Epinephrine in Resuscitation: Curse or Cure?

Robert R Attaran; Gordon A Ewy


Future Cardiol. 2010;6(4):473-482. 

In This Article

Quality of Resuscitation is Critically Important

The message regarding optimal care in cardiac arrest and in particular OHCA should not be lost in the debate over the use of epinephrine. It is the quality of the basic and advanced resuscitation efforts that determines survival. While there is no compelling controlled trial evidence to demonstrate harm or benefit from epinephrine use in human cardiac arrest, we think the lack of demonstrated effects in humans is partly due to the prolonged delay in epinephrine administration and partly due to suboptimal guideline approaches to advanced cardiac life support.

A cogent argument can be made that during the early minutes of resuscitation efforts, there are other interventions that have been shown to improve survival, such as the use of continuous chest compression CPR by bystanders,[83] delaying or eliminating endotracheal intubation,[81,84–88] early and continuous chest compressions and early defibrillation.[84,86,89–91] The requirement for the establishment of intravenous access and intravenous drug therapy (often with its resultant interruptions to chest compressions) is difficult to meet efficiently and may be counterproductive.

Mader et al. recently conducted a study of the emergency medical services (EMS) component of cardiocerebral resuscitation with intraosseous epinephrine versus CPR with intravenous epinephrine using a swine model of OHCA.[89] Following prolonged (10 min of untreated) VF, intraosseous epinephrine was given 11 min after VF arrest and intravenous epinephrine 16.5 min after arrest. Survival was significantly better with the EMS portion of CCR with intraosseus epinephrine than with the CPR with intravenous epinephrine (2005 EMS guidelines). The proportions of VF termination, ROSC and 20-min survival all strongly favored the CCR with intraosseus group. This and other studies suggest that the quality of advanced life support is important and augments the desired hemodynamic effects of epinephrine.[92]

It has now been shown in several clinical studies that CCR (a new ACLS approach that prohibits early endotracheal intubation, advocates 200 chest compressions before and immediately after a single shock and advocates the early administration of epinephrine) significantly improves survival of patients with OHCA who have a witnessed arrest and a shockable rhythm on arrival of the paramedics.[81,84,86,87,93]


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