Vfib protocols

[leviathan]

In ACLS protocols I know amiodarone is listed as the first administered antiarrhythmic after epinephrine or vasopressin, but when is it indicated to use one of the other drugs that they have listd? I understand the reasoning for magnesium sulfate in the case of torsades, but I'm confused as to when the other drugs might be used such as lidocaine or procainamide.

Thanks,

-L

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[sigep628]

As an ACLS instructor we teach that you use Amiodarone 300 mg IVP, and then use the Amiodarone 150 mg IVP. If these don't work then you can go to Lidocaine. It is not suggested to use Procainamide if you have already used Amiodarone as they both prolong the QT interval. I don't think there is a clear cut case where you would go to Lidocaine first. The studies have shown that Amiodarone as a 1st line antiarrhythmic works better in converting VF. Hope this helps.

 

[deleted6669]

acls protocols recommend procainamide for recurrent vfib.
downside to amiodarone is that it takes so long to mix that many folks just use lido as 1st line still.
emedpa( also an acls instructor)

 

[leviathan]

Thanks guys, that seems to answer my Q.

 

[basementbeastie]

i have seen procainamide successfully used in recurrent vfib...i think it may be first line in that scenario...

 

[Freeeedom!]

PLEASE PLEASE remember that ACLS are only guidelines and Amiordarone is a class IIb drug, not an overwhelming endorsement and really not a nod over Lidocaine (class indeterminate). Procainamide is also class IIb...the point being...the jury is out and always will be. Use what you want as long as there are no contraindications to usage (lengthened QT etc).

 

[leviathan]

PLEASE PLEASE remember that ACLS are only guidelines and Amiordarone is a class IIb drug, not an overwhelming endorsement and really not a nod over Lidocaine (class indeterminate). Procainamide is also class IIb...the point being...the jury is out and always will be. Use what you want as long as there are no contraindications to usage (lengthened QT etc).

OK, so the rest of the users have a differing opinion. Thinking back, I suppose that's what I really wanted to know is whether amiodarone was suggested because it was better, or if it was just arbitrary.

 

[vtach]

OK, so the rest of the users have a differing opinion. Thinking back, I suppose that's what I really wanted to know is whether amiodarone was suggested because it was better, or if it was just arbitrary.

As an ACLS instructor, I believe that you have your choice between Amio or Lido. You should not use both. I also believe if you read the new guidelines that you are not supposed to mix anti-arrhythmics. Pick one and stick with it. The old ACLS from the 1993 update was where you started with Lido, then moved to Breytilium and then Procainamide. MgSO4 could be thrown in where ever you felt it might be good. I still teach if one doesn't work then move to procainamide. I just am waitng for my Breytilium to come back on the market! Nothing like the projectile vomiting it will cause in a conx patient.

 

[Sessamoid]

OK, so the rest of the users have a differing opinion. Thinking back, I suppose that's what I really wanted to know is whether amiodarone was suggested because it was better, or if it was just arbitrary.

It's also much more heavily marketed, and it's not clear to me that the AHA is immune to that marketing. In recent years, the AHA seems particularly umm... susceptible... to commercial interests.

 

[Freeeedom!]

That point was made VERY VERY clear on a recent EM RAP by Mel Herbert from USC.
Amiodarone has been marketed quite well.
Just like Xopenex
Just like Cialis
Just like Celebrex
etc

 

[fuegorama]

It's also much more heavily marketed, and it's not clear to me that the AHA is immune to that marketing. In recent years, the AHA seems particularly umm... susceptible... to commercial interests.

I was quoted a cost of $1/mg for amio at my last recert. With the 300mg bolus followed by a drip that is hand mixed, that's a lot of change for a probably-dead person.
The same guy told us Lido. rings in at around $15/100mg tubex.

Of course an article like this makes you sweat that decision a little more.

Dorian P, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A. Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation [Published erratum appears in N Engl J Med 2002;347:955]. N Engl J Med 2002;346:884-90 .

 

[docB]

? about Amiodarone. I've heard that it contains an iodine moiety and that it can cause anaphylaxis in those with contrast allergies. I posted a question about this on the pharm board and the response was that this was true but no discussion (pharmacists ). Anyway, I've given boatloads of amio and never run into a problem although many of the people were dead to begin with. Has anyone else heard this or seen it? Most of the stuff I've seen trying to research this has talked about the oral prep but a few have said it applies to the IV as well.

 

[jf]

If it is impossible to establish IV access on a pt, than Lidocaine is the first line drug of choice since it can be given down the tube, whereas Amiodarone can't. In my readings, I haven't found too much literature to support the use of amiodarone over lidocaine. As far as I know, it does not increase the number of pt's surviving cardiac arrest vs lidocaine. In addition, as previously mentioned, amiodarone is super expensive and is a pain in the ass to administer. Lidocaine is cheap, easy to give and works just as well. The people that develop the protocals must be getting a kickback from the amiodarone people.

 

[12R34Y]

As an ACLS instructor also, I teach that the "jury is out" on lido v.s. amio. But, I also was taught (and teach) that you don't mix them..........meaning pick one and stick with it.

later

 

[roja]

An interesting point about amio by bukata/hoffman at ACEP this past week: AHA recieved HUGE amounts of buck from the amio makers. Sure that didn't affect the way they recommend things.


I have generally found that the VAST majority of EMD's pretty much scoff at the AHA guidlines and I am coming to concur with them over time.

 

[leviathan]

If it is impossible to establish IV access on a pt, than Lidocaine is the first line drug of choice since it can be given down the tube, whereas Amiodarone can't. In my readings, I haven't found too much literature to support the use of amiodarone over lidocaine. As far as I know, it does not increase the number of pt's surviving cardiac arrest vs lidocaine. In addition, as previously mentioned, amiodarone is super expensive and is a pain in the ass to administer. Lidocaine is cheap, easy to give and works just as well. The people that develop the protocals must be getting a kickback from the amiodarone people.

Right, NAVEL.

I think there must be some sort of cooperation going on because if I recall correctly, ACLS guidelines pre-2002 were to give lido and it has now switched to amio without (according to the general consensus here) anything supporting lido's replacement as "first choice".

 

[southerndoc]

I'm not so sure that amio is preferred in the VF/PVT algorithm. People fail to realize that the antiarrhythmics are listed in alphabetical order and not in the order of preference.

Now for the tachydysrhythmias, well amio is certainly preferred in those... However, there is research to support it as a better agent.

 

[Sessamoid]

An interesting point about amio by bukata/hoffman at ACEP this past week: AHA recieved HUGE amounts of buck from the amio makers. Sure that didn't affect the way they recommend things.


I have generally found that the VAST majority of EMD's pretty much scoff at the AHA guidlines and I am coming to concur with them over time.

Organized EM (ACEP, AAEM, and SAEM) is well-aware of this conflict of interest, and in general all the groups are moving away from the AHA guidelines. More and more EM groups are no longer requiring ACLS certification, including the biggest democratic practice group in California.

 

[srlondon]

Pick one and stick with it indeed. But as JF correctly points out above, lido is cheaper, more readily available (in every crash cart I've ever encountered), and has an equivalent survival-to-discharge compared to amiodarone in all data I've seen.

As far as dosing goes, good point re: ability to dose lido down tube, but don't forget to follow the inital lido bolus up with an infusion, as it is quite short-acting.

As an ACLS instructor also, I teach that the "jury is out" on lido v.s. amio. But, I also was taught (and teach) that you don't mix them..........meaning pick one and stick with it.

later