High-Dose Epinephrine for Cardiac Arrest: Case Closed

ABSTRACT & COMMENTARY

Source: Gueugniaud PY, et al. A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. N Engl J Med 1998;339:1595-1601.

In this multicenter study from france and belgium, adults sustaining out-of-hospital cardiac arrests were randomized to receive repeated administrations of either standard-dose or high-dose epinephrine. Subjects were included if they demonstrated ventricular fibrillation after three defibrillation attempts or if they had asystole or pulseless electrical activity. Medical teams in the field administered, in a blinded fashion, epinephrine at three-minute intervals in either high (5 mg) doses or standard (1 mg) doses. Except for the epinephrine dosage, the resuscitations followed standard protocols. Patients with traumatic arrests and those with signs of irreversible arrest were excluded.

Over a two-year period, 3327 patients were enrolled in the study. The high-dose epinephrine group had a statistically higher rate of return of spontaneous circulation than the standard-dose group (40% vs 36%), as well as a higher rate of survival to hospital admission (26% vs 24%). Nevertheless, the rate of survival to hospital discharge was the same in both groups (2-3%), and there was no difference in neurological outcome. Gueugniaud and colleagues conclude that high-dose epinephrine offers no long-term benefit to victims of out-of-hospital cardiac arrest.

Comment by David J. Karras, MD, FACEP, FAAEM

This study is elegant in design and straightforward in its conclusion. Two earlier studies had identical findings but have been criticized for administering only a single dose of high-dose epinephrine,¹ and for only enrolling patients who had already undergone lengthy resuscitation attempts.² This study addresses these limitations, and, with its large sample size, it has the power to be considered the definitive study of high-dose epinephrine.

References

1. Brown CG, et al. Comparison of standard-dose and high-dose epinephrine in cardiac arrest outside the hospital. N Engl J Med 1992;327:1051-1055.

2. Stiell IG, et al. High-dose epinephrine in adult cardiac arrest. N Engl J Med 1992;327:1045-1050.