THURSDAY POTD, ALL TREMOR BEFORE ITS MIGHT

AMIODARONE: THROW IT IN THE TRASH!  

At least, that's what I'm going to try to convince you of today.

Recently there was a patient in stable VTach, awake alert normotensive.

Get 150/300 mg bolus of amio right? That's what everyone goes for. It's familiar, it's comfortable, it's oh so sexy (ok maybe not that one). But they probably shouldn't.

THE BASICS

Amio is typically used in 3 indications in the ED.

1. Afib for cardioversion
2. VTach for cardioversion
3. Refractory VF or pulseless VT

WHY I WON'T BE USING IT IN ANY OF THESE THINGS

1. AFIB
   1.  shown to be no more effective than flecainide/propafenone at 24 hours("pill-in-pocket"), and no more effective than placebo in first 1-2 hours. (https://www.ncbi.nlm.nih.gov/pubmed/12535819)
   2. Procainamide had a better conversion rate with mean time of 55 minutes, with lower incidence of SE (https://www.ncbi.nlm.nih.gov/pubmed/18045891)
   3. Electrical Cardioversion has a conversion rate of >90% with 1 shock, approaching 100% if 2 shocks delivered.
2. VTach (Stable)
   1. PROCAMIO TRIAL: read it, love it, admire it. Use it over and over and over again. (https://www.ncbi.nlm.nih.gov/pubmed/27354046). Basically it says that procainamide is safer and more effective than amio.
3. Refractory VF/Pulseless VT
   1. Multiple studies showing increase of ROSC, but no increase in neurological outcomes. Does it really do anything?

NOTES: Procainamide dosing for VT is 10 mg/kg run over 20 minutes. Dosing for AF is 1 gm over 60 minutes. The AF dosing is in the computer under COMMON MED DRIPS. The major side effect of procainamide is HYPOTENSION, so be care with already hypotensive patients, and have them on a monitor. (but amio also causes hypotension so who really cares???)

SO. I don't know if this changes your practice or not. Definitely read the studies, do your own due diligence. We often reach for amio because it's familiar, but often it can cause more harm than good. I know Jason and the Argonauts, sorry, Pharmacists, support using PROCAINAMIDE in most situations.

Disclaimer: I wish I was getting paid by the makers of procainamide.

Subdued POTD Weds

Today there will be no caps lock, no colors, no pizzazz. Just down to brass tax. That patient that we didn't give Apneic Oxygenation to the other day, coded. Boom. Dead. Asystole. Hasta la vista baby. Now we're coding him.

Epi, push push push, epi, push push push.

PULSE CHECK (sorry that called for all caps). Check the monitor, feel for pulse....get the ultrasound?

Maybe we shouldn't be getting the ultrasound routinely. A recent study showed pretty much what we all know. It showed that pauses in ACLS using POCUS echo were significantly longer than those without. While they didn't study patient mortality/mobility or outcomes, the results speak for themselves. We are taught longer the pause in CPR the lower the mean cardiac arterial pressure.

RESULTS Duration of Pulse Check: Without POCUS: 13.0 seconds (95% CI of 12-15) With POCUS: 21.0 seconds (95% CI of 18-24) p <0.001

Study was done prospectively with videos being reviewed of the cardiac arrests by a 3rd party. It wasn't controlled for POCUS user training (intern vs 3rd year vs attending).

Whether this changes your practice or not (I think this is pretty intuitive and not hugely practice changing), but maybe it serves to remind you that if you take a pause to take a look at the heart, don't spend to long trying to get a perfect picture. Maybe only take a look in the beginning of a code (rule out tamponade or R heart dilation, both problems that need to be fixed), or at the end of a code (to confirm cardiac standstill)

https://www.ncbi.nlm.nih.gov/pubmed/28754527 http://rebelem.com/impact-pocus-cardiac-arrest-resuscitation-compression-pauses/

MONDAY POTD EXTRAVAGANZA

APNEIC OXYGENATION (AO): What is it, and is it even necessary????

• APNEIC OXYGENATION (DEFINITION TIME BOYS!):  Providing 15L NC during the act of intubation (while your blade is in the dudes/dudettes mouth. Thought to decrease odds of desaturation thus preventing the need for bagging (YUK) during intubation.
• ANESTHIOLOGISTS  still bag people almost every intubation. Yet most of those people have been fasting for hours and don't have anything to throw up. We don't have that luxury.
• HYPOXEMIA (result of desaturating during intubation)  can lead to cardiopulmonary arrest. Then you're in deep doodoo. So does throwing a NC on them really help???

BUT JOSH, THIS IS STANDARD OF CARE!$#$^%*&$

WHY NOT JUST PUT ON A NC FOR INTUBATING?????? WHY ARE YOU WASTING DR. PRINCE ROCHLIN'S TIME????

Well we may not have to, and may be harming patients by delaying intubation.

There were 2 papers recently studying apneic oxygenation. (links to critical evals at end of email)

1. FELLOW TRIAL (2011) :150 patients randomized to AO or none. Since center, prospective, randomized, HOWEVER IN ICU. These patients all got PRE-OXYGENATION to 100% for 3 minutes. FOUND NO DIFFERENCE IN:
   • Lowest O2 level, incidence of desaturation, and even HOSPITAL MORTALITY (wow these people are awesome researchers!)
2. ENDAO TRIAL (2017):   200 patients randomized to AO or non. Single center, prospective, randomized. in the ED. Again, all pre-oxygenated. FOUND NO DIFFERENCE IN:
   • Incidence of desaturations, Mortality within 24 hours and Hospital Mortality (see sweet data that follows)

JOSH IT SEEMS LIKE YOUR TELLING ME THAT WE CAN JUST CUT NASAL CANNULA'S OUT OF THE BUDGET FOR INTUBATIONS, SAVE A BUTTLOAD OF MONEY FOR THE HOSPITAL, BE A HERO, AND SAVE SOME GOD DAMN LIVES!

Kind of? Both of these papers glossed over the fact that these patients were pre-oxygenated with either NRB, NC+NRB, HFNC, or BiPAP. Only NRB or BiPAP would require an extra step of putting a NC on in intubation. So if you've already got a NC on, there's no harm in leaving it on. If not? Maybe next time just go for the tube rather than taking those extra 10-15 seconds to put on the NC.