Background: Epinephrine (adrenaline) has been used in advanced life support in cardiac arrest since the early 1960s. Despite the routine recommendation for its use, evidence to support administration is less than ideal.  Although it is clear from multiple observational studies that epinephrine improves return of spontaneous circulation (ROSC) and short-term survival, most evidence suggests an absence of improvements in survival with good neurologic outcomes.  In cardiac arrest we want to take advantage of the alpha effects of epinephrine, including peripheral vasoconstriction, and therefore increasing aortic diastolic pressure, which in turn helps augment coronary and cerebral blood flow.  On the other hand, we want to avoid the potentially detrimental beta effects including dysrhythmias, decreased microcirculation, and increased myocardial oxygen demand all of which increase the chances of recurrent cardiac arrest and decreased neurologic recovery.  The only two interventions in cardiac arrest that have shown improve survival with good neurologic outcomes continue to be high-quality CPR and early defibrillation. The debate over the utility of epinephrine in OHCA has been ongoing for several years now and many providers are left with the ultimate question of what to do with epinephrine in OHCA.

Background: Epinephrine (adrenaline) remains a central part of management of OHCA in ACLS guidelines. Recent studies (i.e. PARAMEDIC-2) have raised concerns about the efficacy and possible deleterious effects of epinephrine on both overall survival and long-term neurological outcomes. Other observational trials have suggested that there may be a time dependent effect of epinephrine on survival, with earlier timing of epinephrine improving outcomes, and later timing of epinephrine causing deleterious effects[2]. This trial attempts to analyze the association between timing and dose of epinephrine given on survival and neurologic outcomes of patients with OHCA.

You are working an ED shift with an experienced EM resident. As the resident prepares to intubate a 100kg patient with pneumonia you suggest that the head of the bed be elevated to aid in first pass success and avoidance of peri-intubation hypoxia. The resident thanks you for your kind suggestion and states ‘I just read an article in Annals of EM suggesting there was no benefit to non-supine position in ED patients.’ This is news to you. You give the resident the benefit of the doubt and ask them to send you a copy of their evidence.

I was working a busy shift in the ED, like many of us do, and the next patient I was going to see was a 57 year old male with no real medical problems complaining of chest pain.  I remember thinking as I walked into the room this guy looks ashen and diaphoretic….he doesn’t look well.  He is a paramedic telling me how he has been having off and on chest pain for the past several months.  He just had a stress test two months ago that was “negative”.  Today he was working on his pool and developed the same chest discomfort as he had been having off and on the past several months, but today, the pain would just not go away.  In his mind, he thought this might be an ulcer and just needed some Pepcid to help. He got put on the monitor and an ECG was run… The patient involved in this case has given permission to share the story, and relevant images with the knowledge that this information will be used for the purposes of education.