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 |
|---|
3–5 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 3–5 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 (0.1–0.2 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).