April 6, 2020

Background: Epinephrine remains a staple in cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OHCA).  However, the optimal dose, timing, and route of administration are still unknown.  Standard dosing of epinephrine is 1mg every 3 to 5 minutes via the intravenous (IV) or intraosseous (IO) route. IO lines are quicker to establish and have a higher first-attempt success rate compared to IV access. Rapid placement and ease of use minimizes delays for critical patients requiring quick access. The literature, although methodologically limited, is mixed about the use of IV vs IO access for epinephrine in OHCA.

March 16, 2020

Traditionally, endotracheal intubation has been the gold standard for airway management in cardiac arrest. However, more recent data suggests that maybe less is more (i.e. supraglottic airways and/or bag valve mask ventilation).  The AHA guidelines have also de-emphasized airway management as the old acronym of ABC's has now been changed to CAB's.  In this talk from Rebellion in EM 2019, Dr. Chris Hicks, MD discusses the optimal airway management in OHCA.

September 9, 2019

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.

August 5, 2019

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.

January 25, 2018

Background: Placement of vascular access for administration of resuscitation drugs and fluids is a common procedure in the management of out of hospital cardiac arrest (OHCA). While intravenous (IV) placement has been the standard approach for decades, intraosseous (IO) access is rapid and safe and may be the preferred approach due to fact that the bone marrow does not collapse during shock states as peripheral veins often do. Despite it’s advantages, there are concerns about IO placement because of the potential for drugs to pool in the marrow and not circulate. Prior studies have shown an association with tibial IO placement and decreased rate of ROSC though no association with worse neurologic outcomes (Feinstein 2017).