You and another medic are on the scene of a cardiac arrest. You find the patient in ventricular fibrillation and immediately defibrillate him into a narrow complex rhythm. You have pulses back and while you take a blood pressure – 130/84, the other medic inserts an IV. The other medic then says to you, “Pass me the amiodarone.”
What do you do?
A. Pass it to him.
B. Say, “No.”
C. Say “Why?”
You go with C. The other medic says, “To give to the patient (Dummy!). He was in v-fib.”
You say, “No, it’s not indicated.”
Who’s right? You or the other medic.
It is amazing how many medics have different views on this question, and some of this depends on when they were trained and how well they have kept up on changing guidelines. It also depends on their local medical control and the protocols they operate under.
Here in Connecticut our state protocols for cardiac arrest call for amiodarone or lidocaine for patients “unresponsive to CPR, defibrillation, and vasopressor therapy.” There is no protocol that allows the administration of amiodarone or lidocaine for patient’s post ROSC unless they are either in VT with pulses or they were given amiodarone or lidocaine while in vfib/pulseless VT. In which case, the medic can consider an infusion.
A patient who is shocked out of vfib or pulseless VT without receiving an antiarrhythmic before hand should not be receiving an antiarrhythmic after obtaining ROSC.
The AHA guidelines are clear. Amiodarone or lidocaine are for refractory VF/pVT only.
The International Liaison Committee on Resuscitation (ILCOR) recently reviewed the use of antiarrhythmic drugs for the management of cardiac arrest and “the period immediately after return of spontaneous circulation (ROSC)” based on the most recent evidence.
Here are their recommendations:
We suggest the use of amiodarone or lidocaine in adults with shock-refractory VF/pVT.
The confidence in effect estimates is currently too low to support an ALS Task Force recommendation about the use of prophylactic antiarrhythmic drugs immediately after ROSC in adults with VF/pVT cardiac arrest.
You can read more here:
2018 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary
Now, some may argue we shouldn’t even be giving antiarythmics to patients in cardiac arrest. They have very good arguments and good science behind them.
Amiodarone vs. Lidocaine vs. Placebo
Read Emergency Medicine Literature of Note:
Amiodarone, Lidocaine, or … Nothing
Read Rogue Medic:
Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest
If you are going to use amiodarone, then you should at least be following the AHA and/or your medical protocols.
In Connecticut that means, only using amiodarone for VF or Pulesless VT “unresponsive to CPR, defibrillation, and vasopressor therapy.”
Bicarb in Cardiac Arrest