“A Study Comparing Amiodarone, Lidocaine, or Placebo in Out-of Hospital Cardiac Arrest (OCHA),” by Kudenchuk et al, examined nontramatic OCHA in adult patients with shock-refractory ventricular fibrillation or pulseless ventricular tachycardia. They found that there was no definitive evidence that any antiarrhythmics improve either survival to discharge or neurological outcomes.
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A further study examined the ability of physicians to use a neurologic exam as a reliable prognosticator of post cardiac arrest patient survival. An original contribution published in 2016 in the American Journal of Emergency Medicine, entitled, “Early Neurologic Examination Is Not Reliable for Prognostication in Post-cardiac Arrest Patients Who Undergo Therapeutic Hypothermia.”
The result was no positive exam findings. “Families want to know…but we really need to refrain from counseling families on positive outcomes,” Dr. Winters said.
He also addressed the findings a task force examining sepsis. “The Third International Consensus Definitions for Sepsis and Septic Shock,” was published in the Journal of the American Medical Association (JAMA) in 2016. He noted that no emergency physicians served on the task force.
They developed the Sequential Organ Failure Assessment (SOFA) Score, which, according to Dr. Winters, is useful in the ICU, “but not so much in the ED.” An ensuing controversy wondered if specifics have been traded for sensitivity.
A study out of Chicago that has not yet been published reviewed a quick SOFA (qSOFA), systemic inflammatory response syndrome (SIRS) and Early Warning Score (EWS) to determine which was most effective. It found that existing early warning scores are more accurate than qSOFA for predicting in-hospital mortality. “The question at the end of the day is, ‘Do patients really benefit?’ and we don’t know,” Dr. Winters said.
He saved the best for last—a study, “Predicting Fluid Responsiveness by Passive Leg Raising: A Systematic Review and Meta Analysis of 23 Clinical Trials,” just published in JAMA examined when enough fluids are enough. It specifically focused on passive leg raise as method to predict fluid responsiveness. “This is one of the article I’d say you should absolutely review,” he said. The technique works across a wide range of patients and was proven to be an extremely accurate predictor of fluid responsiveness. The researchers also determined that physicians treating these patients must have a method to measure carbon monoxide. “Do not use change in arterial pressure,” Dr. Winters said.
He concluded by saying that he has the advantage of generous resources at his hospital. He recognized that not everyone is as lucky, yet they continue to save lives. “You are the true heroes,” he said.