From the Guidelines
Lidocaine is generally preferred over amiodarone in traumatic cardiac arrest. In traumatic cardiac arrest management, the primary focus should be on addressing reversible causes such as hypovolemia, tension pneumothorax, and cardiac tamponade rather than administering antiarrhythmic medications. However, if ventricular arrhythmias occur during resuscitation efforts, lidocaine is typically the preferred antiarrhythmic agent. The recommended dose of lidocaine is 1-1.5 mg/kg IV initially, followed by 0.5-0.75 mg/kg IV every 5-10 minutes if needed, up to a maximum total dose of 3 mg/kg, as suggested by the 2018 American Heart Association guidelines update 1.
Some key points to consider when choosing between lidocaine and amiodarone include:
- Lidocaine has less negative inotropic effects compared to amiodarone, making it less likely to worsen hypotension in already compromised trauma patients.
- Lidocaine has a faster onset of action and shorter half-life, which is beneficial in the dynamic trauma setting where hemodynamic status can change rapidly.
- Amiodarone, while effective for arrhythmias, can cause more pronounced hypotension and has a longer duration of action, which may complicate management in trauma patients who are often already hemodynamically unstable.
- The 2024 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations suggests that both amiodarone and lidocaine may be used in adults with shock-refractory VF/pVT, but the evidence is low-quality and observational studies generally favor amiodarone or lidocaine over placebo 1.
It's essential to note that the primary focus in traumatic cardiac arrest should be on addressing reversible causes, and the use of antiarrhythmic medications should be considered secondary to this. The choice between lidocaine and amiodarone should be made based on the individual patient's needs and the specific circumstances of the cardiac arrest.
From the Research
Traumatic Cardiac Arrest Treatment
There is limited evidence directly comparing lidocaine and amiodarone in traumatic cardiac arrest. However, several studies have investigated their use in out-of-hospital and in-hospital cardiac arrests:
- A randomized, double-blind trial published in The New England Journal of Medicine 2 found no significant difference in survival to hospital discharge between amiodarone, lidocaine, and placebo in nontraumatic out-of-hospital cardiac arrest.
- A systematic review and meta-analysis published in Resuscitation 3 found that amiodarone and lidocaine were equivalent in terms of survival at hospital admission and discharge, but both were associated with higher hospital admission rates compared to placebo.
- A retrospective cohort study published in Chest 4 found that lidocaine was associated with higher odds of return of spontaneous circulation, 24-hour survival, survival to hospital discharge, and favorable neurologic outcome compared to amiodarone in in-hospital cardiac arrest.
- A review article published in Current Opinion in Critical Care 5 noted that the optimal antiarrhythmic drug therapy in cardiac arrest is uncertain and that other factors such as availability and cost should be considered when deciding which drug to use.
- A multicenter retrospective medical record review published in Critical Care Medicine 6 found no difference in survival rates between patients treated with lidocaine, amiodarone, or a combination of both for in-hospital cardiac arrest due to pulseless ventricular tachycardia/ventricular fibrillation.
Key Findings
- Lidocaine and amiodarone have been shown to be equivalent in terms of survival outcomes in some studies 2, 3.
- Lidocaine may be associated with better outcomes than amiodarone in in-hospital cardiac arrest 4.
- The choice of antiarrhythmic drug may depend on factors such as availability, cost, and individual patient characteristics 5.
- Further research is needed to determine the optimal treatment strategy for traumatic cardiac arrest.