The news for epinephrine in cardiac arrest keeps getting worse - it restarts the heart, but at what cost, and with what outcomes?
This is a study, published in JAMA, of 417,188 out-of-hospital cardiac arrest patients in Japan - only 15,030 of which received epinephrine during prehospital transport - a far cry from the U.S., where the toolbox has typically already been emptied prior to the ED. Nearly every baseline characteristic favored the epinephrine group - more witnessed arrests, more received bystander CPR, a physician was more frequently in the ambulance, more patients in ventricular fibrillation/PEA. However, more of these patients also received an advanced airway, which has also been associated with worse outcomes.
In their unadjusted analysis, the epinephrine cohort was three times as likely to have ROSC, and had an OR of 1.15 to be alive at one month. However, they were half as likely to be functional as the non-epinephrine survivors. Then, when they do all their statistical adjustments for all the favorable baseline factors in the epinephrine cohort, all these numbers become less favorable for epinephrine. They also do a propensity-matched cohort of 26,802 patients that has favorable ROSC with epinephrine, but dismal 1 month and functional outcomes.
This data is from before the era of routine hypothermia - which may be beneficial - but it certainly supports what we already expected regarding the damaging physiologic effects of epinephrine while senselessly flogging the heart back into action.
"Prehospital Epinephrine Use and Survival Among Patients With Out-of-Hospital Cardiac Arrest"