New study tests benefit of epinephrine in prehospital-setting cardiac arrests

The study showed a lack of 'clear improvement in functional recovery' in patients treated with epinephrine

If ALS versus BLS in cardiac arrest resuscitation was a Little League game, we’d be awful close to calling the game for BLS based on the mercy rule, writes Kelly Grayson. Is it time to pull our starting pitcher – epinephrine? Learn more in his analysis, and in an episode of Inside EMS, in which our co-hosts discuss the Paramedic-2 study.

By EMS1 Staff

A new study published in the New England Journal of Medicine tested the use of epinephrine in out-of-hospital cardiac arrest patients.

The 30-day double-blind study consisted of 8,014 patients in cardiac arrest in the United Kingdom with similar baseline characteristics to eliminate bias.

After 30 days, 130 patients – 3.2 percent of the total patients – who received epinephrine were alive, compared to 94 patients – 2.4 percent of the total patients – who received the placebo.

While patients who received epinephrine had a “higher 30-day survival rate that those who received the placebo,” the overall survival rate difference was not statistically significant. The study also showed a lack of “clear improvement in functional recovery” in patients treated with epinephrine.

The International Liaison Committee on Resuscitation issued a statement on the study outcome, praising it as the first of its kind, while acknowledging the limitations of the study and the reality that the results did not show any significant improvement for the prehospital use of epinephrine in the long term. 

“This is the first placebo-controlled clinical trial to detect a long-term survival benefit of epinephrine during cardiac arrest and is therefore an important contribution to the field,” the statement read. “However, the study did not demonstrate improved long-term survival with good neurologic function. Limitations of the study include the use of a single fixed epinephrine dosing regimen (1.0 mg every 3-5 minutes) for all patients and an average time from 911 call to first drug dose of 21 minutes (IQR 16-27 minutes). As noted above, both the optimal dose and timing of epinephrine during cardiac arrest remain important knowledge gaps.”

An editorial published in the NEJM said the benefits of using epinephrine may depend on a number of factors, including timing, dosage and initial electrocardiographic rhythm.

In-hospital settings administer epinephrine doses in cardiac arrest patients at a much faster rate than used in the out-of-hospital NEJM study, with an average dose time of three minutes after resuscitation begins.

The response rate of EMS systems may make it impossible to determine if quicker administration of epinephrine in the prehospital setting would increase patient outcomes.

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