Lidocaine vs. Amiodarone

[FireEMT2009]

I have almost completed my paramedic school and we have covered pharm and cardiology 20 times over. The big question I have is which do you perfer when treating VF or pulseless VT, Amiodarone or Lidocaine? I know that both has the potential to calm the heart down and help it beat regularly. I was just wondering ya'll's opinion on it, from a student to a veteran. Thanks for responses.

FireEMT2009

[chbare]

I have almost completed my paramedic school and we have covered pharm and cardiology 20 times over. The big question I have is which do you perfer when treating VF or pulseless VT, Amiodarone or Lidocaine? I know that both has the potential to calm the heart down and help it beat regularly. I was just wondering ya'll's opinion on it, from a student to a veteran. Thanks for responses.

FireEMT2009

Let me put this back on you since you apparently have covered this in depth. What does the current evidence suggest? Does either agent lead to increased survival to discharge?

Take care,

chbare.

[Kiwiology]

It was foretold in Mobile Intensive Care Officer class in 1992 that drugs in cardiac arrest are of little benefit and somehow the idea never caught on

Amiodarone has been shown to improve ROSC but not improve overall survival rates

[celticcare]

Due to the time of my registration and training skill levels, its only ever been Amioderone that I have used, but then bear in mind, that it has only recently been incorporated into the resuscitation guidelines for the event of ROSC.

Some doctors I have worked with have still asked for Lignocaine as that is what they know and have had successes with. I can only comment on giving Amioderone as a standard. All medications have factors which enhance or limit their success. How long the patient has been down, the time of admin, state of the myocardium, hypoxia, sensitivities to the medication, precipitating factors to the arrest *H's and T's etc* and the outcomes with studies have shown favor to amioderone hence the current recomendations for it.

Are meds of little benefit in Cardiac arrest? Who knows, are all cardiac arrests the same? No. So perhaps the statement of that "all meds in cardiac arrest management have little or no effect" is contradicted. But then the date of that statement is also the time we did alright chest compressions and three stacked shocks and only had monophasic defibrillators and intracardiac medications lol.

Times change, meds change and so do protocols. Be interested to see other replies on this thread.

Scotty

[FireEMT2009]

Let me put this back on you since you apparently have covered this in depth. What does the current evidence suggest? Does either agent lead to increased survival to discharge?

Take care,

chbare.

Mr. Chbare,

The current evidence that I have seen and that our emergency pharmacist instructor says is that amiodarone is better and increase chances of ROSC. I am a big fan of amiodarone myself but will use lidocaine if needed. I just wanted to get a couple opinions. Amiodarone and Lidocaine both have their pros and cons in terms of ease of usage. I just like hearing other peoples opinions on things that puts old school (lidocaine) and new school (amiodarone) and see where the population lies.

It was foretold in Mobile Intensive Care Officer class in 1992 that drugs in cardiac arrest are of little benefit and somehow the idea never caught on

Mr. Kiwi,

I guess some research is keeping the ball moving for cardiac arrest drugs in order for AHA to continue pushing forward with them.

Amiodarone has been shown to improve ROSC but not improve overall survival rates

Due to the time of my registration and training skill levels, its only ever been Amioderone that I have used, but then bear in mind, that it has only recently been incorporated into the resuscitation guidelines for the event of ROSC.

Some doctors I have worked with have still asked for Lignocaine as that is what they know and have had successes with. I can only comment on giving Amioderone as a standard. All medications have factors which enhance or limit their success. How long the patient has been down, the time of admin, state of the myocardium, hypoxia, sensitivities to the medication, precipitating factors to the arrest *H's and T's etc* and the outcomes with studies have shown favor to amioderone hence the current recomendations for it.

Are meds of little benefit in Cardiac arrest? Who knows, are all cardiac arrests the same? No. So perhaps the statement of that "all meds in cardiac arrest management have little or no effect" is contradicted. But then the date of that statement is also the time we did alright chest compressions and three stacked shocks and only had monophasic defibrillators and intracardiac medications lol.

Times change, meds change and so do protocols. Be interested to see other replies on this thread.

Scotty

Mr. Scotty

I agree that today it seems amiodarone is being pushed much harder for usage than lidocaine. I know everyone in my class choose amiodarone everytime we did a megacode for our ACLS class.

I think that either choosing to work with lidocaine or amiodarone is a personal choice, lidocaine has been around for a long time and has shown an increase in ROSC, and amiodarone is newer and has shown increase in ROSC as well. Either way your patient could not go wrong with you choosing either drug for their condition. H&Ts are a priority during cardiac arrest, and if they aren't fixed the arrhythmia won't be fixed either so its a cycle.

And as you said not every cardiac arrest is the same, you play that game and have to learn to play it well enough to increase your patients survvival rate.

Thank you everybody for your comments and I will be gladly watching this topic over the next couple days to see how many other comments it gathers.

FireEMT2009

[medicgirl05]

We carry and use Lidocaine. If I remember correctly from paramedic school, and this was 2 years ago so its possible that it has changed since then, Amiodarone has a proven increase of ROSC over Lidocaine; however neither increases the rates of hospital discharge following their use.

I had one code "save' with the use of Lidocaine. I think it had to do more with great timing than anything I or my partner did. V-fib on arrival, defibx2, little Lido. So I think in some situations Lidocaine has the potential to work.

[FireEMT2009]

We carry and use Lidocaine. If I remember correctly from paramedic school, and this was 2 years ago so its possible that it has changed since then, Amiodarone has a proven increase of ROSC over Lidocaine; however neither increases the rates of hospital discharge following their use.

I had one code "save' with the use of Lidocaine. I think it had to do more with great timing than anything I or my partner did. V-fib on arrival, defibx2, little Lido. So I think in some situations Lidocaine has the potential to work.

Ms. Medicgirl,

I am very surprised and interested in the fact that you only have lidocaine available for the ventricular arrhythmias. I would like to hear your opinion on lidocaine. How do you like using it? Do you have complaints or precautions that I should use if I decide to use it? We have both drugs in our drug box available for us to use, so its a medic's preference on which one they use. Thanks in advance.

FireEMT2009

[hatelilpeepees]

Chemically, Amiodarone is supposed to be a better drug because of the receptor sites it interracts with, but in reality, we have been changing the drugs in the ACLS algorythms every 2-4 years of my career, and "OUT OF HOSPITAL ROSC or Discharge from hospital with viable life" has not improved at all. Without quick citizen CPR and ACLS intervention within 4 minutes, I doubt you will ever see a change. I think you would do just as well pushing a fluid bolus and an amp of bicarb, instead of following ACLS algorhythms, as statiscally the outcome will be the same. PS, I had more conversions back when we used bicarb as a first-line drug. With that being said, to quote the person that said each arrest is different, I remember an arrest where we had actually just stopped at the red-light in front of the fast-food restaurant where an arrest had just occurred, the patrons actually ran out and got us before 911 dispatched us. We had less than a one minute response time, the patient was a male in his 50s, had immediate good CPR by a nurse, was still in Vfib, got immediate shocks and treatments, never got him back. So he/she was right, no two arrests are the same.

Edited July 10, 2011 by hatelilpeepees

[tniuqs]

Ok "calm" the heart ?

http://circ.ahajournals.org/content/112/24_suppl/IV-58.full.pdf

This from the "bible" here they have removed lydocaine in its entirety .. and man this stuff is expensive I should have bought shares.

Antiarrhythmics

There is no evidence that any antiarrhythmic drug given routinely during human cardiac arrest increases survival to hospital discharge. Amiodarone, however, has been shown to increase short-term survival to hospital admission when compared with placebo or lidocaine.

VF and Pulseless VT

Amiodarone

IV amiodarone affects sodium, potassium, and calcium channels as well as - and -adrenergic blocking properties. It can be considered for the treatment of VF or pulseless VT unresponsive to shock delivery, CPR, and a vasopressor. In blinded randomized controlled clinical trials in adults with refractory VF/pulseless VT in the out-of-hospital setting (LOE 1),72,73 paramedic administration of amiodarone (300 mg 72 or 5 mg/kg 73) improved survival to hospital admission rates when compared with administration of placebo 72 or 1.5 mg/kg of lidocaine. 73 Additional studies (LOE 7) 74 –78 documented consistent improvement in defibrillation response when amiodarone was given to humans or animals with VF or hemodynamically unstable VT. Amiodarone produced vasodilation and hypotension in 1 of the out-of-hospital studies. 72 A canine study (LOE 6)79 noted that administration of a vasoconstrictor before amiodarone prevented hypotension. A new aqueous formulation of amiodarone does not contain the vasoactive solvents (polysorbate 80 and benzyl alcohol) of the standard formulation. In an analysis of the combined data of 4 prospective clinical trials of patients with VT (some included hemodynamically unstable patients), aqueous amiodarone produced no more hypotension than lidocaine.77 In summary, amiodarone may be administered for VF or pulseless VT unresponsive to CPR, shock, and a vasopressor (Class IIb). An initial dose of 300 mg IV/IO can be followed by one dose of 150 mg IV/IO

Edited July 10, 2011 by tniuqs

[FireEMT2009]

Ok "calm" the heart ?

http://circ.ahajourn.../IV-58.full.pdf

This from the "bible" here they have removed lydocaine in its entirety .. and man this stuff is expensive I should have bought shares.

Antiarrhythmics

VF and Pulseless VT

Amiodarone

Mr. Tniuqs,

"Calming" the heart is the best way for me to explain the power of the antidysrhythmics without going into the mechanism of action of the drug. When I think of ventricular rhythms I think of the heart beating so fast that it starts to just full out shake and cannot slow itself down where the amiodarone or lidocaine can "calm" the heart slowing it down and causing the ventriclesx to pump correctly and causing a perfusable rhythm and pulse; producing ROSC. I am sorry if my wording of choice offended or upset you.

I took ACLS last summer, and when I took it then lidocaine was still considered an antidysrhytmic drug choice.

Your link above did not work but I found this on the AHA ACLS page: http://circ.ahajournals.org/content/122/18_suppl_3/S729.full, it says if amiodarone is unavailable lidocaine may be considered, which means that it is still a vialbe option for a VF/VT patient. I am not trying to be snappy, arrogant, or cocky with my above remark, but giving evidence to support my claim that lidocaine can still be used in VF/VT rhythms. So this contradicts you saying lidocaine has been taken out entirely. It hasn't if the AHA has said that it can still be considered if amiodarone is unavailabe. Thanks for the comment.

FireEMT2009