Drug routes in out-of-hospital cardiac arrest: A summary of current evidence

Hooper, Amy; Nolan, Jerry P.; Rees, Nigel; Walker, Alison; Perkins, Gavin D; Couper, Keith

doi:10.1016/j.resuscitation.2022.10.015

Cited by 9 publications

(2 citation statements)

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“…The risks of misplacement and damage to adjacent structure through attempting central venous cannulation during CPR likely outweigh the benefits. [ 22 , 23 ] The intramuscular route for adrenaline administration in cardiac arrest might facilitate very early drug administration, but ongoing uncertainties regarding its absorption preclude its routine use outside the research setting [ 24 , 25 ].…”

Section: Adrenalinementioning

confidence: 99%

Improving vasopressor use in cardiac arrest

Perkins

Couper

2023

Crit Care

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The Chain of Survival highlights the effectiveness of early recognition of cardiac arrest and call for help, early cardiopulmonary resuscitation and early defibrillation. Most patients, however, remain in cardiac arrest despite these interventions. Drug treatments, particularly the use of vasopressors, have been included in resuscitation algorithms since their inception. This narrative review describes the current evidence base for vasopressors and reports that adrenaline (1 mg) is highly effective at achieving return of spontaneous circulation (number needed to treat 4) but is less effective on long-term outcomes (survival to 30 days, number needed to treat 111) with uncertain effects on survival with a favourable neurological outcome. Randomised trials evaluating vasopressin, either as an alternative to or in addition to adrenaline, and high-dose adrenaline have failed to find evidence of improved long-term outcomes. There is a need for future trials to evaluate the interaction between steroids and vasopressin. Evidence for other vasopressors (e.g. noradrenaline, phenylephedrine) is insufficient to support or refute their use. The use of intravenous calcium chloride as a routine intervention in out of hospital cardiac arrest is not associated with benefit and may cause harm. The optimal route for vascular access between peripheral intravenous versus intraosseous routes is currently the subject of two large randomised trials. Intracardiac, endobronchial, and intramuscular routes are not recommended. Central venous administration should be limited to patients where an existing central venous catheter is in situ and patent.

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Section: Adrenalinementioning

confidence: 99%

Improving vasopressor use in cardiac arrest

Perkins

Couper

2023

Crit Care

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“…The usefulness of intraosseous infusion (IOI) has been demonstrated in different countries [1]. However, IOI has not been widely used in Japan, and its recognition is low in departments other than emergency departments.…”

Section: Introductionmentioning

confidence: 99%

The Usefulness of Humeral Intraosseous Infusion Performed by Rapid Response Vehicle Staff in Patients with Cardiac Arrest: A Single-Centre, Retrospective Study

Takamatsu

Tsubota

Okajima

et al. 2023

Preprint

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Background Humeral intraosseous infusion (IOI) is often performed in the prehospital setting by rapid response vehicle staff. IOI is used to administer extracellular fluid products and resuscitation drugs such as adrenaline to patients with trauma and cardiac arrest when venous channels are difficult to secure. However, in Japan, its usefulness is not well recognised, and it is rarely performed aggressively. This study aimed to demonstrate that humeral IOI is superior to the conventional peripheral venous infusion (VI) in cardiac arrest.Methods Among cases that received emergency care by rapid response vehicle staff from 2017 to 2022, 363 patients with cardiac arrest were transported to our institution with well-defined timing information. Patients were divided into humeral IOI and peripheral VI groups and compared in terms of age, sex, time from dispatch to contact and arrival at the hospital, time spent at the scene, distance travelled, type of injury, and return of spontaneous circulation (ROSC). Incident reports related to IOI during this period were also investigated. Continuous variables were compared by analyses of variance. Categorical data were compared using the chi-square test.Results There were no significant differences in terms of age, sex, time (min) from onset to dispatch (IOI: 3.19 ± 0.88, VI: 3.85 ± 0.60, P = 0.54), contact (IOI: 13.53 ± 0.96, VI: 14.11 ± 0.66, P = 0.62), and hospital arrival (IOI: 30.37 ± 1.15, VI: 30.51 ± 0.79, P = 0.92), time spent at the scene (IOI: 8.96 ± 0.35, VI: 8.25 ± 0.24, P = 0.1), or mileage (km) (IOI: 9.23 ± 0.46, VI: 9.58 ± 0.32, P = 0.53). There were significantly more cases of ROSC in the IOI group than in the VI group (IOI: yes 47: no 70, VI: yes 41: no 95, P = 0.001). There were no incident reports, such as unnoticed complications, continued infusions, and needle stick injury.Conclusions Humeral IOI required the same amount of time to perform as conventional peripheral VI but showed better outcomes in terms of ROSC. Humeral IOI is a valid infusion route until the completion of primary care. This simple and reliable procedure should be feasible for future prehospital emergency care.

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