The Q Word Podcast
"To Epi or Not to Epi?"
Nyssa: Hi, Lisa.
Lisa: Hi, Nyssa. We have a new Fast Track episode this afternoon, don't we?
Nyssa: We do and it falls into the trends of the tips, trends and taboos that we like to talk about.
Lisa: But before we do that, I think we should do some shout outs to some of our fans out there. Okay, so you have a good one that you wanted to tell us about.
Nyssa: Yeah, we wanted to give kudos and appreciation to Lisa H who is a nurse down in Georgia.
Lisa: Lisa is such a great name, isn't it?
Nyssa: Yes! She left us a five star review on iTunes that says love, love, love and all caps. And she says I absolutely loved the podcast. I automatically feel smarter listening to you. Keep up the good work ladies and then three kissy faces.
Lisa: Oh, I love the kissy faces. Thank you, Lisa. We have received a few emails toO. This one comes from a Heartbro. He is a late 20s dude making a career switch from software development into nursing. Hopefully ER or ICU.
Nyssa: ER, definitely.
Lisa: Yeah, we say to the ER. We want you in the ER. He says "your podcast is a great mix of friendly banter and actually useful information. I'm sure it'll help me get a bit ahead of the curve both in school and in the workplace". So we are super excited to hear that and we're happy that you find our information useful.
Nyssa: Yeah, he's gonna make a great nurse.
Lisa: Absolutely.
Nyssa: I also wanted to let you know how much fun we're having meeting all these new friends. I actually had a couple of really great conversations with a nurse educator from, are you ready for this?
Lisa: Tell me!
Nyssa: From Middle Earth.
Lisa: Really? You mean like from down under?
Nyssa: Yes. So my friend Rommel Principe is from New Zealand. And he has some really great ideas about where to take nursing in the future and some of the things that we can do as nurses and nurse educators to improve nursing. But the other fun thing that I learned from Rommel is that all the way down to New Zealand, they believe in The Q Word, superstition as well.
Lisa: So it's International.
Nyssa: It is.
Lisa: That's great. I'm so excited. Well, thank you, Lisa. Thank you Heartbro. And thank you Rommel for your comments. And we hope that the rest of our fans out there will also email us or rate us on iTunes and we'll throw all that information at you towards the end of the episode. We'd love to hear from you.
Nyssa: We would love to hear from you.
Lisa: But now let's talk about today's subject to epi or not to epi. Give us a little background.
Nyssa: So on July 18, just a couple of weeks ago, the New England Journal of Medicine published the results of a research project that has been ongoing since 2014. It's a very, very important research project. It's called the PARAMEDIC2 trial. And it is something that, even though it's only a couple of weeks old, the paramedic population and the emergency physician population have already jumped all over this. There are multiple podcasts and multiple articles in circulation with people's breakdown of this project and its implications. And so I wanted to kind of bring it to the attention of the nurses because I think this is something that we're going to be hearing more about in the next few years.
Lisa: Your goal is to give nurses a heads up about something different you think is about to happen.
Nyssa: That's right. I think we'll see some changes in the way we practice based on this trial. And and so I feel like it's important for them to be aware of it.
Lisa: Well, you sent me the Article to prepare for this and I was tickled by the name of the committee that launched this report, the International Liaison Committee on Resuscitation. That must be a party crowd.
Nyssa: Yeah, this study actually took place in the UK.
Lisa: Okay.
Nyssa: It's called PARAMEDIC3 and as with everything in medicine, the "paramedic" is an acronym.
Lisa: Okay.
Nyssa: And it stands for Pre hospital Assessment of the Role of Adrenaline Measuring the Effectiveness of Drug Administration in Cardiac Arrest.
Lisa: Wow.
Nyssa: Which spells out PARAMEDIC.
Lisa: I like to think that the person who thought of that, you know, got a nice little fat bonus in a check that week.
Nyssa: Yeah, I feel like that's definitely 100 points for Gryffindor for making it so appropriate. So it says the role of adrenaline. So in some other countries besides the United States, adrenaline is synonymous with epinephrine. We use the term epinephrine or epi in the US, but other folks say adrenaline. Here's the big deal about this trial. It was 8000 patients in the UK who experienced pre hospital cardiac arrest.
Lisa: Okay.
Nyssa: And in this study, it's a double blind placebo study. So when the patients were enrolled in the study, half of them would receive epi that we give per ACLs, which is Advanced Cardiac Life Support guidelines every three to five minutes. The other group would get the same amount of fluid infused, but it was just normal saline. So it's just an isotonic solution. What they were trying to determine is who would have a greater survival to discharge, a greater survival 30 days after discharge. Would it be the patients who received epi? Would it be the patients who received normal saline.
Both groups received high quality compressions and defibrillation, if they had a shockable rhythm, so this was the only difference between the two.
Lisa: Just for the lay people out there: We're talking about people who have coded on a table and then their heart needs to be restarted.
Nyssa: So they've coded in the community. They coded at school, at work, at home.
Lisa: Okay.
Nyssa: And then they've been picked up by an ambulance.
Lisa: Let's say and they're on their way to the hospital.
Nyssa: Yes.
Lisa: And the paramedics are trying to determine whether or not they need to give them epinephrine in addition to chest compressions or defibrilation shock in order to get their heart restarted?
Nyssa: So the guidelines right now say you do you give it.
Lisa: Okay.
Nyssa: You give it every three to five minutes. So they're giving them the same injection every three to five minutes. The paramedics have no idea if they're giving epi or just a normal saline, placebo.
Lisa: Okay. Okay.
Nyssa: Here's the deal with epi: epi is a really good drug for cardiac muscle. It helps perfuse the coronary arteries. And so you can get the heart back oftentimes with epi. One of the downsides of it is that it also causes clamping and vasoconstriction in the brain.
Lisa: I guess that leads me to the next question- if the protocol currently calls for the use of epi during advanced cardiac life support, how do you justify withholding that from half of your population?
Nyssa: So epi is in the protocol on a theoretical basis. There are at least eight other prominent studies on the efficacy of epi in arrest. The results are all kind of a mixed bag. But what we do know scientifically is that good quality compressions and early defibrillation, there's overwhelming scientific evidence that those do promote good outcomes. And so the rationale in this study was, we will do the two interventions that we know are based in scientific evidence, and the one that is theoretical is the one that we're testing.
Lisa: Okay, I guess that sounds reasonable. Makes sense.
Nyssa: So what the study found is that the epinephrine group had, overall, a higher number of survivors.
Lisa: That sounds positive.
Nyssa: However, the epinephrine group also had a higher number of survivors with severe neurological impairment.
Lisa: And that sounds less positive.
Nyssa: We're going to talk about what that means. In just a second. The other thing that they found was the survival to discharge with favorable neurological status was even in the epi versus non epi group. There were roughly the same. 87 people in one group. 74 in the other. However, the big important difference came with the severe impairment group. T
The group that received epinephrine- there were 39 individuals, which was considered severe neurological impairment. Whereas in the non epi group, there were only 16. So this is statistically significant. It is more than double the amount of people in the epi group ended up with severe neurological impairment.
Lisa: The article did say that there were some issues with the statistics. So because they had been unable to assess the patients in advance for any neurological conditions that may have contributed to the fact that they were neurologically more impaired after the fact.
Nyssa: Right. So none of these patients had a baseline neurological assessment, because there was no way to predict who is going to have a cardiac arrest in all of the United Kingdom. So that was just an impossibility and it is listed as one of the the limitations of the study.
Lisa: Fair enough.
Nyssa: First, I'd like to recommend that you read the article for yourself. New England Journal of Medicine. It was published the July 18 2018 edition.
Lisa: Yeah, we'll throw that reference up on our show notes for this episode.
Nyssa: And on our website, underneath this picks for favorite podcasts, there's one called REBEL Cast and REBEL stands for Rational Evidence Based Evaluation of Literature.
Lisa: Another acronym.
Nyssa: I told you, we love those. So it's Dr. Salim Rezaie and his buddy the Swami. They're both ER physicians. They do about a 20 to 25 minute breakdown of this article. They do a great job. It's a lot more in depth than what we're going to go into today. I just wanted to introduce people to the idea that epi may be on its way out or at least epi every three to five minutes maybe on its way out.
And the reason is not because we don't get people back but we don't get people back in ways where they can walk again or care for themselves; do their own activities of daily living. These people ended up with severe neurological impairments and that was measured on the Rankin scale.
Lisa: The Rankin scale. What's that?
Nyssa: So it's the neurological impairment scale.
Lisa: Okay.
Nyssa: There were higher levels of fours and fives. Four would be moderate-severe disability, unable to walk, unable to attend to your bodily needs without assistance. And a five is severe disability. You are bedridden. You are incontinent. And you require constant nursing care and attention.
Lisa: In the moment, then, whose choice was it to say, "I would rather not live without all of my faculties"? Right? Like, it's who's playing God here.
Nyssa: The designers of this trial did consider that and so they put it to the community. They actually held a community event. They had 280 participants and they asked them, "Would you want to be brought back knowing that you were going to have to have someone feed, you someone wipe your butt, someone turn you, or that you would never walk again?" Is this worse than death? These outcomes? These severe neurological outcomes? And 95% of that sample of the community said intact neuro status was the goal of resuscitation, if it were them, were their loved one.
Lisa: So if they're brought back, they want to be brought back the way they were before. They don't want to sacrifice any of their job,or to have at least a high level of functionality.
Nyssa: You know, Rankin score of the three is not the same as you and I are right now. But you're at least walking and you're at least able to do some of your own self care. You know, you and I have discussed it. And I think most reasonable people would agree with this, but it wasn't 100% consensus. It was 95. The point of this is that while epinephrine is good for the heart and is good for resuscitating an individual, it potentially may even have some deleterious effects on the brain. So we're not exactly sure why. The folks with the epi had the severe neurological impairment. It could be because of the epi itself. It could be because of a secondary injury from reperfusion. There are multiple theories that are out there. It's time to re-examine whether or not epi is the best thing to be used. So the way that ACLs works is every five years, they update their standards based on research from the previous five years. So if you're a practitioner who's been through ACLs, multiple times, you have seen ACLs become more and more like BLS. They're dropping off some of the extraneous things and focusing more on good compressions, early defibrillation, and just simplifying the algorithm to the point where it's almost basic life support instead of advanced cardiac life support anymore. And because this was such a large sample size, and a significant finding, this is something that we're going to be talking more about over the next couple of years. This is something that's going to be validated by other research. And this may even be a change that we see in ACLs 2020 version.
Lisa: So we're talking about another potential paradigm shift here.
Nyssa: Yes, yes, this is a big one. There are providers who have already moved away from the epi, one milligram, every three to five minutes, because there were previous studies that were sort of leaning in this direction. Well, since this article has come out in the medical community,
and there are a lot of practitioners who when they do resuscitate someone, they don't use this one milligram bolus every three to five minutes. There are practitioners like the SWAMI and Dr. Rezaie who hang an epi drip and they give 200 mics a minute, over five minutes, or 300 mics a minute over three minutes. That ends up being about one milligram every three to five minutes. But instead of giving it as a bolus dose, they give it as a continuous.
Lisa: That's what the SWAMI uses instead? So they are still using epinephrine. They're just using it differently.
Nyssa: Right. And that's, that's the theory. There are some practitioners that I read about who give as little as 10 mics a minute, which is just a fraction of that 1 milligram every three to five minute dose. There's a protocol called Cardiac Surgery Advanced Life Support. So this is for patients who have just undergone bypass graft. If you give them one milligram of epinephrine as a bolus dose, you're going to blow that tiny little fragile bypass that they just had sewn in the last few hours or few days, you're going to blow it right off. So for a long time, our CVICU friends have been giving much smaller titrated doses with the idea that that little vessel can't, you know, you may damage the graft. So they've been practicing that for a long time. And so there are some variations out there that are happening. People have recognized that this one milligram bolus dose may not be the best thing. I just want you to be aware that if you are in a code and the provider is doing something a little bit differently, you recognize what the research is showing and that there are some changes to some fundamental beliefs that we have held for a really long time.
Lisa: Do you think this article was recommending that the procedure of administering epinephrine should be completely curtailed?
Nyssa: They don't come to that conclusion. But the conclusion that they do come to is this is significant. And we need to think about is our goal kind of what you said, are we just interested in bringing back a heartbeat? Or are we interested in bringing back high quality of life, and what is epi doing in that continuum. Another thing to note in this study is that a lot of these patients, a high percentage of these patients, received CPR in the field meaning laypersons CPR. There were bystanders that knew how to do compressions. There's no way to measure the quality of those compressions that they received. But it speaks to the amount of education that is being done just in the community for early intervention, early compressions, and then you know till the EMS is able to respond.
Lisa: Would the circumstances of the injury indicate. . .
Nyssa: I should have said that traumas were excluded from this because, right? So traumas anyone under the age of 16, and anyone presumed or obviously pregnant, were excluded from this.
Lisa: Okay, so that means car accidents were not part of it. What do you want nurses to take away from this?
Nyssa: So the takeaway for nurses is that the efficacy of epi in Advanced Cardiac Life Support is kind of on trial. And there's some very robust data that is showing that it may not be the best thing for patients. That good compressions, early defibrillation, those are very good things and should be the focus. And I wouldn't be surprised if there were some changes in the 2020 ACLs. That's just me going out on a limb. But I definitely think there will be follow up research on this idea about epi.
Lisa: Okay, so nurses be prepared. Keep your eyes open and your ears open and check out the article. If you want to do a deeper dive on this we will put that on the show notes on our website, theqwordpodcast.com.
Nyssa: Go to our Facebook page and let's chat about it. I'd like to know if your providers have already kind of moved away from this or if you guys are following ACLs pretty strictly.
Lisa: Well, thanks for joining us again today and we look forward to you tuning in to the next episode of The Q Word Podcast. Bye Nyssa.
Nyssa: Bye Lisa! That's your fast track.
Lisa: Do you think that the lay people who listen to this episode are going to be coding on the table saying "If that's epinephrine don't give it to because I don't want to be brain dead when I get back?"
Nyssa: If they do that on the advice of two curly headed chicks on a podcast. . .
Bibliography
Perkins, G., Ji, C., Deakin, C., Quinn, T., Nolan, J., Scomparin, C., . . . Regan, S. (2018). A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. The New England Journal Of Medicine. Retrieved from https://www.nejm.org/doi/full/10.1056/NEJMoa1806842
Rezaie, S. (Host). (2018, 20 July). PARAMEDIC-2: Time to Abandon Epinephrine in OHCA? [Audio podcast]. Retrieved from https://rebelem.com/?s=paramedic+2
Keywords
epi, epinephrine, advanced cardiac life support, patients, nurses, article, nursing, milligram, compressions, severe neurological impairment, ACLS, early defibrillation, PARAMEDIC2