This single-center before-and-after study investigated the effect of an initial IM epinephrine dose in OHCA on survival outcomes. Subsequent to a pre-intervention phase with paramedics following standard ACLS protocols (IV/IO), the intervention phase (IM) saw the addition of an initial 5mg IM epinephrine dose while attempts to establish IV/IO access were ongoing. 1,405 adult OHCA patients (IM group, n = 420) regardless of initial rhythm were included after exclusions such as ROSC before epinephrine and traumatic arrest. Demographics were similar between the groups, with differences in age and bystander CPR favoring the IM group. After adjusting for demographics, bystander CPR, and EMS response time, the IM group saw improvement in all measured survival outcomes: survival to hospital admission (37.1% vs 31.6%; adjusted odds ratio [aOR] 1.37, 95%CI 1.06-1.77), survival to hospital discharge (11.0% vs 7.0%; aOR 1.73, 95%CI 1.10-2.71), and neurologically favorable survival (9.8% vs 6.2%; aOR 1.72, 95%CI 1.07-2.76). As may be expected, time to first epinephrine was also shorter in the IM group. There were a host of limitations, from sample size and protocol deviations to the COVID-19 pandemic during the intervention phase; however, the goal of providing motivation for further investigation was achieved.
This study is not practice changing on its own, yet I’m cautiously optimistic. As medicine becomes ever more sophisticated, wouldn’t it be great if straightforward IM epinephrine were the “next big thing” in OHCA care? There should be enough potential for benefit here to warrant rigorous investigation – bring on the RCTs!
Early intramuscular adrenaline administration is associated with improved survival from out-of-hospital cardiac arrest. Resuscitation. 2024 Aug;201:110266. doi: 10.1016/j.resuscitation.2024.110266. Epub 2024 Jun 9. PMID: 38857847.
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