The Bottom Line
The term “Israeli Cardiac Cocktail” has been used to refer to a pre-hospital ACLS protocol, which is implemented by Magen David Adom (MDA) and Israeli Intensive Care Units. Unlike the one-size-fits-all “MONA” protocol (Morphine, Oxygen, Nitrates, Aspirin) commonly used in America (the rest of the world isn’t so crazy about that), Shapira said they used to put an entirely different package into play: 300 mg of chewed Aspirin; a high-dose Isosorbide Dinitrate spray (Isoket); and sometimes Heparin or even sedatives like Diazepam from the back of their Mobile Intensive Care Unit (MICU) at that.
The “secret sauce” is not just the drugs but also how they are administered: Israel was one of the first countries to bring the ER to the patient, instead of rushing the patient to the ER, and we got aggressive pharmacological intervention in somebody’s living room.
For EMTs & Paramedics
The secret mechanics of the protocol
“This is the most import frontline lesson for ACLS-trained providers, that being an aggressive vasodilator and early anticoagulation!
The Counter-Intuitive Approach:
Western medicine loves 02, (oxygen) and morphine first thing. Evidence has suggested that high-flow oxygen in non-hypoxic patients can cause vasoconstriction (blood vessels to constrict) even worsening the infarction. Historically, Israelis would push hard immediate nitrates cmapred to oxygen therapy (unless one is really saturated low).
The Breakdown:
- Aspirin (300mg, Chewed): Not swallowed. Chewing increases bioavailability within minutes. The aim is rapid anti-platelet activity to halt the growth of the clot.
- Isoket Spray (ISDN): Unlike Nitroglycerin sublingual pill used in US, Isoket spray has a greater surface area contact with the mouth lining for better absorption. It rapidly decreases preload (ie, venous return to the heart), thereby significantly decreasing the workload of the heart.
- Heparin (5000 IU IV): Gave in the field by paramedics (MICU level). This is the “stabilizer” that basic protocols elsewhere in Uganda so often lack.
Critical Workflow for Implementation:
Step 1: The “Wet/Dry” Assessment. First of all you have to find out if patient has pulmonary edema –fluid in the lungs.
- “Wet” (Crackles in lungs): The cocktail contains Furosemide (Lasix) to dump fluid.
- If “Dry” (Clear lungs) and Hypotensive: Nitrates are absolutely contraindicated as this may cause rapid cardiovascular collapse.
Step 2: The12-Lead ECG Rule of Pathogenicity. No nitrates are to be administered until a Right-Sided ECG has cleared them of RVI. Why? Since RV MI pts are preload dependent. It is deadly wrong to give these patients nitrates (which lower preload).
For the Military & Tactical Medicine Junkies
Battlefield Triage: Heart Attacks Versus Trauma
In the tactical realm, the ICC is a sword with two edges. The notorious speed of deployment by the IDF (Israel Defense Forces) Medical Corps notwithstanding, a combat environment also demands that the application of this cocktail be bound by ruthless principles of exclusion.
The Tactical Paradox:
In Tactical Combat Casualty Care (TCCC), the “holy grail” of the enemy is bleeding. The Cardiac Cocktail is mostly Aspirin and Heparin — two of the most powerful blood thinners available. If a soldier or civilian has a heart attack as a result of trauma or stress, and bleeds internally (in the case of blast injury), this cocktail will kill them: it simply makes it impossible for their blood to clot.
Protocol for the Field Medic:
- The “Mechanism of Injury” Filter: Get aggressive at ruling out trauma. If there’s the slightest indication that any of them may have been exposed to a blast, shrapnel, or blunt force, the “Cocktail” is off.
- The Stress Check: In the high-stress martial setting, panicked breathing (hyperventilation into chest constriction) looks and feels like cardiac arrest. The Israeli protocol uses Capnography (monitoring of CO2 in breath).
- Low CO2: Probably hyperventilation/panic. Do not drug.
- Normal/High CO2 but ST Elevation on ECG : Cardiac event. Proceed with caution.
- Resource Management: If ever you are in a survival type situation and can only take something smaller with you, the 300mg Aspirin is what you want. 80% of the benefit in survival for 10% of the risk compared with the full cocktail.
To Medical Students & Historians
The ‘Scoop and Run’ vs. ‘Stay and Stabilize’ Debate
The Israeli Cardiac Cocktail represents a relic of a critical turning point in global medical philosophy.
The Historical Context:
In the 1970s and 1980s, “Scoop and Run” was the American model — get that patient to a hospital as quickly as possible. “Israel has implemented the ’Pantridge Model’, from Belfast, known as ‘Stay and Stabilize'”. The thinking was that the first hour (the “Golden Hour”) is when lethal arrhythmias developed.
The Critical Analysis:
Studies from the era of the Jerusalem Heart Study showed that death rates plunged when treatment was started on site by a doctor or advanced paramedic. The “Cocktail” was the device that allowed paramedics to stabilize electrical and plumbing systems of a heart prior to getting on an elevator, its inventor said.
Evolution of the Science:
Modern cardiology has stepped slightly back from the full “Cocktail”.
- Heavy Sedition (Diazepam): Used to tranquilize the patient to clammed heart rate.
- Now: We are aware that benzodiazepines can slow down respiration too much.
- Then: Prophylactic lidocaine to prevent arrhythmias.
- Now: There is evidence that prophylactic Lidocaine increased mortality by inducing asystole (flatline). Lidocaine has been eliminated from the contemporary Israeli protocol of routine use.
For Patients & Caregivers
What This Means for Your Safety
If you are searching for this “cocktail” as a household remedy, you are in the wrong place. This is not a preventive cocktail you can just take as if it were vitamins.
The Reality Check:
The drugs in this cocktail (Nitrates and blood thinners) dangerously interact with prevalent home drugs. For instance, the Nitrate component of this cocktail given to a patient who has ingested medication for ED (such as Viagra or Cialis) in the last 48 hours leads to a devastating hypotensive event and is typically fatal.
Practical Steps for High-Risk Families:
Rather than attempting to mimic a hospital protocol, concentrate on the one element you actually can safely control: Aspirin.
The “By the Bed” Protocol: If you have a family member at high risk for heart attacks, keep baby aspirins (81mg) or regular adult aspirins (325mg/300mg) by the bed.
The Action Plan:
- Dial Emergency Services as soon as possible.
- If directed by the operator, then patient chews (not swallows whole) one adult aspirin (300-325 mg). Chewing is considered the “Israeli” method, which sends the drug into the blood through the lining of your mouth in 5 minutes instead of half an hour when swallowed.
- Unlock the front door.
*Yes, you should not drive them yourself! The Mobile Intensive Care Unit (MICU) can treat a cardiac arrest in the ambulance; passenger car cannot.
Frequently Asked Questions
What is The “Israeli Cardiac Cocktail” and which drugs it contain?
The cocktail is a pre-hospital Advanced Cardiac Life Support (ACLS) protocol utilized by Magen David Adom. This includes traditionally 300mg of chewed Aspirin, the high-dose Isosorbide Dinitrate spray Isoket or in certain cases Heparin and tranquilizers extensivly implemented at the scene on-scene by Mobile Intensive Care Units.
Why is the patient made to chew the Aspirin?
If you chew the Aspirin, absorption via the lining of the mouth will occur within a few minutes…which means that bioavailability shoots up WAY faster compared to taking it by swallowing. This makes platelet-busting action available at once to prevent the blood clot from enlarging during the crucial first minutes of a heart attack.
When should you NOT use the Israeli Cardiac Cocktail or when could it be dangerous?
The cocktail is absolutely contraindicated in patients with Right Ventricular Infarction (RVI) (who are preload dependent), persons suffering from trauma or internal bleeding (due to the blood thinners), and people who have taken erectile dysfunction medication like Viagra or Cialis in the previous 48 hours, as this can result in death due to hypotension.
What are the key distinctions between Israeli “Stay and Stabilize” doctrine and US “Scoop and Run” doctrine?
The American approach, which attempts to get the patient as fast as possible to the hospital is in contrast with the Israeli model that brings the emergency room to where the patient is. That involves stabilizing the heart’s electrical and plumbing systems on site with sophisticated pharmacology before moving the patient, which studies show can lower the risk of death.
Why is this cocktail usually not found in the setting of military or tactical medicine?
Hemorrhage (bleeding) is generally the presenting condition in a combat situation rather than cardiac arrest. Since the cocktail is full of potent blood thinner (Aspirin and Heparin), giving it to a soldier with internal bleeding caused by blast or shrapnel wounds would render him incapable of clotting, likely resulting in his death.
References
Pre-hospital Thrombolysis IN shoulder dislocation, Care:
- Entity: The Hebrew University-Hadassah Medical School, Jerusalem.
- *Title: “The Efficacy of Mobile Intensive Care Units on Mortality in AMI” 375.
- Context: We mention this fundamental research (initiated following the inception of MICUs in Israel during the late 1970s-early 1980s), which proved for the first time that on-scene ‘cocktail’ treatments, as opposed to immediate evacuation, significantly improved treatment results.
- Major Results: Achieved significant reduction in pre-hospital death through on-site treatment of arrhythmias.
Nitrate Spray vs Tablet Comparison:
- Entity: American Journal of Cardiology / Multiple Pharmacokinetic Studies.
- Title: Pharmacokinetics of Isosorbide Dinitrate Spray vs. Sublingual Nitroglycerin.
- Outcome: Sprays have a faster onset and are less dependent of adequate salivation (often diminished in shocked patients) than tablets.
Contraindications of Nitrates:
- Entity- American Heart Association (AHA) & European Society of Cardiology (ESC) Guidelines.
- Title: The treatment of ST segment elevation myocardial infarction (STEMI) in the post-coronary revascularization era.
- Outcomes: Strong contraindication for nitrates in RV MI or recent Phosphodiesterase- 5 inhibitor (Viagra/Cialis) use given possibility of profound hypotension.
