Treatment of Prolonged Ventricular Fibrillation: Immediate Countershock Versus High‐Dose Epinephrine and CPR Preceding Countershock

BackgroundEarly countershock of ventricular fibrillation has been shown to improve immediate and long-term outcome of cardiac arrest. However, a number of investigations in the laboratory and in the clinical population indicate that immediate countershock of prolonged ventricular fibrillation most commonly is followed by asystole or a nonperfusing spontaneous cardiac rhythm, neither of which rarely respond to current therapy. The use of epinephrine in doses greater than those currently recommended has recently been shown to improve both cerebral and myocardial perfusion during cardiopulmonary resuscitation (CPR). The purpose of this study was to compare cardiac resuscitation outcome between immediate countershock of prolonged ventricular fibrillation with high-dose epinephrine therapy and conventional CPR before countershock of prolonged ventricular fibrillation in a canine model. Methods and ResultsAfter sedation, intubation, induction of anesthesia, and instrumentation, ventricular fibrillation was electrically induced in 28 dogs. After 7.5 minutes of ventricular fibrillation, animals were randomly allocated to two treatment groups: group 1, immediate countershock followed by recommended advanced cardiac life support (ACLS) interventions, or group 2, 0.08 mg/kg epinephrine and manual closed-chest CPR before countershock and ACLS. In both groups, ACLS was continued until a spontaneous perfusing rhythm was restored or for 20 minutes (total arrest time, 27.5 minutes). A spontaneous perfusing rhythm was restored in three of 14 group 1 animals and in nine of 14 group 2 animals (p = 0.014 by sequential analysis method of Whitehead). Coronary perfusion pressure (aortic minus right atrial pressure during CPR diastole) before countershock was significantly greater in group 2 (21±7 mm Hg) when compared with mean circulatory pressure in group 1 (9±8, p < 0.01) ConclusionsThe findings of this study suggest that a brief period of myocardial perfusion before countershock improves cardiac resuscitation outcome from prolonged ventricular fibrillation.

[1]  N. Paradis,et al.  Epinephrine in cardiac arrest: a critical review. , 1990, Annals of emergency medicine.

[2]  M. Callaham.  High-dose epinephrine therapy and other advances in treating cardiac arrest. , 1990, The Western journal of medicine.

[3]  H. Werman,et al.  Four case studies: high-dose epinephrine in cardiac arrest. , 1990, Annals of emergency medicine.

[4]  R. Reynolds-Haertle,et al.  Cardiac arrest and resuscitation: a tale of 29 cities. , 1990, Annals of emergency medicine.

[5]  T. Aufderheide,et al.  Prehospital experience with defibrillation of coarse ventricular fibrillation: a ten-year review. , 1990, Annals of emergency medicine.

[6]  M. C. Rogers,et al.  Organ blood flow and somatosensory-evoked potentials during and after cardiopulmonary resuscitation with epinephrine or phenylephrine. , 1989, Circulation.

[7]  W. Black,et al.  Sudden cardiac death: etiologies, pathogenesis, and management. , 1989, Disease-a-month : DM.

[8]  R. Lewis,et al.  Sequential clinical trials in emergency medicine. , 1989, Annals of emergency medicine.

[9]  M. Copass,et al.  Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest. , 1988, The New England journal of medicine.

[10]  J. Lindenfeld,et al.  Failure of epinephrine to improve the balance between myocardial oxygen supply and demand during closed-chest resuscitation in dogs. , 1988, Circulation.

[11]  N. Paradis,et al.  Successful Resuscitation From Cardiac Arrest Using High-Dose Epinephrine Therapy: Report of Two Cases , 1988 .

[12]  R. Hamlin,et al.  Myocardial oxygen delivery/consumption during cardiopulmonary resuscitation: a comparison of epinephrine and phenylephrine. , 1988, Annals of emergency medicine.

[13]  J. A. Weigel,et al.  Initial treatment of ventricular fibrillation: defibrillation or drug therapy. , 1988, The American journal of emergency medicine.

[14]  E A Davis,et al.  The effect of epinephrine versus methoxamine on regional myocardial blood flow and defibrillation rates following a prolonged cardiorespiratory arrest in a swine model. , 1987, The American journal of emergency medicine.

[15]  R. Hamlin,et al.  The effects of graded doses of epinephrine on regional myocardial blood flow during cardiopulmonary resuscitation in swine. , 1987, Circulation.

[16]  W. Montgomery,et al.  Standards and guidelines for cardiopulmonary resuscitation and emergency cardiac care. , 1986, Circulation.

[17]  M. Copass,et al.  Considerations for improving survival from out-of-hospital cardiac arrest. , 1986, Annals of emergency medicine.

[18]  R. Hamlin,et al.  Comparative effect of graded doses of epinephrine on regional brain blood flow during CPR in a swine model. , 1986, Annals of emergency medicine.

[19]  J. Whitehead.  Supplementary analysis at the conclusion of a sequential clinical trial. , 1986, Biometrics.

[20]  M. C. Rogers,et al.  Effect of epinephrine on cerebral and myocardial perfusion in an infant animal preparation of cardiopulmonary resuscitation. , 1986, Circulation.

[21]  M. Copass,et al.  Factors influencing survival after out-of-hospital cardiac arrest. , 1986, Journal of the American College of Cardiology.

[22]  J. Niemann,et al.  Postcountershock pulseless rhythms: response to CPR, artificial cardiac pacing, and adrenergic agonists. , 1986, Annals of emergency medicine.

[23]  C. Otto,et al.  Effect of epinephrine on defibrillation in ischemic ventricular fibrillation. , 1985, The American journal of emergency medicine.

[24]  S. Silverstein.  Amplitude of ventricular fibrillation waveform and outcome after cardiac arrest: Weaver WD, Cobb LA, Dennis D, et al Ann Intern Med 102:53–55 Jan 1985 , 1985 .

[25]  K. Duffens.  Prognostic significance of field response in out-of-hospital ventricular fibrillation: Warne LL, Hoffman JR, Baraff LJ Chest 87:22–28 Jan 1985 , 1985 .

[26]  J. Niemann,et al.  Differences in cerebral and myocardial perfusion during closed-chest resuscitation. , 1984, Annals of emergency medicine.

[27]  M. C. Rogers,et al.  Mechanisms by which epinephrine augments cerebral and myocardial perfusion during cardiopulmonary resuscitation in dogs. , 1984, Circulation.

[28]  C. Babbs,et al.  Regional blood flow during cardiopulmonary resuscitation with abdominal counterpulsation in dogs. , 1984, American Journal of Emergency Medicine.

[29]  J Whitehead,et al.  A FORTRAN program for the design and analysis of sequential clinical trials. , 1983, Computers and biomedical research, an international journal.

[30]  J. Vincent,et al.  A closed-chest model for the study of electromechanical dissociation of the heart in dogs. , 1982, Resuscitation.

[31]  J. Vincent,et al.  Clinical and Experimental Studies on Electromechanical Dissociation , 1981, Circulation.

[32]  M S Eisenberg,et al.  Treatment of out-of-hospital cardiac arrests with rapid defibrillation by emergency medical technicians. , 1980, The New England journal of medicine.

[33]  M. Copass,et al.  Management of out-of-hospital cardiac arrest. Failure of basic emergency medical technician services. , 1980, JAMA.

[34]  C W Otto,et al.  Influence of time and therapy on ventricular defibrillation in dogs , 1980, Critical care medicine.

[35]  C. Otto,et al.  Relative importance of alpha and beta adrenergic receptors during resuscitation. , 1979, Critical care medicine.

[36]  G. Buckberg,et al.  Optimizing myocardial supply/demand balance with alpha-adrenergic drugs during cardiopulmonary resuscitation. , 1978, The Journal of thoracic and cardiovascular surgery.

[37]  M. Elliott.  Successful resuscitation from cardiac arrest using high-dose epinephrine therapy , 1989 .

[38]  L. Baraff,et al.  Prognostic significance of field response in out-of-hospital ventricular fibrillation. , 1985, Chest.

[39]  K. J. Wagner.  Predictive indices of successful cardiac resuscitation after prolonged arrest and experimental cardiopulmonary resuscitation , 1985 .

[40]  M. Copass,et al.  Amplitude of ventricular fibrillation waveform and outcome after cardiac arrest. , 1985, Annals of internal medicine.

[41]  J. Pantridge,et al.  The effects of shock energy, propranolol, and verapamil on cardiac damage caused by transthoracic countershock. , 1984, Circulation.

[42]  T. N. James,et al.  Chance and sudden death. , 1983, Journal of the American College of Cardiology.

[43]  C. Otto,et al.  Mechanism of action of epinephrine in resuscitation from asphyxial arrest. , 1981, Critical care medicine.

[44]  G. Ewy,et al.  Myocardial injury from transthoracic defibrillator countershock. , 1975, Archives of pathology.