The Universal ALS algorithm. An advisory statement by the Advanced Life Support Working Group of the International Liaison Committee on Resuscitation

The impact of time to amiodarone administration on survival from out-of-hospital cardiac arrest

Aim

To examine the impact of time to amiodarone administration on survival from shock-refractory Ventricular Fibrillation/pulseless Ventricular Tachycardia (VF/pVT) following out-of-hospital cardiac arrest (OHCA).

Methods

A retrospective cohort study of adult (≥16 years) OHCA patients in shock-refractory VF/pVT (after 3 consecutive defibrillation attempts) of medical aetiology who arrested between January 2010 and December 2019. Time-dependent propensity score matching was used to sequentially match patients who received amiodarone at any given minute of resuscitation with patients eligible to receive amiodarone during the same minute. Log-binomial regression models were used to assess the association between time of amiodarone administration (by quartiles of time-to-matching) and survival outcomes.

Results

A total of 2,026 patients were included, 1,393 (68.8%) of whom received amiodarone with a median (interquartile range) time to administration of 22.0 (18.0-27.0) minutes. Propensity score matching yielded 1,360 matched pairs. Amiodarone administration within 28 minutes of the emergency call was associated with a higher likelihood of return of spontaneous circulation (ROSC) (≤18minutes: RR = 1.03 (95%CI 1.02, 1.04); 19-22minutes: RR = 1.02 (95%CI 1.01, 1.03); 23-27minutes: RR = 1.01 (95%CI 1.00, 1.02)) and event survival (pulse on hospital arrival) (≤18 minutes: RR = 1.05 (95%CI 1.03, 1.07); 19-22 minutes: RR = 1.03 (95%CI 1.01, 1.05); 23-27 minutes: RR = 1.02 (95%CI 1.00, 1.03). Amiodarone administration within 23 minutes of the emergency call was associated with a higher likelihood of survival to hospital discharge (≤18minutes: RR = 1.17 (95%CI 1.09, 1.24; 19-22 minutes: RR = 1.10 (95%CI 1.04, 1.17).

Conclusion

Amiodarone administered within 23 minutes of the emergency call is associated with improved survival outcomes in shock-refractory VF/pVT, although prospective trials are required to confirm these findings.

Concordance between the 2010 and 2015 Resuscitation Guidelines of International Liaison Committee of Resuscitation Councils (ILCOR) members and the ILCOR Consensus of Science and Treatment Recommendations (CoSTRs)

BACKGROUND

Cardiac arrests are associated with poor outcomes. The International Liaison Committee on Resuscitation (ILCOR) evaluates resuscitation science and produced, until 2015, five-yearly consensus on science and treatment recommendations (CoSTRs), informing global resuscitation guidelines. We aimed to identify similarities/differences in resuscitation guidelines from ILCOR members, noting concurrence over time, and CoSTRs influence on these guidelines.

METHODS

We considered the component elements of paediatric and adult, basic and advanced resuscitation guidelines, published in 2010 and 2015, along with matching ILCOR CoSTRs to examine their influence. We contacted the responsible councils when guidelines were unavailable online.

RESULTS

Complete resuscitation guidelines were found for six of the seven ILCOR council members. The Resuscitation Council of Asia only had adult basic life support (BLS) guidelines in English. Three members used the AHA guidelines. Therefore, five rather than seven sets of resuscitation guidelines were compared to the CoSTRs. Concurrence between CoSTRs recommendations and ILCOR council member's resuscitation guidelines has improved over time. Minor variations were identified in both basic and advanced life support, with most variance in paediatric guidelines, but these narrowed over time.

CONCLUSION

The improved concurrence across the resuscitation guidelines with the CoSTRs suggests that ILCOR members accept and hence incorporate CoSTRs recommendations to inform their own resuscitation guidelines. This is one step towards the development of international universal guidelines for adult and paediatric resuscitation.

Improvement of out-of-hospital cardiac arrest survival rate after implementation of the 2010 resuscitation guidelines

OBJECTIVE

The implementation of cardiopulmonary resuscitation guidelines, updated every five years, appears to improve patient survival rates after Out-Of-Hospital Cardiac Arrest (OHCA). The aim of this study is: 1) to measure the level of improvement in the prognosis of OHCA patient survival rates for the years 2009 and 2010 and the following two years 2011 and 2012; and 2) correlate the improvement in prognosis with the updated 2010 Advanced Cardiovascular Life Support (ACLS) Guidelines.

METHOD

We performed a retrospective observational study based on Geneva's OHCA register that includes data from January 1, 2009 to December 31, 2012. We compared the evolution of prognostic factors that influenced survival at hospital discharge between the periods before and after the implementation of the 2010 guidelines. We then compared the survival rates between each period. Finally, we adjusted the effects on survival in the second period to prognostic factors not linked with the care provided by Emergency Medical Services (EMS) teams, using a multivariable logistic regression model. Changes in advanced resuscitation treatment provided by EMS personnel were also examined.

RESULTS

795 OHCA were resuscitated between 1st January, 2009 and 31st December, 2012. The prognosis of patient survival at the time of hospital discharge rose from 10.33% in 2009-2010 to 17.01% in 2011-2012 (p = 0.007). After making adjustments for the effect of improved survival rates on the second period with factors not related to care provided by EMS teams, the odds ratio (OR) remains comparable (OR = 1.87, 95% CI [1.08-3.22]). Measured changes in treatment provided by EMS personnel were minor.

CONCLUSIONS

Survival rate for OHCA patients improved significantly in 2011-2012. This study suggests that it was probably the improvement in the quality of care provided during CPR and post-cardiac arrest care that have contributed to the increase in survival rates at the time of hospital discharge.

Out-of-hospital cardiac arrest: prehospital management

Sudden out-of-hospital cardiac arrest is the most time-critical medical emergency. In the second paper of this Series on out-of-hospital cardiac arrest, we considered important issues in the prehospital management of cardiac arrest. Successful resuscitation relies on a strong chain of survival with the community, dispatch centre, ambulance, and hospital working together. Early cardiopulmonary resuscitation and defibrillation has the greatest impact on survival. If the community response does not restart the heart, resuscitation is continued by emergency medical services' staff. However, the best approaches for airway management and the effectiveness of currently used drug treatments are uncertain. Prognostic factors and rules for termination of resuscitation could guide the duration of a resuscitation attempt and decision to transport to hospital. If return of spontaneous circulation is achieved, the focus of treatment shifts to stabilisation, restoration of normal physiological parameters, and transportation to hospital for ongoing care.

The International Liaison Committee on Resuscitation-Review of the last 25 years and vision for the future

2017 marks the 25th anniversary of the International Liaison Committee on Resuscitation (ILCOR). ILCOR was formed in 1992 to create a forum for collaboration among principal resuscitation councils worldwide. Since then, ILCOR has established and distinguished itself for its pioneering vision and leadership in resuscitation science. By systematically assessing the evidence for resuscitation standards and guidelines and by identifying national and regional differences, ILCOR reached consensus on international resuscitation guidelines in 2000, and on international science and treatment recommendations in 2005, 2010 and 2015. However, local variation and contextualization of guidelines are evident by subtle differences in regional and national resuscitation guidelines. ILCOR's efforts to date have enhanced international cooperation, and progressively more transparent and systematic collection and analysis of pertinent scientific evidence. Going forward, this sets the stage for ILCOR to pursue its vision to save more lives globally through resuscitation.

Recognizing the causes of in-hospital cardiac arrest--A survival benefit

BACKGROUND

The in-hospital emergency team (ET) may or may not recognize the causes of in-hospital cardiac arrest (IHCA) during the provision of cardiopulmonary resuscitation (CPR). In a previous 4.5-year prospective study, this rate of recognition was found to be 66%. The aim of this study was to investigate whether survival improved if the cause of arrest was recognized by the ET.

METHODS

The difference in survival if the causes were recognized versus not recognized was estimated after propensity score matching patients from these two groups.

RESULTS

Overall survival to hospital discharge was 25%. After propensity score matching, the benefit of recognizing the cause regarding 1-hour survival of the episode was 29% (p<0.01), and 19% regarding hospital discharge, respectively. Variables commonly known to affect the outcome after cardiac arrest were found to be balanced between the two groups. The largest difference was found in patients with non-cardiac causes and non-shockable presenting rhythms. Patient records and pre-arrest clinical symptoms were the information sources most frequently utilized by the ET to establish the causes of arrest.

CONCLUSIONS

Patients suffering an IHCA showed a substantial survival benefit if the causes of arrest were recognized by the ET. Patient records and pre-arrest clinical symptoms were the sources of information most frequently utilized in these instances.

Performance of department staff in the window between discovery of collapse to cardiac arrest team arrival

INTRODUCTION

Guideline-directed therapy during the first minutes of resuscitation may be life saving. This study assessed the performance of American Heart Association (AHA) guidelines by trained departmental staff in the period between discovery of collapse and emergency team arrival.

METHODS

Over a period of 24 months, departmental performance prior to the arrival of the emergency team (median 180 s) was assessed by debriefings conducted within 24h of each event in a 740-bed tertiary hospital with a dedicated certified resuscitation team. Outcome measures were failure to meet AHA treatment recommendations (primary) and return of spontaneous circulation (ROSC)/survival to hospital discharge (secondary).

RESULTS

Two hundred and forty four events were included (216 patients). Mean age was 69+/-17 years; 45% were women. The underlying causes of collapse were mainly cardiac (39%) or respiratory (32%). Residents conducted most of the resuscitations (69%) prior to the arrival of the emergency team. Basic diagnostic measures such as assessments of pulse and rhythm were not performed in 19 and 33% of events. Therapeutic measures such as positive pressure ventilation, chest compressions and defibrillation were not provided according to the guidelines in 17, 12 and 44% of the events. ROSC occurred in 62% of events; 54% of VF/VT, 30% of asystole, 22% of PEA and 76% of bradyarrhythmias/severe bradycardias. Survival to hospital discharge was 37% overall and 41% for patients found in VF/VT (n=33).

CONCLUSIONS

Trained departmental staff performed poorly in the moments between patient discovery and arrival of the emergency team. Since patient outcomes were comparable to those described in the literature, poor resuscitation performance may be commonplace in hospitals where ward personnel are expected to deliver advanced life support prior to arrival of the emergency team.

Educational psychology in medical learning: a randomised controlled trial of two aide memoires for the recall of causes of electromechanical dissociation

OBJECTIVES

Although mnemonics are commonly used in medical education there are few data on their effectiveness. A RCT was undertaken to test the hypothesis that a new aide memoire, "EMD-aide", would be superior to the conventional "4Hs+4Ts" mnemonic in facilitating recall of causes of electromechanical dissociation (EMD) among house officers.

METHOD

"EMD-aide", organises causes of EMD by frequency of occurrence and ease of reversibility: four groups organised by shape, colour, position, numbering, clockwise sequence, and use of arrows. Eight hospitals were randomised in a controlled trial and 149 house officers were then recruited by telephone. Baseline ability to recall causes of EMD was recorded at one minute and overall. House officers were then sent a copy of either "4Hs+4Ts" or "EMD-aide" according to randomisation group. Recall ability was retested at one month.

RESULTS

68 of 80 and 51 of 69 house officers completed the study in the "4Hs+4Ts" and "EMD-aide" groups respectively (NS) with similar baseline recall. After intervention median number of recalled causes was greater in the "EMD-aide" group, eight compared with seven at one minute (p = 0.034) and eight compared with seven overall, p = 0.067. Recall of all eight causes was more common in "EMD-aide" group, 54% compared with 35%, p = 0.054, and these house officers spent longer examining their aide memoire, p<0.001.

CONCLUSIONS

"EMD-aide" may be superior to "4Hs+4Ts" in facilitating the recall of the causes of electromechanical dissociation. Educational psychology of medical learning and the use of aide memoires in general are worthy of further study.

External Cardiac Defibrillation Does Not Cause Acute Histopathological Changes Typical of Thermal Injuries in Pigs with In Situ Cerebral Stimulation Electrodes

Parkinson's disease patients with long-term L-dopa syndrome may benefit from an implanted cerebral stimulation device. When advanced life support demands cardioversion or defibrillation in these patients, undesired effects of monophasic electroshocks might occur in brain tissue adjacent to the stimulation electrodes (e.g., thermal injury), but also in the stimulation device itself. Thus, in this animal study (n = 6 pigs), we investigated the effects of repeated defibrillation (2 x 200 J [n = 1] and 2 x 360 J [n = 5]) at the implantation site of cerebral stimulation electrodes and on stimulation device function. Repeated external cardiac defibrillation did not cause acute histopathologic changes typical of thermal injury to brain tissue adjacent to the cerebral stimulation electrodes. Functionality of the stimulator device after defibrillation, however, ranged from normal to total loss of function. Therefore, when defibrillation is performed, the greatest possible distance between the defibrillation site and the stimulator device implantation site should be considered. Subsequent testing of the stimulator device's function is mandatory.

IMPLICATIONS

Repeated cardiac defibrillation did not cause histopathologic changes typical of thermal injury at the implantation site of cerebral stimulation electrodes. The function of the stimulator device after defibrillation, however, ranged from normal to total loss of function.

[New aspects and perspectives on cardiac arrest]

OBJECTIVES

To analyse the current knowledge based on the experimental and the clinical research studies focused on the main fields of cardiopulmonary resuscitation.

DATA SOURCES

International guidelines and recent review articles. Data collected from the Medline database with the key word: cardiac arrest.

STUDY SELECTION

Research studies published during the last ten years were reviewed. Relevant clinical information was extracted and discussed when it induced changes in guidelines.

DATA SYNTHESIS

Promising improvements on basic and advanced life supports are proposed. Chest compressions prevail over ventilation. Alternatives to classical chest compressions are tested. Ventilatory volume must be reduced from 1000 to approximatively 500 mL for each breath with oxygen. Biphasic waveform defibrillators and automated external defibrillators will be considered as the best devices in the near future. Some non-catecholaminergic vasopressors could reduce the use of epinephrine for advanced cardiac life support. Lidocaine could be replaced by amiodarone as anti-arrhythmic drug of choice. New post-resuscitation therapeutic strategies are evaluated, especially coronary reperfusion when the cause of cardiac arrest is cardiac.

CONCLUSION

Many fields of cardiopulmonary resuscitation are investigated. Some relevant informations are included in the last international guidelines published in 2000, but most of them need complementary studies before other changes could be recommended for routine practice.

Phased chest and abdominal compression-decompression versus conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest

BACKGROUND

Several methods have been developed to improve the efficacy of mechanical resuscitation, because organ perfusion achieved with conventional manual resuscitation is often insufficient. In animal studies, phased chest and abdominal compression-decompression resuscitation by use of the Lifestick device has resulted in a better outcome compared with that of conventional resuscitation. In end-of-life patients, an increased coronary perfusion pressure was achieved. The aim of the present study was to determine the feasibility, safety, and efficacy of the Lifestick compared with conventional resuscitation in patients with sudden nontraumatic out-of-hospital cardiac arrest.

METHODS AND RESULTS

The crews of 4 mobile intensive care units, staffed by an emergency physician and a paramedic, were trained to use the device. Fifty patients were randomized by sealed envelopes to either Lifestick (n=24) or conventional (n=26) resuscitation. No differences were found regarding demographic and logistical conditions between the groups. Nineteen of the patients (73%) with conventional resuscitation had ventricular fibrillation, 13 of whom survived to hospital admission (no survivals with other arrhythmias) and 7 were discharged. In contrast, in the Lifestick-CPR group, only 9 patients had ventricular fibrillation (38%; P=<0.02; OR, 2.5; 95% CI, 0.6 to 10.6). Four of these 9 patients and 5 of 15 patients with other arrhythmias survived to hospital admission, but none survived to hospital discharge. Autopsy in a subgroup of patients who died at the scene revealed less injuries with Lifestick than with conventional resuscitation.

CONCLUSION

Lifestick resuscitation is feasible and safe and may be advantageous in patients with asystole or pulseless electric activity.

Ease of ventilation through the cuffed oropharyngeal airway (COPA), the laryngeal mask airway and the face mask in a cardiopulmonary resuscitation training manikin

The aim of this study was to compare ease of ventilation of a cardiopulmonary resuscitation manikin using a cuffed oropharyngeal airway (COPA), a laryngeal mask airway (LMA) and a face mask, by two groups of people with different levels of earlier experience in cardiopulmonary resuscitation (CPR). Enrolled were, 108 people identified as experienced (54), or inexperienced (54), in CPR. Training equipment included a manikin, a COPA (n=10), an LMA (n=4), a face mask (n=4) and self-inflating bag-valve device. The same investigator explained the theoretical use and practice of the three techniques with the subjects in groups of three. The variables recorded were the number of attempts needed to achieve correct placement (and a tidal volume of 200 ml, was achieved), the insertion time for the COPA and the LMA, and the average time taken to achieve the first ten correct ventilations. The face mask and LMA required fewer attempts for correct placement than did the COPA. The LMA also took less time to insert than the COPA. The face mask required a significantly shorter total time with all attempts and the mean time of placement and time to achieve ten correct ventilations was shorter than with either the LMA or the COPA (P=0.0001). We conclude that the face mask offers an easier and quicker way to provide ventilation for CPR manikins than does the COPA or the LMA. Earlier experience affects the ease of insertion of the LMA and the total time needed to achieve effective ventilation.

The 9 ALS triads--an alphabetical checklist for advanced life support providers

The successful outcome of a resuscitation attempt relies frequently on the performance of many advanced life support interventions. A checklist of 27 procedures, following an alphabetical sequence, is presented as an educational memory aid for healthcare providers.

Cardiopulmonary resuscitation and contrast media reactions in a radiology department

AIM

To assess current knowledge and training in the management of contrast media reactions and cardiopulmonary resuscitation within a radiology department.

MATERIALS AND METHODS

The standard of knowledge about the management of contrast media reactions and cardiopulmonary resuscitation among radiologists, radiographers and nurses were audited using a two-section questionnaire. Our results were compared against nationally accepted standards. Repeat audits were undertaken over a 28-month period. Three full audit cycles were completed.

RESULTS

The initial audit confirmed that although a voluntary training programme was in place, knowledge of cardiopulmonary resuscitation techniques were below acceptable levels (set at 70%) for all staff members. The mean score for radiologists was 50%. Immediate changes instituted included retraining courses, the distribution of standard guidelines and the composition and distribution of two separate information handouts. Initial improvements were complemented by new wallcharts, which were distributed throughout the department, a series of lectures on management of contrast reactions and regular reviews with feedback to staff. In the third and final audit all staff groups had surpassed the required standard.

CONCLUSION

Knowledge of contrast media reactions and resuscitation needs constant updating. Revision of skills requires a prescriptive programme; visual display of advice is a constant reminder. It is our contention all radiology departmental staff should consider it a personal duty to maintain their resuscitation skills at appropriate standards.

European Resuscitation Council Guidelines 2000 for Adult Advanced Life Support. A statement from the Advanced Life Support Working Group(1) and approved by the Executive Committee of the European Resuscitation Council

The European Resuscitation Council (ERC) last issued guidelines for Basic Life Support (BLS) in 1998 [1]. These were based on the 1997 International Liaison Committee on Resuscitation (ILCOR) Advisory Statements [2]. In 1999 and 2000 representatives of ILCOR, at the invitation of the American Heart Association, met on a number of occasions in Dallas to agree a Consensus on Science upon which future guidelines would be based. Representatives from the ERC played a prominent role in the deliberations, which culminated in the publication of "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care--A Consensus on Science" in August 2000 [3]. The consensus was evidence-based wherever possible. The ERC ALS Working Group has considered this document and has recommended some changes in the guidelines that will be suitable for European practice. These changes, together with a summary of the Sequence of Actions in ALS, are presented in this paper.

Outcome after cardiac arrest in adults in UK hospitals: effect of the 1997 guidelines

AIM

To assess the effectiveness of the ILCOR Advisory Statements on Advanced Life Support adopted by the Resuscitation Council (UK), as the standard for resuscitation following cardiac arrest.

METHOD

Over the period May to November 1997, data on the process and outcome of cardiopulmonary resuscitation following in-hospital cardiac arrest were collected from 49 hospitals throughout the UK.

RESULTS

Of 2074 audit forms submitted, 1368 were included in the final analysis. The initial rhythm monitored was ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in 429 patients, of whom 181 (42.2%) were discharged alive, compared to 6. 2% when the initial rhythm was non-VF/VT. Overall, 240 (17.6%) patients were discharged alive. At 6 months after discharge 195 (82. 3%) of 237 patients were still alive. Successful initial resuscitation, defined as return of spontaneous circulation lasting longer than 20 min (ROSC>20 min), was significantly associated with VF/VT as the initial arrest rhythm, return of circulation in less than 3 min, age less than 70 years and the use of an advanced airway (P<0.01). There was a significant increased likelihood of survival to discharge when the circulation was restored in less than 3 min and age was less than 70 years (P<0.05). The administration of any adrenaline (epinephrine) was significantly associated with a reduced likelihood of ROSC>20 min or alive discharge (P<0.0001).

CONCLUSION

Compared to the last major multiple hospital study published in 1992, the results of this study suggest that there appears to have been an improvement in survival of in-hospital patients in the UK who have a VF/VT cardiac arrest. How much of this is directly attributable to the adoption of the latest guidelines is uncertain.

CPR '98: a practical multimedia computer-based guide to cardiopulmonary resuscitation for medical students

This paper describes an initiative to build a multimedia computer-based teaching package for cardiopulmonary resuscitation. The project resulted from a perceived gap in the undergraduate medical curriculum allied to concern from medical students. The software application was designed to be networked and used as an adjunct to taught life support courses for undergraduate medical students. The package comprises tutorials and test questions in basic and advanced life support. It incorporates sound, video, graphics and animation to illustrate the techniques involved and is distributed on CD ROM for the PC. The content is based on the 'Advanced Life Support Manual', produced by the Resuscitation Council (UK) and incorporates all changes to the guidelines made during 1997 and 1998. The basic life support section has been networked locally, and has been tested on more than 60 third year medical students attending a local basic life support course. It was found that students who used the package performed significantly better in theoretical assessments than those who did not.

Leadership of resuscitation teams: "Lighthouse Leadership'

AIM

The purpose of this study was to determine the relationship between leadership behaviour, team dynamics and task performance.

METHODS

This was as an observational study, using video recordings of 20 resuscitation attempts. The Leadership Behaviour Description Questionnaire (LBDQ) was used to measure the level of structure built within the team. Interpersonal behaviour and the tasks of resuscitation were measured with a team dynamics and a task performance scale. The degree to which the leader actively participated, 'hands on', with the tasks of resuscitation, and their previous training in advanced life support (ALS), and experience of resuscitation attempts, were evaluated against the leadership rating.

RESULTS

The degree to which the leader built a structure within the team was found to correlate significantly with the team dynamics (P = 0.000) and the task performance (P = 0.013). Where the leaders participated 'hands on' they were less likely to build a structured team (P = 0.005), the team were less dynamic (P = 0.028) and the tasks of resuscitation were performed less effectively (P = 0.099). Experience gained over a 1-year period did not enhance leadership performance, but leaders who had up to 3 years experience were more likely to be effective in this role (P = 0.072). Interestingly, ALS training did not enhance leadership performance per se. However those leaders who had had recent ALS training were more likely not to participate 'hands on' (P = 0.035). There were some notable shortcomings in the performance of the task and some interesting correlations relating to duration of resuscitation, survival rate estimations, the leaders' attitudes and the teams' level of experience.

CONCLUSION

Leaders must build a structure within a resuscitation team in order for them to perform effectively. An emergency leadership training programme is essential to enhance the performance of leaders and their teams.

In-hospital resuscitation--what should we be teaching?

This paper examines the initial actions that should take place following the sudden collapse of a patient in a hospital. The current Basic Life Support guidelines are not designed for this situation, yet are commonly taught to hospital staff. An alternative algorithm for Hospital Resuscitation has been developed. Additional factors, such as the recognition of the sick patient and the importance of audit should be included in hospital resuscitation training. A tiered approach to resuscitation training within a hospital should be adopted and national standards developed.

A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. European Epinephrine Study Group

BACKGROUND

Clinical trials have not shown a benefit of high doses of epinephrine in the management of cardiac arrest. We conducted a prospective, multicenter, randomized study comparing repeated high doses of epinephrine with repeated standard doses in cases of out-of-hospital cardiac arrest.

METHODS

Adult patients who had cardiac arrest outside the hospital were enrolled if the cardiac rhythm continued to be ventricular fibrillation despite the administration of external electrical shocks, or if they had asystole or pulseless electrical activity at the time epinephrine was administered. We randomly assigned 3327 patients to receive up to 15 high doses (5 mg each) or standard doses (1 mg each) of epinephrine according to the current protocol for advanced cardiac life support.

RESULTS

In the high-dose group, 40.4 percent of 1677 patients had a return of spontaneous circulation, as compared with 36.4 percent of 1650 patients in the standard-dose group (P=0.02); 26.5 percent of the patients in the high-dose group and 23.6 percent of those in the standard-dose group survived to be admitted to the hospital (P=0.05); 2.3 percent of the patients in the high-dose group and 2.8 percent in the standard-dose group survived to be discharged from the hospital (P=0.34). There was no significant difference in neurologic status according to treatment among those discharged. High-dose epinephrine improved the rate of successful resuscitation in patients with asystole, but not in those with ventricular fibrillation.

CONCLUSIONS

In our study, long-term survival after cardiac arrest outside the hospital was no better with repeated high doses of epinephrine than with repeated standard doses.