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

- Rogue Medic

The Relentless Optimism of a Stalker Applied to Medicine


She really does love me, she just has trouble showing it (even though she probably does not even know I exist).

This is the way stalkers think.

Insert any woman you consider to be extremely attractive. For me, the choice is more Diane Lane, than Miley Cyrus (and Kelly Grayson seems to have Christina Hendricks locked up all to himself).

Image credit.

This is the way believers in alternative medicine think.

This is the way believers in anecdote-based medicine think.

Anecdote-based medicine is the intuitive, I’ve seen it work approach to medicine that is not different from alternative medicine in any important way.

Almost always, these anecdote-based treatments are found to be harmful. Not beneficial is the same as harmful, because a treatment that provides no benefit, but exposes the patient to the risks of an unnecessary treatment is dangerous.

Clearly, Diane Lane and Josh Brolin are getting divorced because she wants to be with me, right?

I just need to believe and it will work.

I just need to ignore all objective evidence and it will work.

I just need to trust my inner stalker.


As much as I would like to think that there is something about me that appeals to beautiful women who do not even know I exist, I should not ignore reality.

Does this also apply to EMS treatments?

Prehospital IV therapeutic hypothermia has not demonstrated any benefit when begun by EMS and has demonstrated harm. The outcomes all trend toward harm, so a meta-analysis may show a statistically significant decrease in survival.[1],[2],[3],[4]

We just need to believe and it will work.

We just need to ignore all objective evidence and it will work.

We just need to trust our inner stalkers.


Should we maintain unreasonable optimism?

What if there really is a benefit?

It is much more likely that there really is harm.

Even though harm is more likely, it is more difficult to recognize.


The intervention reduced core body temperature by hospital arrival, and patients reached the goal temperature about 1 hour sooner than in the control group. The intervention was associated with significantly increased incidence of rearrest during transport, time in the prehospital setting, pulmonary edema, and early diuretic use in the ED. Mortality in the out-of-hospital setting or ED and hospital length of stay did not differ significantly between the treatment groups.[4]


If we cannot provide evidence of improved outcomes, all we have is wishful thinking.

Wishful thinking kills.

Diane Lane may really want me, but there is no rational reason to believe this.

Prehospital IV therapeutic hypothermia may really work, but there is no rational reason to believe this.

The same is true for every other treatment that is not supported by evidence of improved outcomes that matter.

We should expect harm, not benefit.

It is irrational to expect benefit, but many of us do expect benefit because we are irrational optimists and we do not pay for our mistakes. Our patients are the ones who pay for our mistakes.


[1] Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial.
Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid Infusion of Cold Hartmanns (RICH) Investigators.
Circulation. 2010 Aug 17;122(7):737-42. doi: 10.1161/CIRCULATIONAHA.109.906859. Epub 2010 Aug 2.
PMID: 20679551 [PubMed – indexed for MEDLINE]

Free Full Text from Circulation.

[2] Podcast 113 – Post-Cardiac Arrest Care in 2013 with Stephen Bernard – Part I
Podcast page with links to research mentioned in the podcast.

Podcast 114 – Post-Arrest Care in 2013 with Stephen Bernard – Part II
Podcast page with links to research mentioned in the podcast.

[3] Targeted temperature management at 33°C versus 36°C after cardiac arrest.
Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wise MP, Åneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Køber L, Langørgen J, Lilja G, Møller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H; TTM Trial Investigators.
N Engl J Med. 2013 Dec 5;369(23):2197-206. doi: 10.1056/NEJMoa1310519. Epub 2013 Nov 17.
PMID:24237006[PubMed – indexed for MEDLINE]

[4] Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac Arrest: A Randomized Clinical Trial.
Kim F, Nichol G, Maynard C, Hallstrom A, Kudenchuk PJ, Rea T, Copass MK, Carlbom D, Deem S, Longstreth WT Jr, Olsufka M, Cobb LA.
JAMA. 2013 Nov 17. doi: 10.1001/jama.2013.282173. [Epub ahead of print]
PMID: 24240712 [PubMed – as supplied by publisher]


Homeopathic Product Recalled for Containing Real Medicine


Homeopathic products are supposed to be diluted down to where they contain nothing.

They definitely are not supposed to contain antibiotics, since antibiotics were not understood when Samuel Hahnemann made up the idea of homeopathy.

FDA has determined that these products have the potential to contain penicillin or derivatives of penicillin, which may be produced during the fermentation process. In patients who are allergic to beta-lactam antibiotics, even at low levels, exposure to penicillin can result in a range of allergic reactions from mild rashes to severe and life-threatening anaphylactic reactions.[1]


The law of similars. Find a poison that produces similar symptoms, preferably not the cause of the illness (not that a homeopath would know) and dilute the poison down to nothing.

The water (or alcohol) is expected to remember the poison, but forget everything else that has been in the water, and magically cure the illness by doing the opposite of what the poison would do.

The water is diluted to 1% of what was in it enough times that there should not be any poison left. The homeopath also hits the water a lot to teach the water to remember the poison. This is the magic memory of water.

The result is nothing.

Image credit.

When blood-letting was a common treatment, this was better than going to a doctor, but still not as good as staying at home and saving your money, because who needs to go buy nothing?

The idea that the more dilute the solution, the more potent the “medicine” is ridiculous. Somebody would be able to demonstrate the differences in strengths, but homeopathy is just another placebo with just another excuse to scam people.

At what concentration of nothing does it start to work?

At what concentration of nothing does it become dangerous?

Is it still a solution when there is nothing in it?


Hover text –

Dear editors of Homeopathy Monthly: I have two small corrections for your July issue. One, it’s spelled “echinacea”, and two, homeopathic medicines are no better than placebos and your entire magazine is a sham.[2]


One of the problems with dealing with a fraud is the inability to tell the difference between incompetence and intentional fraud.

Homeopath X is a true believer. He believes that homeopathy works, but is too incompetent to keep real medicine out of his nothing.

Homeopath XX is willing to sell anything that pays. He knows that homeopathy is nonsense, but wants to add real medicine to make it seem that the water is having some sort of effect beyond a placebo effect. He adds real medicine after the dilution for that effect. This is not rare.

Homeopaths claim that their medicines are safe and that real medicines are dangerous, so why add medicine?

Since homeopathy is all lies, should we believe anything a homeopath says?

If you dilute a lie enough times, does it become truth?

We have enough problems with believing in magic with real medicines without adding the problems of homeopathy, where there is nothing real except fraud.


[1] Pleo Homeopathic Drug Products by Terra-Medica: Recall – Potential for Undeclared Penicillin – Includes Pleo-FORT, Pleo-QUENT, Pleo-NOT, Pleo-STOLO, Pleo-NOTA-QUENT, and Pleo-EX
Posted 03/20/2014
Safety Alert

[2] dilution


Child Killers Sentenced, But Not the Ringleader


Child sacrifice advocate Pastor Nelson Clark can continue to preach alternative medicine that kills and he can continue to blame the victims.

The secret of alternative medicine is to blame the victim.

Image credit. Pastor Nelson Clark of the First Century Gospel Church.
                 I preach human sacrifice!

In an interview with The Inquirer, Clark said God did not want the Schaible children to die.

Instead, he said, the children died because of some “spiritual lack” in the Schaibles’ lives – a flaw they need to correct to prevent future deaths.[1]


If a doctor prescribed prayer for deadly conditions, the doctor should face charges.

Pastor Nelson Clark of the First Century Gospel Church is just another alternative medicine practitioner prescribing alternative medicine for deadly conditions and blaming the victims.

We need to treat all of these medical frauds the same.

We need to stop them from killing children.

Sacrificing children to alternative medicine is wrong.

It does not matter if the alternative medicine is religious, what matters is that we protect children from killers.

The Schaibles were sentenced to 3 1/2 to 7 years in prison, but that won’t stop Pastor Nelson Clark from preaching child sacrifice at the First Century Gospel Church.

The Schaibles lost two children to this fraud, they will spend time in prison, they probably will be prevented from putting a third child in the cemetery, but Pastor Nelson Clark will preach on and he will continue to blame the Schaibles for lacking faith.

States that allow a religious defense to most serious crimes against children include: Idaho, Iowa, and Ohio with religious defenses to manslaughter; West Virginia with religious defenses to murder of a child and child neglect resulting in death; and Arkansas with a religious defense to capital murder, according to Children’s Healthcare, an educational charity. Approximately a dozen U.S. children die in faith healing cases each year, the AP reported.[2]


This human sacrifice is

not the first time that children have died with the help of Pastor Nelson Clark.

not the second time that children have died with the help of Pastor Nelson Clark.

not the third time that children have died with the help of Pastor Nelson Clark.

not the fourth time that children have died with the help of Pastor Nelson Clark.

Pastor Nelson Clark doesn’t have a good record of praying the germs away.

The couple has seven surviving children, while six of them are in foster care, some residing with relatives. The children are getting an education, medical, dental, and vision care now.[2]


Also see –

Update on – Is it OK to kill children in the name of God?


[1] Pastor: ‘Spiritual lack’ killed two boys
By Mike Newall, Inquirer Staff Writer
Posted: April 29, 2013

[2] Pennsylvania Couple Faces Prison After 2nd Prayer Death Of Child With Pneumonia: Should Faith Healing Be Considered Manslaughter?
By Lizette Borreli | Feb 20, 2014 12:00 PM EDT
Medical Daily


Alternative Medicine, Wishful Thinking, and Irresponsible Drug Pushers


Most emergency physicians avoid using homeopathy, acupuncture, Reiki, and other alternative medicine because there is no valid evidence that these treatments work, or because of they are not considered standards of care, or because there is no recommendation to give them from ACEP (American College of Emergency Medicine).

This is good, because alternative medicine is fraud.

Is there an alternative field of aerodynamics making planes for us to fly? Where is this alternative science?

Are people using alternative electricity to power their homes? Where is this alternative science?

According to the homeopathy hypothesis, the more dilute something is, the more powerful it is. We could solve the world’s energy problems – if the alternative science of homeopathy were anything more than wishful thinking.

How does that relate to emergency medicine?

When it comes to emergency treatments for cardiac arrest, stroke, heart failure, possible spinal cord injury, et cetera, many emergency physicians are just as superstitious as your local witch doctor. Currently, the most prominent example of alternative emergency medicine is tPA (Alteplase) for acute ischemic stroke.

But tPA, approved for strokes in 1996, only works if given within 4.5 hours of a stroke.[1]


That is an optimistic interpretation of the research –

The recent release of the American College of Emergency Physicians guideline recommending the use of tPA for ischemic stroke is remarkable. While it is unsurprising that a professional guideline flouts science, the publication is striking for its casual tone and its methodologically inexplicable review of evidence. Scientific thinking is absent.[2]


The evidence is horribly flawed, but the advocates respond just as we expect alternative medicine pushers to respond – with logical fallacies.

Ad hominem attacks on those who criticize the bad research.

These few persistent myths about thrombolytic therapy were first promulgated by self-appointed ‘expert critics’ who are unabashedly anti-intellectual in their opposition to this therapy. They decline to either read or attempt to understand data and rigorous analysis of that data.[3]

Alternative medicine pusher Dr. Patrick Lyden.

What is the appropriate time period for giving tPA?

IST-3 time to treatment randomization and outcomes detail with my edits for clarity.[4]

Patients get better if tPA is begun within 3 hours, get worse if tPA is begun between 3 hours and 4 1/2 hours, but get better when tPA is begun after more than 4 1/2 hours.

Clearly, there is some strong evil magic that is working against tPA in that 3 to 4 1/2 hour time period, but it is all unicorns and rainbows the rest of the time.

Does that make sense?


That suggests that the evidence we have does not adequately assess the effects of tPA for acute ischemic stroke.

Reasonable people can disagree, but Dr. Lyden appears to be calling those who disagree biased just because they disagree. This is bad science and bad medicine.

We need research that is well controlled, not research that requires a lot of excuses.

MedPage Today is providing a good forum for discussion of this actual medical controversy and not just promoting the ad hominem criticisms of Dr. Lyden. There are links to plenty of other sites discuissing the problems with the evidence.[5]

I most recently wrote about this here – The Debate on tPA for Ischemic Stroke at EMCrit – What Does the Research Really Say?

I am not an emergency physician, so this is not something that affects my care of patients. I do not have to worry about being sued for not giving tPA and being accused of allowing a bad outcome. I do not have to worry about being sued for giving tPA and being accused of producing a bad outcome.

If you are an ACEP member, tell ACEP what you think of the evidence, or the flaws in the evidence.


[1] Few stroke patients get clot-busting drug
Liz Szabo,
10 a.m. EST February 13, 2014

[2] The Guideline, The Science, and The Gap
Wednesday, April 17, 2013
Dr. David Newman browngorilla540
Smart EM

[3] ER Briefs: tPA ‘Works’, ACEP on Target
Published: Feb 10, 2014
By Elbert Chu
Interview with Patrick D. Lyden, MD

[4] The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial.
IST-3 collaborative group, Sandercock P, Wardlaw JM, Lindley RI, Dennis M, Cohen G, Murray G, Innes K, Venables G, Czlonkowska A, Kobayashi A, Ricci S, Murray V, Berge E, Slot KB, Hankey GJ, Correia M, Peeters A, Matz K, Lyrer P, Gubitz G, Phillips SJ, Arauz A.
Lancet. 2012 Jun 23;379(9834):2352-63. doi: 10.1016/S0140-6736(12)60768-5. Epub 2012 May 23. Erratum in: Lancet. 2012 Aug 25;380(9843):730.
PMID: 22632908 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.

[5] ER Briefs: Open Season on ACEP tPA Guidelines
Published: Jan 29, 2014 | Updated: Jan 30, 2014
By Elbert Chu

Resolutions for a New Year?


Cyanide and Happiness.

What do I resolve for each New Year?


Is it wrong to be judgmental of people who harm others?


This is an example of what I do not resolve.

This person is harming himself, but he is also harming others by suggesting that his foolishness is not dangerous.

Cyanide is all-natural.

No nasty artificial stuff in cyanide.

Does that make cyanide safe?[1]

Should I remain silent and encourage others to abuse patients with their fraudulent claims that their treatments are better than evidence-based treatments?

Of course not.

If the treatment worked, the proponents of the treatment could provide evidence that it works.

Do we think that objective observation and testing really prevents the treatment from working?

Then the treatment never really worked.

We were just being gullible and allowed ourselves to be fooled by our wishful thinking.

Wishful thinking kills.[2]


All treatments have the potential for damaging side effects, and all screening for early diagnosis and prevention has the potential to cause harm. The wishful thinking that leads to the exaggeration of benefits and the minimisation of harms means that an ever increasing number of patients will be exposed to those harms in pursuit of the promised benefits.[2]


Taking a treatment that does not work is dangerous.

We need to demand evidence of benefit before taking treatments.

We need to demand evidence of benefit before giving treatments to the most vulnerable people – our patients.

It is surely time for medicine to reassert a standard of integrity that seeks out and actively curtails wishful thinking and acknowledges the degree of uncertainty at every level of practice, even at the expense of admitting impotence.[2]


We cannot expect any such honesty from alternative medicine.

My resolution, every year, is to not make resolutions.

Since that immediately fails, I can move on to doing something.

If resolutions are a good motivator for you, go ahead and make resolutions, but make them resolutions that you can accomplish. Next year you can make the resolution more rigorous, increase the difficulty level, or use whatever terminology gets you there.

If the resolution is to be more ignorant by ignoring valid science, don’t do it.


[1] Appeal to nature

[2] The price of wishful thinking
Life and Death
BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c4632 (Published 8 September 2010)
Abstract from BMJ


Selling scams to the most desperate patients

This is alternative medicine at its worst.

When it fails, blame the victim.

At prayer healing services in some Pentecostal churches, pastors invite people infected with HIV to come forward for a public healing, after which they burn the person’s anti-retroviral medications and declare the person cured.[1]


If only there were some documented cases of patients going from high levels of HIV to no HIV measurable with prayer as the only treatment.


The group was asked to undergo a test at a certain clinic in Nairobi, where they were all declared cured.

“We had joined him for crusades around Nairobi slums, telling the people how wonderful the pastor’s miracles were,” she added. “I was upbeat, but after two weeks I started falling sick. When I was tested, the virus was still in me and had multiplied since I was not taking the drugs.”[1]


Falsified AIDS tests convince people that they have been healed.

They then go tell others how wonderful it is.

Then they get sick again.

“I believe people can be healed of all kinds of sickness, including HIV, through prayers,” said Pastor Joseph Maina of Agmo Prayer Mountain, a Pentecostal church on the outskirts of Nairobi.[1]


He is using that belief to kill people.

Maybe you do not believe that convincing people to stop taking the medications that are keeping them alive is killing them.

But the controversial ceremonies are raising red flags as believers’ conditions worsen, and a debate has opened over whether science or religion should take the lead in the fight against the AIDS epidemic.[1]


I propose a simple, clear solution.

Compare the outcomes of AIDS patients who are treated with the magic ceremony against the AIDS patients treated with conventional medicine. Have periodic blood tests to make sure the magic ceremony patients really are not taking medication.

Then compare the numbers at various times.

How many died with each treatment at 3 months, 6 months, 9 months, 1 year, 15 months, . . . .

If prayer works, then the prayer and placebo patients will do as well as, or better than, the prayer and real AIDS medicine patients.

The benefit of the real AIDS medicines would be nonexistent after the benefit of an immediate prayer cure. The side effects of the real AIDS medicines would still be there.

Have half of the patients take a placebo and the other half take real AIDS medicine.

The study would not be overly expensive, unless you count the lives of those going for treatment, since they were going for the prayer treatment anyway.

Even better.

Make it a randomized placebo controlled study among people already going for the prayer treatment.

If the pastor has faith, he has nothing to lose.

Except the pastor appears to be intentionally scamming people for money.

“We don’t ask for money, but we ask them to leave some seed money that they please.”[1]


As if seed money is not real money.

Because separating the request for money from the magic healing ceremony would probably result in much smaller donations.

Pentecostal church pastors often tell people that a lack of faith is the reason the prayer healing isn’t working.[1]


Blame the victim.

“When you are told there is an easier option, you want them (drugs) out of your life,” said Nyawera.[1]


This is the same tactic used by the rest of alternative medicine.

There is another important reason to invest in this kind of study.

The prayer healings are especially worrisome because people who quit treatment may become resistant to the drugs.[1]


Killing people by coercing them to stop taking their medications is bad, but generating more drug-resistant strains of AIDS harms even those who never fell for the scam.


[1] Pentecostal pastors in Africa push prayer, not drugs, for people with HIV
Washington Post
By Fredrick Nzwili
Religion News Service
Published: December 4


Is Earlier Better for Therapeutic Hypothermia? Part I


When is the right time to begin TH (Therapeutic Hypothermia) to produce the best outcomes?

In the ICU (Intensive Care Unit)?

In the ED (Emergency Department)?

In the ambulance?

While the patient is still pulseless?

This question was asked in 2010.

Click on image to make it larger.

Favorable outcomes – 47.5% EMS TH vs 52.6% ED TH.

Worse outcome, but not statistically significant.

Discharge to home – 20.3% EMS TH vs 29.3% ED TH.

Worse outcome, but not statistically significant.

Discharge to rehabilitation – 27.1% EMS TH vs 23.3% ED TH.

Worse outcome, because these patients are not well enough to go home, but not statistically significant.

Dead – 52.5% EMS TH vs 46.6% ED TH.

Worse outcome, but not statistically significant.

The great tragedy of Science — the slaying of a beautiful hypothesis by an ugly fact. -Thomas Henry Huxley.

EMS TH was added to many EMS protocols because of a lack of clear evidence of harm. EMS needed to Just do something.

The results did not support EMS administration of chilled IV (IntraVenous) fluid for prehospital therapeutic hypothermia, but the study was stopped early, because –

At the interim analysis of the first 200 patients, the Steering Committee noted that there was no difference in the primary outcome measure and that it was extremely unlikely that such a difference would emerge between the groups. Therefore, the study was stopped because of futility after 234 patients had been enrolled.[1]


In other words – We will not let the numbers convince us that there is no benefit, because numbers that do not support a positive effect are futile?

If the data would have indicated a negative effect, but had not reached statistical significance, should we expect the Steering Committee to support continuing the study, or would they support discontinuing the study early to protect the enrolled patients, but leave the question unanswered?

When studies are discontinued early to protect patients, do they discourage further studies?

When studies are discontinued early to protect patients, do they only endanger future patients?

Or does early termination encourage further studies because there is not clear evidence of harm and we want to believe that our interventions are beneficial?

What if it works?

Most proposed treatments do not work, so this is just an excuse to continue using something dangerous. What if it works? is the logical fallacy that is used to justify harming patients with alternative medicine.

We should not harm vulnerable patients because of our unreasonable belief in wishful thinking.

If it helps just one patient it is worth it.

This is another logical fallacy, because it completely ignores the harm that the treatment causes.

Some patients will improve after almost any treatment – even cyanide.

That means that alternative medicine advocates could should endorse the use of cyanide, because if it helps just one patient . . . .

We need to have unbiased information about the real benefits (if any) and the real harms (if any), before we encourage using anything on vulnerable patients.

Is it good to just do something?


Is it good to help patients?

If our responsibility is to help patients, one of the best ways to help patients is to avoid causing harm.

Just doing something, with no evidence of benefit, is causing harm.

How many EMS agencies have prehospital therapeutic hypothermia protocols because of a desire to just do something?

I have been criticized for not being a supporter of treatments that do not have evidence of benefit.

Am I a killjoy, desiring bad outcomes?


I understand that treatment that does not have evidence of benefit is almost always going to do more harm than good.

Just do something?


Just demand valid evidence of improved outcomes.


[1] Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial.
Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W; Rapid Infusion of Cold Hartmanns (RICH) Investigators.
Circulation. 2010 Aug 17;122(7):737-42. doi: 10.1161/CIRCULATIONAHA.109.906859. Epub 2010 Aug 2.
PMID: 20679551 [PubMed – indexed for MEDLINE]

Free Full Text from Circulation.

Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W, & Rapid Infusion of Cold Hartmanns (RICH) Investigators (2010). Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial. Circulation, 122 (7), 737-42 PMID: 20679551


Why Did We Remove Atropine From ACLS? Part II


Continuing from Part I.

The AHA (American Heart Association) stopped recommendeding use of atropine for the treatment of PEA (Pulseless Electrical Activity) or asystole in the 2010 ACLS (Advanced Cardiac Life Support) guidelines.

There is not much information given, but that little bit of information just makes it more clear that we never had a good reason for making atropine a standard part of ACLS.

One sentence at a time, look at the reasoning –

Interventions Not Recommended for Routine Use During Cardiac Arrest

Atropine sulfate reverses cholinergic-mediated decreases in heart rate and atrioventricular nodal conduction.[1]


There is a hypothetical justification for atropine based on physiology/pathophysiology.

There has been a hypothetical justification for every treatment found to be harmful. That hypothetical justification did not protect patients from real harm.

No prospective controlled clinical trials have examined the use of atropine in asystole or bradycardic PEA cardiac arrest.[2]


Why was a treatment that had never been demonstrated to improve outcomes recommended and the standard of care?

Without evidence of improved outcomes, should any treatment be used outside of controlled trials?

Lower-level clinical studies provide conflicting evidence of the benefit of routine use of atropine in cardiac arrest.34,295,–,304 [1]


To translate – Useless information is . . . useless.

There is no evidence that atropine has detrimental effects during bradycardic or asystolic cardiac arrest.[1]


Is atropine the alternative medicine of cardiac arrest?

This sentence contradicts the evidence review that led to the removal of atropine from the guidelines.

Here is a listing of the evidence that opposes the use of atropine for cardiac arrest.

Click on image to make it larger.[2]

While the evidence of harm is not great, the evidence of benefit is not great, either.

Evidence of worse outcomes from cardiac arrest is evidence of harm.

There are four studies – three that show a negative correlation with atropine and survival to discharge.

no evidence that atropine has detrimental effects?

The positive studies are also just showing correlation. Poor studies mean poor information. Why were we giving atropine based on poor information?

We were giving atropine based on wishful thinking.

Available evidence suggests that routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb, LOE B).[1]


We should not include treatments that do not have evidence of therapeutic benefit.

For this reason atropine has been removed from the cardiac arrest algorithm.[1]


For this reason, atropine should never have been included in the cardiac arrest algorithms.

For this reason, all treatments that do not have evidence of therapeutic benefit should have an expiration date.

If no evidence is provided, the treatment is removed from the guidelines.

This would apply to ventilations, epinephrine (Adrenaline), vasopressin (Pitressin), norepinephrine (Levophed), and phenylephrine (Neo-Synephrine) in cardiac arrest.

This would also apply to amiodarone (Cordarone), lidocaine (Xylocaine), and Magnesium in VF (Ventricular Fibrillation) cardiac arrest.

What does that leave us with?

Compressions in cardiac arrest.

Defibrillation in VF cardiac arrest.

Therapeutic hypothermia after resuscitation.

In Part III I will look at the most positive study supporting the use of atropine for cardiac arrest.


[1] Atropine
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8.2: Management of Cardiac Arrest
Interventions Not Recommended for Routine Use During Cardiac Arrest
Free Full Text from Circulation.

[2] Atropine for cardiac arrest
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Appendix: Evidence-Based Worksheets
Part 8 ALS
Swee Han Lim
Evidence-Based Worksheet Download in PDF format.

That link is no longer available, but the overall page of evidence-based worksheets is available in PDF format here.