ACLS - Antiarrhythmics in VF-pVT Cardiac Arrest

Amiodarone

• Amiodarone improves survival to hospital admission in OHCA in two studies. Survival to hospital discharge and survival with favorable neurological outcome were not improved by amiodarone, but neither study was powered for those outcomes
• These randomized trials did not explore the timing or sequence of amiodarone versus epinephrine administration. No randomized trials were identified that address the use of amiodarone during in-hospital cardiac arrest.

Lidocaine

The recommended dose of lidocaine is 1.0 to 1.5 mg/kg IV/IO for the first dose and 0.5 to 0.75 mg/kg IV/IO for a second dose if required.

Lidocaine in OHCA

• ROC-ALPS study --> ROSC higher with lidocaine compared to placebo and higher survival to hospital admission

Lidocaine in IHCA

• No RCTs examine this question

Lidocaine After ROSC

• Early studies in patients with acute myocardial infarction found that lidocaine suppressed premature ventricular complexes and nonsustained VT, rhythms that were believed to presage VF/pVT. Later studies noted a disconcerting association between lidocaine and higher mortality after acute myocardial infarction, possibly resulting from a higher incidence of asystole and bradyarrhythmias; thus, the routine practice of administering prophylactic lidocaine during acute myocardial infarction was abandoned.21,22
• One observational study with propensity-matched cohorts23 found that lidocaine was not associated with increased survival when administered prophylactically after ROSC in adults with VF/pVT cardiac arrest, although it decreased the recurrence of VF/pVT. Thus, evidence supporting a potential role for prophylactic lidocaine after VF/pVT arrest is relatively weak, limited to short-term outcomes, and nonexistent for cardiac arrest presenting with nonshockable rhythms.

Summary and Recommendations 1. There is insufficient evidence to support or refute the routine use of lidocaine early (within the first hour) after ROSC. 2. In the absence of contraindications, the prophylactic use of lidocaine may be considered in specific circumstances (such as during emergency medical services transport) when treatment of recurrent VF/pVT might prove to be challenging (Class IIb; Level of Evidence C-LD).

Amiodarone vs Lidocaine

• The ALIVE (NEJM 2002) trial showed that in shock resistant VF OHCA, 5 mg/kg amiodarone in polysorbate improved survival to hospital admission compared with 1.5 mg/kg lidocaine with polysorbate
• The ROC-ALPS trial for OHCA showed that ROSC was higher in patients receiving lidocaine compared with those receiving placebo but not for those receiving amiodarone compared with patients receiving placebo

Summary: Evidence is mixed; use the first drug you can get your hands on.

Resources

1. Panchal AR, Berg KM, Kudenchuk PJ, Del Rios M, Hirsch KG, Link MS, et al. 2018 American Heart Association Focused Update on Advanced Cardiovascular Life Support Use of Antiarrhythmic Drugs During and Immediately After Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation [Internet]. 2018 Dec 4 [cited 2022 Aug 21];138(23):e740–9. Available from: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000613