“There is no evidence that giving any anti-arrhythmic drug routinely during a cardiac arrest increases rate of survival discharge. Despite the lack of long-term outcome data, it is reasonable to continue to use anti-arrhythmic drugs on a routine basis.” — ARC
- Early defibrillation
- High quality, uninterrupted compression (30:2 – adults, 15:1 – children)
- Treatment of reversible causes (H’s and T’s)
Anti-arrhythmics in ILCOR Guidelines
- Amiodarone 300mg or 5mg/kg – only anti-arrhythmic in new adult guidelines, in paediatrics
- Lignocaine 1mg/kg – paediatrics
- Magnesium 0.1-0.2mmo/kg – paediatrics
- Atropine 1-3mg or 20mcg/kg – removed from adult PEA/asystole guidelines, still paediatrics
- NaHCO3 1mmol/kg – paediatrics
RATIONALE AND EVIDENCE
- anti-arrhythmics may be use to cardiovert from VT/VF to a perfusion rhythm either directly or by facilitating electrical cardioversion
- anti-arrhythmics may be used to prevent recurrence of VT/VF following cardioversion
- There is no evidence that any anti-arrhythmic drug given routinely during human cardiac arrest increases survival to hospital discharge.
- Amiodarone, however, has been shown to increase short-term survival to hospital admission when compared with placebo or lidocaine (this may be considered harmful, as it merely changes the geography of death to the ICU)
- Lidocaine is an alternative anti-arrhythmic of long-standing and widespread familiarity with fewer immediate side effects than may be encountered with other anti-arrhythmics. Lidocaine, however, has no proven short- or long-term efficacy in cardiac arrest. Lidocaine may be considered if amiodarone is not available (Class IIb, LOE B).
- complex action (Na+, K+, Ca2+ channel and adrenoreceptor effects)
- effective in supraventricular and ventricular arrhythmias
- less cardiac depressant activity than other agents
- indications: refractory VF/VT (after 3rd shock), prophylaxis of VF/VT
- adverse effects: hypotension, bradycardia, heart block, tissue toxicity if extravasates
- class 1 anti-arrhythmic (Na+ channel blocker)
- indications: second line in VF/VT, prophylaxis in recurrent VF/VT
- adverse effects: neurotoxicity (slurred speech, altered LOC, seizures), cardiovascular (hypotension, bradycardia, heart block)
- electrolyte essential for membrane stability
- hypomagnesaemia causes myocardial hyperexcitablility (especially in low K+ and with digoxin)
- demonstrated as an effective anti-arrhythmic in post cardiac surgical patients
- indications: Torsades, digoxin toxicity, VF, VT, hypokalaemia, low Mg2+
- adverse effects: muscle weakness, respiratory failure
- parasympathetic antagonist (muscarinic)
- indications: severe bradycardia,(no longer recommended for asystole or PEA)
- adverse effects: excitement, delirium, hyperthermia
- can decrease arrhythmogenic effects of acidosis
- indications: severe documented acidosis, where arrhythmogenic potential is felt to outweigh risks of bicarbonate administration; hyperkalemic arrest, sodium channel blocker toxicity
- adverse effects: hypokalaemia, worsening of intracellular acidosis, tissue damage if extravasates, volume overload, rebound alkalosis, hypernatraemia, left shift of oxyHb dissociation curve, hypercapnia
References and Links
- Boyd T, Brady W. The “Code Drugs in Cardiac Arrest”–the use of cardioactive medications in cardiac arrest resuscitation. Am J Emerg Med. 2012 Jun;30(5):811-8. doi: 10.1016/j.ajem.2011.04.009. Epub 2011 Jun 12. Review. PubMed PMID: 21665413.
- Lee SW. Drugs in resuscitation: an update. Singapore Med J. 2011 Aug;52(8):596-602. Review. PubMed PMID: 21879219. [Free Full Text]
- Ong ME, Pellis T, Link MS. The use of antiarrhythmic drugs for adult cardiac arrest: a systematic review. Resuscitation. 2011 Jun;82(6):665-70. doi: 10.1016/j.resuscitation.2011.02.033. Epub 2011 Mar 27. Review. PubMed PMID: 21444143.
- Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L. Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial. JAMA. 2009 Nov 25;302(20):2222-9. doi: 10.1001/jama.2009.1729. PubMed PMID: 19934423.