“Well, they can’t get any deader.”
Patients can be made “deader” and EMS does it every day.

Ask yourself which of the following scenarios is worse:
A) being broke and having no money in the bank
B) being broke and having no money in the bank and then receiving a $800 bill

Just like someone can become “broker” the same holds true for becoming “deader.”

• Slam an amp of d50 in a cardiac arrest and you just made your patient deader.
• Slam an amp of sodium bicarbonate in most cardiac arrests and you just made your patient deader.

Sodium bicarbonate and dextrose are often given as the last ditch attempt during  resuscitation before withdrawing efforts and pronouncing the patient dead.  These treatments are not saving anyone and more  likely the coup de grace for these patients, ensuring they stay dead.

I am just as guilty of this practice as anyone else is. I have given dextrose and sodium bicarbonate to many cardiac arrest patients in the past. I wanted to be able to say that I did everything possible for the patient before calling the coroner, for the patients, their family and my own conscience . My intentions were honorable but I was making them deader.

D50: Patients who are given D50 in a cardiac arrest have worse outcomes than those that do not. Let me just stop you right there, dextrose is not in the ACLS H’s and T’s. There is no evidence that dextrose will restart an asystolic heart. 

In the interest of brevity I am not going to re-invent the wheel. Hyperglycemia is detrimental in cardiac arrest, period. Critmedic has a fantastic podcast about it here. If you are giving D50 to cardiac arrests patients because it “couldn’t hurt, can only help” or because “they can’t get any deader” please rethink your position on this. 

This is not to say that in a known hypoglyecmic mediated cardiac arrest there is no role for restoring euglycemia. There could be but there is no evidence for or against it that I know of. To further muddy the waters there is not a good way to obtain an accurate glucose from a capillary sample in a cardiac arrest. Could correction of hypoglycemia to normal levels of blood sugar be helpful in cardiac arrest? I have no idea. Slamming an amp of D50 and causing hyperglycemia is harmful and decreases the chances of your patient walking out of the hospital and bringing you some cookies and a card a few months later. 

Sodium Bicarbonate: Unless the patient has a sodium channel blocker OD suspected, propranolol OD (also blocks sodium channels), TCA, cocaine or a known metabolic acidosis that precipitated the arrest (and even that practice is questionable) there is no good reason to give sodium bicarbonate in a cardiac arrest.

Notice Hyperkalemia is not mentioned here, that is not an omission on the author’s part¹.

Sodium bicarbonate appears to worsen intracellular acidosis. Read that last sentence again. Unless we are practicing homeopathy and the law of similars then it is making things worse, not better. 

If ventilations are not increased after sodium bicarbonate administration the only thing we’ve accomplished is adding insult to inury by creating a respiratory acidosis on top of the existing metabolic acidosis. If you are giving sodium bicarbonate in a cardiac arrest are you increasing your ventilations? I never did.

Here is an excellent post that explains why sodium bicarbonate is not the panacea we once thought it was. 


Moving Forward.
It is a bitter pill that many of us are having swallow, the notion that many of the things we once believed would save patients are harming them. Our job in EMS is to help people; we need to do this in the most effective and least harmful way possible. We cannot cling to dogma or beliefs about it. We need to be open to new ideas; most importantly we need to be open to the idea that we were wrong. It is fine to be wrong and to learn from the mistakes and grow from them; it is not fine to dismiss our actions and the consequences of them with flawed logic and a catchy saying. It is fine to not know things, it is not fine to promote a culture that embraces ignorance and no accountability for our actions.

 

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1. Unless you are doing a multi-hour sodium bicarbonate infusion [ http://emcrit.org/wp-content/uploads/Management_of_severe_hyperkalemia.18.pdf%5D