Medications on the Fly
Sunday, November 29, 2009
Medications on the Fly
Should IV Drugs be Given During Out-of-Hospital Cardiac Arrest?
For many years folks who study survival related to heart attacks experienced out of the hospital have lobbied for allowing emergency medical technicians (EMTs) to administer a range of drugs as well as other interventions. The clear goal is to improve a person's chances of making it to the hospital alive, where hopefully treatment will result in long term survival. Now a study done in Norway seems to conclude that use of the most common medication, epinephrine, does not result in any benefit to these folks and may actually result in harm. That's in this week's Journal of the American Medical Association: Intravenous Drug Administration During Out-of-Hospital Cardiac Arrest.
This study could only have been done in a country other than the US (that would be Norway), since about half of the study subjects (a total of 851) were given advanced cardiac life support only and the other half given life support plus intravenous drug administration. As Rick says, in this country IV drug administration is dogma, and a failure to use it heresy, in spite of the fact that no direct evidence of the benefits of epinephrine use in this context exists.
The study found that while slightly more people made it to the hospital alive when IV medication was used there was no statistically significant difference between the two groups related to hospital discharge, quality of CPR, or long term survival. The authors conclude, and Rick agrees, that larger studies examining this issue need to be conducted and perhaps some modification of resuscitation guidelines is in order.
Two things emerge from this study that are worth noting: one is the wholesale adoption and institution of a practice, that is, establishment of an IV line and use of epinephrine in those who've suffered cardiac arrest outside the hospital, in the total absence of any data examining this specific issue but rather extrapolations from animal models and other circumstances where a benefit was perceived. At best, rather contrary to our current climate of 'evidence based' medicine.
The other is the ongoing debate about best practices related to resuscitation efforts. Should CPR be done on the chest or the back? Are ventilations (breaths) even necessary? What is the optimal timing for chest compressions? How long should the practice be continued until emergency personnel arrive? What about use of automated external defibrillators?
Perhaps the most compelling reason the debate is so fierce is that heart disease remains the 8000 pound gorilla when it comes to causes of death, killing almost half a million people in 2005, according to American Heart Association statistics. That's a lot of people. By and large, many if not most of these deaths could be avoided if people would never start smoking or quit if they do so currently, watch their weight and diet, and exercise regularly. High blood pressure should be controlled, and those with a family history of cardiac problems perhaps elect other interventions as well. Until then, relying on changes in treatment or management guidelines is a BandAid approach.
Other topics this week include the change in cervical cancer screening guidelines issued by the American College of Obstetricians and Gynecologists, pain and falls in the elderly and no volume benefit seen with angioplasty in this week's JAMA. Until next week, y'all live well.