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Antiarrhythmics In Arrest – New ILCOR Update

January 22, 2019

Written by Clay Smith

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The European Resuscitation Council (ERC) International Liaison Committee on Resuscitation (ILCOR) 2018 guideline has made one minor change regarding antiarrhythmic drugs in arrest: lidocaine, in place of amiodarone, is now a viable, equally effective option in patients with VF/pVT refractory to defibrillation.

Why does this matter?
This is an update on the ERC ILCOR 2018 guidelines after the publication of the ALPS RCT. In ROC ALPS, the subgroup with witnessed arrest had improved survival to discharge with amiodarone or lidocaine vs. placebo.

Small changes
This was a systematic review of 14 RCTs on antiarrhythmic drugs for OHCA including ROC ALPS. Based on this, they made the following changes to the ERC 2018 Guidelines.

  • “We suggest the use of amiodarone or lidocaine in adults with shock-refractory VF/pVT (weak recommendation, low-certainty evidence).” The big change is the addition of lidocaine.

  • The recommendation against the routine use of magnesium in adults with shock-refractory VF/pVT is unchanged.

  • They still don’t recommend prophylactic antiarrhythmic drugs after ROSC.

  • “We suggest that amiodarone or lidocaine be used in the treatment of paediatric shock refractory VF/pVT (weak recommendation, very low certainty evidence).” Amiodarone dose is 5mg/kg for the first or second doses. Lidocaine dose is 1mg/kg, max 100mg, followed by 20–50 micrograms/kg/min infusion. No change here.

Of note, the ERC 2015 guidelines only recommend an antiarrhythmic drug in refractory VF/pVT. The 2015 guideline states, “amiodarone should be given after three defibrillation attempts irrespective of whether they are consecutive shocks, or interrupted by CPR, or for recurrent VF/pVT during cardiac arrest. Give amiodarone 300 mg intravenously; a further dose of 150 mg may be given after five defibrillation attempts.” The big change for 2018 is that lidocaine 100mg IV as the first dose and 50mg IV as needed for the second is a viable, equally effective choice that may be substituted for amiodarone.

European Resuscitation Council Guidelines for Resuscitation: 2018 Update – Antiarrhythmic drugs for cardiac arrest. Resuscitation. 2018 Nov 26. pii: S0300-9572(18)31096-7. doi: 10.1016/j.resuscitation.2018.11.018. [Epub ahead of print]

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