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

- Rogue Medic

Lidocaine for Cardiac Arrest in the 2010 ACLS – Part I

What is the role for lidocaine in the new AHA (American Heart Association) ACLS (Advanced Cardiac Life Support) guidelines?

2010

Lidocaine is an alternative antiarrhythmic of long-standing and widespread familiarity with fewer immediate side effects than may be encountered with other antiarrhythmics. Lidocaine, however, has no proven short- or long-term efficacy in cardiac arrest. Lidocaine may be considered if amiodarone is not available (Class IIb, LOE B). The initial dose is 1 to 1.5 mg/kg IV.[1]

I love the use of the word alternative in there. It is completely appropriate.

lidocaine is an alternative antiarrhythmic of long standing and widespread familiarity with fewer immediate side effects than may be encountered with other antiarrhythmics.

That sounds pretty good, as far as safety is concerned. I would rather use something I am familiar with. Familiarity makes it easier to recognize potential problems early.

Lidocaine, however, has no proven short-term or long-term efficacy in cardiac arrest.

In other words, lidocaine does have side effects, although these side effects may not be as bad as more efficacious other antiarrhythmics.

Examples of these other antiarrhythmics, that may be more efficacious, include –

Eye of Newt,

Viagra,

Acupuncture,

Cocaine,

Or whatever just happens to be lying within reach while we are in a whatever mood.

That ________ looks interesting. Let’s give __________ a try.

Mad Libs ACLS.

Wishful Thinking >>> Evidence

OK. How is this different from what lidocaine was in the 2005 ACLS Guidelines?

That continues with Lidocaine for Cardiac Arrest in the 2010 ACLS – Part II and then with Lidocaine for Cardiac Arrest in the 2010 ACLS – Part III

Footnotes:

[1] Lidocaine
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 8.2: Management of Cardiac Arrest
Medications for Arrest Rhythms
Antiarrhythmics
Free Full Text Article with links to Free Full Text PDF download

.

Comments

  1. The use of the word “alternative” is indeed very interesting. I would say one of the biggest problems with Amiodarone is that it is virtually unusable in the prehospital setting – a place where most cardiac arrests occur. Therefore, Lidocaine is the drug of choice. I would recommend that the drug makers take a look at this and see if something that can be made which has the storage capability of Amiodarone, but has the usable properties of Lidocaine.

    • I keep hearing about the problems with amiodarone administration such as hepatotoxicity and difficult to push down a line, but what is their actual prevalence?

      While lidocaine may be easier to push, it does nothing for the patient.

      • The issue with amiodarone appears to be related to the polysorbate-80 (100mg/mL) which is evidently very vasoactive. However, it appears there is a different aqueous mix of amiodarone without this diluent (Nexterone). I cannot find anywhere to buy it, but perhaps this is because it is no longer packaged with polysorbate-80?

        I found a study which compared the better amiodarone versus lidocaine and it appears to be a no-brainer: “Amiodarone had a 33% drug failure rate, whereas there was a 91% drug failure rate for lidocaine.”[1]

        We’re a lidocaine/procainamide service so I’ve only given in during hospital rotations, hence my questions.

        [1] Somberg, JC, et al. Intravenous lidocaine versus intravenous amiodarone (in a new aqueous formulation) for incessant ventricular tachycardia. Am J Cardio, 2002; 90 (8): 853-859.

    • Ruben Major,

      I would say one of the biggest problems with Amiodarone is that it is virtually unusable in the prehospital setting – a place where most cardiac arrests occur.

      The bigger problem with amiodarone is that it is ineffective in the prehospital setting.

      Therefore, Lidocaine is the drug of choice.

      Lidocaine has no evidence that it improves outcomes from cardiac arrest.

      We should not be giving drugs just to be doing something.

      We should only be doing things that we expect to improve outcomes.

      We have no reason to expect any drugs, routinely given in cardiac arrest, to improve outcomes. Lidocaine is not the only useless drug – useless for the patient.

      Amiodarone has no evidence of improved survival.

      Epinephrine has no evidence of improved survival.

      For victims of witnessed VF arrest, early CPR and rapid defibrillation can significantly increase the chance for survival to hospital discharge.128–133 In comparison, other ACLS therapies such as some medications and advanced airways, although associated with an increased rate of ROSC, have not been shown to increase the rate of survival to hospital discharge.31,33,134–138

      In addition to high-quality CPR, the only rhythm-specific therapy proven to increase survival to hospital discharge is defibrillation of VF/pulseless VT. Therefore, this intervention is included as an integral part of the CPR cycle when the rhythm check reveals VF/pulseless VT. Other ACLS interventions during cardiac arrest may be associated with an increased rate of ROSC but have not yet been proven to increase survival to hospital discharge. Therefore, they are recommended as considerations and should be performed without compromising quality of CPR or timely defibrillation. In other words, vascular access, drug delivery, and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillation. There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest. In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels. Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrest.

      Overview
      2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
      Part 8.2: Management of Cardiac Arrest
      Free Full Text Article with links to Free Full Text PDF download

      I continued this with Lidocaine for Cardiac Arrest in the 2010 ACLS – Part II and then with Lidocaine for Cardiac Arrest in the 2010 ACLS – Part III

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