July 24, 2013

DynaMed EBM Journal Volume 8, Issue 30

DynaMed Weekly Updates

Quick Links

Join Mailing List



Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: July 24, 2013

Expiration Date: July 24, 2014

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD - Assistant Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company

James McLellan, PhD - Senior Medical Writer, DynaMed, Ipswich, Massachusetts, USA


Dr. Ehrlich, Dr. Fleming, Dr. McLellan, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 8, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 6, 2013. Term of approval is for one year from this date with the option of yearly renewal. Each weekly updated is approved for 0.25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.

Program ID: 1304158L


Last week 370 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 192 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article of significant interest was selected by the DynaMed Editorial Team.

Addition of Vasopressin Plus Steroids to Epinephrine Increases Survival to Discharge with Favorable Neurologic Outcomes After In-Hospital Cardiac Arrest
Reference: JAMA 2013 Jul 17;310(3):270, (level 1 [likely reliable] evidence)

The addition of vasopressin and steroids to epinephrine during resuscitation has previously been shown to improve survival following in-hospital cardiac arrest compared to epinephrine alone (Arch Intern Med 2009 Jan 12;169(1):15). A new randomized trial further assessed the efficacy of combined treatment with vasopressin plus steroids in addition to epinephrine in 300 adult patients with in-hospital cardiac arrest.

Patients with in-hospital cardiac arrest requiring epinephrine by European resuscitation guidelines were randomized to vasopressin plus steroids plus epinephrine (VSE) vs. epinephrine alone during resuscitation and were followed until death or hospital discharge. The VSE group received vasopressin 20 units/cycle plus epinephrine 1 mg/cycle for the first 5 resuscitation cycles plus methylprednisolone 40 mg on first cycle. The epinephrine alone group had epinephrine 1 mg/cycle plus normal saline placebo for the first 5 cycles. All patients could receive additional epinephrine as needed. Patients in the VSE group who had postresuscitation shock also received hydrocortisone IV 300 mg daily for up to 7 days with gradual taper (patients in the epinephrine group with postresuscitation shock received placebo saline.) Favorable neurologic outcome was defined as a Cerebral Performance Category score of 1 (conscious, alert, and able to work, with possible mild neurologic or psychologic deficit) or 2 (moderate disability, but sufficient cerebral function for independent activities of daily life).

The intention to treat analysis included all patients who received the allocated treatment (Sixteen patients in each group had confirmed return of spontaneous circulation before administration of study treatment and were excluded from analyses.) The rate of survival to discharge with favorable neurological outcome was 13.9% with VSE vs. 5.1% with epinephrine alone (p = 0.02, NNT 12). VSE was also associated with a higher rate of return of spontaneous circulation for at least 20 minutes (83.9% vs. 65.9%, p = 0.005, NNT 6). In a subgroup analysis of 149 patients who had postresuscitation shock, 21.1% of the VSE group and 8.2% of the epinephrine group survived to discharge with good neurologic outcome (p = 0.02, NNT 8). There were no significant differences in the rates of complications, postarrest morbidity, or causes of death in analysis of 162 patients who survived ≥ 4 hours.

For more information, see the Cardiac arrest topic in DynaMed.

Earn CME Credit for reading this e-Newsletter.
For more information on this educational activity, see the CME sidebar.

New Topic Added to DynaMed this Week

Acute sinusitis in adults
Acute sinusitis in children and adolescents

Call for Peer Reviews

We are currently seeking reviewers for:

Hypoplastic left heart syndrome

Long QT syndrome

Learn more about DynaMed Contribution Opportunities

DynaMed Peer Review
Editorial Policies for Reviewers
Education for Clinicians in Training

DynaMed is Hiring! We are looking for talented medical writers and editors to join our ever expanding team. Click here to learn what opportunities are available.