Time to epinephrine administration and survival from nonshockable out-of-hospital cardiac arrest among children and adults

Resuscitation Outcomes Consortium Investigators

Research output: Contribution to journalArticle

26 Citations (Scopus)

Abstract

BACKGROUND: Previous studies have demonstrated that earlier epinephrine administration is associated with improved survival from out-of-hospital cardiac arrest (OHCA) with shockable initial rhythms. However, the effect of epinephrine timing on patients with nonshockable initial rhythms is unclear. The objective of this study was to measure the association between time to epinephrine administration and survival in adults and children with emergency medical services (EMS)–treated OHCA with nonshockable initial rhythms. METHODS: We performed a secondary analysis of OHCAs prospectively identified by the Resuscitation Outcomes Consortium network from June 4, 2011, to June 30, 2015. We included patients of all ages with an EMS-treated OHCA and an initial nonshockable rhythm. We excluded those with return of spontaneous circulation in <10 minutes. We conducted a subgroup analysis involving patients <18 years of age. The primary exposure was time (minutes) from arrival of the first EMS agency to the first dose of epinephrine. Secondary exposure was time to epinephrine dichotomized as early (<10 minutes) or late (≥10 minutes). The primary outcome was survival to hospital discharge. We adjusted for Utstein covariates and Resuscitation Outcomes Consortium study site. RESULTS: From 55568 EMS-treated OHCAs, 32101 patients with initial nonshockable rhythms were included. There were 12238 in the early group, 14517 in the late group, and 5346 not treated with epinephrine. After adjusting for potential confounders, each minute from EMS arrival to epinephrine administration was associated with a 4% decrease in odds of survival for adults, odds ratio=0.96 (95% confidence interval, 0.95–0.98). A subgroup analysis (n=13290) examining neurological outcomes showed a similar association (adjusted odds ratio, 0.94 per minute; 95% confidence interval, 0.89–0.98). When epinephrine was given late in comparison with early, odds of survival were 18% lower (odds ratio, 0.82; 95% confidence interval, 0.68–0.98). In a pediatric analysis (n=595), odds of survival were 9% lower (odds ratio, 0.91; 95% confidence interval, 0.81–1.01) for each minute delay in epinephrine. CONCLUSIONS: Among OHCAs with nonshockable initial rhythms, the majority of patients were administered epinephrine >10 minutes after EMS arrival. Each minute delay in epinephrine administration was associated with decreased survival and unfavorable neurological outcomes. EMS agencies should consider strategies to reduce epinephrine administration times in patients with initial nonshockable rhythms.

Original languageEnglish (US)
Pages (from-to)2032-2040
Number of pages9
JournalCirculation
Volume137
Issue number19
DOIs
StatePublished - Jan 1 2018

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Out-of-Hospital Cardiac Arrest
Epinephrine
Emergency Medical Services
Survival
Resuscitation

Keywords

  • Cardiopulmonary resuscitation
  • Epinephrine
  • Heart arrest
  • Out-of-hospital cardiac arrest
  • Resuscitation

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Time to epinephrine administration and survival from nonshockable out-of-hospital cardiac arrest among children and adults. / Resuscitation Outcomes Consortium Investigators.

In: Circulation, Vol. 137, No. 19, 01.01.2018, p. 2032-2040.

Research output: Contribution to journalArticle

Resuscitation Outcomes Consortium Investigators. / Time to epinephrine administration and survival from nonshockable out-of-hospital cardiac arrest among children and adults. In: Circulation. 2018 ; Vol. 137, No. 19. pp. 2032-2040.
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title = "Time to epinephrine administration and survival from nonshockable out-of-hospital cardiac arrest among children and adults",
abstract = "BACKGROUND: Previous studies have demonstrated that earlier epinephrine administration is associated with improved survival from out-of-hospital cardiac arrest (OHCA) with shockable initial rhythms. However, the effect of epinephrine timing on patients with nonshockable initial rhythms is unclear. The objective of this study was to measure the association between time to epinephrine administration and survival in adults and children with emergency medical services (EMS)–treated OHCA with nonshockable initial rhythms. METHODS: We performed a secondary analysis of OHCAs prospectively identified by the Resuscitation Outcomes Consortium network from June 4, 2011, to June 30, 2015. We included patients of all ages with an EMS-treated OHCA and an initial nonshockable rhythm. We excluded those with return of spontaneous circulation in <10 minutes. We conducted a subgroup analysis involving patients <18 years of age. The primary exposure was time (minutes) from arrival of the first EMS agency to the first dose of epinephrine. Secondary exposure was time to epinephrine dichotomized as early (<10 minutes) or late (≥10 minutes). The primary outcome was survival to hospital discharge. We adjusted for Utstein covariates and Resuscitation Outcomes Consortium study site. RESULTS: From 55568 EMS-treated OHCAs, 32101 patients with initial nonshockable rhythms were included. There were 12238 in the early group, 14517 in the late group, and 5346 not treated with epinephrine. After adjusting for potential confounders, each minute from EMS arrival to epinephrine administration was associated with a 4{\%} decrease in odds of survival for adults, odds ratio=0.96 (95{\%} confidence interval, 0.95–0.98). A subgroup analysis (n=13290) examining neurological outcomes showed a similar association (adjusted odds ratio, 0.94 per minute; 95{\%} confidence interval, 0.89–0.98). When epinephrine was given late in comparison with early, odds of survival were 18{\%} lower (odds ratio, 0.82; 95{\%} confidence interval, 0.68–0.98). In a pediatric analysis (n=595), odds of survival were 9{\%} lower (odds ratio, 0.91; 95{\%} confidence interval, 0.81–1.01) for each minute delay in epinephrine. CONCLUSIONS: Among OHCAs with nonshockable initial rhythms, the majority of patients were administered epinephrine >10 minutes after EMS arrival. Each minute delay in epinephrine administration was associated with decreased survival and unfavorable neurological outcomes. EMS agencies should consider strategies to reduce epinephrine administration times in patients with initial nonshockable rhythms.",
keywords = "Cardiopulmonary resuscitation, Epinephrine, Heart arrest, Out-of-hospital cardiac arrest, Resuscitation",
author = "{Resuscitation Outcomes Consortium Investigators} and Matthew Hansen and Schmicker, {Robert H.} and Craig Newgard and Brian Grunau and Frank Scheuermeyer and Sheldon Cheskes and Veer Vithalani and Fuad Alnaji and Thomas Rea and Idris, {Ahamed H.} and Heather Herren and Jamie Hutchison and Mike Austin and Debra Egan and Daya, {Mohamud Ramzan}",
year = "2018",
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doi = "10.1161/CIRCULATIONAHA.117.033067",
language = "English (US)",
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pages = "2032--2040",
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TY - JOUR

T1 - Time to epinephrine administration and survival from nonshockable out-of-hospital cardiac arrest among children and adults

AU - Resuscitation Outcomes Consortium Investigators

AU - Hansen, Matthew

AU - Schmicker, Robert H.

AU - Newgard, Craig

AU - Grunau, Brian

AU - Scheuermeyer, Frank

AU - Cheskes, Sheldon

AU - Vithalani, Veer

AU - Alnaji, Fuad

AU - Rea, Thomas

AU - Idris, Ahamed H.

AU - Herren, Heather

AU - Hutchison, Jamie

AU - Austin, Mike

AU - Egan, Debra

AU - Daya, Mohamud Ramzan

PY - 2018/1/1

Y1 - 2018/1/1

N2 - BACKGROUND: Previous studies have demonstrated that earlier epinephrine administration is associated with improved survival from out-of-hospital cardiac arrest (OHCA) with shockable initial rhythms. However, the effect of epinephrine timing on patients with nonshockable initial rhythms is unclear. The objective of this study was to measure the association between time to epinephrine administration and survival in adults and children with emergency medical services (EMS)–treated OHCA with nonshockable initial rhythms. METHODS: We performed a secondary analysis of OHCAs prospectively identified by the Resuscitation Outcomes Consortium network from June 4, 2011, to June 30, 2015. We included patients of all ages with an EMS-treated OHCA and an initial nonshockable rhythm. We excluded those with return of spontaneous circulation in <10 minutes. We conducted a subgroup analysis involving patients <18 years of age. The primary exposure was time (minutes) from arrival of the first EMS agency to the first dose of epinephrine. Secondary exposure was time to epinephrine dichotomized as early (<10 minutes) or late (≥10 minutes). The primary outcome was survival to hospital discharge. We adjusted for Utstein covariates and Resuscitation Outcomes Consortium study site. RESULTS: From 55568 EMS-treated OHCAs, 32101 patients with initial nonshockable rhythms were included. There were 12238 in the early group, 14517 in the late group, and 5346 not treated with epinephrine. After adjusting for potential confounders, each minute from EMS arrival to epinephrine administration was associated with a 4% decrease in odds of survival for adults, odds ratio=0.96 (95% confidence interval, 0.95–0.98). A subgroup analysis (n=13290) examining neurological outcomes showed a similar association (adjusted odds ratio, 0.94 per minute; 95% confidence interval, 0.89–0.98). When epinephrine was given late in comparison with early, odds of survival were 18% lower (odds ratio, 0.82; 95% confidence interval, 0.68–0.98). In a pediatric analysis (n=595), odds of survival were 9% lower (odds ratio, 0.91; 95% confidence interval, 0.81–1.01) for each minute delay in epinephrine. CONCLUSIONS: Among OHCAs with nonshockable initial rhythms, the majority of patients were administered epinephrine >10 minutes after EMS arrival. Each minute delay in epinephrine administration was associated with decreased survival and unfavorable neurological outcomes. EMS agencies should consider strategies to reduce epinephrine administration times in patients with initial nonshockable rhythms.

AB - BACKGROUND: Previous studies have demonstrated that earlier epinephrine administration is associated with improved survival from out-of-hospital cardiac arrest (OHCA) with shockable initial rhythms. However, the effect of epinephrine timing on patients with nonshockable initial rhythms is unclear. The objective of this study was to measure the association between time to epinephrine administration and survival in adults and children with emergency medical services (EMS)–treated OHCA with nonshockable initial rhythms. METHODS: We performed a secondary analysis of OHCAs prospectively identified by the Resuscitation Outcomes Consortium network from June 4, 2011, to June 30, 2015. We included patients of all ages with an EMS-treated OHCA and an initial nonshockable rhythm. We excluded those with return of spontaneous circulation in <10 minutes. We conducted a subgroup analysis involving patients <18 years of age. The primary exposure was time (minutes) from arrival of the first EMS agency to the first dose of epinephrine. Secondary exposure was time to epinephrine dichotomized as early (<10 minutes) or late (≥10 minutes). The primary outcome was survival to hospital discharge. We adjusted for Utstein covariates and Resuscitation Outcomes Consortium study site. RESULTS: From 55568 EMS-treated OHCAs, 32101 patients with initial nonshockable rhythms were included. There were 12238 in the early group, 14517 in the late group, and 5346 not treated with epinephrine. After adjusting for potential confounders, each minute from EMS arrival to epinephrine administration was associated with a 4% decrease in odds of survival for adults, odds ratio=0.96 (95% confidence interval, 0.95–0.98). A subgroup analysis (n=13290) examining neurological outcomes showed a similar association (adjusted odds ratio, 0.94 per minute; 95% confidence interval, 0.89–0.98). When epinephrine was given late in comparison with early, odds of survival were 18% lower (odds ratio, 0.82; 95% confidence interval, 0.68–0.98). In a pediatric analysis (n=595), odds of survival were 9% lower (odds ratio, 0.91; 95% confidence interval, 0.81–1.01) for each minute delay in epinephrine. CONCLUSIONS: Among OHCAs with nonshockable initial rhythms, the majority of patients were administered epinephrine >10 minutes after EMS arrival. Each minute delay in epinephrine administration was associated with decreased survival and unfavorable neurological outcomes. EMS agencies should consider strategies to reduce epinephrine administration times in patients with initial nonshockable rhythms.

KW - Cardiopulmonary resuscitation

KW - Epinephrine

KW - Heart arrest

KW - Out-of-hospital cardiac arrest

KW - Resuscitation

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U2 - 10.1161/CIRCULATIONAHA.117.033067

DO - 10.1161/CIRCULATIONAHA.117.033067

M3 - Article

C2 - 29511001

AN - SCOPUS:85046711212

VL - 137

SP - 2032

EP - 2040

JO - Circulation

JF - Circulation

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