Adrenaline in traumatic cardiac arrest
Date First Published:
March 9, 2015
Last Updated:
October 5, 2016
Report by:
Dr Peter Hulme, Consultant EM (Manchester Royal Infirmary)
Three-Part Question:
In [patients in traumatic cardiac arrest] does [IV adrenaline] [improve survival]
Clinical Scenario:
A 45 year old cyclist is brought up into resus after being knocked off his bicycle by a lorry. He is in traumatic cardiac arrest. ATLS is in progress you wonder whether IV adrenaline would improve his chances of survival?
Search Strategy:
In [adults with traumatic cardiac arrest] does [IV Adrenaline] [improve survival?]
Search Details:
EMBASE, BNI, Medline, CINAHL
1. Traumatic.ti,abt
2. (cardiac AND arrest).ti,abt
3. Adrenaline.ti,abt
4. Epinephrine.ti,ab
5. Vasopressors.ti,abt
6. 1 AND 2tttt
7. 3 OR 4 OR 5t
8. 6 AND 7
1. Traumatic.ti,abt
2. (cardiac AND arrest).ti,abt
3. Adrenaline.ti,abt
4. Epinephrine.ti,ab
5. Vasopressors.ti,abt
6. 1 AND 2tttt
7. 3 OR 4 OR 5t
8. 6 AND 7
Outcome:
104 unique papers of which 3 answered the clinical question. On closer inspection 2 of the papers were the same cohort of patients with the earlier paper being a poster abstract.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Prehospital intravenous epinephrine may boost survival of patients with traumatic cardiac arrest: a retrospective cohort study. Chiang et al 2015 Taiwan | 514 patients >18 years old with traumatic cardiac arrest in Taiwan | Retrospective trauma registry review | Use of adrenaline | Survival to hospital- adjusted odds ratio 2.57 (95% CI 1.24-5.31) | Retrospective data. Only 43 (8.4%) of patients received IV adrenaline. Unclear why certain patients were given IV adrenaline and others not. |
| Use of adrenaline | Survival to hospital discharge- adjusted odds ratio 3.53 (95%CI 0.84-15.47) | ||||
| Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service Sherren et al 2013 Australia | Suggested algorithm based on experience, expert opinion and review of the evidence. | Use of adrenaline in blunt traumatic cardiac arrest | Consider 10mcg/kg if cardiac motion seen on US with no pericardial effusion. | Some evidence for recommendations extracted from animal studies. | |
| Use of adrenaline in penetrating traumatic cardiac arrest. | Consider 10mcg/kg after clamshell thoracotomy if thoracotomy fails to restore ROSC and the heart is full. |
Author Commentary:
The use of adrenaline in cardiac arrests is controversial and most studies looking at its use exclude traumatic cardiac arrests. There were only 2 papers relevant to the three part question. In the paper by Chiang et al which suggested improved survival rates the patients receiving adrenaline were more likely to have had a witnessed collapse, initial 'shockable' rhythm, placement of advanced airway, longer total prehospital time and less blunt injury.
Bottom Line:
The role of adrenaline in traumatic cardiac arrests needs further evaluation but there may be a role for it in certain circumstances.
Level of Evidence:
Level 3: Small numbers of small studies or great heterogeneity or very different population
References:
- Chiang et al. Prehospital intravenous epinephrine may boost survival of patients with traumatic cardiac arrest: a retrospective cohort study.
- Sherren et al. Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service