Tag Archive for: Cardiac Arrest

Is Amiodarone Dead?

12 Jun
June 12, 2017

Background: Amiodarone is a class III antidysrhythmic first released for human use in 1962. As with other drugs in this class, amiodarone acts by blocking potassium channels thus prolonging the action potential. This, in turn, leads to a lengthening of depolarization of the atria and ventricles. The drug spread rapidly through US hospitals as it was touted as “always works, and no side effects,” by it’s pharmaceutical manufacturer (Bruen 2016).

Of course, nothing comes free and soon after the drug became widely used, a multitude of adverse effects became apparent. These included minor issues – sun sensitivity and corneal deposits – to major ones – thyroid dysfunction (hypo- and hyperthyroidism), pulmonary toxicity and liver damage. Additionally, the medication’s mechanism of action wasn’t clean and simple – amiodarone is no known to have sodium-channel blocking (Class I), beta-blocking (Class II) and calcium-channel blocking (Class IV) effects.

Despite the multitude of issues, the drug continued to be used extensively because of it’s purported benefits. The drug was most commonly applied in the Emergency Department (ED) for conversion of atrial fibrillation, conversion of stable ventricular tachycardia and in refractory VF/VT cardiac arrest.

This post dives into the three most common places amiodarone is employed in the ED: cardioverion of atrial fibrillation, cardioversion of VT and in refractory VF/VT cardiac arrest and demonstrates that superior evidence points to better options for management. Read more →

In-Hospital Cardiac Arrest: The First 15 Minutes

27 Apr
April 27, 2017

Background: Over the past few years there has been a shift in cardiac arrest from the mantra of ABC (Airway, Breathing, Circulation) to CAB (Circulation, Airway, Breathing).  There has been increased emphasis on circulation and a de-emphasis of airway management in cardiac arrest.  Physiologically, this makes sense as the only two interventions in cardiac arrest that have been shown to make a difference in neurological outcomes are early, high quality CPR and defibrillation.  The reason for this is increased coronary and cerebral perfusion pressure, which improve oxygenation to ischemic tissue.  The less ischemic cardiomyocytes are the more likely they will convert to a perfusing rhythm.  Similarly, the less ischemic neurons are, the more likely we will have a better neurologic outcome for our patients.  It has been fairly well established in the peer reviewed literature that advanced airway management in the prehospital setting is associated with decreased survival with good neurologic outcome.  There is considerably less literature exploring this area in in-hospital cardiac arrest. Read more →

Cardiac Arrest, Return of Spontaneous Circulation (ROSC) With No ST-Segment Elevation on ECG. Now What?

15 Dec
December 15, 2016

cardiac-arrestBackground: The American Heart Association/American College of Cardiology (AHA/ACC) give a Class I recommendation for activation of the cardiac catheterization lab in patients with out-of-hospital cardiac arrest (OHCA) whom ST-segment elevation myocardial infarction (STEMI) is present.  The evidence for early cardiac catheterization in patients after cardiac arrest, with ROSC and no STEMI is a bit more controversial.  The most recent 2015 AHA/ACC guidelines recommend, “it may be reasonable,” to perform an emergent cardiac catheterization in select patients without STEMI. Read more →

Beyond ACLS: Pre-Charging the Defibrillator

24 Mar
March 24, 2016

Post Written By: Sam Ghali (Twitter: @EM_RESUS)

Beyond ACLS - Pre-Charging the DefibrillatorIn cardiac arrest care there has been a lot of focus over the years on limiting interruptions in chest compressions during CPR. In fact, this concept has become a major focus of the current AHA Guidelines. Why? Because we know interruptions are bad [1,2]. One particular aspect of CPR that has gotten a lot of attention in this regard is the peri-shock period. It has been well established that longer pre- and peri-shock pauses are independently associated with decreased chance of survival [3,4].

Read more →

Classic Journal Review: The OPALS Study

14 Jan
January 14, 2016


The Ontario Prehospital Advanced Life Support (OPALS) Study

Background: Sudden cardiac arrest is common and, obviously, very bad. In the US, there are about 500,000 cardiac arrests each year. About half of these cardiac arrests are OHCA and the survival rate is pretty poor. The most recent survival estimates put it at 7 – 9.5% in most communities. About 10-12 years ago, the American Heart Association built the 4-step “chain-of-survival.”

  • Step One – Early access to emergency care
  • Step Two – Early CPR
  • Step Three – Early defibrillation

There is little debate about these three steps as the sum of the data supports that they lead to better outcomes.

The 4th step in the chain, however, is slightly more controversial; early advanced care. This basically means rapid access to ACLS type resuscitation skills (intubation and intravenous drug therapy). Despite it being the 4th step, ACLS has little evidence to defend it.  Read more →

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