Cardiovascular Critical Care II
| d. | Medication therapy for VF/pVT |
|---|
Previous guidelines suggested medication consideration after one shock and 2 minutes of CPR
(one cycle). Data from witnessed OHCA suggest that early administration of epinephrine is
associated with improved survival in shockable rhythms (Resuscitation 2015;96:180-5) and
that every minute beyond 5 minutes significantly increases the odds of death. With IHCA
for shockable rhythms, patients receiving epinephrine within 2 minutes of initial shock was
associated with a decreased odds of survival, ROSC, and good functional outcome (BMJ
2016;353:i1577). Guideline recommendation supports the use of epinephrine for shockable
rhythms after two initial defibrillation attempts have failed (Circulation 2019;140:e881-e894).
ii.
Vasopressors:
| (a) | First-line medication is epinephrine. A randomized, double-blind, placebo-controlled |
|---|
trial showed that use of epinephrine in OHCA (around 20% shockable rhythms) was
associated with greater 30-day survival, but there was no difference in neurologically
favorable outcomes because of the severe neurologic impairment of survivors (N Engl J
Med 2018;379:711-21).
| (1) | A meta-analysis of randomized controlled trials found that epinephrine (1 mg every |
|---|
3β5 minutes) when compared to placebo for OHCA increased rate of ROSC, survival to
hospital admission and survival to hospital discharge but did not change discharge with
favorable neurological function (Resuscitation 2019;139:106-21). The administration
of epinephrine 1 mg every 3β5 minutes has been the standard medication within
the cardiac arrest algorithm. An option to provide epinephrine every 4 minutes as a
midrange has been added. This allows the provider to administer epinephrine every
other 2-minute rhythm check (https://acls-algorithms.com/2021-aha-acls-guideline-
changes/adult-cardiac-arrest-algorithm-changes/).
| (2) | The traditional dose of epinephrine is considered 1 mg. Data analyses suggest that lower |
|---|
doses (e.g., 0.5 mg) are not associated with a change in survival to hospital discharge or
favorable neurologic outcomes (Resuscitation 2018;124:43-8).
| (3) | High-dose epinephrine (0.1β0.2 mg/kg) has been investigated and although it may |
|---|
increase the rate of ROSC, it has not been found to increase rate of survival to hospital
admission, survival to hospital discharge, or survival with favorable neurological
function (Circulation 2019;140:e881-e894).
| (b) | Vasopressin has previously been removed from guidelines because of an equivalence of |
|---|
effect with epinephrine and a drive to simplify treatment (Figure 1; Table 3). A meta-
analysis affirms the equivalence of vasopressin with epinephrine (either in isolation or in
combination), supporting the recommendation that vasopressin offers no advantage over
epinephrine in cardiac arrest (Resuscitation 2019;139:106-21).
| (c) | No other vasopressors (e.g., phenylephrine or norepinephrine) have shown any benefit |
|---|
1985;29:610-3).
| (d) | Adding methylprednisolone and vasopressin to epinephrine during ACLS plus stress dose |
|---|
hydrocortisone for post-ROSC shock compared with placebo may aid in ROSC during
cardiac arrest and improve neurologic function at discharge. Role of steroids may be debated,
meta-analysis suggests that the combination of vasopressin-steroids-epinephrine was the
Med 2018;46:e443-e451). Guidelines suggest this treatment bundle may be considered, but
further confirmatory data are needed (Circulation 2015;132(suppl 2):S315-S367). Newer
evidence suggests this bundle may improve the chances of ROSC, but is not powered to
assess survival outcomes (Andersen 2021).