Early epinephrine and defibrillation save lives

Patel KK, Spertus JA , Khariton Y et el published in Circulation a retrospective study of patients of in hospital cardiac arrest looking at timing of Epinephrine in PEA arrest and defibrillation in shockable rhythm.

They looked at the data for 36,961 patients aged ≥65 years with an IHCA at 517 hospitals between 2000 and 2011. (National IHCA registry with Medicare)

These patients were stratified in to 4 groups. Shockable rhythm [prompt (≤2 min) vs. delayed (>2 min) defibrillation] and PEA arrest [prompt (≤ 5 min) vs. delayed (>5 min) epinephrine treatment].

Of 8119 patients with an IHCA due to VT/VF, the rate of 1-year survival was higher in those treated with prompt defibrillation than with delayed defibrillation (25.7% [1466/5714] vs. 15.5% [373/2405]; adjusted RR, 1.49 [1.32, 1.69]; p<0.0001)

Of 28,842 patients with an IHCA due to asystole/PEA, the rate of 1-year survival with prompt epinephrine treatment was higher than with delayed treatment (5.4% [1341/24,885] vs. 4.3% [168/3957]; adjusted RR, 1.20 [1.02, 1.41]; p=0.02).

Furthermore, Prompt defibrillation for IHCA due to VT/VF was associated with higher rates of long-term survival throughout 5 years of follow-up, whereas prompt epinephrine treatment for asystole/PEA was associated with greater survival at 1 year, but not at 3 or 5 years.

FEW THOUGHTS

  1.  This is data from medicare registry, and retrospective. Data can be as good as you enter in it. Plus it only involves patients older than 65 yrs.
  2.  This study as well as others  have shown that prompt defibrillation and epinephrine saves lives.
  3. Delivery of above modalities of treatment require following
    1. Availability of equipment and medication within reasonable proximity of the patient.
    2. Prompt identification of the patient in cardiac arrest(Only few patients are in monitored beds in current healthcare scenario). Even those who are monitored, there is delay in identifying PEA arrest.
    3. Availability of trained staff to identify and deliver the care 24/7. We already know that patients having cardiac arrests on night and weekends die more
    4. Not all patients have IV access during hospitalization.

Following should be done to improve survival in cardiac arrest patients

  1.  All hospitalized patients should be on continuous monitoring, it is a cheap way to insure early detection. Designation of various floors in to med surg or telemetry are purely for billing or staffing purposes which can remain same.
  2. Implementation of advanced monitors to detect the decline in patient’s hemodynamics.
  3. All hospitalized patients should have good IV access.
  4. Presence of “code carts” in all areas.
  5. Staffing should not be “thinned” in night and weekends.