Cardiac arrest: ACLS drugs no not improve survival.

Clinical bottom line (level 2b)

  1. A third of patients with an in-hospital cardiac arrest will have successful resuscitation.
  2. In-patients who have a cardiac arrest who require epinephrine, atropine, bicarbonate, calcium, or lidocaine are at increased risk of dying in the next hour.
  3. There is no clear effect from bretylium.
van Walraven et al: Annals of Emergency Medicine 1998; 32 (5): 544-553
Expires October 2003

The study

Inception cohort study with objective outcomes, adjusted for confounding factors, not validated in an independent set of patients.

Setting: 5 acute hospitals, Canada

773 patients (aged mean 68, 56% male) treated for cardiac arrest (32% in VF or VT) in hospital

Excluded if
  • aged <16 years
  • terminal illness
  • been without basic CPR for >15 minutes
  • acute trauma or exsanguination
  • recent sternotomy
  • in the operating, delivery or recovery rooms at time of arrest
  • judged by blind observers to have not undergone true cardiac arrest



    • Factors studied:
  • ACLS drugs
  • atropine
  • epinephrine
  • bicarbonate
  • calcium
  • lidocaine
  • bretylium


    • All patients were resuscitated using ACLS protocols.

    Multivariate logistic regression analysis used to adjust for confounding factors (age, sex, previous cardiac or respiratory disease, cause of arrest and initial cardiac arrhythmia)

    ?100% followed for 1 hour
    Outcomes studied:
  • successful resuscitation at one hour with a continuous measure of pulse and blood pressure

    • The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    successful resuscitation 1 hour 269/773 35%
    (31% to 38%)

    prognostic factor for
    successful resuscitation     		time to outcome control rate (%) adjusted OR
    (95% CI)    		 NNF+
    (95% CI)
    atropine 60 minutes 114/190
    (60%)     		0.24
    (0.17 to 0.35)     		-3
    (-4 to -3)
    epinephrine 60 minutes 75/90
    (80%)     		0.08
    (0.04 to 0.14)     		-2
    (-2 to -2)
    bicarbonate 60 minutes 218/513
    (42.5%)     		0.31
    (0.21 to 0.44)     		-4
    (-6 to -3)
    calcium 60 minutes 250/667
    (37.5%)     		0.32
    (0.18 to 0.55)     		-5
    (-8 to -4)
    lidocaine 60 minutes 210/558
    (37.6%)     		0.48
    (0.33 to 0.71)     		-7
    (-13 to -5)
    bretylium 60 minutes 255/720
    (35.4%)     		0.55
    (-.29 to 1.07)     		-8
    (-5 to 64)

    Comments

    1. Data taken from a randomised controlled trial of active compression-decompression. The drugs were given 'as required'. The patients receiving the ACLS drugs could have had clinical factors which result in poorer outcomes independent of the drugs.
    2. Only patients who receive calcium sooner were more likely to survive.
    3. Non-survivors were more likely to have receive epinephrine after 2 minutes of starting CPR or atropine after 10 minutes of starting CPR than survivors.
    4. The study is too small to show any effect from bretylium since few patients received this drug.

    Citation

    1. van Walraven C, Stiell IG, Wells GA, et al: Do Advanced Cardiac Life Support drugs increase resuscitation rates for in-hospital cardiac arrest?. Annals of Emergency Medicine 1998; 32 (5): 544-553
    Search Terms: hand-search
    Contributor: Chris Ball and Clare Wotton, October 1999
    Reviewer: Clare Liddy

    Clinical Question.
    Patient cardiac arrest
    Intervention or Exposure ACLS drugs; epinephrine, atropine, bicarbonate, calcium, lidocaine, bretylium
    Outcome survival