https://orcid.org/0000-0002-3466-8813
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Abstract
Background
Cardiac arrest guidelines recommend epinephrine every 3–5 minutes during cardiac arrest resuscitation. However, it is unclear if multiple epinephrine doses are associated with improved outcomes. The objective of this study was to determine if a single-dose epinephrine protocol was associated with improved survival compared to traditional multidose protocols.
Methods
We conducted a pre-post study across five North Carolina EMS agencies from 11/1/2016 to 10/29/2019. Patients ≥18 years old with attempted resuscitation for non-traumatic prehospital cardiac arrest were included. Data were collected 1 year before and after implementation of the single-dose epinephrine protocol. Prior to implementation, all agencies used a multidose epinephrine protocol. The Cardiac Arrest Registry to Enhance Survival (CARES) was used to obtain patient outcomes. Study outcomes were survival to hospital discharge (primary) and return of spontaneous circulation (ROSC). Analysis was by intention to treat. Outcomes were compared pre- vs. post-implementation using generalized estimating equations to account for clustering within EMS agencies. Adjusted analyses included age, sex, race, shockable vs. non-shockable rhythm, witnessed arrest, automatic external defibrillator availability, EMS response interval, and bystander cardiopulmonary resuscitation.
Results
During the study period there were 1,690 encounters (899 pre- and 791 post-implementation). The population was 74.7% white, 61.1% male, and had a median age of 65 (IQR 53–76) years. Survival to hospital discharge was similar pre- vs. post-implementation [13.6% (122/899) vs. 15.4% (122/791); OR 1.19, 95%CI 0.89–1.59]. However, ROSC was more common post-implementation [42.3% (380/899) vs. 32.5% (257/791); OR 0.66, 95%CI 0.54–0.81]. After adjusting for covariates, the single-dose protocol was associated with similar survival to discharge rates (aOR 0.88, 95%CI 0.77–1.29), but with decreased ROSC rates (aOR 0.58, 95%CI 0.47–0.72).
Conclusion
A prehospital single-dose epinephrine protocol was associated with similar survival to hospital discharge, but decreased ROSC rates compared to the traditional multidose epinephrine protocol.
Acknowledgments
We appreciate the EMS agencies in Forsyth, Iredell, Randolph, Stanly, and Surry counties for participating in this work. We also thank Clark Tyson from CARES for his assistance. We also appreciate Amanda Treadway from Iredell EMS for offering her time and support.
Authors’ Contributions
NPA and JPS conceived the study idea. NPA and NN coordinated data management. ACS, NN, and NPA performed data analysis. BPB, JTW, RDN, and JPS provided prehospital expertise. NPA and SAM drafted the manuscript. All authors contributed to the manuscript and substantially to its revision. NPA takes responsibility for the manuscript as a whole.
Disclosure Statement
Dr. Ashburn received funding from NHLBI (T32HL076132). Dr. Snavely received funding from Abbott and HRSA (1H2ARH399760100). Dr. Stopyra received research funding from NCATS/NIH (KL2TR001421), HRSA (1H2ARH399760100), Roche Diagnostics, Abbott Laboratories, Pathfast, Genetesis, Cytovale, Forest Devices, Vifor Pharma, and Chiesi Farmaceutici. Dr. Mahler received funding/support from Roche Diagnostics, Abbott Laboratories, Ortho Clinical Diagnostics, Siemens, Grifols, Pathfast, Quidel, Genetesis, Cytovale, and HRSA (1H2ARH399760100). He is a consultant for Roche, Quidel, Abbott, Genetesis, Inflammatix, Radiometer, and Amgen and the chief medical officer for Impathiq Inc. The other authors have no disclosures to report.