Despite guidelines and worse outcomes, researchers find significant deviations nationwide in cardiac arrest responses

In cases of cardiac arrest due to a shockable rhythm, current Advanced Cardiac Life Support (ACLS) guidelines recommend immediate defibrillation as the first line treatment. Epinephrine is recommended only if the person remains pulseless after two defibrillation attempts. As a result, the use of epinephrine in cardiac arrest treatment is not recommended as the first line of treatment for people with cardiac arrest due to shockable rhythm.

In a study published this week in the BMJ led by Erin Evans MD, critical care fellow; Morgan Bobb Swanson, BS, Medical Scientist Training Program student; and Saket Girotra, MBBS, MS, associate professor in Cardiovascular Medicine, researchers found that more than 1 in 4 people with shockable in-hospital cardiac arrest (IHCA) are treated with epinephrine instead of defibrillation first. Use of epinephrine before defibrillation was correlated with lower survival rates and neurological complications. Moreover, defibrillation was also delayed in those who received epinephrine. The researchers analyzed data on 34,820 participants from 497 hospitals participating in the 2000–2018 American Heart Association’s Get with the Guidelines-Resuscitation registry.

“To our knowledge, this is the first study to examine use of epinephrine before first defibrillation in patients with shockable IHCA and adds to the growing evidence of the potential harm of early epinephrine in these patients,” Evans said.

“We were surprised to see how often epinephrine was used in this setting, despite strong guideline recommendations for immediate defibrillation. Our findings suggest that there is an urgent need to develop interventions that prioritize defibrillation over epinephrine in such patients,” Girotra said.

UI collaborators include Nassar Boulos, MD, MPH, clinical associate professor in Pulmonary, Critical Care, and Occupational Medicine; Mary Vaughan-Sarrazin, associate professor in General Internal Medicine; and Nicholas Mohr, MD, MS, professor of Emergency Medicine. In addition to the UI Health Care team, Paul S Chan, MD, professor in Cardiology at the University of Missouri-Kansas’ Saint Luke’s Mid America Heart and Vascular Institute, contributed to this study.