The effect of intravenous adrenaline on electrocardiographic changes during resuscitation in patients with initial pulseless electrical activity in out of hospital cardiac arrest

Abstract

Introduction: Presence of electrocardiographic rhythm in the absence of palpable pulses defines pulseless electrical activity (PEA) and the electrocardiogram (ECG) may provide a source of information during resuscitation. The aim of this study was to examine the development of ECG characteristics during advanced life support (ALS) from Out-of-hospital cardiac arrest (OHCA) with initial PEA, and to explore the potential effects of adrenaline on these characteristics. Methods: Patients with OHCA and initial PEA, part of randomized controlled trial of ALS with or without intravenous access and medications, were included. A total of 4840 combined observations of QRS complex rate (heart rate) and width were made by examining defibrillator recordings from 170 episodes of cardiac arrest. Results: We found Increased heart rate (47 beats per minute) and reduced QRS complex width (62 ms) during ALS in patients who obtained return of spontaneous circulation (ROSC); while patients who received adrenaline but died increased their heart rate (22 beats per minute) without any concomitant decrease in QRS complex width. Conclusion: ECG changes during ALS in cardiac arrest were associated with prognosis, and the administration of adrenaline impacted on these changes.

The effects of adrenaline in out of hospital cardiac arrest with shockable and non-shockable rhythms: Findings from the PACA and PARAMEDIC-2 randomised controlled trials

“…Some of the causes of cardiac arrest associated with non-shockable rhythms such impaired myocardial contractility, reduced systemic vascular resistance and failure of myocardial conduction may be more responsive to treatment with adrenaline. 26,27 This study has several limitations. Although defined as an a priori analyses, exploration of the treatment effects of adrenaline according to the initial rhythm were not the primary intent of either the PACA or PARAMEDIC-2 study.…”

The effects of adrenaline in out of hospital cardiac arrest with shockable and non-shockable rhythms: Findings from the PACA and PARAMEDIC-2 randomised controlled trials

“…Some of the causes of cardiac arrest associated with non-shockable rhythms such impaired myocardial contractility, reduced systemic vascular resistance and failure of myocardial conduction may be more responsive to treatment with adrenaline. 26,27 This study has several limitations. Although defined as an a priori analyses, exploration of the treatment effects of adrenaline according to the initial rhythm were not the primary intent of either the PACA or PARAMEDIC-2 study.…”

Heart rate and QRS duration as biomarkers predict the immediate outcome from pulseless electrical activity

“…Several investigators have demonstrated bradycardia in patients prior to arrest 26,29 and HR changes during resuscitation possibly due to chest compressions and/or epinephrine. 11,30 Limitations Defining ROSC as an organized rhythm without chest compressions for more than one minute is one of the major limitations in this study. Differing between ROSC and PEA in retrospect is difficult without objective measures of circulation.…”

Differences in Pathophysiology and Treatment Efficacy Based on Heterogeneous Out-of-Hospital Cardiac Arrest

“…These differential effects of epinephrine, depending on the initial waveform, might be explained by differences in the underlying mechanisms. Given the background of cardiac disease in patients with shockable CA, epinephrine has been associated with increased myocardial oxygen demand, increased incidence of recurrent CA, and worse myocardial dysfunction after ROSC, suggesting that patients with shockable CA may benefit less from epinephrine than those without non-shockable CA [ 27 ].…”

The effects of adrenaline in out of hospital cardiac arrest with shockable and non-shockable rhythms: Findings from the PACA and PARAMEDIC-2 randomised controlled trials

“…Some of the causes of cardiac arrest associated with non-shockable rhythms such impaired myocardial contractility, reduced systemic vascular resistance and failure of myocardial conduction may be more responsive to treatment with adrenaline. 26,27 This study has several limitations. Although defined as an a priori analyses, exploration of the treatment effects of adrenaline according to the initial rhythm were not the primary intent of either the PACA or PARAMEDIC-2 study.…”

Heart rate and QRS duration as biomarkers predict the immediate outcome from pulseless electrical activity

“…Several investigators have demonstrated bradycardia in patients prior to arrest 26,29 and HR changes during resuscitation possibly due to chest compressions and/or epinephrine. 11,30 Limitations Defining ROSC as an organized rhythm without chest compressions for more than one minute is one of the major limitations in this study. Differing between ROSC and PEA in retrospect is difficult without objective measures of circulation.…”

Differences in Pathophysiology and Treatment Efficacy Based on Heterogeneous Out-of-Hospital Cardiac Arrest

“…These differential effects of epinephrine, depending on the initial waveform, might be explained by differences in the underlying mechanisms. Given the background of cardiac disease in patients with shockable CA, epinephrine has been associated with increased myocardial oxygen demand, increased incidence of recurrent CA, and worse myocardial dysfunction after ROSC, suggesting that patients with shockable CA may benefit less from epinephrine than those without non-shockable CA [ 27 ].…”

The effects of adrenaline in out of hospital cardiac arrest with shockable and non-shockable rhythms: Findings from the PACA and PARAMEDIC-2 randomised controlled trials

“…Some of the causes of cardiac arrest associated with non-shockable rhythms such impaired myocardial contractility, reduced systemic vascular resistance and failure of myocardial conduction may be more responsive to treatment with adrenaline. 26,27 This study has several limitations. Although defined as an a priori analyses, exploration of the treatment effects of adrenaline according to the initial rhythm were not the primary intent of either the PACA or PARAMEDIC-2 study.…”

Heart rate and QRS duration as biomarkers predict the immediate outcome from pulseless electrical activity

“…Several investigators have demonstrated bradycardia in patients prior to arrest 26,29 and HR changes during resuscitation possibly due to chest compressions and/or epinephrine. 11,30 Limitations Defining ROSC as an organized rhythm without chest compressions for more than one minute is one of the major limitations in this study. Differing between ROSC and PEA in retrospect is difficult without objective measures of circulation.…”

Differences in Pathophysiology and Treatment Efficacy Based on Heterogeneous Out-of-Hospital Cardiac Arrest

“…These differential effects of epinephrine, depending on the initial waveform, might be explained by differences in the underlying mechanisms. Given the background of cardiac disease in patients with shockable CA, epinephrine has been associated with increased myocardial oxygen demand, increased incidence of recurrent CA, and worse myocardial dysfunction after ROSC, suggesting that patients with shockable CA may benefit less from epinephrine than those without non-shockable CA [ 27 ].…”