A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest

Perkins, Gavin D.; Ji, Chen; Deakin, Charles D.; Quinn, Tom; Nolan, Jerry P.; Scomparin, Charlotte; Regan, Scott; Long, John; Slowther, Anne; Pocock, Helen; Black, John J.; Moore, Fionna; Fothergill, Rachael; Rees, Nigel; O’Shea, Lyndsey; Docherty, Mark; Gunson, Imogen; Han, Kyee; Charlton, Karl; Finn, Judith; Petrou, Stavros; Stallard, Nigel; Gates, Simon; Lall, Ranjit

doi:10.1056/nejmoa1806842

Cited by 564 publications

(491 citation statements)

References 35 publications

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“…Several experimental studies reported that although adrenaline increased cerebral perfusion pressure, it paradoxically impaired cerebral microvascular blood flow, indicating its potential to worsen brain injury after ROSC . Consistent with these studies, Perkins et al reported in a recent randomised trial of adrenaline in out‐of‐hospital cardiac arrest that the increase in ROSC rate with the use of adrenaline did not translate into an increase in survival with good neurologic outcome because more survivors had severe neurologic impairment in the adrenaline group . Although pralidoxime facilitated ROSC by potentiating the pressor effect of adrenaline in the present study, it may potentiate the adverse effects of adrenaline as well, thereby offsetting the beneficial effects of pralidoxime on ROSC.…”

Section: Discussionmentioning

confidence: 92%

“…Adrenaline remains the mainstay medication in the treatment of cardiac arrest. Clinical trials have shown that adrenaline increases rates of restoration of spontaneous circulation (ROSC) and survival to hospital admission . However, the vast majority of patients with out‐of‐hospital cardiac arrest still do not achieve ROSC or survive to hospital admission despite receiving adrenaline, warranting the need for novel therapeutic modalities.…”

Section: Introductionmentioning

confidence: 99%

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Pralidoxime administered during cardiopulmonary resuscitation facilitates successful resuscitation in a pig model of cardiac arrest

Jung

Lee

Jeung

et al. 2019

Clin Exp Pharma Physio

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Pralidoxime is a common antidote for organophosphate poisoning; however, studies have also reported pralidoxime's pressor effect, which may facilitate the restoration of spontaneous circulation (ROSC) after cardiac arrest by improving coronary perfusion pressure (CPP). We investigated the immediate cardiovascular effects of pralidoxime in anaesthetised normal rats and the effects of pralidoxime administration during cardiopulmonary resuscitation (CPR) in a pig model of cardiac arrest. To evaluate the immediate cardiovascular effects of pralidoxime, seven anaesthetised normal rats received saline or pralidoxime (20 mg/kg) in a randomised crossover design, and the responses were determined using the conductance catheter technique. To evaluate the effects of pralidoxime administration during CPR, 22 pigs randomly received either 80 mg/kg of pralidoxime or an equivalent volume of saline during CPR. In the rats, pralidoxime significantly increased arterial pressure than saline (P = .044). The peak effect on arterial pressure was observed in the first minute. In a pig model of cardiac arrest, CPP during CPR was higher in the pralidoxime group than in the control group (P = .002). ROSC was attained in three animals (27.3%) in the control group and nine animals (81.8%) in the pralidoxime group (P = .010). Three animals (27.3%) in the control group and eight animals (72.2%) in the pralidoxime group survived the 6‐hour period (P = .033). In conclusion, pralidoxime had a rapid onset of pressor effect. Pralidoxime administered during CPR led to significantly higher rates of ROSC and 6‐hour survival by improving CPP in a pig model.

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Section: Discussionmentioning

confidence: 92%

Section: Introductionmentioning

confidence: 99%

Pralidoxime administered during cardiopulmonary resuscitation facilitates successful resuscitation in a pig model of cardiac arrest

Jung

Lee

Jeung

et al. 2019

Clin Exp Pharma Physio

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“…Current guidelines recommend the use of epinephrine and amiodarone, both of which improve short-term outcomes in out-of-hospital cardiac arrest, but there is limited evidence supporting substantial neurological improvement when these medications are used. 59,60 Given the differences between in-hospital and out-of-hospital cardiac arrest (Table 1), especially the much earlier administration of drugs in the in-hospital setting, it is unclear whether findings from studies of out-of-hospital cardiac arrest apply to in-hospital cardiac arrest. For in-hospital events, early administration of epinephrine in patients with a nonshockable rhythm is associated with better outcomes.…”

Section: Resultsmentioning

confidence: 99%

In-Hospital Cardiac Arrest

Andersen

Holmberg

Berg

et al. 2019

JAMA

629

535

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IMPORTANCE In-hospital cardiac arrest is common and associated with a high mortality rate. Despite this, in-hospital cardiac arrest has received little attention compared with other high-risk cardiovascular conditions, such as stroke, myocardial infarction, and out-of-hospital cardiac arrest. OBSERVATIONS In-hospital cardiac arrest occurs in over 290 000 adults each year in the United States. Cohort data from the United States indicate that the mean age of patients with in-hospital cardiac arrest is 66 years, 58% are men, and the presenting rhythm is most often (81%) nonshockable (ie, asystole or pulseless electrical activity). The cause of the cardiac arrest is most often cardiac (50%-60%), followed by respiratory insufficiency (15%-40%). Efforts to prevent in-hospital cardiac arrest require both a system for identifying deteriorating patients and an appropriate interventional response (eg, rapid response teams). The key elements of treatment during cardiac arrest include chest compressions, ventilation, early defibrillation, when applicable, and immediate attention to potentially reversible causes, such as hyperkalemia or hypoxia. There is limited evidence to support more advanced treatments. Post–cardiac arrest care is focused on identification and treatment of the underlying cause, hemodynamic and respiratory support, and potentially employing neuroprotective strategies (eg, targeted temperature management). Although multiple individual factors are associated with outcomes (eg, age, initial rhythm, duration of the cardiac arrest), a multifaceted approach considering both potential for neurological recovery and ongoing multiorgan failure is warranted for prognostication and clinical decision-making in the Post–cardiac arrest period. Withdrawal of care in the absence of definite prognostic signs both during and after cardiac arrest should be avoided. Hospitals are encouraged to participate in national quality-improvement initiatives. CONCLUSIONS AND RELEVANCE An estimated 290 000 in-hospital cardiac arrests occur each year in the United States. However, there is limited evidence to support clinical decision making. An increased awareness with regard to optimizing clinical care and new research might improve outcomes.

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“…In the United Kingdom, in a trial of 8014 patients with OHCA, randomized to epinephrine or placebo, 30‐day survival was higher in the former group (3.2% [ n = 130] vs 2.4% [ n = 94]). After subgroup analysis, the survival benefit (OR = 2.10) was noted only in patients with a nonshockable initial rhythm; the subgroup known to have the worse outcomes . This being said, negative prognostic factors, notably lack of initial shockable rhythm could be regarded as markers of advanced stage of cardiac arrest and patients with these criteria would benefit most from intubation and/or vasoactive resuscitative drugs.…”

Section: Discussionmentioning

confidence: 99%

Epidemiology, etiology, and outcomes of out‐of‐hospital cardiac arrest in young patients in lebanon

Refaat

Kozhaya

Abou‐Zeid

et al. 2019

Pacing Clinical Electrophis

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Background The burden of out‐of‐hospital cardiac arrest (OHCA) on different population segments in developing countries is not well studied. Previous studies from Lebanon report poor survival to hospital discharge (4.8%‐5.5%). This study describes characteristics and outcomes of young OHCA victims in Beirut, Lebanon Methods This retrospective observational study included young patients (<35 years of age) with OHCA admitted to the emergency department (ED) of a tertiary care center in Lebanon over a 10‐year period. Results Fifty‐four patients with OHCA were identified. Most were males (74.1%, n = 40) and the mean age was 17.9 ± 10.9 years. The most common arrest location was home (44.4%, n = 24). The majority were witnessed (78.8%, n = 41) with 15.4% (n = 8) witnessed by emergency medical services (EMS). Prehospital cardiopulmonary resuscitation was done for 22 patients (41.5%) mostly by EMS (n = 19, 86.4%), 9.1% (n = 2) by a bystander, and 4.5% (n = 1) by a family member. Prehospital automated external defibrillator use was documented in 13% (n = 7) of cases. Most patients (n = 48, 88.9%) were resuscitated in the ED where the most common rhythm was asystole (55.6%, n = 30). Half of the patients (50%, n = 27) survived to hospital admission. Overall survival to hospital discharge was 16.7% (n = 9). Good neurologic outcome (cerebral performance category 1 or 2) was documented in seven patients (9.3%). Conclusion Survival rate of young OHCA victims in Lebanon (16.7%) is higher than previously reported rates of OHCA in the overall population. Targeted community activities and medical oversight of EMS activities are needed to link EMS activities to clinical outcomes.

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A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest

Cited by 564 publications

References 35 publications

Pralidoxime administered during cardiopulmonary resuscitation facilitates successful resuscitation in a pig model of cardiac arrest

Pralidoxime administered during cardiopulmonary resuscitation facilitates successful resuscitation in a pig model of cardiac arrest

In-Hospital Cardiac Arrest

Epidemiology, etiology, and outcomes of out‐of‐hospital cardiac arrest in young patients in lebanon

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