Beyond ACLS: Epinephrine in Out-of-Hospital Cardiac Arrest Poll

15 Mar
March 15, 2015

epinephrineRecently, I wrote a post on the use of epinephrine in out-of-hospital cardiac arrest (OHCA) and this triggered some interesting discussion on twitter. Are we at a point that we can just stop using epinephrine in OHCA?  Has anyone stopped actually using epinephrine in OHCA and if so, why or why not? The evidence seems to point to no “good” neurologic benefit over basic life support (BLS).  I would love to hear more peoples thoughts on this.

What is the topic being debated? 

Has anyone stopped actually using epinephrine in OHCA and if so, why or why not?

Epinephrine in OHCA

Screen Shot 2015-03-25 at 10.03.35 PM

What is current standard of care (SOC) in OHCA?

Standard of Care

Epinephrine in OHCA

Currently, epinephrine is recommended by Advanced Cardiovascular Life Support (ACLS) in OHCA, but is not the “standard of care.”

What studies have evaluated the effectiveness of epinephrine in OHCA?

Epinephrine in OHCA

Why the change?

Every time we stop CPR we are halting blood flow to our patients heart and brain. The most important parts of OHCA care are still early, highquality CPR with limited interruptions and early defibrillation (a.k.a. Basic Life Support), not ACLS.

Halting CPR in OHCA

Is there already protocol change coming into effect anywhere? 

Not that I am aware of, but the PARAMEDIC 2: The Adrenaline Trial is a currently ongoing study that is actively recruiting via the University of Warwick Clinical Trial Unit in the United Kingdom. The study will collect information on about 8,000 patients who have been treated for OHCA. Half the patients will receive epinephrine and the other half placebo. The outcomes are survival and neurologic function at 30 days.

What is the suggested new approach?

Cardio Cerebral Resuscitation (CCR) is a concept of resuscitation that had its beginnings in the United States out of the state of Arizona in 2003. The concept is simple: NonRebreather, no intubation and continuous, highquality CPR without pauses. The thought is spending more time doing compressions and less time with more advanced modalities such as intubation, IVF,IV access, and ACLS medications increases perfusion to vital organs. However, stopping the use of epinephrine in OHCA is still an academic musing, unfortunately at this time ACLS still recommends epinephrine in  OHCA, which means we still give epinephrine for OHCA but the ACLS algorithm should be readdressed as epinephrine results in more ROSC, but no increase in “good” neurologic outcomes after OHCA.

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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of R.E.B.E.L. EM
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5 replies
  1. Anand Swaminathan says:

    Stopped may be a bit of an overstatement. I do not use it as currently recommended in the ACLS guidelines since these are based on poor data at best.

    However, I do consider epinephrine based on the case scenario typically at push dose pressor amounts in patients with “PEA” who actually have cardiac activity.

    Reply
    • Salim Rezaie says:

      Is it an overstatement? I don’t know….I agree that use of epinephrine as it is currently “recommended” by ACLS is based on poor data, but is there any data that shows improved neuro outcome with push-dose epi in pseudo-PEA patients? It sounds great in theory, but is there evidence to support? And if there is no evidence, then is it a far stretch to say we should focus more on high-quality, limited interruption CPR and early defibrillation and not waste time with IVF, IV ACLS medications?

      Not sure I have the right answer either, but best evidence does not support epi use at this time

      Salim

      Reply
  2. Lakshay Chanana says:

    I have changed my practise to q5min instead of q3min now, find it hard to convince everyone in the resus room on this. We need to educate nurses/paramedics/PAs to be on the same page.

    And I think even if ACLS gets rid of it completely, physicians will be slow to catch up and will take their own time (like what we did with atropine) to stop its use. This is engrained in us!!

    Reply
  3. J. Scott Wieters says:

    I’ve moved from reflexively giving epi to using it once at the start of the code and then watching to see if my ETCO2 is <30 or DBP with good compressions on art line is <30, then use epi. Not sure there is good science for what i'm doing but trying to listen to smart folks I respect?

    Reply
    • Salim Rezaie says:

      Hello Scott,
      TY for reading and like your approach. I guess we will have to wait for the publication of the Paramedic 2 trial to see if we should be using at all.

      Salim

      Reply

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