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Epinephrine or Airway First in OHCA?

March 5, 2024

Written by Michael Stocker

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In adults presenting to EMS after OHCA, those receiving epinephrine prior to advanced airway management (AAM = supraglottic airway, SGA, or endotracheal tube) experienced better outcomes and prehospital ROSC than those receiving AAM before epinephrine. This was true for both shockable and non-shockable initial rhythms.

Epi before advanced airway keeps the reaper away
This retrospective cohort study utilized the All-Japan Utstein Registry OHCA data from 2014 through 2019 to examine the effect of the sequence of epinephrine and AAM on patient outcomes. 259,237 patients 18 years and older experiencing OHCA of any etiology less than 30 minutes prior to EMS arrival were analyzed after exclusion criteria, such as missing intervention data and ROSC before either intervention. Shockable (8.3%) and nonshockable (91.7%) initial rhythms were analyzed separately, and patients were grouped into AAM-first, the majority of whom received SGA, and epinephrine-first. Group differences were controlled for using propensity scores and inverse probability of treatment weighting (IPTW). For both initial shockable and non-shockable rhythms, epinephrine-first was associated with increased likelihood of 1-month survival: OR 1.19 (95%CI 1.09-1.30) and 1.28 (95%CI 1.19-1.37), respectively; 1-month survival with favorable functional outcome: OR 1.24 (95%CI 1.10-1.39) and 1.39 (95%CI 1.17-1.64), respectively; and prehospital ROSC: OR 1.74 (95%CI 1.61-1.88) and 2.59 (95%CI 2.50-2.68), respectively. Secondary sensitivity analyses yielded similar results. While it had limitations – e.g. interventions were not randomized – this study highlights that prioritizing AAM over epinephrine in OHCA may come at great expense to the patient.

How will this change my practice
While managing the airway is important in OHCA, current evidence would suggest bag mask ventilation is sufficient early on, and AAM should not take precedence over high quality ACLS. I will continue to prioritize time to first epinephrine and first shock as appropriate, while favoring bag mask ventilation in OHCA in both my prehospital and ED practices.

Sequence of Epinephrine and Advanced Airway Placement After Out-of-Hospital Cardiac Arrest. JAMA Netw Open. 2024 Feb 5;7(2):e2356863. doi: 10.1001/jamanetworkopen.2023.56863.

What are your thoughts?