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Epinephrine Dosing in Refractory VF/pVT
Question# 954
Progressive pre-hospital systems around the world seem to be adapting to the complexity of Cardiac Arrests and Pre-Arrest presentations. Some examples of these adaptations are differentiating true VTACH from metabolic disorders such as Hyper-K, Sodium-Channelopathy/toxicity (with-holding sodium-channel blocking meds) and "electrical storm" arrests more commonly known as refractory VF arrests (with-holding 1:10000 Epinephrine administration and using first-line Esmolol administration). Both these scenarios are very likely to lead to poor outcome in these specific presenting problems if the traditional ACLS guidelines were applied.
My question is in relation to refractory VF arrests. Research and studies suggest 1:10000 EPI administration in these cases to be detrimental and exacerbating of the refractory VF. Would it be prudent and acceptable to initiate BHP consult and ask to with-hold 1:10000 Epinephrine in these cases?
My question is in relation to refractory VF arrests. Research and studies suggest 1:10000 EPI administration in these cases to be detrimental and exacerbating of the refractory VF. Would it be prudent and acceptable to initiate BHP consult and ask to with-hold 1:10000 Epinephrine in these cases?
Answer:
What is being described here are cases of electrical storm and refractory VF/VT which is triggered by sympathetic overdrive (cocaine toxicity, sudden sniffing death, channelopathies). In those specific cases, we ultimately aim to reduce this sympathetic drive in the ED with agents such as esmolol as mentioned but these are done in specific cases after active management with ACLS protocol.
Management of underlying etiologies resulting in a VT or VF arrest is an important consideration including sodium channel toxicity, channelopathies and hyperkalemia as mentioned. These are determined based on clinical suspicion, history and ECG changes although are not always readily apparent at the peak of resuscitation. In such cases of channelopathy, administration of bicarbonate or other antiarrhythmics is helpful to achieve ROSC.
As we progress towards professionalization of paramedicine, it is absolutely recommended to critically think of these interventions and it would be reasonable to contact BHP on call for consult and consideration of bicarbonate as an intervention +/- withholding additional doses of epinephrine. That being said, we should prioritize transport to definitive care as there may be access to other antidotes or reversal agents in refractory cases. The mainstay of care of patients in VT/VF would be defibrillation and administration of epinephrine and subsequent lidocaine.
It is important to note that in the context of an ongoing research study such as EpiDOSE it is critical to the study objectives and data integrity that if paramedics are enrolling the patient in a study where Epi dosing or timing is a variable that the paramedics adhere strictly to the study protocols.
EpiDOSE will likely bring some high-quality evidence to bear on this question and that even in that study epinephrine is being provided to both groups.
- General management in refractory VF/VT cases occurs in an increasing manner within the ED:
- Optimize ABCs
- Treat underlying causes as possible (ex. hyperkalemia)
- Effective CPR and defibrillation
- Identify refractory VF / pulseless VT (typically multiple shocks / doses of epi) and management
- Dual sequential defibrillation vs Vector change Defibrillation
- Medications: Amiodarone, lidocaine
- Attenuate sympathetic drive: esmolol, hold further doses of epinephrine if indicated
Management of underlying etiologies resulting in a VT or VF arrest is an important consideration including sodium channel toxicity, channelopathies and hyperkalemia as mentioned. These are determined based on clinical suspicion, history and ECG changes although are not always readily apparent at the peak of resuscitation. In such cases of channelopathy, administration of bicarbonate or other antiarrhythmics is helpful to achieve ROSC.
As we progress towards professionalization of paramedicine, it is absolutely recommended to critically think of these interventions and it would be reasonable to contact BHP on call for consult and consideration of bicarbonate as an intervention +/- withholding additional doses of epinephrine. That being said, we should prioritize transport to definitive care as there may be access to other antidotes or reversal agents in refractory cases. The mainstay of care of patients in VT/VF would be defibrillation and administration of epinephrine and subsequent lidocaine.
It is important to note that in the context of an ongoing research study such as EpiDOSE it is critical to the study objectives and data integrity that if paramedics are enrolling the patient in a study where Epi dosing or timing is a variable that the paramedics adhere strictly to the study protocols.
EpiDOSE will likely bring some high-quality evidence to bear on this question and that even in that study epinephrine is being provided to both groups.