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As I was catching up on my weekly EM/pharmacology blogs, I stumbled across an article featuring our very own Dr Martin Huecker on the Academic Life in Emergency Medicine (ALiEM) website. It is a great article about staying healthy and balancing life in EM. I’ve attached the link for your viewing pleasure.
https://www.aliem.com/2016/martin-huecker-healthy-in-em/
I’m sure you guys have heard about the new sepsis definitions unveiled at the SCCM conference last week which were originally published in JAMA (2016;315(8):801-810); if not you’re in luck because I’ve outlined them for you below. Keep in mind the sepsis definition has not been updated since most of you were still in high school- or middle school- I’m showing my age, in 2001, with Sepsis-2.
Sepsis-3:
New Terms and Definitions
The new 2015 ACLS guidelines were published this month! I love new guidelines! I’ve highlighted the important drug stuff (you guys are on your own for the rest).
Vasopressin: REMOVED FROM ALGORITHM: This was no surprise to me as vasopressin has never been shown to offer any advantage over epinephrine in studies to date.
“Vasopressin offers no advantage as a substitute for epinephrine in cardiac arrest (Class IIb, LOE B-R)”
“Vasopressin in combination with epinephrine offers no advantage as a substitute for standard-dose epinephrine in cardiac arrest (Class IIb, LOE B-R)”
Steroids: I’ve been skeptical of the use of steroids in cardiac arrest since 2009 inhospital cardiac arrest trial (steroids were combined with a vasopressor bundle or cocktail of epi and vasopressin). Will need much more convincing data before I’ll recommend routine use- and that is exactly what our guidelines endorse as well. Because: no one in the ICU dies before receiving a course of steroids. The pre-hospital use of steroids is pretty clear: no benefit.
“In IHCA, the combination of intra-arrest vasopressin, epinephrine, and methylprednisolone and post-arrest hydrocortisone as described by Mentzelopoulos et al may be considered; however, further studies are needed before recommending the routine use of this therapeutic strategy (Class IIb, LOE C-LD)”
“For patients with OHCA, use of steroids during CPR is of uncertain benefit (Class IIb, LOE C-LD)”
Epinephrine: Nothing groundbreaking here. A few trials did demonstrate ROSC advantage with high-dose epi over standard dose; however, no improvement in survival to discharge (emphasis on good neurologic recover) over standard dose. There is much concern with adverse effects of higher dose epi in the post-arrest period which may negate potential advantages during intra-arrest period.
“Standard-dose epinephrine (1 mg every 3 to 5 minutes) may be reasonable for patients in cardiac arrest (Class IIb, LOE B-R)”
“High-dose epinephrine is not recommended for routine use in cardiac arrest (Class III: No Benefit, LOE B-R)”
Antiarrhythmics: Really no changes. Emphasized use of amiodarone over lidocaine (which is not new).
“Amiodarone may be considered for VF/pVT that is unresponsive to CPR, defibrillation, and a vasopressor therapy (Class IIb, LOE B-R)”
“Lidocaine may be considered as an alternative to amiodarone for VF/pVT that is unresponsive to CPR, defibrillation, and vasopressor therapy (Class IIb, LOE C-LD)”
“The routine use of magnesium for VF/pVT is not recommended in adult patients (Class III: No Benefit, LOE B-R)”
Circulation 2015:132:S444-64
Since its approval in 1987, controversy has surrounded a drug that we all know is near and dear to my heart, recombinant tissue Plasminogen Activator (insert eye roll). In similar discreetness of a Hollywood wedding, the FDA updated the prescribing information of tPA with important changes made to the contraindications to the use of tPA in the setting of acute ischemic stroke. It is unclear as to what prompted these updates and why. There have been no recent studies of significance published to support these modifications.
2/2015 updated prescribing info:
“Do not administer Activase to treat acute ischemic stroke in the following situations in which the risk of bleeding is greater than the potential benefit:
• Current intracranial hemorrhage
• Subarachnoid hemorrhage
• Active internal bleeding
• Recent (within 3 months) intracranial or intraspinal surgery or serious head trauma
• Presence of intracranial conditions that may increase the risk of bleeding (e.g., some neoplasms, arteriovenous malformations, or aneurysms)
• Bleeding diathesis
• Current severe uncontrolled hypertension”
Now contrast the new package insert to the 2013 package insert. Pay special attention to the omissions of the exclusion of contraindications in patients with history of intracranial hemorrhage and seizure at onset of stroke. It is pertinent to note that the wording regarding the contraindications has also changed. The previous consequences being “significant disability or death” have now been replaced with “situations in which the risk of bleeding is greater than the potential benefit.”
From the 2013 package insert (changes are italicized):
“Activase therapy in patients with acute ischemic stroke is contraindicated in the following situations because of an increased risk of bleeding, which could result in significant disability or death:
o Current use of oral anticoagulants (e.g., warfarin sodium) or an International Normalized Ratio (INR) > 1.7 or a prothrombin time (PT) > 15 seconds
o Administration of heparin within 48 hours preceding the onset of stroke and have an elevated activated partial thromboplastin time (aPTT) at presentation.
o Platelet count < 100,000/mm3”
The new 2/2015 update does provide some vague conditions in which the risks of bleeding must be outweighed against the anticipated benefits (however, note that these are not firm contraindications):
• Recent major surgery or procedure, (e.g., coronary artery bypass graft, obstetrical delivery, organ biopsy, previous puncture of noncompressible vessels)
• Cerebrovascular disease
• Recent intracranial hemorrhage
• Recent gastrointestinal or genitourinary bleeding
• Recent trauma
• Hypertension: systolic BP above 175 mm Hg or diastolic BP above 110 mm Hg
• High likelihood of left heart thrombus, e.g., mitral stenosis with atrial fibrillation
• Acute pericarditis
• Subacute bacterial endocarditis
• Hemostatic defects including those secondary to severe hepatic or renal disease
• Significant hepatic dysfunction
• Pregnancy
• Diabetic hemorrhagic retinopathy, or other hemorrhagic ophthalmic conditions
• Septic thrombophlebitis or occluded AV cannula at seriously infected site
• Advanced age [see Use in Specific Populations (8.5)]
• Patients currently receiving anticoagulants (e.g., warfarin sodium)
• Any other condition in which bleeding constitutes a significant hazard or would be particularly difficult to manage because of its location.
Currently the guidelines have not updated their list of contraindications to tPA in acute stroke, but I wouldn’t be surprised to see them included when the guidelines are updated.
So like Oprah says, you get tPA! You get tPA! Everyone gets tPA!