Resuscitation That's (Un)Shockable: Time to Get the Adrenaline Flowing

June 9, 2014

Resuscitation That's (Un)Shockable: Time to Get the Adrenaline Flowing

  1. Daniel D. Dressler, MD, MSc, SFHM, FACP

Inpatients who experience nonshockable cardiac arrest are more likely to survive when epinephrine is administered early.

  1. Daniel D. Dressler, MD, MSc, SFHM, FACP

A large and increasing percentage of patients with cardiac arrests exhibit initial nonshockable rhythms (asystole or pulseless electrical activity [PEA]; 82% in 2009 vs. 69% in 2000; NEJM JW Hosp Med Nov 14 2012). Cardiac arrest guidelines recommend early use of epinephrine to manage patients with nonshockable rhythms (Circulation 2010; 122:S729), but this recommendation lacks strong evidence to support efficacy.

Investigators retrospectively evaluated more than 25,000 patients (at 570 U.S. hospitals) with in-hospital cardiac arrests who were not in intensive care units or emergency departments and who exhibited initial rhythms of asystole or PEA. Half of patients received their first dose of epinephrine >3 minutes following the start of resuscitation. Delayed administration of epinephrine was associated significantly with lower chance for survival to hospital discharge, in stepwise fashion (12%, 10%, 8%, and 7% survival, respectively, for patients receiving their first epinephrine dose ≤3 minutes, 4–6 minutes, 7–9 minutes, and >9 minutes after arrest). Neurologically intact survival to hospital discharge was significantly more likely after earlier epinephrine administration.


Most cardiac arrests have initial nonshockable rhythms. A focus on time to epinephrine administration — in addition to high-quality chest compressions — might be the best early intervention and, possibly, the next (or only) quality metric in PEA and asystole arrests.

Editor Disclosures at Time of Publication

  • Disclosures for Daniel D. Dressler, MD, MSc, SFHM, FACP at time of publication Editorial boards Hospital Medicine Reviews; Journal of Hospital Medicine


Reader Comments (1)

DR GEOFF CUTTER Physician, Emergency Medicine, Queensland Health

At first blush this huge study appears to be an ethical way of assessing the efficacy of adrenaline use in cardiac arrest with Non-Shockable Rhythm (NSR). But there several other major variables not allowed for in this study. In particular, Time from Cardiac Arrest to initiation of resuscitation ( initiation of chest compressions ) and a further variable would be the efficiency of those compressions .
Experience shows that "on ward" arrests - particularly at night time are undiscovered for a variable period of time and that initiation of resuscitation may be delayed and/or initiated by an inexperienced operator ( such as a junior nurse or doctor ) .
These other variables may invalidate this otherwise pleasing study.

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