VASOPRESSIN OR EPI WHATS YOUR CHOICE

[Dustdevil]

Anybody got the latest stats? Last I heard, vasopressin was showing increased ROSC, but no difference in survival to discharge.

[mrmeaner]

Anybody got the latest stats? Last I heard, vasopressin was showing increased ROSC, but no difference in survival to discharge.

No stats, but that's what we were told at the ACLS refresher.

[als2170]

We carry both, and protocols say either one for first 2 rounds. Personally working a code with just my EMT-B partner, it's a lot quicker and simpler to push the epi (hand me the mustard yellow box). The only times I have used it was on long carry downs. The winding 4 story narrow staircases around here don't allow for stopping and resting, let alone pushing a round of epi.

[JPINFV]

Hate to be hijacking this thread, but why is any system having their responders carry patients in cardiac arrest down 4 stories?

[als2170]

how else do you get them down

If it's a hard carry we can call for FD, but the truth is most of the staircases can't fit more then 2 maybe 3 people carrying the pt. Either way my point was vaso is easier than stopping for a round of epi. most of the time i have to disconnect the monitor to do the carry . . .

[akroeze]

I think the point is, why are you carrying a patient in arrest?

It is much more logical to work the full ACLS arrest and when all reasonable efforts have been exhausted the patient is pronounced on scene.

[JPINFV]

how else do you get them down

If it's a hard carry we can call for FD, but the truth is most of the staircases can't fit more then 2 maybe 3 people carrying the pt. Either way my point was vaso is easier than stopping for a round of epi. most of the time i have to disconnect the monitor to do the carry . . .

What exactly is any drug going to be doing in a patient without CPR happening? I can't imagine that stopping resuscitation for several minutes while carrying a patient down the stairs helps your area's save rates.

[als2170]

being that most of our transports are less than 10 minutes, we don't usually call a code we worked. I understand your reasoning, now that you mention it you're probably right. I'm going to speak to med control to clarify, but what we do is monitor/shock, iv/meds, tube, few rounds of meds (cpr, of course) and then start moving. Like I said, 2 people doing cpr better start moving. Optimally, an extra set of hands during transport is good too

[Mateo_1387]

This reeks of "cookbook" providers.

What reeks of "cookbook" providers?

By using vasopressin "just like it was epi" you are not following the recommendations from the manufacturer or the current ECC guidelines.

Who exactly is the ECC?

Beside not allowing the drug to work, have you had any success following this regimen?

How does giving an epi three minutes after a round of vasopressin not allow it to work? Vasopressin is used to cause vasoconstriction. As far as I know there is nothing that epi does to stop vasopressin from working. Two different MOAs between epi and vasopressin.

Is this outlined in your protocols? Did your medical direction sign off on this?

Yes this is in our protocols. Yes this is what our medical director signed us off to do. Our success rates in Wake County for Vfib/Vtach cardiac arrest is 34%. This is of course in conjunction with induced hypothermia for ROSC.

[fiznat]

Who exactly is the ECC?

ECC stands for Emergency Cardiac Care, and is pretty much everything you do in ACLS (save airway stuff) that is not CPR. Just another acronym to remember, really.

http://circ.ahajournals.org/content/vol112/24_suppl/

I'm not sure what AZCEP is getting at here either. Some quotes from the AHA ECC guidelines:

If VF/VT persists after delivery of 1 or 2 shocks plus CPR, give a vasopressor (epinephrine every 3 to 5 minutes during cardiac arrest; one dose of vasopressin may replace either the first or second dose of epinephrine—see Box 6). Do not interrupt CPR to give medications.

If the rhythm check confirms asystole or PEA, resume CPR immediately. A vasopressor (epinephrine or vasopressin) may be administered at this time. Epinephrine can be administered approximately every 3 to 5 minutes during cardiac arrest; one dose of vasopressin may be substituted for either the first or second epinephrine dose (Box 10).

Vasopressin

Vasopressin is a nonadrenergic peripheral vasoconstrictor that also causes coronary and renal vasoconstriction.58,59 Despite 1 promising randomized study (LOE 2),60 additional lower-level studies (LOE 5),61–63 and multiple well-performed animal studies, 2 large randomized controlled human trials (LOE 1)64,65 failed to show an increase in rates of ROSC or survival when vasopressin (40 U, with the dose repeated in 1 study) was compared with epinephrine (1 mg, repeated) as the initial vasopressor for treatment of cardiac arrest. In the large multicenter trial involving 1186 out-of-hospital cardiac arrests with all rhythms (LOE 1),65 a post-hoc analysis of the subset of patients with asystole showed significant improvement in survival to hospital discharge but not neurologically intact survival when 40 U (repeated once if necessary) of vasopressin was used as the initial vasopressor compared with epinephrine (1 mg, repeated if necessary).

A meta-analysis of 5 randomized trials (LOE 1)66 showed no statistically significant differences between vasopressin and epinephrine for ROSC, 24-hour survival, or survival to hospital discharge. The subgroup analysis based on initial cardiac rhythm did not show any statistically significant difference in survival to hospital discharge (LOE 1).66

In a large in-hospital study of cardiac arrest, 200 patients were randomly assigned to receive either 1 mg of epinephrine (initial rhythm: 16% VF, 3% VT, 54% PEA, 27% asystole) or 40 U of vasopressin (initial rhythm: 20% VF, 3% VT, 41% PEA, 34% asystole). There was no difference in survival to 1 hour (epinephrine: 35%, vasopressin: 39%) or to hospital discharge (epinephrine: 14%, vasopressin: 12%) between groups or subgroups.64

A retrospective analysis documented the effects of epinephrine alone (231 patients) compared with a combination of vasopressin and epinephrine (37 patients) in out-of-hospital cardiac arrest with VF/VT, PEA, or asystole. There was no difference in survival or ROSC when VF or PEA was the presenting rhythm, but ROSC was increased in the epinephrine plus vasopressin group among patients presenting with asystole.67

Because vasopressin effects have not been shown to differ from those of epinephrine in cardiac arrest, one dose of vasopressin 40 U IV/IO may replace either the first or second dose of epinephrine in the treatment of pulseless arrest (Class Indeterminate).

Asystole and Pulseless Electrical Activity

Vasopressors

The studies described above enrolled patients with PEA and asystole and failed to show that either vasopressin or epinephrine is superior for treatment of PEA regardless of the order of administration. In the case of asystole, a single post-hoc analysis of a larger study found a survival benefit of vasopressin over epinephrine but did not find an increase in intact neurologic survival.

On the basis of these findings, providers may consider vasopressin for treatment of asystole, but there is insufficient evidence to recommend for or against its use in PEA. Further studies are required. Epinephrine may be administered every 3 to 5 minutes during the attempted resuscitation; vasopressin may be substituted for the first or second epinephrine dose.

It seems that much of the research shows that there is very little difference between the two drugs as far as patient outcome, so I suppose it makes sense that the drugs may be used interchangeably (in the method according to the guideline).