SGEM#329: Will Corticosteroids Help if…I Will Survive a Cardiac Arrest?

Date: May 7th, 2021 Guest Skeptic: Dr. Ryan Stanton is a community emergency physician with Central Emergency Physicians in Lexington, KY. He is on the Board of Directors for the American College of Emergency Physicians and host of the ACEP Frontline Podcast. He is an EMS medical director with Lexington Fire/EMS as well as the AMR/NASCAR Safety Team. Reference: Shah and Mitra. Use of Corticosteroids in Cardiac Arrest - A Systematic Review and Meta-Analysis. Crit Care Med Feb 2021 Case: A 58-year-old male has a witnessed cardiac arrest while admitted to the observation unit for a chest pain evaluation. CPR is initiated and a hospital rapid response team is called. The resuscitation team arrives and ACLS protocols are continued. The issue of whether corticosteroids should be administered is brought up during the code. Background: Cardiac arrests have  high morbidity and mortality rates both in-hospital cardiac arrests (IHCAs) and out of hospital cardiac arrests (OHCAs). It is estimated that the survival to discharge for an IHCA is approximately 18% with only 10% for OHCAs. This contrasts with what the public sees watching CPR being done on TV. Survival on screen is four to five times higher than reality, according to one study (see graphic). Improving outcomes for patients with cardiac arrests has been an ongoing challenge in pre-hospital and in hospital medicine. We have discussed many aspects of such care on the SGEM including: Therapeutic hypothermia (SGEM#54, SGEM#82, SGEM#183 and SGEM#275) Epinephrine (SGEM#64 and SGEM#238) IV vs IO Access (SGEM#231) Supraglottic Airways (SGEM#247) Crowd Sourcing CPR (SGEM#143 and SGEM#306) Mechanical CPR (SGEM#136) We understand more physiologic changes that take place following cardiac arrest and there have been several studies looking at the potential role of corticosteroids in the intra-arrest timeframe. SGEM#50 looked at a RCT published in JAMA 2013 looking to see if a vasopressin, steroids, and epinephrine (VSE) protocol for IHCAs could improve survival with favorable neurologic outcome compared to epinephrine alone. That RCT had 268 patients and demonstrated a better odds ratio for ROSC and survival to discharge with good neurologic outcome. The SGEM bottom line at the time was that the results were very interesting, but a validation study should be done to try and replicate the results. I have not seen a validation study published. We know that epinephrine can increase ROSC, survival to hospital, and even survival to hospital discharge based on the Paramedic 2 Trial. Unfortunately, epinephrine was not superior to placebo for the patient-oriented outcome of survival with good neurologic outcome. Corticosteroids have been suggested as a possible therapy in these clinical situations. However, there is an old RCT that looked at dexamethasone in OHCA and it failed to demonstrate an improvement in survival to hospital discharge (Paris et al AEM 1984). A SRMA published in 2020 on the use of steroids after cardiac arrest reported an increase in ROSC and survival to discharge but was limited by the availability of adequately powered high-quality RCTs (Liu et al JIMR 2020). Clinical Question: Does the use of corticosteroids impact neurologic outcomes and mortality in patients with a cardiac arrest? Reference: Shah and Mitra. Use of Corticosteroids in Cardiac Arrest - A Systematic Review and Meta-Analysis. Crit Care Med Feb 2021 Population: Randomized controlled trials and comparative observational studies of patients with in or out of hospital cardiac arrests Exclusions: Any single arm studies, case reports/ series, narrative reviews, and studies irrelevant to the focus of this article. Intervention: Corticosteroids as adjunct therapy in cardiac arrest Comparison: Patients that did not receive corticosteroids in cardiac arrest Outcome: Primary Outcomes: Good neurologic outcome (measured using the G...