European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances.

This Part of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) addresses cardiac arrest in situations that require special treatments or procedures other than those provided during basic life support (BLS) and advanced cardiovascular life support (ACLS).

This Part summarizes recommendations for the management of resuscitation in several critical situations, including cardiac arrest associated with pregnancy (Part 10.1), pulmonary embolism (PE) (10.2), and opioid-associated resuscitative emergencies, with or without cardiac arrest (10.3). Part 10.4 provides recommendations on intravenous lipid emulsion (ILE) therapy, an emerging therapy for cardiac arrest due to drug intoxication. Finally, updated guidance for the management of cardiac arrest during percutaneous coronary intervention (PCI) is presented in Part 10.5. A table of all recommendations made in this 2015 Guidelines Update as well as those made in the 2010 Guidelines is contained in the Appendix.

The special situations of resuscitation section (Part 12) of the 2010 AHA Guidelines for CPR and ECC 1 covered 15 distinct topic areas. The following topics were last updated in 2010:

Additional information about drowning is presented in Part 5 of this publication, “Adult Basic Life Support and Cardiopulmonary Resuscitation Quality.”

The recommendations in this 2015 Guidelines Update are based on an extensive evidence review process that was begun by the International Liaison Committee on Resuscitation (ILCOR) with the publication of the ILCOR 2010 International Consensus on CPR and ECC Science With Treatment …

Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Background The prevalence of chronic low back pain and related disability is rapidly increasing as are the myriad treatments, including epidural injections. Even though epidural injections are one of the most commonly performed procedures in managing low back and lower extremity pain, starting in 1901 with local anesthetic alone, conflicting recommendations have been provided, despite the extensive literature. Recently Chou et al performed a technology assessment review for Agency for Healthcare Research and Quality (AHRQ) part of which was published in Annals of Internal Medicine showing lack of effectiveness of epidural steroid injections in managing lumbar radiculopathy and spinal stenosis. In contrast, multiple other publications have supported the efficacy and use of epidural injections. Purpose To assess the efficacy of 3 categories of epidural injections for lumbar and spinal stenosis: performed with saline with steroids, local anesthetic alone, or steroids with local anesthetic and separate facts from opinions. Data sources PubMed, Cochrane Library, US National Guideline Clearinghouse, prior systematic reviews, and reference lists. The literature search was performed through August 2015. Study selection Randomized trials, either placebo or active control, of epidural injections for lumbar radiculopathy and spinal stenosis. Data extraction Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Evidence was summarized utilizing principles of best evidence synthesis. Data synthesis Thirty-nine randomized controlled trials met inclusion criteria. There were 9 placebo-controlled trials evaluating epidural corticosteroid injections, either with sodium chloride solution or bupivacaine, compared to placebo injections. There were 12 studies comparing local anesthetic alone to local anesthetic with steroid. Results A meta-analysis of 5 studies utilizing sodium chloride or bupivacaine with steroid showed a lack of efficacy.A comparison of lidocaine to lidocaine with steroids in 7 studies showed significant effectiveness from baseline to long-term follow-up periods. Meta-analysis showed a similar effectiveness for pain and function without non-inferiority of lidocaine compared to lidocaine with steroid at 3 months and 12 months. Limitations The review was restricted to the data available with at least 3 months of follow-up, which excluded some studies. The inclusion criteria were restricted to English language studies. Conclusion Epidural corticosteroid injections for radiculopathy or spinal stenosis with sodium chloride solution or bupivacaine were shown to be ineffective. Lidocaine alone or lidocaine in conjunction with steroids were significantly effective.

Epidural Injections for Lumbar Radiculopathy and Spinal Stenosis: A Comparative Systematic Review and Meta-Analysis.

Background: Although intravenous lipid emulsion (ILE) was first used to treat life-threatening local anesthetic (LA) toxicity, its use has expanded to include both non-local anesthetic (non-LA) poisoning and less severe manifestations of toxicity. A collaborative workgroup appraised the literature and provides evidence-based recommendations for the use of ILE in poisoning.Methods: Following a systematic review of the literature, data were summarized in four publications: LA and non-LA poisoning efficacy, adverse effects, and analytical interferences. Twenty-two toxins or toxin categories and three clinical situations were selected for voting. Voting statements were proposed using a predetermined format. A two-round modified Delphi method was used to reach consensus on the voting statements. Disagreement was quantified using RAND/UCLA Appropriateness Method.Results: For the management of cardiac arrest, we recommend using ILE with bupivacaine toxicity, while our recommendations are neutral regardin...

https://www.tandfonline.com/doi/pdf/10.1080/15563650.2016.1214275

Evidence-based recommendations on the use of intravenous lipid emulsion therapy in poisoning*

The direct thrombin inhibitor dabigatran and the anti-Xa agents rivaroxaban, edoxaban, and apixaban are a new generation of oral anticoagulants. Their advantage over the vitamin K antagonists is the lack of the need for monitoring and dose adjustment. Their main disadvantage is currently the absence of a specific reversal agent. Dabigatran’s, unlike the anti-Xa agents, absorption can be reduced by activated charcoal if administered shortly after ingestion and it can be removed from the blood with hemodialysis. Prothrombin complex concentrate, activated prothrombin complex concentrate, and recombinant factor VIIa all show some activity in reversing the anticoagulant effect of these drugs but this is based on ex vivo, animal, and volunteer studies. It is unclear, which, if any, of these drugs is the most suitable for emergency reversal. Three novel molecules (idarucizumab, andexanet, and PER977) may provide the most effective and safest way of reversal. These agents are currently in premarketing studies.

Antidotes for Novel Oral Anticoagulants Current Status and Future Potential

Context Conflicts of interest (COIs) may influence medical literature. However, it is unclear whether medical journals have consistent policies for defining and soliciting COI disclosures. Objective To determine the prevalence of author COI policies, requirements for signed disclosure statements, and variability in COI definitions among medical journals. Design A cross-sectional survey of Instructions for Authors and manuscript submission documents, including authorship responsibility forms, for high-impact medical journals across 35 subject categories available from March through October 2008. Main Outcome Measure Presence of language referring to COI disclosure in the Instructions for Authors or manuscript submission documents. Results Of 256 journals, 89% had author COI policies. Fifty-four percent required authors to sign a disclosure statement, and 77% provided definitions of COI. Most definitions were limited to direct financial relationships; a minority of journals requested disclosure of other potential conflicts such as personal relationships (42%), paid expert testimony (42%), relationships with other organizations (26%), or travel grants (12%). The prevalence of policies varied by subject category: all internal medicine, respiratory medicine, and toxicology journals studied had comprehensive COI definitions, with 19 of these 24 journals requiring signed disclosure attestations. In contrast, 6 of 19 geriatrics, radiology, and rehabilitation journals requested author COI disclosure. Most journals that officially endorsed International Committee of Medical Journal Editors guidelines had COI policies (68/69), compared with 84% of journals not endorsing the guidelines (158/187). Conclusions In 2008, most medical journals with relatively high impact factors had author COI policies available for public review. Among journals, there was substantial variation in policies for solicitation of author COIs and in definitions of COI.

https://jamanetwork.com/journals/jama/articlepdf/184918/jbr90004_2230_2234.pdf

Requirements and Definitions in Conflict of Interest Policies of Medical Journals

Pretreatment With Intravenous Lipid Emulsion Reduces Mortality From Cocaine Toxicity in a Rat Model

Intravenous lipid emulsion (ILE) is an adjunctive antidote used in selected critically ill poisoned patients. These patients may also require administration of advanced cardiac life support (ACLS) drugs. Limited data is available to describe interactions of ILE with standard ACLS drugs, specifically epinephrine. Twenty rats with intra-arterial and intravenous access were sedated with isoflurane and split into ILE or normal saline (NS) pretreatment groups. All received epinephrine 15 μm/kg intravenously (IV). Continuous mean arterial pressure (MAP) and heart rate (HR) were monitored until both indices returned to baseline. Standardized t tests were used to compare peak MAP, time to peak MAP, maximum change in HR, time to maximum change in HR, and time to return to baseline MAP/HR. There was a significant difference (p = 0.023) in time to peak MAP in the ILE group (54 s, 95 % CI 44–64) versus the NS group (40 s, 95 % CI 32–48) and a significant difference (p = 0.004) in time to return to baseline MAP in ILE group (171 s, 95 % CI 148–194) versus NS group (130 s, 95 % CI 113–147). There were no significant differences in the peak change in MAP, peak change in HR, time to minimum HR, or time to return to baseline HR between groups. ILE-pretreated rats had a significant difference in MAP response to epinephrine; ILE delayed the peak effect and prolonged the duration of effect of epinephrine on MAP, but did not alter the peak increase in MAP or the HR response.

/pdf/intravenous-lipid-emulsion-alters-the-hemodynamic-response-ot8xd50jdf.pdf

Intravenous Lipid Emulsion Alters the Hemodynamic Response to Epinephrine in a Rat Model

Objectives

The anticoagulant dabigatran has no reversal agent and may cause life-threatening bleeding in patients with trauma or closed-space hemorrhage. Intravenous lipid emulsion (ILE) is thought to create a lipid compartment in serum that sequesters lipophilic drugs. Dabigatran is lipophilic, and its anticoagulant effects are concentration dependent. The study objective was to determine if ILE therapy reverses dabigatran's anticoagulant effects.



Methods

Twenty rats were selected at random, 10 in the ILE group and 10 in a normal saline (NS) control group. Animals had a baseline tail bleeding time (T0), followed by oral dabigatran administration (15 mg/kg). At 45 minutes (T45), a second tail bleed time measurement was performed, followed by a 7-minute infusion of 15 mL/kg ILE or NS. A final 60-minute (T60) bleed time measurement was obtained. An ILE-only group of five animals had bleeding times assessed prior to (T0) and 15 minutes after (T15) ILE therapy. A mixed-effect repeated-measures analysis of variance modeling the effect of time, group, and the interaction of group and time on bleed times was conducted.



Results

There was a significant within-subject change in bleeding time across the assessment points (F(2,36) = 33; p < 0.001), but there were no effect of group (F(1,18) = 1.42, p = 0.25) or an interaction between group and assessment point on mean bleeding time (F(2,36) = 0.59, p = 56). Between T0 and T45, average bleeding times increased from 109.5 seconds (95% confidence interval [CI] = 94 to 125 seconds) to 231.8 seconds (95% CI = 193 to 271 seconds; p < 0.0001) for both the ILE group and the NS control group. Between T45 and T60, bleeding times in the ILE group decreased by 31.5 seconds (95% CI = –77 to 14 seconds) and by 6 seconds (95% CI = –67 to 55 seconds) in the NS group (p = 0.46). In the five ILE-only animals, the average bleeding time at T0 was 114 seconds (95% CI = 62 to 166 seconds), which increased significantly at T15 to 237 seconds (95% CI = 161 to 313 seconds; p = 0.02).



Conclusions

The anticoagulant effects of dabigatran are not reversed with ILE therapy. Although ILE itself significantly prolonged bleeding times, when administered to dabigatran-anticoagulated rats, bleeding times did not change significantly. There may be a complex interaction of ILE with dabigatran that this study was not able to elucidate.


Resumen
Objetivos

El anticoagulante dabigatran no tiene antidoto y puede causar sangrado con riesgo vital en los pacientes con traumatismos o hemorragias de espacios cerrados. La emulsion lipidica intravenosa (ELI) se penso para crear un compartimento graso en el plasma que secuestre los medicamentos lipofilicos. Dabigatran es lipofilico, y sus efectos anticoagulantes son concentracion dependiente. El objetivo fue determinar si la terapia con ELI revierte los efectos anticoagulantes del dabigatran.



Metodologia

Se seleccionaron 20 ratas y se, asignaron de forma aleatoria, 10 al grupo ELI y 10 a un grupo control con suero salino fisiologico (SSF). Se determin elo tiempo basal de sangrado de la cola (T0), seguido por la administracion de dabigatran por via oral (15 mg/kg). A los 45 minutos (T45), se realizo una segunda medida del tiempo de sangrado de la cola, seguida por una infusion de 7 minutos de 15 mL/kg de ELI o SSF. Se obtuvo una medida final a los 60 minutos del tiempo de sangrado (T60). A un grupo adicional de solo 5 animales se le administro la ELI y se le determino el tiempo de sangrado de forma previa (T0) y 15 minutos despues (T15) tras su tratamiento. Se realizo un analisis de la varianza de medidas repetidas de efecto mixto controlando el efecto del tiempo y el grupo, y la interaccion del grupo y tiempo en los tiempos de sangrado.



Resultados

Hubo un cambio significativo en el tiempo de sangrado a lo largo de los momentos valorados (F (2,36) = 33; p < 0,001), pero no hubo efecto de grupo (F (1,18) = 1,42, p = 0,25), y/o interaccion entre el grupo y el momento de valoracion en el tiempo medio de sangrado (F (2,36) = 0,59, p = 56). Entre T0 y T45, los tiempos medios de sangrado se incrementaron de 109,5 segundos (IC 95% = 94 a 125) a 231,8 segundos (IC 95% = 193 a 271); (p < 0,0001) tanto para el grupo ELI como para el grupo control SSF. Entre T45 y T60, los tiempos de sangrado en el grupo ELI descendieron 31,5 segundos (IC 95% = -77 a 14) y 6 segundos (IC 95% = -67 a 55) en el grupo SSF; (p = 0,46). En el grupo de 5 ratas a las que solo se administro la ELI, el tiempo medio de sangrado en T0 fue de 114 segundos (IC 95% = 62 a 166), con un incremento significativo en T15 a 237 segundos (IC 95% = 161 a 313); (p = 0,02).



Conclusiones

Los efectos anticoagulantes de dabigatran no son revertidos con la ELI. Aunque la ELI por si misma prolongo significativamente los tiempos de sangrado, cuando se administro a las ratas anticoaguladas con dabigatran, los tiempos de sangrado descendieron, pero no significativamente. Puede haber una interaccion compleja de la ELI con dabigatran que este estudio no es capaz de dilucidar.

https://www.onlinelibrary.wiley.com/doi/pdf/10.1111/acem.12225

Intravenous Lipid Emulsion Does Not Reverse Dabigatran-induced Anticoagulation in a Rat Model

We felt our recent experience attempting to use atropine in a rat model would be informative for other investigators and refresh the literature on the subject. In preparation for research investigating the effects of intravenous lipid emulsion on Advanced Cardiac Life Support medications, we attempted to elucidate the proper dose of atropine to reliably cause cardiovascular effects in male Sprague Dawley rats weighing approximately 250 g. Performing our dose response experiment was necessary due to the equivocal results of previous literature on the subject. Junior et al. 1

Jared Blum

Papers

Requirements and Definitions in Conflict of Interest Policies of Medical Journals

Pretreatment With Intravenous Lipid Emulsion Reduces Mortality From Cocaine Toxicity in a Rat Model

Intravenous Lipid Emulsion Alters the Hemodynamic Response to Epinephrine in a Rat Model

Intravenous Lipid Emulsion Does Not Reverse Dabigatran-induced Anticoagulation in a Rat Model

Difficulty creating an anticholinergic rat model with atropine.