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

- Rogue Medic

A Critic Reads My Mind, But Does He Read What I Write

In response to What Will Be the Next Standard Of Care We Eliminate is this attempt at reason from SARmission

@Roguemedic. After reading a number of your blogs I have come to the following conclusion. Your purpose in writing is not to make, those reading, better medics. Rather it is to create controversy, and try to make statements that you are not qualified to make.

You are entitled to your opinion, but you have not provided any evidence to support your opinion. You appear to be just trying to create controversy.

I present people with both my opinion and the evidence on which I base that opinion.

You have based your whole position on this epi debate on an OPINION paper.

How do you know what I have based my conclusions on? Please provide some evidence of your psychic ability.

I have been writing about epinephrine since long before the editorial by Dr. Callaway. I was also teaching about the problems with epinephrine before the AAEM Position statement and AAEM Working Group Report, but I was not writing a blog at that time.

Perhaps you are referring to the AAEM Position Paper, which includes a review of the literature and analysis by Amal Mattu, MD FAAEM, Carey Chisholm, MD FAAEM, and Jerome R. Hoffman, MA MD FAAEM.

I have written about epinephrine a lot –

2008

Epinephrine in Cardiac Arrest
Sun, 06 Apr 2008

Dead VT vs Not Quite Dead, Yet VT.
Tue, 08 Apr 2008

More on Epinephrine in Cardiac Arrest.
Sat, 19 Apr 2008

Narrative Fallacy I
Fri, 24 Oct 2008

2009

EMS Mythology Starter Kit
Tue, 10 Feb 2009

EMS Garage, CPR, Continuous Compressions, and Resuscitation – Jamie Davis comment
Tue, 21 Apr 2009

Why Can’t Medics Resuscitate? II
Tue, 14 Jul 2009

Narrative Fallacy II
Wed, 15 Jul 2009

C A S T and Narrative Fallacy comment from Shaggy
Wed, 22 Jul 2009

The Blame Game
Tue, 27 Oct 2009

Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.
Thu, 24 Dec 2009

2010

EMS EdUCast – Journal Club 2: Episode 43
Thu, 28 Jan 2010

Correction on Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.
Sun, 07 Mar 2010

How to Study Epinephrine in Cardiac Arrest
Fri, 30 Apr 2010

Current Drug Shortages
Fri, 30 Jul 2010

More on Drug Calculations
Mon, 02 Aug 2010

A Letter To Mom
Tue, 14 Sep 2010

Most Survive with Mystery Treatment for Cardiac Arrest – Comments from Christopher
Tue, 14 Sep 2010

More Drug Shortage Paranoia – Epinephrine
Wed, 06 Oct 2010

Ethics, Research, and IRBs – Part II
Tue, 26 Oct 2010

Ethics, Research, and IRBs – Part III
Fri, 29 Oct 2010

A Mistaken Bolus of Epinephrine Given to a Living Patient
Tue, 07 Dec 2010

2011

Changes to Pennsylvania Protocols – Post-Resuscitation Care – Part I
Wed, 20 Apr 2011

Rhythm Interpretation and Inattentional Blindness
Tue, 19 Jul 2011

Bogus Ethics and Epinephrine in Cardiac Arrest
Sat, 30 Jul 2011

A Couple of Comments on Bogus Ethics and Epinephrine in Cardiac Arrest – Part I
Sun, 31 Jul 2011

A Couple of Comments on Bogus Ethics and Epinephrine in Cardiac Arrest – Part II
Wed, 03 Aug 2011

A Couple of Comments on Bogus Ethics and Epinephrine in Cardiac Arrest – Part III
Mon, 08 Aug 2011

Cardiac Arrest Management is an EMT-Basic Skill
Wed, 07 Dec 2011

Does Epinephrine Improve Survival from Cardiac Arrest
Mon, 12 Dec 2011

Cardiac Arrest Management is an EMT-Basic Skill – The BLS Evidence – Comment from Windy City Medic
Sat, 17 Dec 2011

Where is the Evidence for Epinephrine in the 2010 ACLS Guidelines
Mon, 19 Dec 2011

The Danger of ROSC – Return Of Spontaneous Circulation
Tue, 20 Dec 2011

Why Does Epinephrine Cause Brain Damage During Resuscitation
Mon, 26 Dec 2011

2012

When Does Post-Resuscitation Care Begin
Wed, 18 Jan 2012

Why We Deceive Ourselves With Explanations
Sat, 04 Feb 2012

Killing Patients Just to Get a Temporary Pulse With Epinephrine
Wed, 21 Mar 2012

Dr. Ken Grauer on Killing Patients Just to Get a Temporary Pulse With Epinephrine – Part I
Thu, 22 Mar 2012

Dr. Ken Grauer on Killing Patients Just to Get a Temporary Pulse With Epinephrine – Part II
Fri, 23 Mar 2012

PROVE Epinephrine is Harmful
Mon, 26 Mar 2012

What Will Be the Next Standard Of Care We Eliminate
Wed, 28 Mar 2012

The Importance of Having ROSC
Sun, 01 Apr 2012

Before you start beating your drum, wait for the FACTS.

Facts?

The evidence that we are not waiting for before we give dangerous drugs to patients?

We should have been waiting for evidence that epinephrine works, or demanding that somebody find out with a large, randomized placebo controlled trial.

We have based treatment with epinephrine on only superficial facts.

Here is the research, look closely:

 

 

There isn’t anything there – just a black hole full of nothing.

Consider these statements by the AHA (American Heart Association) – the people who write the guidelines that guide cardiac arrest treatment in the US – about the research on epinephrine –

 

Deemphasis on Devices and Advanced Cardiovascular Life Support Drugs During Cardiac Arrest
At the time of the 2010 International Consensus Conference there were still insufficient data to demonstrate that any drugs or mechanical CPR devices improve long-term outcome after cardiac arrest.45 Clearly further studies, adequately powered to detect clinically important outcome differences with these interventions, are needed.
[1]

The AHA calling for research a couple of years ago.

Why?

Lack of evidence of benefit from epinephrine.

To date no placebo-controlled trials have shown that administration of any vasopressor agent at any stage during management of VF, pulseless VT, PEA, or asystole increases the rate of neurologically intact survival to hospital discharge. There is evidence, however, that the use of vasopressor agents is associated with an increased rate of ROSC.[2]

We have evidence of improved ROSC. I have never denied that.

I do not think that we should be harming patients just for ROSC.

There is no evidence that increasing ROSC with epinephrine improves any important outcome.

There are no RCTs that adequately compare epinephrine with placebo in treatment of and outcomes related to out-of-hospital cardiac arrest. A retrospective study267 compared epinephrine to no epinephrine for sustained VF and PEA/asystole and found improved ROSC with epinephrine but no difference in survival between the treatment groups. A meta-analysis and other studies have found improved ROSC, but none have demonstrated a survival benefit of high-dose epinephrine versus standard-dose epinephrine in cardiac arrest.135,268,–,272 [2]

No facts to justify routinely using epinephrine.

The causes of cardiac arrest are numerous; by far the most common in adults is ischemic cardiovascular disease.4-6 The arrest is usually associated with the lethal arrhythmia of ventricular fibrillation triggered by an acutely ischemic or infarcted myocardium or by a primary electrical disturbance.[3]

Are we supposed to be giving epinephrine to patients having heart attacks?

We are routinely giving epinephrine to patients who are likely to be having heart attacks.

There is very little high-level evidence for resuscitation therapies, and many traditional treatment recommendations such as the use of epinephrine/adrenaline, are based on animal studies and reluctance to change an existing treatment recommendation until it is proven ineffective or less effective than a novel therapy.[4]

We don’t seem to need facts to use a treatment on a patient.

We do not seem to believe in the ethics of first, do no harm.

We seem to wait until there is so much evidence of harm that we cannot ignore the evidence any longer.

Then we get rid of the dangerous treatment.

Epinephrine is ordinarily administered with extreme caution to patients who have heart disease.[5]

There is nothing cautious about the routine administration of 1 mg epinephrine every 3 to 5 minutes to everybody who is still dead when we reach that part of the algorithm.

Before you say it, I know that reading a blog is a choice. I choose to stop reading yours. Thank you for you time.

That suggests that this is not exactly your first time making controversial comments on a blog.

Is making controversial comments constructive when you do it, but destructive when others do it?

I present people with both my opinion and the evidence on which I base that opinion.

Footnotes:

[1] Deemphasis on Devices and Advanced Cardiovascular Life Support Drugs During Cardiac Arrest
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 1: Executive Summary
John M. Field, Co-Chair*; Mary Fran Hazinski, Co-Chair*; Michael R. Sayre; Leon Chameides; Stephen M. Schexnayder; Robin Hemphill; Ricardo A. Samson; John Kattwinkel; Robert A. Berg; Farhan Bhanji; Diana M. Cave; Edward C. Jauch; Peter J. Kudenchuk; Robert W. Neumar; Mary Ann Peberdy; Jeffrey M. Perlman; Elizabeth Sinz; Andrew H. Travers; Marc D. Berg; John E. Billi; Brian Eigel; Robert W. Hickey; Monica E. Kleinman; Mark S. Link; Laurie J. Morrison; Robert E. O’Connor; Michael Shuster; Clifton W. Callaway; Brett Cucchiara; Jeffrey D. Ferguson; Thomas D. Rea; Terry L. Vanden Hoek
New Developments in Resuscitation Science Since 2005
Free Full Text from Circulation with link to PDF Download

[2] Vasopressors
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.2: Management of Cardiac Arrest
Medications for Arrest Rhythms
Free Full Text from Circulation with link to PDF Download

[3] Cardiac resuscitation.
Eisenberg MS, Mengert TJ.
N Engl J Med. 2001 Apr 26;344(17):1304-13. Review. No abstract available.
PMID: 11320390 [PubMed – indexed for MEDLINE]

Free Full Text with link to Free Full Text PDF Download

[4] Controversial Topics from the 2005 International Consensus Conference on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations.
Nolan JP, Hazinski MF, Steen PA, Becker LB.
Resuscitation. 2005 Nov-Dec;67(2-3):175-9. No abstract available.
PMID: 16324986 [PubMed – indexed for MEDLINE]

Free Full Text from Circulation

[5] EPIPEN (epinephrine) injection
EPIPEN JR (epinephrine) injection
[DEY]

DailyMed
FDA Label

.

Comments

  1. Rogue, this is somewhat unrelated (more to do with new treatments than anything else), but I just saw this article:

    http://www.jems.com/article/news/study-injection-saves-lives-heart-attack

    Other than a brief abstract on its testing in dogs, I’m having difficulty finding anything pertinent about this study. Have you heard of it? What are you thoughts if so?

  2. who cares??? back and forth we go with this debate on the best way to work a code. one stat sticks in my mind some 400,000 deaths related to acs but when you look at the studies on [insert drug/procedure/voodoo ritual] you see 300 people here and 400 people there do they really mean anything? we still have a lazy pseudo profession that wants to do the bear minimum to get by and complain about how they arent respected. why dont we have national databases where we collect enough data to make the study meaningful?
    let me ask this; if you dont have ROSC, you have a dead person arguably a negative outcome. why not do what is needed to obtain ROSC and deal with the negative effects later? how many of us have driven faster than 55 on the donut?
    or why bother working them? we dont want to harm the dead person…….? were ok breaking ribs and lacerating the crap out of everything underneath and applying electrical current 100 times higher than what the heart normally handles and say this is good, but an extra milligram of epi or the wrong antidysrhythmic at the wrong time is bad.

    • mike mohler,

      You would have a point, if it did not matter how much damage we do in obtaining ROSC.

      You say that there is no harm to dead people, but ROSC does not mean dead.

      The research shows that we harm patients to obtain ROSC.

      If we have more people getting ROSC with epinephrine, but we decrease the number of people leaving the hospital, are we doing any good?

      More people leave the hospital alive when they do not receive epinephrine, even though they are much less likely to have ROSC.

      Which is more important? ROSC or leaving the hospital alive?

      .

    • Mike,

      It makes a difference because you might get ROSC back without Epi and be healthy; but if you give Epi, the patient will have severe brain damage. It’s not like Epi is the drug of last resort, where nothing else has worked; it’s reasonable to think that Epi has been given to some people when it wasn’t needed, and it possibly did harm.

      ROSC is not a valid measure of whether the patient will survive or not. It’s a “feel-good” statistic that means nothing. There are plenty of things that can be done that result in short-term improvement but ultimately end up doing more harm than good. Just because the patient is doing a little better on arrival at the ED doesn’t mean that your intervention fixed them; it might just have masked the problem until it’s too late to do anything about it.

      The problem isn’t the people; it’s the fact that EMS is divided up into so many little fiefdoms (fire vs. private, volunteer vs. paid, state vs. state, county vs. county); and the people who CAN do something are more interested in “protecting their turf” than in making the system work properly. Bitching about the entire “pseudo profession” being lazy and whiny sure as hell isn’t going to improve anything.

      Oh, and the databases do exist. Every state has a required data set that emergency transport companies must report (based on NEMSIS). The problem is that, unless you do research (i.e. compare a treatment to placebo or an existing treatment), that data doesn’t tell you anything about how effective or harmful a treatment might be.

  3. With regard to the glucose-insulin-potassium study, some large dose of skepticism is warranted. Jus like epi, 30-day mortality is no different.

    My humble effort at an review of this new study is at : http://millhillavecommand.blogspot.com/2012/03/immediate-trial-shoukd-ems-give-glucose.html.

    Rogue, would love to see your thoughts on this new, and well-popularized, study!

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