April 11, 2012
Volume 7 - Issue 15   

DynaMed Weekly Update

For the week ending April 6, 2012 

Last week 700 articles were evaluated via DynaMed's Systematic Literature Surveillance and 268 were added to DynaMed content.    


Based on the editors' criteria of selecting "articles most likely to change clinical practice," two articles of significant interest was selected for the DynaMed Weekly Update. 
Feature Article

Prehospital Epinephrine Appears to Increase Return of Spontaneous Circulation but Decrease 1-Month Survival in Patients with Out-of-Hospital Cardiac Arrest


Epinephrine is a common and accepted element of early treatment for patients with out-of-hospital cardiac arrest, and it is part of the standard treatment algorithm for both shockable and non-shockable rhythms recommended by the American Heart Association (Circulation 2010 Nov 2;122(18 Suppl):S640). Epinephrine increases coronary perfusion pressure during resuscitation, and this increase in coronary blood flow is believed to increase the likelihood of successfully resuscitating the heart. However, despite being in widespread use since the 1960s, the efficacy of epinephrine has rarely been investigated. A new large cohort study conducted in Japan calls current recommendations into question, suggesting that prehospital epinephrine treatment may be harmful.


A total of 417,188 patients (mean age 72 years) with out-of-hospital cardiac arrest from 2005 to 2008 were included in the study. All patients had cardiac arrest before the arrival of emergency medical services, were treated by emergency medical personnel, and were then transported to the hospital. Of this group, 15,030 patients (3.6%) were treated with IV epinephrine prior to hospital arrival.


The investigators used a propensity analysis to control for confounding factors and selection bias. For each patient, a propensity score based on demographic and clinical factors was calculated to estimate the probability of receiving epinephrine treatment. Demographic factors included age, sex, year of treatment, and presence of bystander or family member eyewitnesses. Clinical factors included the etiology of the cardiac arrest, whether resuscitation was attempted by bystanders, makeup of ambulance staff, use of advanced life support, times to ambulance arrival and hospital arrival, type of first documented rhythm, and insertion of an IV line. A subgroup of 26,802 patients (half of these receiving epinephrine) were included in the propensity-matched analysis.


In the propensity-matched cohort, spontaneous circulation returned before hospital arrival in 18.3% of epinephrine-treated patients and 10.5% of nontreated patients (p < 0.001, NNT 13) (level 2 [mid-level] evidence). However, 1-month survival was significantly reduced in the epinephrine group (5.1% vs. 7%, p < 0.001, NNH 52). Survival with good or moderate cerebral performance at 1 month was also reduced for epinephrine (1.3% vs. 3.1%, p < 0.001, NNH 55). Similar results were attained in analyses of the complete cohort (JAMA 2012 Mar 21;307(11):1161). It is important to note that this study looked at the effects of epinephrine use in the pre-hospital setting only . These findings should not be considered generalizable to the broader use of epinephrine in situations where more resources for treating all aspects of the patient's condition are available.


For more information, see the Cardiac arrest topic in DynaMed.

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Please stop by the DynaMed booth (#1517) at the ACP Conference April 19th through the 21st. It's a great opportunity to give feedback, offer content suggestions, and explore collaboration opportunities.

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About DynaMed Weekly Update

Prepared by the clinician members of the DynaMed Editorial Team, DynaMed Weekly Update is a compilation of one to five articles selected from DynaMed's Systematic Literature Surveillance as articles most likely to change clinical practice.

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CME Information


0.25 AMA PRA Category I Credit(s)™
Family Physicians: 0.25 Prescribed credits
Nurse Practitioners: 0.25 Contact hours
Release Date: April 11, 2012
Expiration Date: April 11, 2013
Estimated Completion Time:
15 minutes
There is no fee for this activity.

To Receive Credit 
In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.
Faculty Information
Alan Ehrlich, MD - Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company

Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.
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AAFP: This activity, DynaMed Weekly Update 2011, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP accreditation begins March 2, 2011. Term of approval is for one year from this date. Each Weekly Update is approved for 0.25 Prescribed credits. Credit may be claimed for one year from the date of each Weekly Update.


AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.  

Program ID 1102072F.

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