Transcript December 18, 2009

Published in Journal Watch Emergency Medicine
December 18, 2009
Do IV Meds Matter in Out-of-Hospital Cardiac
Arrest?
Use of IV drugs did not affect long-term neurological outcome or survival.
Summary and Comment by John A. Marx, MD, FAAEM
Copyright © 2009. Massachusetts Medical Society. All rights reserved.
Covering
• Olasveengen TM et al. Intravenous drug administration during outof-hospital cardiac arrest: A randomized trial. JAMA 2009 Nov 25;
302:2222.
Copyright © 2009. Massachusetts Medical Society. All rights reserved.
Background
• Intravenous access and drug administration have long been central
elements of advanced cardiac life support (ACLS) protocols despite
the absence of evidence that they improve outcomes.
• In a randomized, controlled, nonblinded trial, 851 consecutive adult
patients with out-of-hospital, nontraumatic cardiac arrest in Oslo,
Norway from 2003 to 2008 were randomized to receive ACLS with
IV access and drug administration (epinephrine, atropine, and
amiodarone were used) or ACLS with no IV access.
Copyright © 2009. Massachusetts Medical Society. All rights reserved.
The Research
• In the group that received ACLS with no IV access, IV access was
established within 5 minutes after return of spontaneous circulation
(ROSC).
• In both groups, patients with ventricular fibrillation received
cardiopulmonary resuscitation for 3 minutes before the first shock
and between unsuccessful series of shocks.
• Endotracheal intubation was standard, and postresuscitation
therapeutic hypothermia was instituted regardless of initial rhythm or
course of arrest.
• Quality of CPR was determined by transthoracic impedance signals
from defibrillators.
• The primary outcome was survival to discharge.
Copyright © 2009. Massachusetts Medical Society. All rights reserved.
The Research
• The rate of hospital admission for patients with ROSC was
significantly higher in the group with IV access than in the group
without IV access (32% vs. 21%).
• However, no significant differences were found between the IVaccess and no-IV-access groups in rates of survival to discharge
(10% and 9%), survival with favorable neurological outcome (10%
and 8%), and survival at 1 year (10% and 8%).
• CPR was performed according to guidelines, and its quality was
similar in both groups.
Copyright © 2009. Massachusetts Medical Society. All rights reserved.
Comment
• This first effort to evaluate the effect of IV access and drug
administration on outcomes in patients with out-of-hospital cardiac
arrest, after more than 4 decades of use, yields provocative results:
These long-standing interventions were not associated with
improvement in long-term survival or neurological outcome.
• The results are in concert with those from studies in which
epinephrine, atropine, and amiodarone improved short-term but not
long-term outcomes compared with placebo.
• In addition, IV access had no negative effect on the quality of CPR.
• This trial begs for research targeted at novel pharmacologic
therapies and should prompt the rethinking of ACLS guidelines.
Copyright © 2009. Massachusetts Medical Society. All rights reserved.
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Copyright © 2009. Massachusetts Medical Society. All rights reserved.