.

      If we are interested in a human being with a functioning brain being discharged from the hospital, then these drugs are not only inadequate, but possibly harmful.

      consider drug therapy?

      I do consider drug therapy.

      I consider drug therapy to be more of a problem, than a solution

      • 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.

        🙂

        • Christopher,

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

          I think that we will eventually find a subset of patients (not just anaphylactic and asthmatic patients) who do benefit from epinephrine.

          I think that the routine administration of epinephrine to everyone who does not respond quickly to BLS treatments is harmful.

          It may be that patients who require longer resuscitation are unlikely to respond without epinephrine.

          Applying these treatments in the absence of evidence of benefit (improved survival to neurologically intact survival) is alternative medicine – which I oppose.

          If we want to practice alternative medicine, we should change our names to something mystical, use a lot of incense, and claim that everything is Quantum or Qi or some other Q word.

          If we are going to practice alternative medicine, we don’t need any valid evidence.

          Alternative medicine – the evidence-free alternative to real medicine.

          Of course, once we grow up, we realize that the Tooth Fairy is a myth.

          Alternative medicine is just refusing to admit that there is no Tooth Fairy.

  8. High dose nitro!

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