Consensus on Science with Treatment Recommendations (CoSTR)
The primary source for the recommendation to keep things the same is a brand new study - PARAMEDIC2.
This showed no statistically significant improvement in the only outcome that matter - survival without severe brain damage.
A larger study might show that there is a real improvement - or it may put the epi hypothesis out of its misery.
I will eventually have a cardiac arrest. If I am resuscitated, whom will ILCOR send to change my diaper, and attend to the other things I can no longer attend to?
We need evidence of a significant benefit in order to justify distracting everyone from interventions that actually do improve survival without severe brain damage.
In remote areas where the first responder with health care training is likely to be a nurse, and sometimes no-one else with adequate training, a supraglottic airway is feasible and makes CPR simpler. Endotracheal tube is usually outside their scope of practice, and juggling a bag valve mask with chest compressions wastes time.
I find Rory Spiegel's arguments against the use of epinephrine in cardiac arrest very persuasive. A minimal number of extra survivors at a very high price in terms of the neurologically impaired ones, who will suffer themselves, cause suffering to their relatives and consume a lot of expensive health care resources in the long term.
ROSC is only the first step in successful resuscitation. The goal is a neurologically or "nearly neurological " intact survivor. Remember Peter Safar's writings on "Cardiopulmonary - Cerebral Resuscitation".
I would respectfully ask the committee to review the evidence again and reconsider their recommendations,which will have an impact over the next 5 years.If epinephrine was a new drug - would it be recommended.
If we wish to promote bystander CPR to be done by members of the general public, then the supraglottic airway, bag valve mask, will be more easier for them, as training is more easy, with the skills more easier to retain. Moreover, success in using these skills shall be better, and this will help to uplift their willingness to help in emergencies.
The ILCOR treatment recommendations concerning vasopressors in cardiac arrest call for the administration of epinephrine during cardiopulmonary resuscitation This is designated as a strong recommendation with low to moderate certainty of evidence. The authors justify this recommendation stating, “the findings that epinephrine compared with placebo substantially improves ROSC, and also improves hospital admission and survival. The task force made a strong recommendation given that the intervention may reduce mortality in a life-threatening situation and adverse events are not prohibitive.”
In their literature review, the authors discuss Perkins et al (1), the major RCT examining the use of bolus-dose epinephrine in cardiac arrest. They note Perkins et al demonstrated a statistically significant difference in 30-day survival (3.2% vs 2.4% unadjusted odds ratio for survival 1.39; 95% confidence interval 1.06 to 1.82; P=.02), when the use of bolus dose epinephrine was compared to placebo. Perkins et al also reported an increase in the number of patients who were transported to the hospital (50.8% vs 30.7%) and survived to ICU admission (14.1% vs 6.8%). Despite a small increase in overall survival, there was no difference in the rate of neurologically intact survival in patients randomized to receive epinephrine versus placebo.
When writing the ILCOR recommendations, the authors state they balanced the potential benefits and harms associated with the use of bolus-dose epinephrine in cardiac arrest. Despite this assertion, Perkins et al demonstrates a clear signal of harm not discussed by the authors. In this case we are asked to weigh a 0.8% increase in survival to hospital discharge with the harms associated with its use. The harms come in the form of a significant increase in the risk of survival with neurologic devastation. Although more patients who received epinephrine were transported to the hospital (50.8% vs 30.7%) and survived to ICU admission (14.1% vs 6.8%), 31% of the survivors in the epinephrine group had a modified Rankin Scale score of 4 or 5 (unable to walk or bedridden), compared with 17% in the placebo group. These results suggest the use of bolus-dose epinephrine does not result in a larger number of neurologically intact survivors. Rather it shifts a small number of patients from death to a state of neurological devastation. This is not a small price. Imagine the increase in societal resources required to care for the large increase in the number of patients transported to the hospital alive, the moderate increase in the number of patients that survive to ICU admission, and the few neurologically devastated patients requiring long-term care. All with no increase in clinically meaningful neurologically intact survival.
Perkins GD, Ji C, Deakin CD, et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N. July 2018. doi:10.1056/nejmoa1806842
I completely agree that in the out of hospital patient population bag mask ventilation is superior per the EB findings. This in no way indicates that the same would be true in a controlled setting in hospital, per this research "There were no RCTs of airway management for in-hospital cardiac arrest." Future RCTs comparing endotracheal intubation, LMA insertion and video laryngoscopy use for endotracheal intubation with time and success rates would be beneficial.
LMA is a user-friendly device with a high success rate.
If there is any difficulty in securing the airway with LMA (which is a possibility), an oropharyngeal airway of appropriate size might be adequate for ventilation until skilled help is available for an advanced airway. Aspiration can happen with any device.
I think that having the airway secure and sealed against bronchoaspiration is the best but it is time consuming technique and could be dodgy in an out-of -hospital scenario where we are facing adverse conditions. Better a supraglottic device as an airway rescue to earn time .