Immediately Shock Patients with Shockable Rhythms in Cardiac Arrest

Educational Objectives

Summary

Immediately Shock Patients with Shockable Rhythms in Cardiac Arrest

For patients with shockable rhythms (i.e., ventricular fibrillation or pulseless ventricular tachycardia), guidelines recommend epinephrine only after several refractory defibrillation attempts. However, epinephrine frequently is administered inappropriately prior to the first or second defibrillation attempt. To determine the effect of epinephrine when it is administered for shockable rhythms prior to initial defibrillation, researchers retrospectively identified 35,000 patients — hospitalized at 500 U.S. hospitals between 2000 and 2018 — with in-hospital arrest due to ventricular fibrillation or pulseless ventricular tachycardia. Epinephrine was given before defibrillation in 28% of patients. About 9000 patients who received epinephrine before defibrillation were compared with 9000 propensity-matched patients who did not receive epinephrine. Details appear on the website of The BMJ (https://doi.org/10.1136/bmj-2021-066534).

Patients who received epinephrine before defibrillation were significantly less likely to survive to hospital discharge (25% vs 30%) or to survive to discharge with favorable neurological outcomes (19% vs 21%). The median time to defibrillation was 3 minutes in the epinephrine group and 0 minutes in the no-epinephrine group. The negative association of epinephrine with survival persisted even after matching according to defibrillation time.

Despite guidelines recommending prompt defibrillation in patients with shockable rhythms, more than a quarter of inpatients inappropriately received epinephrine prior to defibrillation. This might be due to delays in assessing the rhythm or the assumption of asystole or pulseless electrical activity — rhythms that occur in >85% of cardiac arrests and for which epinephrine is the initial treatment of choice. Understanding the underlying factors behind these findings is critical in designing interventions that ensure best practices during cardiopulmonary resuscitation.

Neil H. Winawer, MD, SFHM

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Disclosures

Acknowledgements

CME/CE INFO

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The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Lecture ID:

JW330130

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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