https://orcid.org/0000-0002-6777-038X
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Abstract
Background
A single dose epinephrine protocol (SDEP) for out-of-hospital cardiac arrest (OHCA) achieves similar survival to hospital discharge (SHD) rates as a multidose epinephrine protocol (MDEP). However, it is unknown if a SDEP improves SHD rates among patients with a shockable rhythm or those receiving bystander cardiopulmonary resuscitation (CPR).
Methods
This pre-post study, spanning 11/01/2016-10/29/2019 at 5 North Carolina EMS systems, compared pre-implementation MDEP and post-implementation SDEP in patients ≥18 years old with non-traumatic OHCA. Data on initial rhythm type, performance of bystander CPR, and the primary outcome of SHD were sourced from the Cardiac Arrest Registry to Enhance Survival. We compared SDEP vs MDEP performance in each rhythm (shockable and non-shockable) and CPR (bystander CPR or no bystander CPR) subgroup using Generalized Estimating Equations to account for clustering among EMS systems and to adjust for age, sex, race, witnessed arrest, arrest location, AED availability, EMS response interval, and presence of a shockable rhythm or receiving bystander CPR. The interaction of SDEP implementation with rhythm type and bystander CPR was evaluated.
Results
Of 1690 patients accrued (899 MDEP, 791 SDEP), 19.2% (324/1690) had shockable rhythms and 38.9% (658/1690) received bystander CPR. After adjusting for confounders, SHD was increased after SDEP implementation among patients with bystander CPR (aOR 1.61, 95%CI 1.03-2.53). However, SHD was similar in the SDEP cohort vs MDEP cohort among patients without bystander CPR (aOR 0.81, 95%CI 0.60-1.09), with a shockable rhythm (aOR 0.96, 95%CI 0.48-1.91), and with a non-shockable rhythm (aOR 1.26, 95%CI 0.89-1.77). In the adjusted model, the interaction between SDEP implementation and bystander CPR was significant for SHD (p = 0.002).
Conclusion
Adjusting for confounders, the SDEP increased SHD in patients who received bystander CPR and there was a significant interaction between SDEP and bystander CPR. Single dose epinephrine protocol and MDEP had similar SHD rates regardless of rhythm type.
Acknowledgments
We appreciate the EMS systems 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.
Author Contributions
TSG and NPA conceived the study idea. NPA and JPA coordinated data management. ACS, TSG, and NPA performed data analysis. BPB, JTW, RDN, and JPS provided prehospital expertise. TSG and NPA drafted the manuscript. All authors contributed to the manuscript and substantially to its revision. TSG takes responsibility for the manuscript as a whole.
Disclosure Statement
Dr. Ashburn receives funding from AHRQ (R01HS029017). Dr. Snavely receives funding from Abbott, HRSA (1H2ARH399760100), and AHRQ (R01HS029017). Dr. Winslow receives funding from the National Cancer Institute (NCI) and the National Institute on Minority Health and Health Disparities (NIMHD). Dr. Stopyra receives research funding from HRSA (H2ARH39976-01-00), AHRQ (R01HS029017 and R21HS029234), The Duke Endowment, Roche Diagnostics, Abbott Laboratories, Pathfast, Genetesis, Cytovale, Forest Devices, Vifor Pharma, and Chiesi Farmaceutici. Dr. Mahler receives funding/support from Roche Diagnostics, Abbott Laboratories, QuidelOrtho, Siemens, Grifols, Pathfast, Beckman Coulter, Genetesis, Cytovale, National Foundation of Emergency Medicine, Duke Endowment, Brainbox, HRSA (1H2ARH399760100), and AHRQ (R01HS029017 and R21HS029234). He is a consultant for Roche, QuidelOrtho, Abbott, Siemens, Inflammatix, and Radiometer and is the Chief Medical Officer for Impathiq Inc.