Journal Club #1: Goto et al. Effects of prehospital epinephrine... Critical Care 2013

[Christopher]

Barring reversible (and otherwise refractory) causes, that would be my vote.

Not to steer this too far from Goto-san's paper, but applying the results of this reminds me of Eisenburg's editorial on endotracheal intubation in cardiac arrest and how his prehospital survival rates have not decreased because of this practice...because they have already maximally optimized BLS care.

Basically, when you look at a paper by Wang or Goto-san and wish to apply it to your practice, it is worth considering how similar their "environment" is to yours.

 

[Av8or007]

One random though i just had, although not directly related to the paper: Has anyone ever done s well designed study comparing epi to placebo (or however else it needs to be designed to get around the "ethics" board people) WITH and WITHOUT therapeutic hypothermia.

It would be interesting to see if TH attenuates some of the bad neurological outcomes associated with the epi - is getting the brain back a whole separate issue from getting the heart back (via ROSC)?

 

[Brandon O]

One random though i just had, although not directly related to the paper: Has anyone ever done s well designed study comparing epi to placebo (or however else it needs to be designed to get around the "ethics" board people) WITH and WITHOUT therapeutic hypothermia.

It would be interesting to see if TH attenuates some of the bad neurological outcomes associated with the epi - is getting the brain back a whole separate issue from getting the heart back (via ROSC)?

I used to be optimistic about this model as well, and it may still bear fruit. But if the question is "does therapeutic hypothermia change the 'ROSC now, die in the hospital' pattern characteristic of epi?" the answer is probably no. I don't know of any head-to-head trials that analyze both epi and hypothermia, and the latter is so clearly beneficial at this point that it would probably be unethical. But we have seen epi trials where post-arrest hypothermia was used copiously, and it's not like the ratio of ROSC-to-longterm-survival is dramatically different. Olasveengen for instance had ~71% hypothermia in both arms.

Also interesting on this subject is to look at the actual cause of death in the "late diers" who are lost after admission. Are they potentially reversible causes? When a study reports this, make sure to check it out. (Many of those deaths are often from, basically, massive brain damage.)