image by: HWN

HWN Suggests

Episode 364: The 2018 ACLS Antiarrhythmic Drug Update

So lidocaine is now officially side-by-side with amiodarone in the ACLS algorithm for treatment of shock-refractory VF/pVT. The ACLS dose of lidocaine is 1 to 1.5 mg/kg IV/IO for the initial dose and if needed a repeat dose of 0.5 to 0.75 mg/kg IV/IO may be used. Although the ROC-ALPS study used a fixed bolus dose of lidocaine for ease of execution, the ACLS guidelines still recommend weight based dosing for what they believe is enhanced patient safety.

Keep in mind that neither amiodarone or lidocaine have been shown to improve clinically relevant outcomes like long-term survival or survival with good neurological outcome. For this reason, I do not put a lot of emphasis on the choice…

read full article

Featured

 Not Stayin' Alive More Often with Amiodarone or Lidocaine in OHCA

Overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia.

Articles of Interest

Amiodarone vs Lidocaine vs Placebo in Cardiac Arrest: The ALPS Trial

The use of medications in cardiac arrest has been one of those things that we all do, but that we know the evidence isn’t great for.

Amiodarone, Lidocaine or Placebo in OHCA

The use of amiodarone or lidocaine during OHCA with shock refractory VF or pulseless VT has no significant benefit over placebo, when focused on patient centered outcomes.

Amiodarone, Lidocaine, or … Nothing

I think these drugs probably have value – but, their value won’t be maximized until in-hospital care produces either a better yield of neurologically intact survivors or better prognosticates resuscitation to reduce ultimate resource utilization.

The Case of the Perfect Imperfection

While the administration of of either amiodarone or lidocaine will likely have little effect on patient outcomes, it is important not to lose sight of the bigger picture. Our current strategy in the management of sudden cardiac arrest is to regain a perfusing rhythm through the application of CPR and rapid defibrillation.

The Clinical Pharmacology of Lidocaine as an Antiarrhythymic Drug

On the basis of this information, we present our current approach to the clinical use of lidocaine in the treatment of ventricular arrhythmias, with particular reference to patients with acute myocardial infarction.

VT, VF, and Electrical Storm

Lidocaine and amiodarone have not been shown to be superior to placebo, but keep in mind that these studies were in pre-hospital arrests. There may be a benefit for monitored inpatient arrests, where they are discovered early and defibrillation/CPR can be initiated immediately.

What is New in Pharmacologic Therapy for Cardiac Resuscitation?

The pharmacologic therapy for cardiac resuscitation has not changed dramatically in many years. The last major change was in the guidelines, turning from lidocaine as a first-line antiarrhythmic to the preferred use of amiodarone. Three studies supported the first-line use of amiodarone for the treatment of ventricular tachycardia (VT), or ventricular fibrillation (VF) cardiac arrest.

Buffering lidocaine

Fill a syringe first with the 1mL of bicarbonate, then add the 10 mL of lidocaine. Flip the syringe over several times to mix (no need to shake vigorously).

Dangerously Numb

Local anesthetics act through sodium channel blockade of nerve cells when administered locally. When administered systemically, either intentionally or inadvertently, sodium channel blockade of CNS nerve cells and cardiac causing neurotoxicity and cardiotoxicity.

Is there Evidence for IV Lidocaine for Acute Pain in the ED?

IV lidocaine is not considered the standard of care for pain in the ED. Despite some promising studies for specific subsets of pain, more research is required to determine its safety profile. At this time I am hesitant to employ IV lidocaine in my practice, there are a number of studies underway which will hopefully justify its use in future.

Lidocaine Infusion: An Antiarrhythmic With Neurologic Toxicities

Despite the daily use of lidocaine in many practice settings, an understanding of the importance of its potential toxicities and knowledge of how to manage them is vital. These toxicities can manifest as life-threatening conditions that may initially present as subtle neurological symptoms but can progress quickly to overt status epilepticus.

Lidocaine Toxicity

Lidocaine’s toxic dose is 4.5 mg/kg, which in a 70kg patient is 315mg. Given that 1% lidocaine means 10mg/ml, that means >31.5ml of 1% lidocaine falls into the toxic dose for a 70kg patient. However, if you decide to use 2% lidocaine, now you approach toxicity with only 15.75ml.

More Than a Local Agent: 10 Pearls of IV Lidocaine Use for Pain in the ED

Lidocaine is an amide-type local anesthetic that exerts its pharmacological action through the blockade of sodium channels in neural tissues, interrupting neuronal transmission. The exact mechanism by which IV lidocaine provides systemic analgesia remains largely unknown.

Prophylactic lidocaine for myocardial infarction

This Cochrane review found evidence of low quality to suggest that prophylactic lidocaine has very little or no effect on mortality or ventricular fibrillation in people with acute myocardial infarction. The safety profile is unclear. This conclusion is based on randomised controlled trials with high risk of bias.

Resources

25‐Year‐Old Swedish Pain‐Killing Drug Is Now Used in Treating Heart Patients

Cardiologists learned that suddent death after a heart attack often resulted from development of serious abnormal rhythms called ventricular tachycardia and fibrillation. Lidocaine's unusual cardiac benefit was to suppress development of these life‐threatening rhythms. The need for lidocaine became increasingly crucial, and after five years of further testing in heart patients, the Food and Drug Administration in 1969 approved the old, marketed drug for its new cardiac use.