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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. [Cardiac arrest under special circumstances]. Notf Rett Med 2021; 24:447-523. [PMID: 34127910 PMCID: PMC8190767 DOI: 10.1007/s10049-021-00891-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/10/2023]
Abstract
These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Deutschland
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Tschechien
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Tschechien
| | - Anette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife Großbritannien
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Teaching and research Unit, Emergency Territorial Agency ARES 118, Catholic University School of Medicine, Rom, Italien
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spanien
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Köln, Deutschland
| | - Jerry P. Nolan
- Resuscitation Medicine, Warwick Medical School, University of Warwick, CV4 7AL Coventry, Großbritannien
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, BA1 3NG Bath, Großbritannien
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | - Karl-Christian Thies
- Dep. of Anesthesiology and Critical Care, Bethel Evangelical Hospital, University Medical Center OLW, Bielefeld University, Bielefeld, Deutschland
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
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Adverse events associated with administration of vasopressor medications through a peripheral intravenous catheter: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:146. [PMID: 33863361 PMCID: PMC8050944 DOI: 10.1186/s13054-021-03553-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/26/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND It is unclear whether vasopressors can be safely administered through a peripheral intravenous (PIV). Systematic review and meta-analysis methodology was used to examine the incidence of local anatomic adverse events associated with PIV vasopressor administration in patients of any age cared for in any acute care environment. METHODS MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials, and the Database of Abstracts of Reviews of Effects were searched without restriction from inception to October 2019. References of included studies and related reviews, as well as relevant conference proceedings were also searched. Studies were included if they were: (1) cohort, quasi-experimental, or randomized controlled trial study design; (2) conducted in humans of any age or clinical setting; and (3) reported on local anatomic adverse events associated with PIV vasopressor administration. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials or the Joanna Briggs Institute checklist for prevalence studies where appropriate. Incidence estimates were pooled using random effects meta-analysis. Subgroup analyses were used to explore sources of heterogeneity. RESULTS Twenty-three studies were included in the systematic review, of which 16 and 7 described adults and children, respectively. Meta-analysis from 11 adult studies including 16,055 patients demonstrated a pooled incidence proportion of adverse events associated with PIV vasopressor administration as 1.8% (95% CI 0.1-4.8%, I2 = 93.7%). In children, meta-analysis from four studies and 388 patients demonstrated a pooled incidence proportion of adverse events as 3.3% (95% CI 0.0-10.1%, I2 = 82.4%). Subgroup analyses did not detect any statistically significant effects associated with stratification based on differences in clinical location, risk of bias or design between studies, PIV location and size, or vasopressor type or duration. Most studies had high or some concern for risk of bias. CONCLUSION The incidence of adverse events associated with PIV vasopressor administration is low. Additional research is required to examine the effects of PIV location and size, vasopressor type and dose, and patient characteristics on the safety of PIV vasopressor administration.
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Perkins GD, Ji C, Achana F, Black JJ, Charlton K, Crawford J, de Paeztron A, Deakin C, Docherty M, Finn J, Fothergill RT, Gates S, Gunson I, Han K, Hennings S, Horton J, Khan K, Lamb S, Long J, Miller J, Moore F, Nolan J, O'Shea L, Petrou S, Pocock H, Quinn T, Rees N, Regan S, Rosser A, Scomparin C, Slowther A, Lall R. Adrenaline to improve survival in out-of-hospital cardiac arrest: the PARAMEDIC2 RCT. Health Technol Assess 2021; 25:1-166. [PMID: 33861194 DOI: 10.3310/hta25250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Adrenaline has been used as a treatment for cardiac arrest for many years, despite uncertainty about its effects on long-term outcomes and concerns that it may cause worse neurological outcomes. OBJECTIVES The objectives were to evaluate the effects of adrenaline on survival and neurological outcomes, and to assess the cost-effectiveness of adrenaline use. DESIGN This was a pragmatic, randomised, allocation-concealed, placebo-controlled, parallel-group superiority trial and economic evaluation. Costs are expressed in Great British pounds and reported in 2016/17 prices. SETTING This trial was set in five NHS ambulance services in England and Wales. PARTICIPANTS Adults treated for an out-of-hospital cardiac arrest were included. Patients were ineligible if they were pregnant, if they were aged < 16 years, if the cardiac arrest had been caused by anaphylaxis or life-threatening asthma, or if adrenaline had already been given. INTERVENTIONS Participants were randomised to either adrenaline (1 mg) or placebo in a 1 : 1 allocation ratio by the opening of allocation-concealed treatment packs. MAIN OUTCOME MEASURES The primary outcome was survival to 30 days. The secondary outcomes were survival to hospital admission, survival to hospital discharge, survival at 3, 6 and 12 months, neurological outcomes and health-related quality of life through to 6 months. The economic evaluation assessed the incremental cost per quality-adjusted life-year gained from the perspective of the NHS and Personal Social Services. Participants, clinical teams and those assessing patient outcomes were masked to the treatment allocation. RESULTS From December 2014 to October 2017, 8014 participants were assigned to the adrenaline (n = 4015) or to the placebo (n = 3999) arm. At 30 days, 130 out of 4012 participants (3.2%) in the adrenaline arm and 94 out of 3995 (2.4%) in the placebo arm were alive (adjusted odds ratio for survival 1.47, 95% confidence interval 1.09 to 1.97). For secondary outcomes, survival to hospital admission was higher for those receiving adrenaline than for those receiving placebo (23.6% vs. 8.0%; adjusted odds ratio 3.83, 95% confidence interval 3.30 to 4.43). The rate of favourable neurological outcome at hospital discharge was not significantly different between the arms (2.2% vs. 1.9%; adjusted odds ratio 1.19, 95% confidence interval 0.85 to 1.68). The pattern of improved survival but no significant improvement in neurological outcomes continued through to 6 months. By 12 months, survival in the adrenaline arm was 2.7%, compared with 2.0% in the placebo arm (adjusted odds ratio 1.38, 95% confidence interval 1.00 to 1.92). An adjusted subgroup analysis did not identify significant interactions. The incremental cost-effectiveness ratio for adrenaline was estimated at £1,693,003 per quality-adjusted life-year gained over the first 6 months after the cardiac arrest event and £81,070 per quality-adjusted life-year gained over the lifetime of survivors. Additional economic analyses estimated incremental cost-effectiveness ratios for adrenaline at £982,880 per percentage point increase in overall survival and £377,232 per percentage point increase in neurological outcomes over the first 6 months after the cardiac arrest. LIMITATIONS The estimate for survival with a favourable neurological outcome is imprecise because of the small numbers of patients surviving with a good outcome. CONCLUSIONS Adrenaline improved long-term survival, but there was no evidence that it significantly improved neurological outcomes. The incremental cost-effectiveness ratio per quality-adjusted life-year exceeds the threshold of £20,000-30,000 per quality-adjusted life-year usually supported by the NHS. FUTURE WORK Further research is required to better understand patients' preferences in relation to survival and neurological outcomes after out-of-hospital cardiac arrest and to aid interpretation of the trial findings from a patient and public perspective. TRIAL REGISTRATION Current Controlled Trials ISRCTN73485024 and EudraCT 2014-000792-11. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 25. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.,Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Chen Ji
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Felix Achana
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - John Jm Black
- South Central Ambulance Service NHS Foundation Trust, Bicester, UK
| | - Karl Charlton
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - James Crawford
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Adam de Paeztron
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Mark Docherty
- West Midlands Ambulance Service University NHS Foundation Trust, Brierley Hill, UK
| | - Judith Finn
- Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), Curtin University, Perth, WA, Australia
| | | | - Simon Gates
- Cancer Research Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, UK
| | - Imogen Gunson
- West Midlands Ambulance Service University NHS Foundation Trust, Brierley Hill, UK
| | - Kyee Han
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Susie Hennings
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jessica Horton
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Kamran Khan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sarah Lamb
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - John Long
- Patient and Public Involvement Representative, Warwick, UK
| | - Joshua Miller
- West Midlands Ambulance Service University NHS Foundation Trust, Brierley Hill, UK
| | - Fionna Moore
- South East Coast Ambulance Service NHS Foundation Trust, Crawley, UK
| | - Jerry Nolan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.,Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | | | - Stavros Petrou
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Helen Pocock
- South Central Ambulance Service NHS Foundation Trust, Bicester, UK
| | - Tom Quinn
- Emergency, Cardiovascular and Critical Care Research Group, Faculty of Health, Social Care and Education, Kingston University London and St George's, University of London, London, UK
| | - Nigel Rees
- Welsh Ambulance Service NHS Trust, St Asaph, UK
| | - Scott Regan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Andy Rosser
- West Midlands Ambulance Service University NHS Foundation Trust, Brierley Hill, UK
| | - Charlotte Scomparin
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Anne Slowther
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021; 161:152-219. [PMID: 33773826 DOI: 10.1016/j.resuscitation.2021.02.011] [Citation(s) in RCA: 280] [Impact Index Per Article: 93.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Germany.
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Catholic University School of Medicine, Teaching and Research Unit, Emergency Territorial Agency ARES 118, Rome, Italy
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spain
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Jerry P Nolan
- Resuscitation Medicine, University of Warwick, Warwick Medical School, Coventry, CV4 7AL, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karl-Christian Thies
- Department of Anesthesiology, Critical Care and Emergency Medicine, Bethel Medical Centre, OWL University Hospitals, Bielefeld University, Germany
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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Tran QK, Mester G, Bzhilyanskaya V, Afridi LZ, Andhavarapu S, Alam Z, Widjaja A, Andersen B, Matta A, Pourmand A. Complication of vasopressor infusion through peripheral venous catheter: A systematic review and meta-analysis. Am J Emerg Med 2020; 38:2434-2443. [DOI: 10.1016/j.ajem.2020.09.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/18/2020] [Accepted: 09/21/2020] [Indexed: 12/22/2022] Open
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Vasopressor and Inotrope Use in Canadian Emergency Departments: Evidence Based Consensus Guidelines. CAN J EMERG MED 2016; 17 Suppl 1:1-16. [PMID: 26067924 DOI: 10.1017/cem.2014.77] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Tennyson J. Controversies in the Care of the Acute Asthmatic in the Prehospital and Emergency Department Environments. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2015. [DOI: 10.1007/s40138-015-0082-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ibrahim AF, Blohm E, Hammad H. Management of Status Asthmaticus. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2015. [DOI: 10.1007/s40138-015-0081-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care 2015; 30:653.e9-17. [PMID: 25669592 DOI: 10.1016/j.jcrc.2015.01.014] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 01/10/2015] [Accepted: 01/15/2015] [Indexed: 11/15/2022]
Abstract
PURPOSE The aim of this study was to collect and describe all published reports of local tissue injury or extravasation from vasopressor administration via either peripheral intravenous (IV) or central venous catheter. METHODS A systematic search of Medline, Embase, and Cochrane databases was performed from inception through January 2014 for reports of adults who received vasopressor intravenously via peripheral IV or central venous catheter for a therapeutic purpose. We included primary studies or case reports of vasopressor administration that resulted in local tissue injury or extravasation of vasopressor solution. RESULTS Eighty-five articles with 270 patients met all inclusion criteria. A total of 325 separate local tissue injury and extravasation events were identified, with 318 events resulting from peripheral vasopressor administration and 7 events resulting from central administration. There were 204 local tissue injury events from peripheral administration of vasopressors, with an average duration of infusion of 55.9 hours (±68.1), median time of 24 hours, and range of 0.08 to 528 hours. In most of these events (174/204, 85.3%), the infusion site was located distal to the antecubital or popliteal fossae. CONCLUSIONS Published data on tissue injury or extravasation from vasopressor administration via peripheral IVs are derived mainly from case reports. Further study is warranted to clarify the safety of vasopressor administration via peripheral IVs.
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Affiliation(s)
- Osama M Loubani
- Departments of Critical Care Medicine and Emergency Medicine, Dalhousie University, Room 377, Bethune Building, 1276 South Park St, Halifax, Nova Scotia B3H 2Y9, Canada.
| | - Robert S Green
- Departments of Critical Care Medicine and Emergency Medicine, Dalhousie University, Room 377, Bethune Building, 1276 South Park St, Halifax, Nova Scotia B3H 2Y9, Canada; Trauma Nova Scotia, 1276 South Park St, Centennial Building Room 1-026B, Halifax, Nova Scotia B3H 2Y9, Canada
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Wood JP, Traub SJ, Lipinski C. Safety of epinephrine for anaphylaxis in the emergency setting. World J Emerg Med 2014; 4:245-51. [PMID: 25215127 DOI: 10.5847/wjem.j.issn.1920-8642.2013.04.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Accepted: 10/02/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND While epinephrine is the recommended first-line therapy for the reversal of anaphylaxis symptoms, inappropriate use persists because of misunderstandings about proper dosing and administration or misconceptions about its safety. The objective of this review was to evaluate the safety of epinephrine for patients with anaphylaxis, including other emergent conditions, treated in emergency care settings. METHODS A MEDLINE search using PubMed was conducted to identify articles that discuss the dosing, administration, and safety of epinephrine in the emergency setting for anaphylaxis and other conditions. RESULTS Epinephrine is safe for anaphylaxis when given at the correct dose by intramuscular injection. The majority of dosing errors and cardiovascular adverse reactions occur when epinephrine is given intravenously or incorrectly dosed. CONCLUSION Epinephrine by intramuscular injection is a safe therapy for anaphylaxis but training may still be necessary in emergency care settings to minimize drug dosing and administration errors and to allay concerns about its safety.
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Affiliation(s)
- Joseph P Wood
- Department of Emergency Medicine, Mayo Clinic Hospital, Phoenix, AZ 85054, USA
| | - Stephen J Traub
- Department of Emergency Medicine, Mayo Clinic Hospital, Phoenix, AZ 85054, USA
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Somasundaram K, Ball J. Medical emergencies: pulmonary embolism and acute severe asthma. Anaesthesia 2013; 68 Suppl 1:102-16. [PMID: 23210560 DOI: 10.1111/anae.12051] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In this, the second of two articles covering specific medical emergencies, we discuss the definitions, epidemiology, pathophysiology, acute and chronic management of pulmonary embolus and acute severe asthma.
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Travers AH, Jones AP, Camargo CA, Milan SJ, Rowe BH. Intravenous beta(2)-agonists versus intravenous aminophylline for acute asthma. Cochrane Database Syst Rev 2012; 12:CD010256. [PMID: 23235686 DOI: 10.1002/14651858.cd010256] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Inhaled beta(2)-agonist therapy is central to the management of acute asthma. For rapid bronchodilation in severe cases, penetration of inhaled drug to the affected small conducting airway may be impeded, and the intravenous (IV) rather than inhaled administration of bronchodilators may provide an earlier response. IV beta(2)-agonist agents and IV aminophylline may also be considered as additional interventions in this setting and this review compares IV beta-agonist agents and IV aminophylline in the treatment of people with acute asthma. OBJECTIVES To compare the benefit of IV beta(2)-agonists versus IV aminophylline for acute asthma treated in the emergency department and in patients admitted to hospital with acute severe asthma. SEARCH METHODS Randomised controlled trials (RCTs) were identified using the Cochrane Airways Group Register, which is compiled from systematic searches of bibliographic databases as well as handsearching of respiratory journals and conference abstracts. The latest search was run in September 2012. We searched bibliographies from included studies and known reviews were also searched. Primary authors and content experts were contacted to identify eligible studies. SELECTION CRITERIA We included RCTs of patients who presented to the emergency department with acute asthma, and patients admitted to hospital with acute severe asthma, and were treated with IV beta(2)-agonists versus IV aminophylline. Two review authors independently selected potentially relevant articles and selected articles for inclusion. Methodological quality was independently assessed using two scoring systems and two review authors. DATA COLLECTION AND ANALYSIS Data were extracted independently by two review authors. Missing data were obtained from authors or calculated from data present in the papers. Trials were combined using a random-effects model for odds ratios (OR) or mean differences (MD) and reported with 95% confidence intervals (95% CI). MAIN RESULTS Eleven studies met our inclusion criteria and in total they included 350 patients. However, opportunities to combine these studies in meta-analyses were limited by the variations in the range of outcomes reported in the trials.Length of stayTwo studies reported length of stay. They were both paediatric trials (with one in paediatric intensive care unit), and there was no significant difference between the two groups (MD 23.19 hours; 95% CI -2.40 to 48.77 hours; 2 studies; N = 73). Individual separate MD analyses for the two studies also indicated no significant difference between the aminophylline and beta(2)-agonist on this outcome. However, this finding should be interpreted with caution owing to the small number of trials and participants the analysis.Pulmonary functionThere were no significant differences in the sequential or summative pulmonary function demonstrated across the studies.Heart rateData for serial heart rates were reported in three studies at various points from 15 to 60 minutes and in each case there were no significant differences between people in the IV aminophylline or beta(2)-agonist groups. The difference between the two groups with respect to final heart rate was statistically significant (MD 10.00; 95% CI 0.99 to 19.01), although these data are from a single, small study and should be interpreted with caution.Adverse effectsThe analyses for giddiness (OR 59.22; 95% CI 2.80 to 1253.05; 1 study; N = 30), nausea/vomiting (where reported as a combined outcome) (OR 14.18; 95% CI 1.62 to 124.52; 2 studies; N = 96) and nausea (OR 6.53; 95% CI 1.60 to 26.72; 2 studies; N = 49) all significantly favoured beta(2)-agonists. In view of the very small number of studies and number of patients contributing to these analyses these results should be interpreted with caution. A closely related review considering the possible benefits of adding IV aminophylline to beta-agonists in adults with acute asthma also indicates a higher incidence of adverse effects associated with IV aminophylline. AUTHORS' CONCLUSIONS In the included RCTs there was no consistent evidence favouring either IV beta(2)-agonists or IV aminophylline for patients with acute asthma. The opportunity to draw clear conclusions is limited by the heterogeneity of outcomes evaluated and the small sample sizes in the included studies. It is recommended that these data should be viewed carefully alongside the conclusions from separate Cochrane reviews comparing IV beta(2)-agonists plus inhaled beta(2)-agonists versus inhaled beta(2)-agonists alone and IV aminophylline plus inhaled beta(2)-agonists versus inhaled beta(2)-agonists alone.
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Affiliation(s)
- Andrew H Travers
- Department of Emergency Medicine and Community Health and Epidemiology, Emergency Health Services, Nova Scotia, Canada
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Lubret M, Bervar JF, Thumerelle C, Deschildre A, Tillie-Leblond I. [Asthma: treatment of exacerbations]. Rev Mal Respir 2012; 29:245-53. [PMID: 22405117 DOI: 10.1016/j.rmr.2011.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Accepted: 04/12/2011] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Exacerbations remain, in both adults and children, a common reason for emergency consultation. The management of the asthmatic patient with an acute exacerbation is well defined. BACKGROUND The initial evaluation, based on the background risk factors and the clinical examination, will determine the choice of treatment and management. Treatment is based on bronchodilators and corticosteroids in the majority of cases. VIEWPOINTS An episode of exacerbation may be the opportunity to establish contact with the patient (an educational approach) to improve the adherence to long-term treatment with inhaled corticosteroids, which remain the best way of preventing future exacerbations. CONCLUSION Early and appropriate management of exacerbations of asthma should reduce asthma morbidity and mortality. It could also reduce the socioeconomic costs of these episodes and the number and duration of hospital admissions.
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Affiliation(s)
- M Lubret
- Unité de pneumologie allergologie pédiatriques, hôpital Jeanne-de-Flandre, CHRU de Lille, Lille cedex, France
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Prischl FC. A "summertime differential diagnosis" of elevated cardiac troponin. Am J Emerg Med 2011; 30:375-6. [PMID: 22100471 DOI: 10.1016/j.ajem.2011.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 09/08/2011] [Indexed: 10/15/2022] Open
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Jacobsen RC, Millin MG. The Use of Epinephrine for Out-of-Hospital Treatment of Anaphylaxis: Resource Document for the National Association of EMS Physicians Position Statement. PREHOSP EMERG CARE 2011; 15:570-6. [DOI: 10.3109/10903127.2011.598619] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Levis JT, Ford JB, Kuo AM. Intracranial Hemorrhage After Prehospital Administration of Intramuscular Epinephrine. J Emerg Med 2011; 40:e107-10. [DOI: 10.1016/j.jemermed.2008.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 11/30/2007] [Accepted: 01/07/2008] [Indexed: 10/21/2022]
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Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, Jeejeebhoy FM, Gabrielli A. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S829-61. [PMID: 20956228 DOI: 10.1161/circulationaha.110.971069] [Citation(s) in RCA: 388] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Hodder R, Lougheed MD, Rowe BH, FitzGerald JM, Kaplan AG, McIvor RA. Management of acute asthma in adults in the emergency department: nonventilatory management. CMAJ 2010; 182:E55-67. [PMID: 19858243 PMCID: PMC2817338 DOI: 10.1503/cmaj.080072] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Rick Hodder
- Division of Pulmonary Medicine, University of Ottawa, Ottawa, Ontario.
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Holley AD, Boots RJ. Review article: management of acute severe and near-fatal asthma. Emerg Med Australas 2009; 21:259-68. [PMID: 19682010 DOI: 10.1111/j.1742-6723.2009.01195.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Despite a decline in the Australian overall asthma mortality, near-fatal/critical asthma continues to be a significant management issue for emergency physicians and intensivists. Near-fatal asthma is a unique subtype of asthma, with a variety of clinical presentations, requiring rapid and aggressive intervention. The pharmacological and non-pharmacological management of near-fatal asthma remains very complex. The present review discusses recent advances and evidence for current available strategies targeting this time critical emergency.
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Affiliation(s)
- Anthony D Holley
- Department of Intensive Care Medicine, The University of Queensland, Queensland, Australia.
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Abstract
PURPOSE OF REVIEW Epinephrine (adrenaline) is a medication widely used in the pediatric emergency department. This article reviews the most recent evidence and recommendations behind the many applications of epinephrine as they apply to the care of children in emergency departments. RECENT FINDINGS Recent publications address epinephrine's role in the treatment of anaphylaxis, croup, asthma, bronchiolitis and as an adjunct to local anesthesia. Additionally, authors discuss epinephrine autoinjectors and the various routes of epinephrine administration. SUMMARY Epinephrine is the recommended first-line treatment for anaphylaxis and moderate-to-severe croup. Its role in asthma and bronchiolitis is less clear. Traditional beta2-agonists are seen as first-line therapies for moderate bronchiolitis and asthma exacerbations. Epinephrine may have a role for subsets of patients with both of these illnesses. The preferred route for parenteral treatment is intramuscular. Epinephrine is well tolerated as an adjunct to local anesthesia when used in digital blocks in digits with normal perfusion. Although autoinjectors allow faster access to epinephrine for anaphylaxis, there are many issues surrounding their use and indications.
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Wiebe K, Rowe BH. Nebulized racemic epinephrine used in the treatment of severe asthmatic exacerbation: a case report and literature review. CAN J EMERG MED 2007; 9:304-8. [PMID: 17626698 DOI: 10.1017/s1481803500015220] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute asthma is a common emergency department (ED) problem that is typically treated with bronchodilators and anti-inflammatories. Nebulized selective, short-acting beta-agonists, such as salbutamol, are the bronchodilators of choice in most Canadian EDs. Other important treatments in moderate-to-severe cases include systemic corticosteroids and in severe cases may include the addition of ipratropium bromide and magnesium sulfate. Despite aggressive management, some patients do not respond adequately to nebulized salbutamol. Treatment options in these patients are limited to interventions such as parenteral epinephrine, and non-invasive and mechanical ventilation (or both). Both parenteral epinephrine and mechanical ventilation have associated risks, so alternative treatments with a lower risk profile would be useful for the treatment of life-threatening asthma. The following case report describes a patient in whom nebulized racemic epinephrine was used successfully to treat severe acute asthma following failure of standard first-line therapies.
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Affiliation(s)
- Kristopher Wiebe
- Department of Emergency Medicine, Chilliwack General Hospital, BC.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2006. [DOI: 10.1002/pds.1185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Shuster J. Hypothyroidism Associated with Quetiapine Therapy; Paradoxical Bronchospasm Associated with Albuterol; Alcohol Cravings with Paroxetine Therapy?; Lamotrigine-Induced Toxic Epidermal Necrolysis – Three Cases; Acute Lung Injury with Vinorelbine; Adverse Events Related to Epinephrine Use in Asthma Patients Seen in the Emergency Department; Collecting Information from Patients Having Adverse Events; New Anticonvulsants – New Adverse Effects. Hosp Pharm 2006. [DOI: 10.1310/hpj4107-632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The purpose of this feature is to heighten awareness of specific adverse drug reactions (ADRs), discuss methods of prevention, and promote reporting of ADRs to the FDA's medWatch program (800-FDA-1088). If you have reported an interesting preventable ADR to medWatch, please consider sharing the account with our readers.
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Affiliation(s)
- Joel Shuster
- ISMP, 1800 Byberry Road, Suite 810, Huntingdon Valley, PA 19006
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Rowe BH, Camargo CA. Emergency department treatment of severe acute asthma. Ann Emerg Med 2006; 47:564-6. [PMID: 16713786 DOI: 10.1016/j.annemergmed.2006.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2006] [Revised: 02/09/2006] [Accepted: 02/10/2006] [Indexed: 11/18/2022]
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