Dataset Information

One and Done Epinephrine in Out-of-Hospital Cardiac Arrest? Outcomes in a Multiagency United States Study.

ABSTRACT:

Background

Cardiac arrest guidelines recommend epinephrine every 3-5 minutes during cardiac arrest resuscitation. However, it is unclear if multiple epinephrine doses are associated with improved outcomes. The objective of this study was to determine if a single-dose epinephrine protocol was associated with improved survival compared to traditional multidose protocols.

Methods

We conducted a pre-post study across five North Carolina EMS agencies from 11/1/2016 to 10/29/2019. Patients ≥18 years old with attempted resuscitation for non-traumatic prehospital cardiac arrest were included. Data were collected 1 year before and after implementation of the single-dose epinephrine protocol. Prior to implementation, all agencies used a multidose epinephrine protocol. The Cardiac Arrest Registry to Enhance Survival (CARES) was used to obtain patient outcomes. Study outcomes were survival to hospital discharge (primary) and return of spontaneous circulation (ROSC). Analysis was by intention to treat. Outcomes were compared pre- vs. post-implementation using generalized estimating equations to account for clustering within EMS agencies. Adjusted analyses included age, sex, race, shockable vs. non-shockable rhythm, witnessed arrest, automatic external defibrillator availability, EMS response interval, and bystander cardiopulmonary resuscitation.

Results

During the study period there were 1,690 encounters (899 pre- and 791 post-implementation). The population was 74.7% white, 61.1% male, and had a median age of 65 (IQR 53-76) years. Survival to hospital discharge was similar pre- vs. post-implementation [13.6% (122/899) vs. 15.4% (122/791); OR 1.19, 95%CI 0.89-1.59]. However, ROSC was more common post-implementation [42.3% (380/899) vs. 32.5% (257/791); OR 0.66, 95%CI 0.54-0.81]. After adjusting for covariates, the single-dose protocol was associated with similar survival to discharge rates (aOR 0.88, 95%CI 0.77-1.29), but with decreased ROSC rates (aOR 0.58, 95%CI 0.47-0.72).

Conclusion

A prehospital single-dose epinephrine protocol was associated with similar survival to hospital discharge, but decreased ROSC rates compared to the traditional multidose epinephrine protocol.

SUBMITTER: Ashburn NP

PROVIDER: S-EPMC10088522 | biostudies-literature | 2023

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

One and Done Epinephrine in Out-of-Hospital Cardiac Arrest? Outcomes in a Multiagency United States Study.

Ashburn Nicklaus P NP Beaver Bryan P BP Snavely Anna C AC Nazir Niaman N Winslow James T JT Nelson R Darrell RD Mahler Simon A SA Stopyra Jason P JP

Prehospital emergency care 20220926 6

<h4>Background</h4>Cardiac arrest guidelines recommend epinephrine every 3-5 minutes during cardiac arrest resuscitation. However, it is unclear if multiple epinephrine doses are associated with improved outcomes. The objective of this study was to determine if a single-dose epinephrine protocol was associated with improved survival compared to traditional multidose protocols.<h4>Methods</h4>We conducted a pre-post study across five North Carolina EMS agencies from 11/1/2016 to 10/29/2019. Patie ...[more]

PMID: 36041188

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Project description:ImportanceRecent reports from communities severely affected by the coronavirus disease 2019 (COVID-19) pandemic found lower rates of sustained return of spontaneous circulation (ROSC) for out-of-hospital cardiac arrest (OHCA). Whether the pandemic has affected OHCA outcomes more broadly is unknown.ObjectiveTo assess the association between the COVID-19 pandemic and OHCA outcomes, including in areas with low and moderate COVID-19 disease burden.Design, setting, and participantsThis study used a large US registry of OHCAs to compare outcomes during the pandemic period of March 16 through April 30, 2020, with those from March 16 through April 30, 2019. Cases were geocoded to US counties, and the COVID-19 mortality rate in each county was categorized as very low (0-25 per million residents), low (26-100 per million residents), moderate (101-250 per million residents), high (251-500 per million residents), or very high (>500 per million residents). As additional controls, the study compared OHCA outcomes during the prepandemic period (January through February) and peripandemic period (March 1 through 15).ExposureThe COVID-19 pandemic.Main outcomes and measuresSustained ROSC (≥20 minutes), survival to discharge, and OHCA incidence.ResultsA total of 19 303 OHCAs occurred from March 16 through April 30 in both years, with 9863 cases in 2020 (mean [SD] age, 62.6 [19.3] years; 6040 men [61.3%]) and 9440 in 2019 (mean [SD] age, 62.2 [19.2] years; 5922 men [62.7%]). During the pandemic, rates of sustained ROSC were lower than in 2019 (23.0% vs 29.8%; adjusted rate ratio, 0.82 [95% CI, 0.78-0.87]; P < .001). Sustained ROSC rates were lower by between 21% (286 of 1429 [20.0%] in 2020 vs 305 of 1130 [27.0%] in 2019; adjusted RR, 0.79 [95% CI, 0.65-0.97]) and 33% (149 of 863 [17.3%] in 2020 vs 192 of 667 [28.8%] in 2019; adjusted RR, 0.67 [95% CI, 0.56-0.80]) in communities with high or very high COVID-19 mortality, respectively; however, rates of sustained ROSC were also lower by 11% (583 of 2317 [25.2%] in 2020 vs 740 of 2549 [29.0%] in 2019; adjusted RR, 0.89 [95% CI, 0.81-0.98]) to 15% (889 of 3495 [25.4%] in 2020 vs 1109 of 3532 [31.4%] in 2019; adjusted RR, 0.85 [95% CI, 0.78-0.93]) in communities with very low and low COVID-19 mortality. Among emergency medical services agencies with complete data on hospital survival (7085 total patients), survival to discharge was lower during the pandemic compared with 2019 (6.6% vs 9.8%; adjusted RR, 0.83 [95% CI, 0.69-1.00]; P = .048), primarily in communities with moderate to very high COVID-19 mortality (interaction P = .049). Incidence of OHCA was higher than in 2019, but the increase was largely observed in communities with high COVID-19 mortality (adjusted mean difference, 38.6 [95% CI, 37.1-40.1] per million residents) and very high COVID-19 mortality (adjusted mean difference, 28.7 [95% CI, 26.7-30.6] per million residents). In contrast, there was no difference in rates of sustained ROSC or survival to discharge during the prepandemic and peripandemic periods in 2020 vs 2019.Conclusions and relevanceEarly during the pandemic, rates of sustained ROSC for OHCA were lower throughout the US, even in communities with low COVID-19 mortality rates. Overall survival was lower, primarily in communities with moderate or high COVID-19 mortality.

Project description:ImportanceAdministration of epinephrine has been found to be associated with an increased chance of survival after out-of-hospital cardiac arrest (OHCA), but the optimal timing of administration has not been fully investigated.ObjectiveTo ascertain whether there is an association between timing of epinephrine administration and patient outcomes after OHCA.Design, setting, and participantsThis cohort study included adults 18 years or older with OHCA treated by emergency medical services (EMS) personnel from April 1, 2011, to June 30, 2015. Initial cardiac rhythm was stratified as either initially shockable (ventricular defibrillation or pulseless ventricular tachycardia) or nonshockable (pulseless electrical activity or asystole). Eligible individuals were identified from among publicly available, deidentified patient-level data from the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registry, a prospective registry of adults with EMS-treated, nontraumatic OHCA with 10 sites in North America. Data analysis was conducted from May 2019 to April 2021.ExposuresInterval between advanced life support (ALS)-trained EMS personnel arrival at the scene and the first prehospital intravenous or intraosseous administration of epinephrine.Main outcomes and measuresThe primary outcome was survival to hospital discharge. In each cohort of initial cardiac rhythms, patients who received epinephrine at any period (minutes) after EMS arrival at the scene were matched with patients who were at risk of receiving epinephrine within the same period using time-dependent propensity scores calculated from patient demographic characteristics, arrest characteristics, and EMS interventions.ResultsOf 41 079 eligible individuals (median [interquartile range] age, 67 [55-79] years), 26 579 (64.7%) were men. A total of 10 088 individuals (24.6%) initially had shockable cardiac rhythms, and 30 991 (75.4%) had nonshockable rhythms. Those who received epinephrine included 8223 patients (81.5%) with shockable cardiac rhythms and 27 901 (90.0%) with nonshockable rhythms. In the shockable cardiac rhythm cohort, the risk ratio (RR) for receipt of epinephrine with survival to hospital discharge was highest between 0 and 5 minutes after EMS arrival (1.12; 95% CI, 0.99-1.26) across the categorized timing of the administration of epinephrine by 5-minute intervals after EMS arrival; however, that finding was not statistically significant. Treating the timing of epinephrine administration as a continuous variable, the RR for survival to hospital discharge decreased 5.5% (95% CI, 3.4%-7.5%; P < .001 for the interaction between epinephrine administration and time to matching) per minute after EMS arrival. In the nonshockable cardiac rhythm cohort, the RR for the association of receipt of epinephrine with survival to hospital discharge was the highest between 0 and 5 minutes (1.28; 95% CI, 0.95-1.72), although not statistically significant, and decreased 4.4% (95% CI, 0.8%-7.9%; P for interaction = .02) per minute after EMS arrival.Conclusions and relevanceAmong adults with OHCA, survival to hospital discharge differed across the timing of epinephrine administration and decreased with delayed administration for both shockable and nonshockable rhythms.

Project description:AbstractOut of hospital cardiac arrest (OHCA) remains a leading cause of mortality among adults in the United States. Environmental impact on incidence and outcomes of OHCA has not been fully investigated in recent years. Previous studies showed a possible increase in incidence and mortality in winter season and during seasons with temperature extremes. This study examines seasonal variation in incidence and outcomes of OHCA in the United States.Retrospective study of adult OHCA using the Nationwide Emergency Department Sample was carried out. Monthly incidence rate per 100,000 ED presentations was calculated. Survival rates for each month of admission were examined by hospital region. Multivariate analyses were conducted to determine the effect of the season and month of admission on survival.A total of 122,870 adult OHCA cases presented to emergency departments (EDs) in 2014 and were included. Average incidence of OHCA cases was 147 per 100,000 ED presentations. Overall survival rate in the study population was 5.6% (95% confidence intervals [CI] = 5.4%-5.9%). Patients had an average age of 65.5 (95% CI: 65.3-65.7) years and were mainly men (61.8%). Rates of OHCA presentations were highest during December and January (9.9% and 10.0%) while survival rates were lowest during December (4.6%) and highest in June (6.9%). Regional variation in OHCA outcomes was also noted with highest average survival rate in West (7.8%) and lowest in South (4.3%). After adjusting for confounders including region of hospital, Summer season (Ref: all other seasons), and more specifically month of June (Ref: all other months) were found to be positively associated with survival (OR 1.27, 95% CI [1.07-1.52], P-value = .008) and (OR 1.43, 95% CI [1.08-1.89], P-value = .012 respectively).Incidence and outcomes of out of hospital cardiac arrest presentations to the emergency departments in the United States have seasonal variation. Both incidence and mortality of OHCA increase during colder months, and survival is significantly higher in summer season or in June. Exploring how to use this variation to improve outcomes through refresher training of medical providers or through other mitigation plans is needed.

Dataset Information

One and Done Epinephrine in Out-of-Hospital Cardiac Arrest? Outcomes in a Multiagency United States Study.

Background

Methods

Results

Conclusion

Publications

One and Done Epinephrine in Out-of-Hospital Cardiac Arrest? Outcomes in a Multiagency United States Study.

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