[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Wenzel V, Krismer AC, Arntz HR, Sitter H, Stadlbauer KH, Lindner KH.European Resuscitation Council Vasopressor During Cardiopulmonary Resuscitation Study Group.  A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation.  N Engl J Med. 2004;350(2):105-11314711909PubMedGoogle ScholarCrossref
Steering Committee of the Physicians' Health Study Research Group.  Final report on the aspirin component of the ongoing Physicians' Health Study.  N Engl J Med. 1989;321(3):129-1352664509PubMedGoogle ScholarCrossref
Trialists Collaboration.  Collaborative overview of randomised trials of antiplatelet therapy, I: prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients: Antiplatelet Trialists' Collaboration.  BMJ. 1994;308(6921):81-1068298418PubMedGoogle ScholarCrossref
Nishime EO, Cole CR, Blackstone EH, Pashkow FJ, Lauer MS. Heart rate recovery and treadmill exercise score as predictors of mortality in patients referred for exercise ECG.  JAMA. 2000;284(11):1392-139810989401PubMedGoogle ScholarCrossref
Tang W, Weil MH, Sun S, Noc M, Yang L, Gazmuri RJ. Epinephrine increases the severity of postresuscitation myocardial dysfunction.  Circulation. 1995;92(10):3089-30937586280PubMedGoogle ScholarCrossref
Angelos MG, Butke RL, Panchal AR,  et al.  Cardiovascular response to epinephrine varies with increasing duration of cardiac arrest.  Resuscitation. 2008;77(1):101-11018164797PubMedGoogle ScholarCrossref
Ristagno G, Sun S, Tang W, Castillo C, Weil MH. Effects of epinephrine and vasopressin on cerebral microcirculatory flows during and after cardiopulmonary resuscitation.  Crit Care Med. 2007;35(9):2145-214917855828PubMedGoogle ScholarCrossref
Pearson JW, Redding JS. Epinephrine in cardiac resuscitation.  Am Heart J. 1963;66:210-21414051187PubMedGoogle ScholarCrossref
Otto CW, Yakaitis RW. The role of epinephrine in CPR: a reappraisal.  Ann Emerg Med. 1984;13(9 pt 2):840-8436383142PubMedGoogle ScholarCrossref
ECC Committee, Subcommittees, and Task Forces of the American Heart Association.  2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.  Circulation. 2005;112:(suppl 24)  IV-1-IV-203Google ScholarCrossref
Morrison LJ, Deakin CD, Morley PT,  et al; Advanced Life Support Chapter Collaborators.  2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, part 8: advanced life support.  Circulation. 2010;122(16):(suppl 2)  S345-S42120956256PubMedGoogle ScholarCrossref
Holmberg M, Holmberg S, Herlitz J. Low chance of survival among patients requiring adrenaline (epinephrine) or intubation after out-of-hospital cardiac arrest in Sweden.  Resuscitation. 2002;54(1):37-4512104107PubMedGoogle ScholarCrossref
Ong MEH, Tan EH, Ng FSP,  et al; Cardiac Arrest and Resuscitation Epidemiology Study Group.  Survival outcomes with the introduction of intravenous epinephrine in the management of out-of-hospital cardiac arrest.  Ann Emerg Med. 2007;50(6):635-64217509730PubMedGoogle ScholarCrossref
Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L. Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.  JAMA. 2009;302(20):2222-222919934423PubMedGoogle ScholarCrossref
Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL. Effect of adrenaline on survival in out-of-hospital cardiac arrest: a randomized double-blind placebo-controlled trial.  Resuscitation. 2011;82(9):1138-114321745533PubMedGoogle ScholarCrossref
Kitamura T, Iwami T, Kawamura T, Nagao K, Tanaka H, Hiraide A.Implementation Working Group for the All-Japan Utstein Registry of the Fire and Disaster Management Agency.  Nationwide public-access defibrillation in Japan.  N Engl J Med. 2010;362(11):994-100420237345PubMedGoogle ScholarCrossref
Ogawa T, Akahane M, Koike S, Tanabe S, Mizoguchi T, Imamura T. Outcomes of chest compression only CPR vs conventional CPR conducted by lay people in patients with out of hospital cardiopulmonary arrest witnessed by bystanders: nationwide population based observational study.  BMJ. 2011;342:c710621273279PubMedGoogle ScholarCrossref
Kitamura T, Iwami T, Kawamura T,  et al; Implementation Working Group for All-Japan Utstein Registry of the Fire and Disaster Management Agency.  Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study.  Lancet. 2010;375(9723):1347-135420202679PubMedGoogle ScholarCrossref
 Japanese Guidelines for Emergency Care and Cardiopulmonary Resuscitation. 3rd ed. Tokyo, Japan: Health Shuppansha; 2007
Cummins RO, Chamberlain DA, Abramson NS,  et al.  Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein style: a statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council.  Circulation. 1991;84(2):960-9751860248PubMedGoogle ScholarCrossref
Jacobs I, Nadkarni V, Bahr J,  et al; International Liaison Committee on Resuscitation; American Heart Association; European Resuscitation Council; Australian Resuscitation Council; New Zealand Resuscitation Council; Heart and Stroke Foundation of Canada; InterAmerican Heart Foundation; Resuscitation Councils of Southern Africa; ILCOR Task Force on Cardiac Arrest and Cardiopulmonary Resuscitation Outcomes.  Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein template for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation.  Circulation. 2004;110:3385-339715557386PubMedGoogle ScholarCrossref
 Fire and Disaster Management Agency Guidelines for Resuscitation by Emergency Lifesaving Technicians. February 14, 2006. FDMA Instructions No. 1. http://www.sukagawa119.jp/d1w_reiki/41897020000100000000/41897020000100000000/41897020000100000000.html. Accessed February 24, 2012
Cummins RO, Chamberlain DA, Hazinski MF,  et al; American Heart Association.  Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the in-hospital “Utstein style.”  Circulation. 1997;95(8):2213-22399133537PubMedGoogle ScholarCrossref
Hsieh FY, Bloch DA, Larsen MD. A simple method of sample size calculation for linear and logistic regression.  Stat Med. 1998;17(14):1623-16349699234PubMedGoogle ScholarCrossref
Joffe MM, Rosenbaum PR. Propensity scores.  Am J Epidemiol. 1999;150(4):327-33310453808PubMedGoogle ScholarCrossref
Parsons LS. Reducing Bias in a Propensity Score Matched-Pair Sample Using Greedy Matching Techniques. http://www2.sas.com/proceedings/sugi26/p214-26.pdf#search='propensityscore,sas'. Accessed May 14, 2011
Stiell IG, Wells GA, Field B,  et al; Ontario Prehospital Advanced Life Support Study Group.  Advanced cardiac life support in out-of-hospital cardiac arrest.  N Engl J Med. 2004;351(7):647-65615306666PubMedGoogle ScholarCrossref
Bernard SA, Gray TW, Buist MD,  et al.  Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia.  N Engl J Med. 2002;346(8):557-56311856794PubMedGoogle ScholarCrossref
Grogaard HK, Wik L, Eriksen M, Brekke M, Sunde K. Continuous mechanical chest compressions during cardiac arrest to facilitate restoration of coronary circulation with percutaneous coronary intervention.  J Am Coll Cardiol. 2007;50(11):1093-109417825721PubMedGoogle ScholarCrossref
Virkkunen I, Paasio L, Ryynänen S,  et al.  Pulseless electrical activity and unsuccessful out-of-hospital resuscitation: what is the cause of death?  Resuscitation. 2008;77(2):207-21018249482PubMedGoogle ScholarCrossref
Rivers EP, Wortsman J, Rady MY, Blake HC, McGeorge FT, Buderer NM. The effect of the total cumulative epinephrine dose administered during human CPR on hemodynamic, oxygen transport, and utilization variables in the postresuscitation period.  Chest. 1994;106(5):1499-15077956410PubMedGoogle ScholarCrossref
Caring for the Critically Ill Patient
March 21, 2012

Prehospital Epinephrine Use and Survival Among Patients With Out-of-Hospital Cardiac Arrest

Author Affiliations

Author Affiliations: Department of Health Services Management and Policy, Kyushu University Graduate School of Medicine (Drs Hagihara and Wakata and Mr Abe), and Department of Emergency and Critical Care Center, Kyushu University Hospital (Dr Nagata), Fukuoka, Japan; and Ambulance Service Planning Division, Fire and Disaster Management Agency, Ministry of Internal Affairs and Communications (Dr Hasegawa), and Department of Acupuncture and Moxibustion, Faculty of Health Care, Teikyo Heisei University (Dr Miyazaki), Tokyo, Japan.

JAMA. 2012;307(11):1161-1168. doi:10.1001/jama.2012.294

Context Epinephrine is widely used in cardiopulmonary resuscitation for out-of-hospital cardiac arrest (OHCA). However, the effectiveness of epinephrine use before hospital arrival has not been established.

Objective To evaluate the association between epinephrine use before hospital arrival and short- and long-term mortality in patients with cardiac arrest.

Design, Setting, and Participants Prospective, nonrandomized, observational propensity analysis of data from 417 188 OHCAs occurring in 2005-2008 in Japan in which patients aged 18 years or older had an OHCA before arrival of emergency medical service (EMS) personnel, were treated by EMS personnel, and were transported to the hospital.

Main Outcome Measures Return of spontaneous circulation before hospital arrival, survival at 1 month after cardiac arrest, survival with good or moderate cerebral performance (Cerebral Performance Category [CPC] 1 or 2), and survival with no, mild, or moderate neurological disability (Overall Performance Category [OPC] 1 or 2).

Results Return of spontaneous circulation before hospital arrival was observed in 2786 of 15 030 patients (18.5%) in the epinephrine group and 23 042 of 402 158 patients (5.7%) in the no-epinephrine group (P < .001); it was observed in 2446 (18.3%) and 1400 (10.5%) of 13 401 propensity-matched patients, respectively (P < .001). In the total sample, the numbers of patients with 1-month survival and survival with CPC 1 or 2 and OPC 1 or 2, respectively, were 805 (5.4%), 205 (1.4%), and 211 (1.4%) with epinephrine and 18 906 (4.7%), 8903 (2.2%), and 8831 (2.2%) without epinephrine (all P <.001). Corresponding numbers in propensity-matched patients were 687 (5.1%), 173 (1.3%), and 178 (1.3%) with epinephrine and 944 (7.0%), 413 (3.1%), and 410 (3.1%) without epinephrine (all P <.001). In all patients, a positive association was observed between prehospital epinephrine and return of spontaneous circulation before hospital arrival (adjusted odds ratio [OR], 2.36; 95% CI, 2.22-2.50; P < .001). In propensity-matched patients, a positive association was also observed (adjusted OR, 2.51; 95% CI, 2.24-2.80; P < .001). In contrast, among all patients, negative associations were observed between prehospital epinephrine and long-term outcome measures (adjusted ORs: 1-month survival, 0.46 [95% CI, 0.42-0.51]; CPC 1-2, 0.31 [95% CI, 0.26-0.36]; and OPC 1-2, 0.32 [95% CI, 0.27-0.38]; all P < .001). Similar negative associations were observed among propensity-matched patients (adjusted ORs: 1-month survival, 0.54 [95% CI, 0.43-0.68]; CPC 1-2, 0.21 [95% CI, 0.10-0.44]; and OPC 1-2, 0.23 [95% CI, 0.11-0.45]; all P < .001).

Conclusion Among patients with OHCA in Japan, use of prehospital epinephrine was significantly associated with increased chance of return of spontaneous circulation before hospital arrival but decreased chance of survival and good functional outcomes 1 month after the event.