1. In those with out-of-hospital cardiac arrest (OHCA) and attempted resuscitation by emergency medical services (EMS) personnel, patients who received epinephrine first had an increased likelihood of 1-month survival, 1-month survival with functional outcomes, and prehospital ROSC, compared with those who received advanced airway management (AAM) first.

Evidence Rating Level: 2 (Good)

Out-of-hospital cardiac arrest (OHCA) poses a significant public health challenge globally. Emergency medical services (EMS) provide crucial initial care, including interventions like epinephrine administration and advanced airway management (AAM). Current guidelines offer recommendations for their timing, but the optimal sequence remains unclear. This cohort study identified 259 237 patients (median [IQR] age was 79 (69-86) years; 58.7% male) with OHCA and attempted resuscitation by EMS personnel from the All-Japan Utstein Registry, a population-based OHCA registry, from January 2014 to December 2019 to assess the impact of the sequence of intra-arrest epinephrine and AAM on OHCA patient outcomes. Among 21,592 patients (8.3%) initially presenting with a shockable rhythm, 28.8% received epinephrine first, 69.4% received AAM first, and 1.8% received both in the same whole minute. Among the 237,645 patients (91.7%) with an initial non-shockable rhythm, 17.4% received epinephrine first, 81.4% received AAM first, and 1.2% received both in the same whole minute. Among those with an initial shockable rhythm, patients receiving epinephrine first had an increased likelihood of 1-month survival (odds ratio [OR], 1.19; 95% CI, 1.09-1.30), 1-month survival with favorable functional status (OR, 1.24; 95% CI, 1.10-1.39) and prehospital ROSC (OR, 1.74; 95% CI, 1.61-1.88) compared with patients receiving AAM first. Among those with an initial non-shockable rhythm  (OR, 1.28; 95% CI, 1.19-1.37), patients receiving epinephrine first had an increased likelihood of 1-month survival, 1-month survival with favorable functional status (OR, 1.39; 95% CI, 1.17-1.64), and prehospital ROSC (OR, 2.59; 95% CI, 2.50-2.68). These findings were similar in patients who received epinephrine and AAM within the same minute. Overall, these findings support the administration of epinephrine before the placement of an advanced airway in cases of OHCA. 

Click to read the study in JAMA Network Open

Image: PD

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