Prehospital arrest survival improved by 400%

[rcdavis]

I alluded to this study in a convo w/ emedpa, forgot to post it.

 

you ems guys, and EM guys oughta take a look.. fascinating

 

 

 

 

http://pulmccm.org/2013/randomized-controlled-trials/vasopressin-steroid-epinephrine-cocktail-improved-cardiac-arrest-outcomes-jama/

[True Anomaly]

Well, that's a start in challenging current dogma that only compression and electricity make any difference in cardiac arrest.

[EMEDPA]

alright. vasopresin/solumedrol it is...

[Davo]

Interesting. I wonder how aggressive induced hypothermia protocols would impact this study.

[rcdavis]

Probably not at all.

I know of EMS protocols which call for Prehospital "article freeze" institution in cardiac arrest, unless there has been a spont return of circulation.

 

And it is would NOT indicated in my part of the country in a straight forward arrest initially.

 

The protocols for hypothermic induction include RSI, dopamine as needed, baseline labs, etc.. All of which take time. There is the infamous Wake Forrest Protocals which pretty much has not panned out, and in my opinion causes significant delay of transport.

 

Vasopressin was used a lot in arrests in the lid 90s to maybe early 2000s, but in much higher doses ( 40-60 units, then 0.03 units/kg/hr... Didn't work. Was associated with increased mortality and decreased 30 day discharge rates.

 

The thing here is the low dose VPN plus the steroid.if duplicated, this is a major study.

[MediMike]

Haha beat me to it with the WC reference!

 

It will be huge if this is duplicated RC, I'd love to see it happen!

[Davo]

Probably not at all.

I know of EMS protocols which call for Prehospital "article freeze" institution in cardiac arrest, unless there has been a spont return of circulation.

 

And it is would NOT indicated in my part of the country in a straight forward arrest initially.

 

The protocols for hypothermic induction include RSI, dopamine as needed, baseline labs, etc.. All of which take time. There is the infamous Wake Forrest Protocals which pretty much has not panned out, and in my opinion causes significant delay of transport.

 

Vasopressin was used a lot in arrests in the lid 90s to maybe early 2000s, but in much higher doses ( 40-60 units, then 0.03 units/kg/hr... Didn't work. Was associated with increased mortality and decreased 30 day discharge rates.

 

The thing here is the low dose VPN plus the steroid.if duplicated, this is a major study.

 

Indeed this would be a huge improvement. I remember vasopressin (ADH), its rare to see it around here, paramedics sure aren't carrying it. ACLS recommends hypothermia for patients with ROSC, to improve neurological outcomes (notably it appears to work). In hospital, time to induced hypothermia appears to be critical, so while labs etc might delay implementation, its not insurmountable prior to admissions and seems like it could be done quickly enough, what do you think?

 

Also, where is prehospital survival mentioned? I see info on in-hospital arrests in the op.

[rcdavis]

I do not disagree: hypothermia works in ohca pts with a return of spontaneous rhythm and pulse. But, unless you are of the mind that "staying and playing " is more appropriate than bringing to the hospital quickly, after instituting CPR, then you are BUSY in the truck.

 

I guess undressing and placing ice packs won't hurt, though peripheral cooling has lead to pretty irratic temperatures.

[EMEDPA]

Our medics do ice packs to b/l neck/axilla/groin in out of hospital ROSC pts

[Davo]

I dont see having an EMT place cold packs in the groin, axilla, and neck as well as the IV bag as stay and play, in fact it would likely be done en route, but only after primary measures were employed. Besides, non-invasive cooling is fairly benign and is only a start to induced hypothermia.

[Davo]

Our medics do ice packs to b/l neck/axilla/groin in out of hospital ROSC pts

So do ours, I know of at least one arrest in my county that happened at a grocery store where frozen veggies were used. :)

We used to only carry a few cold packs on the rig.

[MediMike]

So do ours, I know of at least one arrest in my county that happened at a grocery store where frozen veggies were used. :)

We used to only carry a few cold packs on the rig.

 

Did they have to pay for those at checkout...? ;)

[EMEDPA]

_{tried this today in a code. pt currently in icu after ROSC. will see if it makes a difference in a few days.}

_{68 yr old male alcoholic found down by family after being short of breath earlier in the day. cpr started. medics found asystole, started cpr and pt developed pea. after fluid boluses and dopamine had pulses. intubated in the field. arrived with no iv access after IO inadvertently dislodged during transfer. 2 IVs established rapidly on arrival.} 

 _{in/out of pea with cpr(although  + cardiac wall motion by bedside u/s throughout). tube placement good clinically and by pcxr. several rounds of epi. vasopresin and solumedrol given. blood > 300 cc in OG tube without ongoing bleeding.dopamine weaned. foley placed. hypothermia protocol done. 10 mg of vec given .pt to floor with pulses and bp of 180/100. labs as expected post code. ph 7.15. H+H nl. tox screen nl.}

_{per family ? hx of ulcer or varices. given protonix and octreotide. head ct done from ICU shows diffuse edema without herniation. unlikely to have good outcome at this point. ct chest neg for PE.}

[medic25]

Very interesting E; is this something that your whole institution is implementing?  The JAMA study involved up to 7 days of hydrocortisone as well as the vasopressin/solumedrol in the intra-arrest setting.  I'd be interested to see if the single doses in the ED provide the same changes in outcome if the ICU isn't continuing the inpatient regimen.

[PM2PA]

Frozen veggies... Love it.

 

 

 

[EMEDPA]

Very interesting E; is this something that your whole institution is implementing?  The JAMA study involved up to 7 days of hydrocortisone as well as the vasopressin/solumedrol in the intra-arrest setting.  I'd be interested to see if the single doses in the ED provide the same changes in outcome if the ICU isn't continuing the inpatient regimen.

we don't have a protocol in place yet. the intensivist was on board with this( I asked him before trying) and his plan was to continue with hydrocortisone in the unit. we got a head ct from the icu showing significant anoxic brain injury and edema so I believe they kept him on life support only long enough for distant family to come and the harvesting of a few organs...I didn't expect much in the way of outcome with over an hr of cpr done after initial arrest before admission to the unit. I didn't mention the medics had a 15 min eta to the scene, spent 20 min on scene, then had a 20 min eta to us. this was at my rural coastal job.

[fuma102]

No surprise on the poor outcome.  in your case, you say medics found pt in asystole and had an unwitnessed arrest. Pt's technically not a candidate for hypothermia based on current ACEP guidelines.  

 

http://www.acep.org/News-/Publications/ACEP-News/Focus-On--Therapeutic-Hypothermia-After-Cardiac-Arrest/

 

"To be eligible for therapeutic hypothermia, patients must meet all of the following criteria:

• Be an adult successfully resuscitated from witnessed arrest from presumed cardiac cause.
• Be comatose and intubated.
• Have an initial rhythm of ventricular fibrillation or nonperfusing ventricular tachycardia.
• Be hemodynamically stable after resuscitation (though some data support using therapeutic hypothermia in patients in cardiogenic shock after resuscitation)."