Should Epinephrine still be used in Cardiac Arrest Patients?

Epinephrine has been a cornerstone in the management of cardiac arrest for decades, with its use deeply ingrained in resuscitation protocols worldwide. Despite its widespread use, the precise impact of epinephrine on outcomes in cardiac arrest, particularly in terms of survival and neurological function, remains a topic of ongoing debate and investigation (Jung et al., 2018). The lack of robust experimental studies examining the clinical effects of epinephrine has led to continued recommendations for its use in cardiac arrest scenarios (Garfinkel et al., 2022). Both the American Heart Association (AHA) and the European Resuscitation Council (ERC) currently advocate for the administration of epinephrine in both shockable and non-shockable rhythms during resuscitation efforts (Amoako et al., 2023).

While epinephrine is the most commonly used medication in cardiac arrest, its efficacy and potential adverse effects have been subjects of scrutiny. Studies have shown that the timing of epinephrine administration may play a crucial role in patient outcomes, with delays in administration associated with decreased chances of return of spontaneous circulation (ROSC) and survival (Yauger et al., 2020). Furthermore, the ideal dosage of epinephrine during cardiac arrest remains a topic of discussion, with no conclusive evidence supporting a maximum dose recommendation.

The adverse effects of epinephrine remain a significant issue in resuscitation medicine. In adults with out-of-hospital cardiac arrest, the use of epinephrine resulted in a significantly higher rate of 30-day survival than the use of placebo, but there was no significant between-group difference in the rate of a favorable neurologic outcome because more survivors had severe neurologic impairment in the epinephrine group (Perkins, 2018). This indicates the possibility that epinephrine may not be the optimal intervention in all cardiac arrest pathologies.

The use of epinephrine in pediatric cardiac arrest cases has also been a focus of research, with studies evaluating the impact of epinephrine administration on outcomes in pediatric patients. Additionally, the route of epinephrine administration, whether intravenous or endotracheal, has been investigated, with studies suggesting that endotracheal administration may offer a faster restoration of ROSC in certain scenarios.

In conclusion, while epinephrine continues to be a fundamental component of cardiac arrest management, ongoing research is essential to further elucidate its optimal dosing, timing of administration, and overall impact on patient outcomes. The balance between the potential benefits of epinephrine in achieving ROSC and its adverse effects on neurological outcomes remains a critical area for future investigation in the field of resuscitation medicine.

References:

  • Amoako, J., Komukai, S., Izawa, J., Callaway, C., & Okubo, M. (2023). Evaluation of use of epinephrine and time to first dose and outcomes in pediatric patients with out-of-hospital cardiac arrest. Jama Network Open, 6(3), e235187.
    https://doi.org/10.1001/jamanetworkopen.2023.5187
  • Garfinkel, E., Michelsen, K., Johnson, B., Margolis, A., & Levy, M. (2022). Temporal changes in epinephrine dosing in out-of-hospital cardiac arrest: a review of ems protocols across the united states. Prehospital and Disaster Medicine, 37(6), 832-835.
    https://doi.org/10.1017/s1049023x22001418
  • Jung, J., Rice, J., & Bord, S. (2018). Rethinking the role of epinephrine in cardiac arrest: the paramedic2 trial. Annals of Translational Medicine, 6(S2), S129-S129.
    https://doi.org/10.21037/atm.2018.12.31
  • Perkins GD, Ji C, Deakin CD, Quinn T, Nolan JP, Scomparin C, Regan S, Long J, Slowther A, Pocock H, Black JJM, Moore F, Fothergill RT, Rees N, O’Shea L, Docherty M, Gunson I, Han K, Charlton K, Finn J, Petrou S, Stallard N, Gates S, Lall R; A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. PARAMEDIC2 Collaborators. N Engl J Med. 2018 Aug 23;379(8):711-721. doi: 10.1056/NEJMoa1806842. Epub 2018 Jul 18. PMID: 30021076
  • Yauger, Y., Beaumont, D., Brady, K., Schauer, S., O'Sullivan, J., Hensler, J., … & Johnson, D. (2020). Endotracheal administered epinephrine is effective in return of spontaneous circulation within a pediatric swine hypovolemic cardiac arrest model. Pediatric Emergency Care, 38(1), e187-e192.
    https://doi.org/10.1097/pec.0000000000002208


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