There were not a lot of big changes in the 2015 AHA PALS recommendations. Nevertheless I did want to touch briefly on a few issues raised in the update, which you should all read. You can check out the full pdf here.
Atropine as a pre-intubation medication
Prior to, during and after intubation patients can become bradycardia due to hypoxia, vagal response upon intubation, reflex response to PPV or through the effects of some drug – in our situation usually succinylcholine. The evidence behind the use of atropine as a pre-medication medicine in rapid sequence intubation is thin. Per the authors “there is no evidence that preintubation use of atropine improves survival or prevents cardiac arrest in infants and children.” However in some patients, and they don’t explicitly state who is in that some. So here’s what makes sense to me based on the available evidence. Atropine 0.02 mg/kg (no minimum dose) 3-5 minutes prior to sedative and paralytic drugs for RSI for patients who are:
- Age <12 months
- <5 years and receiving succinylcholine
- Receiving a 2nd dose of succinylcholine (generally for the second attempt at endotracheal intubation)
Amiodarone or Lidocaine for V fib and V tach?
In 2005 and 2010 amiodarone was recommended over lidocaine for ventricular fibrillation and ventricular tachycardia. The evidence was derived from case series and adult studies but was lacking. Recently, lidocaine was found superior to amiodarone in ROSC via a retrospective study by Valdes et al in Resuscitation in 2014. In a review of 889 patients with in hospital arrest v fib or pulseless v tac 484 (54%) of which had ROSC, with 194 (22%) surviving to discharge, the authors noted the following:
- 171 (19%) received amiodarone
- 295 (33%) received lidocaine
- 82 (10%) received both
- Lidocaine was associated with improved ROSC – adjusted OR 2.02 (95% CI 1.36-3)
- Lidocaine was also associated with greater 24 hour survival – adjusted OR 1.66 (95% CI 1.11-2.49)
- Amiodarone use was not associated with ROSC, 24h survival, or survival to discharge
Interestingly in this study the odds of ROSC were greater in cardiac surgery patients – aOR 2.15 (95% CI 1.35-3.45). Trauma patients however, saw the exact opposite with the aOR 0.51 (95% CI 0.28-0.93). Read the whole study here.
The bottom line is that for shock-refractory V fib or pulseless v tach, you can choose either amiodarone or lidocaine – but based on at least this single study, Lidocaine seems to be the more attractive option.
Not so fast vasopressin
This one is more relevant to adults, and given that PEM in PEMBlog stands for Pediatric Emergency Medicine I’ll only touch on it briefly. But essentially the AHA has stated that they are no longer recommending vasopressin as a substitute/alternative for epinephrine during resuscitation. There was no clear evidence that it offered a benefit, and in an effort to clarify and streamline the ACLS algorithm it was removed.