Drugs for Cardiac Arrest

Revised and reviewed 1 Feb 2013

OVERVIEW

“While the listed drugs have theoretical benefits in selected situations, no medication has been shown to improve long term survival in humans after cardiac arrest. Priorities are defibrillation, oxygenation and ventilation together with external cardiac compression.” — ARC Statement

VASOPRESSORS

Rationale

  • TBC

Adrenaline

  • 1mg IV/IO Q 3min
  • part of ALCS
  • physiological and pharmacological with some animal data
  • no survival benefit

Vasopressin

  • TBC

Evidence

  • TBC

ANTI-ARYHYTHMICS

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

  • 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

Evidence

  • There is no evidence that any antiarrhythmic 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 antiarrhythmic of long-standing and widespread familiarity with fewer immediate side effects than may be encountered with other antiarrhythmics. 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)

Amiodarone

  • 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

Lignocaine

  • class 1 antiarrhythmic (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)

Magnesium

  • 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

Atropine

  • parasympathetic antagonist (muscarinic)
  • indications: severe bradycardia,(no longer recommended for asystole or PEA)
  • adverse effects: excitement, delirium, hyperthermia

Amiodarone

  • 300mg IV
  • part of ALCS
  • given for refractory VF after 3rd shock
  • no survival benefit

Atropine

  • was given during PEA or asystole
  • now no longer recommended

OXYGEN

  • recognition that hyperoxaemia can be harmful after ROSC
  • titrate to SpO2 94-98%

SODIUM BICARBONATE

  • alkali
  • 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

DRUGS VS NO DRUGS

Recent Norwegian RCT (Olasveengen, JAMA 2009)

  • IV drug administration vs No drug administration -> increases short term survival but no difference in hospital discharge, quality of CPR or long term survival (1 year)

VASOPRESSIN, STEROIDS AND EPINEPHRINE

TBC


References and Links

Journal articles

  • 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.
  • Callaway CW. Epinephrine for cardiac arrest. Curr Opin Cardiol. 2013 Jan;28(1):36-42. doi: 10.1097/HCO.0b013e32835b0979. Review. PubMed PMID: 23196774.
  • Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation. 2011 Sep;82(9):1138-43. doi: 10.1016/j.resuscitation.2011.06.029. Epub 2011 Jul 2. PubMed PMID: 21745533.
  • Larabee TM, Liu KY, Campbell JA, Little CM. Vasopressors in cardiac arrest: a systematic review. Resuscitation. 2012 Aug;83(8):932-9. doi: 10.1016/j.resuscitation.2012.02.029. Epub 2012 Mar 15. Review. PubMed PMID: 22425731.
  • Lee SW. Drugs in resuscitation: an update. Singapore Med J. 2011 Aug;52(8):596-602. Review. PubMed PMID: 21879219. [Free Full Text]
  • Mentzelopoulos SD, Zakynthinos SG, Siempos I, Malachias S, Ulmer H, Wenzel V. Vasopressin for cardiac arrest: meta-analysis of randomized controlled trials. Resuscitation. 2012 Jan;83(1):32-9. doi: 10.1016/j.resuscitation.2011.07.015. Epub 2011 Jul 23. Review. PubMed PMID: 21787738.
  • Mentzelopoulos SD, Malachias S, Chamos C, Konstantopoulos D, Ntaidou T, Papastylianou A, Kolliantzaki I, Theodoridi M, Ischaki H, Makris D, Zakynthinos E, Zintzaras E, Sourlas S, Aloizos S, Zakynthinos SG. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. JAMA. 2013 Jul 17;310(3):270-9. doi: 10.1001/jama.2013.7832. PubMed PMID: 23860985.
  • 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.
  • 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.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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