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Author |
Christiana Gregory Nechelle Wall |
Date |
2021-12-15 |
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Reviewer |
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Edited |
You respond to a motor vehicle accident and arrive to find a 45 year old female patient in cardiac arrest. You notice bystander cardiopulmonary resuscitation (CPR) is in progress; bystanders report that the patient's vehicle was struck at approximately 70 km/hr by a second vehicle that ran a red light. You note marked compartment intrusion where your patient was sitting.
You initiate cardiac arrest management and give epinephrine. You question epinephrine’s benefit on patient outcomes in the case of significant trauma.
“In the traumatic out-of-hospital cardiac arrest (OHCA) patient cohort, does epinephrine administration affect (1) return of spontaneous circulation (ROSC) and (2) survival?”
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Population |
Traumatic OHCA Cohort |
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Intervention |
Epinephrine |
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Control |
No epinephrine |
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Outcome(s) |
(1) ROSC; and (2) Survival |
Search completed: 2021-12-02
Database: PubMed
Terms: (Traumatic OHCA OR Traumatic Out-of-Hospital OR Traumatic Prehospital) AND (Cardiac Arrest OR Heart Arrest) AND (Epinephrine OR Adrenaline) AND (Survival OR Mortality)
36 results (4 relevant, 1 additional)
Research on epinephrine use in traumatic OHCA and its impact on survival and ROSC is burgeoning and presently sparse, with the first study on the topic published in 2015. The studies and their reported findings are summarised below.
Chiang and colleagues (2015) were the first to undertake a retrospective cohort study to evaluate the efficacy of epinephrine in treating traumatic OHCAs. This single centre study enrolled N = 504 patients over the course of three years, with patients divided into two cohorts: (1) prehospital epinephrine (n = 43); (2) and no prehospital epinephrine (n = 417). The study delineated an increase in both sustained ROSC (41.9 % vs. 17.6 %, p < 0.01) and survival to discharge (14.0 % vs. 3.0 %, p < 0.01) within the epinephrine cohort.
Whereas Chiang et al. (2015) reported favourable outcomes, a retrospective population-based study by Irfan et al. (2017) did not. In their investigation, Irfan and colleagues (2017) found decreased ROSC (OR = 0.53; 95% CI = 0.3-0.9, p = 0.02) and survival (OR = 0.045; 95% CI = 0.006-0.358, p = 0.003) in traumatic OHCA patients who received epinephrine However, this study was limited by the analysis that could be performed due to the low number of survivors. As a result, multivariate analysis was not utilised to assess survival.
A few years later, Aoki et al. (2019) conducted a post-hoc analysis of a prospective population-based OHCA registry, assessing epinephrine’s effect on survival at 30 days and prehospital ROSC in traumatic OHCA patients injured in traffic collisions. Out of N = 5,203 traumatic OHCA patients analysed, n = 758 received prehospital epinephrine and n = 4,449 did not. After propensity score matching and adjusting for confounders, the study found that while prehospital epinephrine administration was not associated with increased 30-day survival (OR 2.363; 95% Cl = 0.606-9.223; p = 0.340), it did result in higher rates of prehospital ROSC (OR 6.870; 95% Cl = 3.326-14.192, p < 0.001).
Yamamoto et al. (2019) published a similar study. This time, a post-hoc analysis of a prospective, multicentre observational study of traumatic OHCA patients who had received in-hospital epinephrine. In this study, N = 1030 traumatic OHCA patients were enrolled with n = 822 receiving epinephrine and n = 208 not. Based on their results, they found decreased survival at 7 days ([1.1%] vs [5.3%]; OR = 0.11; 95% CI = 0.01-0.85; p = 0.02) and higher in-hospital ROSC rates in the epinephrine group ([18.0%] vs. [9.0%]; OR = 2.21; 95% CI = 1.16-4.19; p = 0.01). Of note, rates of survival reported within this study were based solely on in-hospital epinephrine administration, causing a marked reduction in external validity.
The aforementioned studies share similarities in regard to methodology and findings, and therefore limitations. Their descriptive nature inherently renders them prone to several biases that will need to be addressed in future research on this topic. Moreover, as these studies do not share comparable findings, the results remain equivocal.
Research on survival following epinephrine administration in traumatic OHCA is an emerging field of study. Until studies with higher levels of evidence are executed, the benefit or harm of epinephrine use in traumatic OHCA remains inconclusive. Future research should aim to address the limitations and strength of the current evidence in order to precisely infer the relationship between epinephrine, ROSC and survival.
Yamamoto R, Suzuki M, Hayashida K, et al. Epinephrine during resuscitation of traumatic cardiac arrest and increased mortality: a post hoc analysis of prospective observational study. 2019. [LINK]
Aoki M, Abe T, Oshima K. Association of Prehospital Epinephrine Administration With Survival Among Patients With Traumatic Cardiac Arrest Caused By Traffic Collisions. 2019. [LINK]
Irfan FB, Consunji R, El-Menyar A et al. Cardiopulmonary resuscitation of out-of-hospital traumatic cardiac arrest in Qatar: A nationwide population-based study. 2017. [LINK]
Chiang WC, Chen SY, Ko PC, et al. Prehospital intravenous epinephrine may boost survival of patients with traumatic cardiac arrest: a retrospective cohort study. 2015. [LINK]
Smith JE, Rickard A, Wise D. Traumatic cardiac arrest. 2015. [LINK]