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

Recently, 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.

Cite this article as: Salim Rezaie, "Beyond ACLS: Epinephrine in Out-of-Hospital Cardiac Arrest Poll", REBEL EM blog, March 15, 2015. Available at:

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