Do IV Meds Matter in Out-of-Hospital Cardiac Arrest?
Use of IV drugs did not affect long-term neurological outcome or survival.
Intravenous access and drug administration have long been central elements of advanced cardiac life support (ACLS) protocols despite the absence of evidence that they improve outcomes. In a randomized, controlled, nonblinded trial, 851 consecutive adult patients with out-of-hospital, nontraumatic cardiac arrest in Oslo, Norway from 2003 to 2008 were randomized to receive ACLS with IV access and drug administration (epinephrine, atropine, and amiodarone were used) or ACLS with no IV access.
In the group that received ACLS with no IV access, IV access was established within 5 minutes after return of spontaneous circulation (ROSC). In both groups, patients with ventricular fibrillation received cardiopulmonary resuscitation for 3 minutes before the first shock and between unsuccessful series of shocks. Endotracheal intubation was standard, and postresuscitation therapeutic hypothermia was instituted regardless of initial rhythm or course of arrest. Quality of CPR was determined by transthoracic impedance signals from defibrillators. The primary outcome was survival to discharge.
The rate of hospital admission for patients with ROSC was significantly higher in the group with IV access than in the group without IV access (32% vs. 21%). However, no significant differences were found between the IV-access and no-IV-access groups in rates of survival to discharge (10% and 9%), survival with favorable neurological outcome (10% and 8%), and survival at 1 year (10% and 8%). CPR was performed according to guidelines, and its quality was similar in both groups.
This first effort to evaluate the effect of IV access and drug administration on outcomes in patients with out-of-hospital cardiac arrest, after more than 4 decades of use, yields provocative results: These long-standing interventions were not associated with improvement in long-term survival or neurological outcome. The results are in concert with those from studies in which epinephrine, atropine, and amiodarone improved short-term but not long-term outcomes compared with placebo. In addition, IV access had no negative effect on the quality of CPR. This trial begs for research targeted at novel pharmacologic therapies and should prompt the rethinking of ACLS guidelines.
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine December 18, 2009
Citation(s): Olasveengen TM et al. Intravenous drug administration during out-of-hospital cardiac arrest: A randomized trial. JAMA 2009 Nov 25; 302:2222.