Yesterday the American Medical Association published a landmark study (nonrandomized, observational) challenging conventional wisdom and possibly tolling the death knell for the use of epinephrine in cardiac arrest. In a study encompassing over 400,000 out-of-hospital cardiac arrests in Japan from 2005-2008, researchers are declaring that epinephrine in cardiac arrest may lead to worse survival and neurological outcomes than no drug at all. While their study also shows epinephrine leads to increased rates of return of spontaneous circulation (18% to 5%), despite this seemingly positive link to return of circulation, they are suggesting the longer term deleterious effects of the epinephrine may outweigh the short term positive effects. This study now clears the way for what previously would have been an unethical (because epi has been the standard of care) study – a randomized, blinded trial of epinephrine versus placebo.
The article and accompanying editorial are available to be read at the following links.
Twenty years in the field have taught me that getting pulses back with epi, particularly on a patient with asystole or PEA, does not mean the patient is going to walk out of the hospital. It feels great to get pulses and pressure back and have the patient start to breathe on their own, but in most cases, their name shows up in the obituaries within a week or two. They either die or their family faced with confirmed brain death agrees to pull the plug. I did a call a week ago – a patient in asystole who with a quick combitube, good CPR, and two doses of epi had pulses back. Some dopamine, normal saline, a fourth floor carry down and transport with no loss of circulation, had us all shaking each other’s hands. Yet each day, I check the obits looking for the patient’s name, just as I did a month ago for another patient who came back from asystole with a single dose of epi only to show up in the death pages a week later. Epi seems to jump start their hearts, but its effect on the brain may be a different story. Most of my true saves have been people who have dropped in public, gotten bystander CPR and come back with defibrillation. Years ago they said high-dose epi was bad for the patient, today it looks like any epi at all may be bad.
Now I am on a new death watch. As I have checked the obits for the names of my patients, in 2015, I will check the new AHA guidelines checking for epinephrine’s demise.