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Epinephrine for OHCA – A Meta-analysis

December 18, 2019

Written by Michael Wolf

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In out-of-hospital cardiac arrest (OHCA), epinephrine improves ROSC and survival to hospital discharge, showing clear advantage over placebo/no drug.

Why does this matter?
A recent trial, PARAMEDIC2, has gotten lots of press and has led some to doubt whether epinephrine should have a role in OHCA.

If it ain’t broke…
This was a meta-analysis of 15 trials including 20,716 adults with OHCA. Compared to placebo or no drug, epinephrine improved ROSC (RR 2.03, 95% CI 1.18-3.51), survival to hospital admission (RR 2.04, 95% CI 1.22-3.43), and survival to hospital discharge (RR 1.34, 95% CI 1.08-1.67). High-dose epinephrine resulted in higher rates of ROSC compared with standard-dose (which for the record is 1 mg every 3-5 minutes until ROSC), and higher rates of survival to hospital admission compared with placebo/no drug. Neither standard nor high-dose epinephrine made statistically significant improvements in survival with favorable neurologic outcome. However, patients treated with epinephrine had a numerically but not statistically higher rate of survival with good neurologic outcome at discharge, with a 95% confidence interval that barely crossed 1. (RR 1.22, 95% CI 0.99-1.51).
TL;DR: Epinephrine promotes ROSC and survival in OHCA. We can’t say that epinephrine improves survival with good neurologic outcome. High-dose epinephrine is interesting but we need to study it more before deciding whether to use it.

Another Spoonful
Justin Morgenstern, First10EM, exhaustively reviewed the literature on epi in arrest in this epic post.

Epinephrine for out of hospital cardiac arrest: A systematic review and meta-analysis of randomized controlled trials. Resuscitation. 2019 Nov 4. pii: S0300-9572(19)30675-6. doi: 10.1016/j.resuscitation.2019.10.026. [Epub ahead of print]

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