Advanced Cardiac Drugs Don't Work Anyway....Or Do They?

The study copied below concluded that advanced cardiac life support drugs like epinephrine and atropine don't help the patient much during certain types of cardiac arrest.

But maybe they DO help if a cardiac arrest is from an asthma or anaphylactic arrest or a pediatric drowning. Who knows?

Does this mean that Advanced Medical Transport in Peoria will stop giving drugs like epinephrine at the scene of a cardiac arrest? Will AMT explain to the family that they are going to WITHHOLD drugs and quote statistics regarding Uncle George's small chance of being discharged from the hospital with good neurologic function?

Do most families want Uncle George dying in the backyard next to the lawnmower or in an intensive care unit two days later?

And, I digress slightly, but who will tell the people in Peoria who have lost loved ones during heart attacks, asthma attacks, drownings, etc., during the last 15 years that the Peoria Fire Department, until this summer, had NO advanced life support drugs to give them in the first place? Even though giving advanced life support drugs was and is the standard of care for advanced life support, the doctors that run EMS tried to reassure Peoria's City Council and Peorians that all was fine and good...until this summer when they changed it all.

Please see article below:

From Heartwire CME
Hold the Epi: No Advantage Seen With IV Drugs at Out-of-Hospital Cardiac Arrest CME
News Author: Steve Stiles
CME Author: Penny Murata, MD

December 4, 2009 — Facing off with longstanding policy and tradition, a large randomized trial found that giving intravenous (IV) drugs like epinephrine and atropine in the setting of out-of-hospital cardiac arrest made it more likely that patients would be admitted to the hospital but little difference in whether they survived to discharge [1].

That outcome was in spite of their undergoing resuscitation longer and receiving more defibrillations, and more often reattaining a spontaneous circulation, compared with another group that didn't receive IV drugs during arrest, observe the authors, led by Dr Theresa M Olasveengen (Oslo University Hospital, Norway), in this week's Journal of the American Medical Association.

The trial is only the latest of several in recent years to reappraise the efficacy of major elements of conventional cardiopulmonary resuscitation.

For now, the cornerstones of optimal cardiac resuscitation include high-quality cardiopulmonary resuscitation with minimal interruptions for anything, including any drug administration, and early defibrillation.

"These researchers present important and compelling data, which challenge the efficacy of one of the most common procedures in cardiac resuscitation: the administration of intravenous epinephrine," said Dr Bentley J Bobrow (Arizona Department of Health Services, Phoenix) in an email to heartwire . Bobrow, who wasn't involved in the study, is medical director of his state's Bureau of Emergency Medical Services & Trauma System.

"While epinephrine administration has been part of the guidelines for resuscitation for many years, there has been very little evidence supporting its benefit and some convincing evidence suggesting worse outcomes with higher doses of epinephrine," he remarked.

"The message for emergency providers is that, for now, the cornerstones of optimal cardiac resuscitation include high-quality cardiopulmonary resuscitation with minimal interruptions for anything, including any drug administration, and early defibrillation."

Olasveengen et al randomized 851 consecutive adults with nontraumatic out-of-hospital cardiac arrest to management according to advanced-cardiac-life-support guidelines with or without access to IV drug administration. In the no-IV-access group, those who achieved "return to spontaneous circulation" could receive IV drugs five minutes later, if indicated.

Those treated with access to IV drugs fared significantly better at first, but didn't outdo those managed without IV drug access for the primary end point of survival to hospital discharge.

Outcomes of Resuscitation in Out-of-Hospital Cardiac Arrest, With and Without IV Drug Access End point IV drugs (%), n=418 No IV drugs (%), n=433 OR (95% CI) p
Return of spontaneous circulation 40 25 1.99 (1.48-2.67) 0.001
Hospital admission 43 29 1.81 (1.36-2.40) 0.001
Survival to hospital discharge* 10.5 9.2 1.16 (0.74-1.82) 0.61


*Primary end point

Nor was there a significant difference for the primary end point in an analysis that controlled for response time, whether the arrest occurred in a public place or was witnessed, or whether ventricular fibrillation was the initial rhythm (odds ratio, 1.15; 95% CI, 0.69-1.91).

The quality of delivered cardiopulmonary resuscitation (including chest-compression rate, ventilation rate, and other factors), a prospectively defined secondary end point, was within guidelines and comparable in the two groups, Olasveengen et al report. So was the prevalence of therapeutic hypothermia as part of management, which exceeded 70%.

The trial has a number of limitations, the group notes, including the inability to blind emergency responders to the randomization and the involvement of a single emergency-response system. It also doesn't preclude the potential usefulness of other IV drug regimens. But, "at a minimum, our results indicate that clinical equipoise exists on the efficacy of intravenous drugs in the treatment of cardiac arrest and that more definitive trials could be ethically undertaken."

Olasveengen reports receiving fees for speaking from Medtronic and research support from Laerdal Medical. Of the coauthors, Dr Petter A Steen (Oslo University Hospital) reports being on the board of directors for Laerdal Medical and the Norwegian Air Ambulance Foundation (which provided partial funding for the study); and Dr Lars Wik (Oslo University Hospital) reports being on the medical advisory board of Physio-Control, consulting for Laerdal, Zoll, and Jolife, and being principle investigator of a Zoll-sponsored clinical trial.

Reference

1. Olasveengen TM, Sunde K, Brunborg C, et al. Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial. JAMA 2009; 302:2222-2229.

Clinical Context

Current cardiopulmonary resuscitation guidelines, as reported by the American Heart Association in the December 13, 2005, issue of Circulation, include IV drug administration. However, the benefits of epinephrine administration during advanced cardiac life support are not clear. In the July 2002 issue of Resuscitation, a retrospective study by Holmberg and colleagues found that the need for epinephrine after an out-of-hospital cardiac arrest was an independent predictor of poor outcome. Possible reasons include the effects of epinephrine or poor quality of cardiopulmonary resuscitation during the process of IV access and administration.

This prospective, randomized controlled trial assesses whether IV vs no IV drug administration during advanced cardiac life support after an out-of-hospital cardiac arrest in adults affects survival to hospital admission with return of spontaneous circulation (ROSC), survival to hospital discharge, 1 year survival, survival with favorable neurologic outcome, or quality of cardiopulmonary resuscitation.


Study Highlights

851 of 946 eligible adults older than 18 years with nontraumatic out-of-hospital cardiac arrest were randomly assigned to receive advanced cardiac life support with or without IV drug administration.

Exclusion criteria were cardiac arrest witnessed by ambulance team, resuscitation started or interrupted by physicians outside of ambulance team, or cardiac arrest resulting from asthma or anaphylactic shock.

Participants did not differ from nonparticipants in demographic data or outcomes.
418 patients were in the IV group.
433 patients were in the no-IV group, which received IV access and drugs (if indicated) 5 minutes after ROSC.
Mean age was 64 years.

IV vs no-IV group did not differ in sex, cardiac cause, location of cardiac arrest, bystander involvement, initial rhythm, presence of physician-staffed ambulance, response interval, or intubation.

Standard protocol included the 2000 International Guidelines (Circulation. 2000;102[8 Suppl]:I11-I11) modified by 3 minutes of cardiopulmonary resuscitation before first shock and between unsuccessful shocks for patients with ventricular fibrillation, defibrillators in manual mode, endotracheal intubation to secure airway, therapeutic hypothermia, and electrocardiogram transmission to cardiologist after ROSC.

Defibrillation attempts occurred more in the IV vs the no-IV group (47% vs 37%; odds ratio [OR], 1.16; 95% confidence interval [CI], 0.74 - 1.82).
Of patients who received defibrillation, more shocks were given to the IV vs the no-IV group (median, 3 vs 2; P = .008).

The primary outcome measure of survival to hospital discharge was similar for the IV vs the no-IV group (44 [10.5%] of 418 vs 40 [9.2%] of 433; OR, 1.16), even after adjusting for confounders (adjusted OR, 1.15).

Quality of cardiopulmonary resuscitation, assessed by hands-off ratio (hands-off time divided by total time without ROSC), compression rates, and ventilation rates, was adequate and similar for the IV vs the no-IV group.

Survival with favorable neurologic outcome (defined as good cerebral performance or moderate cerebral disability) was similar for the IV vs the no-IV group (9.8% vs 8.1%).

Short-term survival was greater in the IV vs the no-IV group:
ROSC (40% vs 25%; OR, 1.99; 95% CI, 1.48 - 2.67; P < .001)
Admission to hospital (43% vs 29%; OR, 1.81; 95% CI, 1.36 - 2.40; P < .001)
Admission to intensive care unit (30% vs 20%; OR, 1.67; 95% CI, 1.22 - 2.29; P = .002)

In patients with initial ventricular fibrillation or pulseless ventricular tachycardia, there were no outcome differences between groups.

In patients with initial nonshockable rhythms, the rates for ROSC, hospital admission, and intensive care unit admission were higher in the IV vs the no-IV group.

Multivariate analysis, adjusted for public location of cardiac arrest, response interval, and initial ventricular fibrillation, showed greater long-term survival if cardiac arrest showed initial ventricular fibrillation or pulseless ventricular tachycardia, was witnessed by bystander, or occurred in a public place.

Long-term survival odds decreased by 17% per minute of prolonged response interval (adjusted OR, 0.83).

Adjusted survival to intensive care unit was greater for the IV vs the no-IV group (adjusted OR, 1.78).

Cumulative survival rates for the IV vs the no-IV group include 7-day survival (14.6% vs 12.8%), 1-month survival (11.3% vs 8.8%), and 1-year survival (9.8% vs 8.4%).
Study limitations included inability to blind ambulance team to treatment group, cardiopulmonary resuscitation quality assessment in only 75% of cases, lack of reliable time line for drug administration, and lack of data on time of cardiac arrest.

Clinical Implications

In adults with an out-of-hospital cardiac arrest, IV vs no IV drug administration as part of advanced cardiac life support guidelines results in higher rates of short-term survival but does not affect survival to hospital discharge.

In adults with an out-of-hospital cardiac arrest, IV vs no IV drug administration as part of advanced cardiac life support guidelines does not affect 1-year survival duration, survival with favorable neurologic outcome, or quality of cardiopulmonary resuscitation.