VSE: Evidence about vasopressin, steroid, and epinephrine
V-E: Evidence about vasopressin and epinephrine
S-E: Evidence about steroid and epinephrine
S: Theoretical basis for steroid in post-arrest shock
Summary of all evidence
Putting evidence into practice
In-hospital cardiac arrest (IHCA) vs. out-of-hospital cardiac arrest (OHCA)
European 2015 Guidelines
- VSE is the only pharmacotherapy that has ever been shown to improve survival with good neurologic outcome. The AHA/ACC weakly recommends VSE (Class IIb) for inpatient cardiac arrest.
- The addition of vasopressin alone to epinephrine has not improved outcomes, leading the AHA/ACC to recommend against adding vasopressin alone to epinephrine.
- In a context where VSE cannot be implemented, a reasonable approach might be to simply add 40 mg of methylprednisolone during CPR with epinephrine. The AHA/ACC weakly supports this, with a Class IIb recommendation to use steroid for out-of-hospital arrest.
- The occurrence of post-cardiac arrest shock is common, with some similarities to septic shock (i.e. excessive inflammation causing vasodilation). Stress-dose steroid may be considered for these patients.
- More evidence is needed, but in the interim it seems reasonable to utilize therapies where the benefit appears to outweigh the risks.
- Pubmed link to full study
- EMCrit podcast
- The Bottom Line review
- EM Lit of Note
- Buddineni et al. in Critical Care
- Medscape review of the trial
- Full AHA/ACC guidelines in Circulation 18 (Suppl 2)
- Full ERC guidelines here
- Rebel Cast: Five AHA/ACC updates
- EM Cases: ACLS guidelines 2015
- IBCC chapter:Guide to APRV for COVID-19 - April 8, 2020
- PulmCrit Theoretical Post – The COVID Severity Index (CSI 1.0) - April 2, 2020
- PulmCrit wee – Why the SCCM/AARC/ASA/APSF/AACN/CHEST joint statement on split ventilators is wrong. - March 29, 2020