Guidelines 2000 for ACLS and Emergency Cardiovascular Care

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Guidelines 2000 for ACLS and Emergency
Cardiovascular Care

• Dr. Joel Turner, MD, FRCP-IV

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Guidelines 2000 Conference A consensus on
science
To create valid, widely accepted international
resuscitation guidelines, based on international
science and produced by international
resuscitation experts.
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• Outline of Todays talk
• Historical Perspective
• Evidence-based guidelines - methodology of
  International Guidelines 2000 conference.
• Some of the changes in ACLS guidelines
• A (Airway) confirmation of ET tube placement
• Algorithms
• ? V. Tachycardia
• ? S.V.T.
• ? V.Fib/V.tach

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Historical Perspective
1950s Safar et al and Elam et al "rediscovered"
mouth-to-mouth ventilation by reading how
midwives used the technique to resuscitate
newly born infants 1956 Termination of
ventricular fibrillation by externally
applied electricity was first
described 1960 Kouwenhoven et al observed that
forceful chest compressions produced
respectable arterial pulses. Could sustain life
while awaiting more definitive care
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Milestones on the Way to International Guidelines
2000
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2000The First International Conference on
Guidelines for CPR and ECC
Objectives of the Guidelines 2000 Conference
Fulfill the 1992 goal of producing the first (a)
international guidelines (b) supported by
international science and (c) developed by
international collaboration.
Review and revise recommendations from past
conferences, based on scientific evidence that
had accumulated since the previous guidelines
Review and recommend changes in the methods
recommended for teaching the knowledge and skills
of ECC, BLS, PALS, and ACLS.
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Resuscitation Guidelines Now Internationally
Developed, Science-Based, and Evidence-Based

• Review all the science, and all the evidence
  published internationally, including
  non-English-language sources

• Research task force set up to teach critical
  appraisal of scientific literature and how to
  develop evidence-based guidelines

• Template worksheet developed and made available
  to all participants

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• Keep the basic principles of 1) first, do no
  harm. 2) never commit type II diagnostic errors.
  3) accept only zero-risk interventions

• Revisions of or deletions from existing
  guidelines occurred for any of 3 reasons
• 1) Lack of evidence to confirm effectiveness
• 2) Additional evidence to suggest harm or
  ineffectiveness
• 3) Evidence that superior therapies have become
  available.

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How to develop Evidence-based guidelines
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STEP 1 STATE THE PROPOSAL.
Example Vasopressin in adult Cardiac arrest.
Dr. Charles F. Babbs

• State proposed new guideline revision to
  current guideline deletion of current guideline
• Relevant Existing Guideline, Practice or Training
  activity
• Refine the hypothesis/recommendation.

• Revise ACLS drug algorithms to include
  Vasopressin as the drug of choice for promoting
  return of spontaneous circulation in cardiac
  arrest and CPR.
• Guidelines pp. 2208 (text) and 2217, 2219, 2220,
  2221 (algorithm figures). "recommend that
  epinephrine, 1 mg, i.v. continue to be the first
  agent in cardiac arrest.
• "Vasopressin 40 units, i.v., as first agent in
  VF." (Proposal 1)
• " either epinephrine 1 mg or Vasopressin 40
  units, i.v., as first agent in asystole or PEA."
  (Proposal 2)

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Step 1B Gather the Evidence define your search
strategy.
List the major search terms used to search
databases Vasopressin AND (CPR OR
resuscitation OR cardiac arrest)
State major ways in which you limited or
expanded your search? Peer reviewed full
papers. Whole animal Level 6 studies.
List Electronic Databases searched ISI Web
of Science PubMed (NLM)

• Summarize your yield from hand-searches of
  journals
• None.

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Step 1B Gather the Evidence.
Vasopressin in adult Cardiac arrest. Dr. Charles
F. Babbs
Summarize the yield of any other sources, e.g.
investigator interviews, unpublished
manuscripts, book chapters Vasopressin, edited
by Robert W. Schrier, Raven press, new York,
1985 Goodman and Gilmans The Pharmacological
Basis of Therapeutics, Ninth Edition Innovative
pharmacologic approaches to CPR, J Clin
Pharmacol 199838765-772. Kelly C.M.
Vasopressin use in CPR, The Annals of
Pharmacotherapy 1 977311523-25.
Number found specifically matching question
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Step 2 Asses the quality of the study Step 2A
Determine the Level of Evidence. For each
article/source from step 1, assign a level of
evidence based on study design and methodology.
 
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Step 2A (continued) SORT THE STUDIES List the
studies that you considered best met the original
selection criteria for review, by their Level of
Evidence. Use short citations or citation numbers
so that articles can be identified specifically.
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• Step 2B Critically assess each article/source in
  terms of research design and methods.
• Was the study well executed?
• Assess design and methods and provide an overall
  rating.
• Ratings apply within each Level a Level 1 study
  can be excellent or poor as a clinical trial,
  just as a Level 6 study could be excellent or
  poor as an animal study.

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Step 2C Determine the direction of the results

• supportive?
• neutral?
• opposed?

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Vasopressin in adult Cardiac arrest. Dr. Charles
F. Babbs
Supporting Evidence
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STEP 3. DETERMINE THE CLASS OF RECOMMENDATION.
Select from these summary definitions
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Step 3 Propose a Class of Recommendation for the
Guideline Proposal
Vasopressin in adult Cardiac arrest. Dr. Charles
F. Babbs
"Vasopressin 40 units, i.v., as first agent in
VF." (Proposal 1) Class I or IIA " either
epinephrine 1 mg or Vasopressin 40 units, i.v.,
as first agent in asystole or PEA." (Proposal
2) Class IIA or IIB
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Final rules of engagement for evidence-based
guideline development

• Animal Data how much can animal studies supply
  the evidence in new guidelines?
• ? Best evidence available must be used.
• ? The role of animal data is to provide
  justification to proceed to human trials
• ? Animal data alone will never be used as the
  evidence which to base human recommendations.

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I. New Guidelines on Tracheal Tube Confirmation
and Prevention of Dislodgment

• 1992 Gold Standard for tracheal tube placement
  confirmation
• ? Seeing tube pass through, chest expansion,
  vapor condensation
• Hearing auscultation
• No single-use devices were recommended
• Guidelines on how to prevent tube dislodgement
  nonexistent.
• (1994 ACLS textbook contains only 2 word secure
  tube)

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• 1992-1999 evidence from lawsuits frequency of
  undetected esophageal intubations and undetected
  tracheal tube dislodgement was much higher than
  expected.

• American Society of Anesthesiology (ASA).
• ? examined surgical databases and legal claims
• ? Of 1097 claims
• ? 32 would have been prevented if monitoring
  devices were used.

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• Gausche, et al 1998. Acad Emerg Med
• ? 177 pediatric pts intubated and transported
  (L.A. EMS).
• ? intubations did not improve survival vs.
  bag-mask (for short transport intervals)
• ? 8 had esophageal, or dislodged tracheal
  intubation

• Katz, et al. 1998. Acad Emerg Med
• ? 108 consecutive pts intubated on scene.
• ? 25 had improperly placed tubes

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Solution??

• Addition of device for secondary tube
  confirmation
• Qualitative end-tidal CO2 detector
• Capnography
• Esophageal detector devices (EDD)

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Initial Proposal made at International Conference
A device should be used to confirm endotracheal
tube position after every intubation in all
settings (e.g., prehospital, emergency department
and ICU).
Colorimetric qualitative or continuous
quantitative measurements of expired carbon
dioxide are specific for endotracheal tube
placement after six ventilations
Esophageal detector devices may be used to
confirm endotracheal tube position, particularly
in patients in cardiac arrest
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Evidence-based approach to Tracheal Tube
Confirmation

• Search terms used in database searches.
• End-tidal, "intubation, intratracheal", explode
  capnography, colorimetry, carbon
  dioxide/analysis, esophagus, "esophageal detector
  device"
• Number of articles found ? 27
• -5 RCT (level 2)
• -4 Cohort studies (level 3)
• -12 Case Series (level 5)
• -6 Animal studies and extrapolations (level 6-7)

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Esophageal Detector Devices Sensitivity
Specificity (compared to capnography) ?
100 Reliability of EDD NOT affected by NG tube
or cuff deflation
Williams. 1989. Anaesthesia Zaleski, et al. 1993.
Anesthesiology
Salem, et al. 1994. Anesthesiology
Reliability decreased in morbid obesity (30 FN)
when EDD is compressed prior to attaching to ETT
Lang, et al. 1996. Anesthesiology.
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End-tidal CO2 devices

• Represents the standard of care in the
  operating room.

• All patients undergoing emergency intubations
• Sensitivity ?88-98
• Specificity ?92-100

Hayden, et al. 1995. Acad Emerg Med Chow, et al.
1993. Chung Hua Tsa Chih Schaller, et al. 1997.
Prehosp Dis Med Macleod, et al. 1991. Ann Emerg
Med

• Macleod, et al. 1991. Ann Emerg Med
• Patients with a pulse Sensitivity 100
  Patients in Cardiac Arrest Sensitivity 72

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International Guideline 2000 Confirmation of ET
tube Placement

• Primary Confirmation
• See the tube passing through the cords.
• 5-point auscultation.
• Chest expand with each ventilation.
• Oxygen saturation.
• Vapor condensation.

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International Guideline 2000 Confirmation of ET
tube Placement

• Secondary Confirmation
• Expired CO2 detectors recommended in patients
  with perfusing rhythm (Class IIA)
• In Cardiac arrest patients, if CO2 detector is
  negative, EDD is recommended as second method
  (Class IIB)

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ACLS 2000 Arrhythmia protocols

• PEA, asystole, and bradycadia essentially
  the same.
• Main changes found with tachycardias and VF/VT

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Tachycardias
(1992 algorithm)
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Tachycardias Narrow, Wide, Unstable
The international Guidelines 2000 Conference

• Unstable rhythms, immediate cardioversion
• For tachycardic patients not in need of immediate
  cardioversion, 2000 Guidelines place much more
  emphasis on 2 themes not previously highlighted

• Making a specific rhythm diagnosis
• Recognizing those patients with impaired cardiac
  fxn. EFlt40)

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Specific Rhythm diagnosis.

• Before, underemphasis on rhythm diagnosis
• ? Overuse of narrow-spectrum drugs (adenosine
  Lidocaine)

• ACLS providers should make a reasonable attempt
  to distinguish stable VT from SVT with aberrancy

? Always obtain 12-lead ECG
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Stable VT from SVT with aberrancy

• Complex rules exist (Brugada) for making the
  correct rhythm diagnosis by QRS morphology alone
• Difficult to teach, learn, remember, and apply
  repeatedly
• History of CAD or other structural heart
  disease suggests ventricular origin.
• History of previous aberrant rhythms, accessory
  pathways, preexisting bundle-branch block, or
  rate- dependent bundle-branch blocks suggests
  supraventricular aberrancy
• If this fails, use a broad-spectrum drug

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Antiarrhythmic or Proarrhythmic?

• All antiarrhythmics can have proarrhythmic
  effects (especially in damaged hearts)
• Combining antiarrhythmics increases risk
  significantly.

• Guidelines 2000 recommendation
• Only 1 antiarrhythmic per patient.
• If appropriate dose fails, use electrical
  cardioversion instead of 2nd medication.

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I. Stable Ventricular Tachycardia
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II. Stable Ventricular Tachycardia
1992 Antiarryhthmic Guidelines 1. Lidocaine
1-1.5 mg/kg IVP (Class IIa) 2. Procainamide
20-30 mg/min (Class IIa) 3. Bretylium 5-10 mg/kg
(Class IIa)
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Initial Proposal made at International Conference

• Evidence that has accumulated since the 1992
  Guidelines supports a recommendation that
  treatment of hemodynamically stable ventricular
  tachycardia, in cases where electrical
  cardioversion is undesirable or not possible, be
  revised as follows
• IV lidocaine (class IIA)
• IV procainamide (Class IIA)
• IV amiodarone (Class IIA)
• IV sotalol (not FDA-approved for use in the
  United States) (Class IIA)
• IV bretylium (class IIB)

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Evidence-based approach to Stable V. Tach

• Number of articles found ? 30 (no animal studies
  used)
• -2 RCT (Procainamide vs. Lidocaine Sotalol vs.
  Lidocaine)
• -6 Case Series (level 5)
• -22 Reasonable extrapolations from existing
  data quasi-experimental designs
  pathophysiological and nonquantitative
  reasoning (level 7)

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1. Procainamide and stable VT (Class IA drug)

• 2 Case series (35 patients), of inducible
  sustained V.tach.
• 20-50mg/min, max 1,0 g
• V. tach was suppressed in 31 patients
• (Giardina, et al. 1973. Ann Intern Med,
  Callans, et al. 1992. J Am Coll Cardiol)

• 1 double blinded control study (8 patients),
  procainamide (7.5 mg/kg) vs. placebo
• patients with frequent PVCs
• Procainamide significantly frequency of PVCs
• (lots of selection bias) (Schwartz, et al.
  1970. Am J Cardiol)

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Procainamide and VT

• Gorgels, et al. 1996. Am J Cardiol
• 29 patients with spontaneous monomorphic V. tach
• Excluded were pts with V. tach that were
  unstable, 2o MI, Dig tox, non cardiac
• Pts were randomized to receive either
  Lidocaine, or procainamide. When V. Tach was not
  converted with initial drug, other drug was given.

Lidocaine converted 1/3
Pronestyl converted 8/11

• A total of 41 episodes, 4/15 responded to
  Lidocaine 20/26 responded to Procainamide
  (plt0.01)

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2. Sotalol and Stable VT
Only 2 studies 1. Case series 2. RCT (lidocaine
vs. sotalol)

• Griffith, et al. 1990. Lancet
• ? Sotalol (1mg/kg) given after electrically
  induced stable ventricular tachycardia.
• ? 5/14 patients had termination of tachycardia

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2. Randomized Control crossover study of Sotalol
(100 mg) vs. Lidocaine (100 mg) in stable
Ventricular Tachycardia Ho, et al. 1994.
Lancet
Sotalol (100 mg)
Lidocaine (100 mg)
(NNT2)
Sotalol subsequently stopped 7/14
Lidocaine subsequently stopped 1/5
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Bretylium

• 4 clinical trials
• 3 case series (total of 35 pts) studying ability
  to suppress inducible V. tach
• ? only 1 patient was suppressed after bretylium
• ? 7 patients suffered severe hypotension
• 1 RCT comparing Bretylium vs. Amiodarone in
  unstable V. Tach
• ? Comparable effects, higher rate of hypotension

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Conclusion Bretylium has been removed from ACLS
treatment algorithms and guidelines because of a
high occurrence of side effects, the availability
of safer agents at least as efficacious, and the
limited supply and availability of the drug.
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Stable Ventricular Tachycardia Use of Amiodarone

• No RCT study done specifically looking at
  Amiodarone and stable VT lots with
  hemodynamically unstable VT

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Hemodynamic effects of IV amiodarone in patients
with impaired left ventricular function
Remme, et al. 1991. Am Heart J
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2000 ACLS guidelines
Stable Ventricular Tachycardia

• Electrical cardioversion remains recommended
  therapy for stable ventricular tachycardia (Class
  I).

• IV procainamide (IIA), IV sotalol (IIA) , IV
  amiodarone (IIB), or IV ß-blockers.

• Choice of agent based on E.F. and QT interval

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II. Narrow-Complex Supraventricular Tachycardias
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1992 ACLS guidelines Narrow Complex tachycardia
Once diagnosis of PSVT, this remains as initial
treatment
This part has changed
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• Rate control with CCB, ßB is well established
• New Antiarrhythmics introduced
• Sotalol
• Procainamide
• Amiodarone
• New recommendations based on status of LV
  function
• Very few studies specific to PSVT LOTS based on
  studies with A-fib

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Narrow Complex tachycardia

• Procainamide
• Support for use in PSVT base on
• ?1 level 2 study.
• ? Numerous level 7 studies (extrapolation from
  a-fib)

• Chapman, et al 1993 Intens Care Med
• RCT, procainamide vs. amiodarone in SVT
• 24 patients in ICU, with spontaneous SVT

• 71 response rate in procainamide group
• 70 response rate in amiodarone group

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Narrow Complex tachycardia
II. Sotalol Support for use in PSVT based on ?
2 level 1 studies (RCT) ? Several level 7
studies (extrapolation)
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• Jordaens, et al. 1991. Am J Cardiol
• Double blind, placebo-controlled, crossover study
• 38 patients with spontaneous/induced SVT
• AV block, CHF, shock, recent MI, QTcgt0.45,
  a-fib/flutter were excluded

• Sotalol response rate 83 (15/18) vs. 15 (3/20)
  (plt0.001)
• Crossover response rate 82 (14/17) vs. 0 (0/3)

• Sung, et al 1995. Am Heart J
• Randomized, double-blind, placebo-controlled
  study, dose-response
• 93 patients (45 with SVT, 48 with a-fib) with
  spontaneous/induced arrhythmias
• AV block, CHF, shock, recent MI, QTcgt0.45, HTN
  were excluded

• Sotalol Response rate 14 (2/14) (placebo)
  67 (10/15) (1.0 mg/kg) 67 (10/15) (1.5
  mg/kg)

(Plt0.008)
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Narrow Complex tachycardia
III. Amiodarone. Support for use based on ?
Apr. 10 level 5 studies (case reports) ? Level 2
study (vs. procainamide) ? Majority of supporting
evidence - extrapolations from a-fib studies
(level 7)
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III. Amiodarone review of case
reports Source n ind/spont rhythm result Gomes,
et al, 1984 9 induced PSVT 100 Holt, et al,
1985 14 induced WPW/AF 50 Viett-Ramus,
1992 44 spontaneous WPW/AF 89 Kuga, et al,
1999 13 induced WPW 92
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Guidelines 2000 Narrow Complex tachycardia
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Ventricular Fibrillation/Pulseless V. Tach
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1.Vasopressor which one to use?
Epinephrine, 1 mg IV, Q3-5 min
Vasopressin ???
2. Antiarrhythmic which one to use?
Lidocaine, Bretylium, MgSO4, Procainamide
Amiodarone ???
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Vasopressin and Cardiac Arrest

• Endogenous, 9 amino-acid peptide that under
  physiological
• conditions is a naturally occurring antidiuretic
  hormone
• At much higher doses, Vasopressin acts as a
  non-adrenergic
• peripheral vasoconstrictor.
• Currently used treat bleeding esophageal
  varices and in abdominal angiography

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Pharmacology of two endogenous pressors,
massively released in circulatory shock
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Pharmacology of two endogenous pressors,
massively released in circulatory shock
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International Guidelines 2000 Conference
Vasopressin in adult V. Fib

• Number of articles found ? 17-19 (depending on
  researcher)
• -1 RCT (Vasopressin vs. std ACLS)
• -2-3 Case Series
• -13 Animal studies
• -2-3 level 7 studies (extrapolations, etc)

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Vasopressin - Initial Studies
Lindner, et al. 1996. Heart Endogenous
Vasopressin levels in patients undergoing CPR
are significantly higher in patients who survive
than in patients who do not have ROSC
Before epinephrine
After Epinephrine
ROSC (12)
ROSC (24)
Died (14)
Died (36)
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Vasopressin Animal studies
1. Wenzel, et al. 1999 Crit Care Med Following
prolonged arrest, significant improvement in
ROSC, and vital organ blood flow following
Vasopressin (0.8U/kg) vs. epinephrine (200 µg/kg)
2. Wenzel, et al. 1998 Stroke Combination of
Vasopressin and epinephrine decreases cerebral
perfusion pressure compared with Vasopressin
alone during CPR in Pigs.
3. Wenzel, et al. 2000 J Amer Coll
Card Increased survival with full neurologic
recovery and no cerebral pathology after CPR
with Vasopressin (0.4U/kg x 3) vs. Epinephrine
(45 µg/kg x 3) vs. placebo
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Vasopressin Human studies

• 1. Lindner, et al. 1996. Ann Intern Med.
• Case report of 8 adults with in-hospital cardiac
  arrest who failed resuscitation efforts with
  (pre-2000) ACLS guidelines.
• CPR and ACLS was provided for gt 12 min before
  Vasopressin (40 U bolus) was administered
• All patients had ROSC
• 3/8 patients survived with intact neurological
  function.
• Nonsurvivors Age 45, 63, 69, 71, 73
• Survivors Age - 28, 31, 78

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Vasopressin Human studies

• 2. Lindner, et al. 1997. Lancet
• Double blind, randomized control trial (the
  only one published so far)
• 40 consecutive patients with out of hospital
  cardiac arrest
• Inclusion criteria V. fib arrest, resistant to
  electrical defibrillation
• Exclusion criteria trauma, terminal illness,
  and pregnancy

• Method 40 consecutive patients randomized to
  receive
• Epinephrine 1mg IV (n20), or
• Vasopressin 40 IU IV (n20)

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Results
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Results
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Vasopressin Ongoing studies

• Larger (n200), in-hospital clinical trial was
  reviewed at the time of the Guidelines 2000
  Conference. Survival for 1 hour and to hospital
  discharge was not different whether initial
  pharmacological treatment was Vasopressin or
  epinephrine (Ian Stiell, MD, oral communication)

• A large randomized controlled trial evaluating
  Vasopressin vs. epinephrine in out-of-hospital
  cardiac patients is in progress in Europe

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Summary Vasopressin in Cardiac arrest

• 1992 Guidelines
• The 1992 guidelines did not refer to
  Vasopressin therapy.

• 2000 Guidelines
• Vasopressin (40 IU x 1) can be used as an
  alternative to epinephrine for the treatment of
  adult shock- refractory VF (Class IIB)
• Epinephrine (1mg). (Class Indeterminate)

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Amiodarone V. tach/V. fib.

• originally studied as an antianginal
  vasodilator during the 1960s

• The parenteral formulation of amiodarone, also
  used worldwide, was introduced in the U.S. in
  1995

• Initially categorized as a class III
  antiarrhythmic

• Subsequent work demonstrated effect with all 4
  antiarrhythmic class activities

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1983
1988
1988
1989
1990
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Amiodarone Dose-ranging Studies
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Dose-Ranging study of IV Amiodarone in Patients
with Life-Threatening VT
Scheinman, et al. 1995.Circulation
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Randomized, double-blind comparison of IV
Amiodarone and Bretylium in the treatment of
patients with recurrent, hemodynamically
destabilizing VT or VF
Kowey, et al. 1995. Circulation
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who remained event-free
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Amiodarone for Resuscitation after
Out-of-Hospital Cardiac Arrest Due to Ventricular
Fibrillation Peter J. Kudenchuk, Leonard A. Cobb,
Michael K. Copass, Richard O. Cummins, Alidene M.
Doherty, Carol E. Fahrenbruch, Alfred P.
Hallstrom, William A. Murray, Michele Olsufka,
Thomas Walsh New England Journal Medicine
1999. Vol 341 871-878
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Summary antiarrhythmics in Cardiac arrest.

• 1992 guidelines
• Lidocaine, Bretylium, Procainamide, and
  Magnesium Sulfate (in hypomagnesemic states or
  in cases of torsades de pointes) are recommended
  (class IIA)

• 2000 guidelines
• Amiodarone (300 mg IVP) is recommended after
  defibrillation and pressor agent in cardiac
  arrest with persistent VT or VF (Class IIB)
• repeat dose of 150 mg IV (max 2.2 g/24 hours)

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Summary antiarrhythmics in Cardiac arrest.

• 2000 guidelines cont
• Lidocaine (Class Indeterminate)
• MgSO4 - if Torsades or Hypomagnesemic (Class
  IIB)
• Procainamide (30 mg/min) for intermittent VF/VT
  (Class IIB)
• Consider buffers

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No pharmacological interventions for cardiac
arrest have yet been found to improve survival to
hospital discharge
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Sotalol??
Vasopressin??
Procainamide??
Amiodarone??