Using Adrenaline the right way in Cardiac Resuscitation

Subscribe to Resus

Get the latest updates on our Conferences PLUS our Webcasts and Education Newsletters. And it's FREE!

  • We respect your privacy
  • This field is for validation purposes and should be left unchanged.

Register Now:

Emcore
Learn More

ADRENALINE AND CARDIAC RESUSCITATION

How much to use, when to use it and when not to use it.

The resuscitation guidelines were born in the black-and-white television era, at the end of the 1950’s. The use of 1 mg of adrenaline which initially came from canine models, was introduced at this time and has been a major part of all resuscitations since then.
The clinical significance of adrenaline is uncertain. It’s been shown to give no improvement and even to decrease survival to hospital discharge and decrease the rate of favourable neurological outcomes(1). Steil(2) in the multi-centre OPALS study demonstrated no improvement in neurologically intact survivors to hospital discharge when using advanced life-support. We know that high-dose adrenaline doesn’t improve outcomes(3).

Jacobs(4), further randomised 601 cardiac arrest patients and found a significantly improved likelihood of achieving return of spontaneous circulation(ROSC) in the adrenaline group. There was a trend to increased survival to discharge in this group, unfortunately the study was underpowered.

IS THERE A RIGHT DOSE OF ADRENALINE?

Giving 1mg of adrenaline to a heart that has just resumed beating, can have dire consequences. The effect of markedly increased afterload against which a weak heart must beat, can result in a rapid loss of circulation. The adrenaline dose must be titrated to achieve adequate coronary and cerebral perfusion.

Our aim should be to achieve a coronary perfusion pressure of above 15 – 20 mmHg. This equates to diastolic blood pressure of 25 – 35 mmHg (5), which has been shown to provide adequate cerebral perfusion pressure.
Monitoring with an arterial line is the only way to do this accurately. As I have discussed at several EMCORE conferences, the aim is to locate the femoral artery with ultrasound during the first rhythm check pause and to then pass the catheter during the second rhythm check. This requires practice and coordination of the team.

If you don’t have an arterial line, don’t trust the pulse check, or the electrical wave form. Use the cardiac ultrasound to verify whether the heart is beating or not.
In the FEEL study(6) it was found the 38% of patients with asystole on the ECG, had coordinated cardiac motion on echo. It was further found that 58% of those in PEA had coordinated cardiac motion seen when the heart was visualised. Hypothesize what might happen with the massive alpha effects of giving 1 mg of adrenaline to these hearts. Keep the dose small if the heart is beating.

WHEN SHOULD ADRENALINE NOT BE GIVEN?

1. If the heart is beating and the diastolic blood pressure is > 40mmHg, don’t give adrenaline. If the blood pressure is less than this, a small amount can be given ie., 30-50mcg, but not the full 1mg.

2. In Refractory VT/VF. This is due to a catecholamine surge. Adrenaline only serves to increase that surge. If you can’t get the patient out of these rhythms for a prolonged period, then stop the adrenaline.

A recent study demonstrated esmolol as being very effective for these catecholamine driven arrhythmias. This was a small retrospective study(7) where they used 500mcg/kg as a bolus dose and then an infusion to follow. This may have been a small study, but the use of  beta blockers for ‘electrical storm’ is known to be effective in these situations.

3. Do not give adrenaline late in the resuscitation.
Dumas(8) describes the three phases of cardiac resuscitation:

  • The Electrical Phase: This occurs in the first few minutes following cardiac arrest. There is no place for adrenaline at this point.
  • The Circulatory Phase: This lasts for 10-15 minutes and it is the phase where patients benefit most form CPR and adrenaline.
  • The Metabolic Phase: This phase occurs approximately 20 minutes after a cardiac arrest. In this phase adrenaline has been found to be detrimental.

Consider not giving adrenaline after the first 3 doses or after 20 minutes into the resuscitation.

Giving the right dose of adrenaline at the right time and knowing when not to give it, are essential for improved survival from cardiac arrest.

References

  1. Reardon P. et al.  Epinephrine in out of hospital cardiac arrest: A critical review. World J of EM. Vol 4, No 2, 2013.
  2. Steil I G et al. Advanced cardiac life-support and out of hospital cardiac arrest. NEJM 2004:351:pp647 -656.
  3. Steil I G et al. High dose epinephrine in adult cardiac arrest. NEJM 1992; 327: 1045-1050
  4. Jacobs I G et al. Affect of adrenaline on survival in out of hospital cardiac arrest: A randomised double blind placebo controlled trial. Resuscitation, September 2011. Vol 82, Iss 9, pp1138-1143.
  5. Sutton R M et al. Hemodynamic directed CPR improves short-term survival from asphyxia – associated cardiac arrest. Resuscitation 2013, May; 84 (5): pp696-701.
  6. Breitkreutz R et al. Focused echocardiographic evaluation of life-support and peri-resuscitation of emergency patients: A prospect of trial. Resuscitation November 2010, vol 81, iss 11 , pp 1527-1533.
  7. Driver BE et al. Use of esmolol after failure of standard Cardiopulmonary Resuscitation to treat patients with the refectory ventricular fibrillation. Resuscitation 2014 Oct; 85 (50): pp1337-1341.
  8. Dumas F et al. Is epinephrine during cardiac arrest associated with worst outcomes in resuscitated patients? JACC. Vol 64. No 22 Dec 9, 2014. pp2360-2367.

Dr Peter Kas

Dr Peter Kas

Emergency Physician, Educator. Key Interests: Resuscitation, Airway, Emergency Cardiology, Clinical Examination. Creator resus.com.au.

54 Comments

  1. MUSA on 16/10/2018 at 9:00 am

    Dear A/Prof Dr Kas
    Thank you for thin enlightening summary about Adrenaline role in resuscitation. This highlights the facts that Adrenaline is really a double sided sword and the current practice is to use its sharp edge, early, aggressively and for prolonged period of time. I hope some of the facts you have shared on your Blog could be incorporated into the currently available resuscitation guidelines.

  2. […] there a better way to dose epinephrine in cardiac arrest? Resus Australia has some  epinephrine dosing recommendations […]

  3. Gabe on 13/11/2018 at 6:20 pm

    ” after the first 3 doses or after 20 minutes into the resuscitation”

    it seems the first 3 doses should occur far before 20 mins in almost all resus attempts, no?

    • admin on 14/11/2018 at 8:45 am

      It’s probably true in many cases. However in cases where there is witnessed arrest and CPR giving low flow and rapid response, we get them before that time. In situations where they have received 3 mg of adrenaline for example and they come in late, I don’t keep giving it.

  4. Malek on 29/11/2018 at 5:03 pm

    All of your references are rather old without clear evidence. Refer to G. Perkin et al., NEJM, 2018: PARAMEDIC-2 trial (Pre-hospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug administration In Cardiac arrest). Significant increase of ROSC, only small increase of worse neurological outcome.

    • admin on 10/06/2019 at 7:02 pm

      The point we all make and what we take away from these trials differ. My whole purpose is to try and get patients well and out. The Paramedic II trial gives me even greater hope. I’m interested in them getting to my ED. When that happens, when we treat them in the right way results in increased possibilities. That’s what I take from this. New trial, doesn’t change my practice much, not many other resuscitation guys approaches. Thanks for reading and for the comment. We debated this at the EMCORE.

      Peter

  5. Proxies For Instagram on 31/08/2021 at 9:15 pm

    Buy Cheapest USA Elite Private Proxies – Only On DreamProxies.com – Most useful Proxy Prices!

  6. Stormproxies on 01/09/2021 at 6:27 pm

    I see something truly interesting about your blog so I saved to fav.

  7. Bestproxy on 02/09/2021 at 1:04 am

    I simply desired to appreciate you once again. I am not sure the things that I would have created in the absence of the actual methods documented by you over my concern. It was an absolute challenging situation in my opinion, nevertheless seeing a well-written style you solved it made me to cry with fulfillment. I am happier for your assistance and thus trust you recognize what an amazing job your are putting in teaching other individuals through your web page. I know that you’ve never encountered any of us.

  8. Free Private Proxies on 10/09/2021 at 7:31 am

    Greetings! I know this is kinda off topic however I’d figured I’d ask. Would you be interested in trading links or maybe guest authoring a blog post or vice-versa? My website discusses a lot of the same topics as yours and I believe we could greatly benefit from each other. If you might be interested feel free to shoot me an email. I look forward to hearing from you! Awesome blog by the way!

  9. Gia on 18/09/2021 at 10:44 am

    Hmm it seems like your site ate my first comment (it was super
    long) so I guess I’ll just sum it up what I submitted and
    say, I’m thoroughly enjoying your blog. I too am an aspiring blog writer but I’m still new to the whole
    thing. Do you have any tips for newbie blog writers? I’d certainly appreciate it.

  10. Pure CBD Softgels on 18/09/2021 at 10:50 am

    You actually make it appear so easy along with your presentation however I to
    find this matter to be actually one thing that I feel I’d
    by no means understand. It kind of feels too complicated and
    very large for me. I’m looking ahead for your subsequent publish, I will
    try to get the dangle of it!

    Feel free to visit my blog post; Pure CBD Softgels

  11. TestoXmen on 18/09/2021 at 10:58 am

    Hello, Neat post. There’s a problem with your web site in web explorer, might test this?
    IE nonetheless is the market leader and a huge component to folks will
    leave out your wonderful writing due to this problem.

    Feel free to visit my webpage; TestoXmen

  12. Ultra Quick Keto Burn Reviews on 18/09/2021 at 11:04 am

    It’s actually a cool and helpful piece of information. I am satisfied
    that you shared this helpful information with us.

    Please keep us up to date like this. Thanks for sharing.

    Check out my web-site: Ultra Quick Keto Burn Reviews

  13. Bioneo Farms CBD Reviews on 18/09/2021 at 11:10 am

    I really enjoy studying on this website, it has got fantastic
    blog posts.

    Visit my webpage – Bioneo Farms CBD Reviews

  14. proxyusa.org on 18/09/2021 at 11:12 am

    Heya i’m for the first time here. I came across this board and I find It
    really useful & it helped me out much. I hope to give
    something back and help others like you helped me.

  15. mariamylove.com on 18/09/2021 at 11:14 am

    I will right away take hold of your rss feed as I can’t in finding your e-mail
    subscription hyperlink or newsletter service. Do you’ve any?
    Please permit me know in order that I could subscribe.
    Thanks.

  16. https://blackbeargolfcomplex.com on 18/09/2021 at 11:29 am

    I could not resist commenting. Very well written!

  17. Extreme Muscle XXL Review on 18/09/2021 at 11:38 am

    I simply desired to thank you very much once more.
    I am not sure the things I would’ve created without the entire tips shared by
    you on such area of interest. It was before a real frightening case for me personally, but looking at your well-written technique you dealt with the issue forced me to cry for contentment.
    I am thankful for your work as well as hope you comprehend what a great job you are always
    putting in teaching the others using your blog
    post. Most likely you have never come across
    any of us.

    My blog; Extreme Muscle XXL Review

  18. GrownMD CBD Gummies on 18/09/2021 at 11:40 am

    Thank you for your site post. Jones and I are already saving for just a
    new publication on this matter and your article
    has made us all to save all of our money. Your notions really
    answered all our queries. In fact, above what we had thought of previous to the time we
    came across your wonderful blog. My spouse and i no longer have doubts along with a troubled mind because you have attended to all of our needs right here.
    Thanks

    Feel free to surf to my web page – GrownMD CBD Gummies

  19. Erectesto XL Pills on 18/09/2021 at 11:58 am

    Everything is very open with a clear explanation of the
    challenges. It was truly informative. Your website is
    useful. Many thanks for sharing!

    Feel free to visit my webpage Erectesto XL Pills

  20. Absolutely indited subject matter, regards for selective information.

    My web-site Bioneo Farms CBD Reviews (http://sylvbuster.free.fr/modules.php?name=Your_Account&op=userinfo&username=SherlynWre)

  21. Mega Male Enhancement Review on 18/09/2021 at 12:24 pm

    Some genuinely marvelous work on behalf of the owner of this internet site,
    perfectly outstanding subject matter.

    Feel free to surf to my web blog: Mega Male Enhancement Review

  22. Extreme Keto EFX Review on 18/09/2021 at 12:44 pm

    I enjoy the efforts you have put in this,
    thank you for all the great blog posts.

    My webpage Extreme Keto EFX Review

  23. Erectesto XL Review on 18/09/2021 at 12:55 pm

    I like this web blog it’s a master piece! Glad I discovered this on google.

    My webpage – Erectesto XL Review

  24. A1 Keto BHB Reviews on 18/09/2021 at 12:58 pm

    Yes! Finally something about 7 A1 Keto BHB Reviews weight loss.

  25. Hey! This post could not be written any better! Reading this post reminds me of my good old room mate!

    He always kept chatting about this. I will forward this post to him.
    Fairly certain he will have a good read. Thank you for sharing!

    Also visit my homepage … UltraXTend Reviews – http://www.hltkd.tw/hl4/userinfo.php?uid=189788

  26. Terra Xtract CBD Tincture on 18/09/2021 at 1:24 pm

    F*ckin’ awesome issues here. I’m very satisfied to look your post.
    Thank you a lot and i am looking forward to contact you.
    Will you kindly drop me a mail?

    Also visit my web site Terra Xtract CBD Tincture

  27. Keto X3 Reviews on 18/09/2021 at 1:32 pm

    This site truly has all of the info I needed concerning this subject and didn?t know who to ask.

    Feel free to surf to my web site; Keto X3 Reviews

  28. GrownMD CBD Gummies on 18/09/2021 at 1:46 pm

    I’ve been surfing on-line greater than three
    hours today, yet I never found any attention-grabbing article
    like yours. It is beautiful value sufficient for me.
    In my opinion, if all website owners and bloggers made excellent content as
    you probably did, the net will likely be a lot more
    helpful than ever before.

    Also visit my homepage – GrownMD CBD Gummies

  29. Ultra Quick Keto Reviews on 18/09/2021 at 2:38 pm

    Wow that was odd. I just wrote an incredibly long comment but after I clicked submit my comment didn’t appear.
    Grrrr… well I’m not writing all that over again. Regardless, just wanted to say excellent blog!

    Here is my webpage … Ultra Quick Keto Reviews

  30. Renew Brite Review on 18/09/2021 at 2:58 pm

    hello there and thank you for your info – I have certainly picked up something new from right here.
    I did however expertise some technical issues using this
    web site, as I experienced to reload the web
    site many times previous to I could get it to load properly.
    I had been wondering if your web host is OK? Not that I am
    complaining, but sluggish loading instances times will often affect your placement
    in google and could damage your high-quality score
    if ads and marketing with Adwords. Well I
    am adding this RSS to my email and can look out for much more of your respective fascinating content.
    Make sure you update this again very soon..

    Feel free to visit my homepage Renew Brite Review

  31. Tundra Breeze Portable AC on 18/09/2021 at 3:13 pm

    Thank you a lot for sharing this with all folks you actually recognize what you’re talking approximately!
    Bookmarked. Kindly also talk over with my website =).
    We will have a hyperlink alternate arrangement between us!

    My web-site Tundra Breeze Portable AC

  32. Quick Keto Trim Ingredients on 18/09/2021 at 3:35 pm

    Thanks for the auspicious writeup. It if truth be told was a leisure
    account it. Look complex to far delivered agreeable
    from you! However, how can we communicate?

    my homepage – Quick Keto Trim Ingredients

  33. http://www.hltkd.tw/ on 18/09/2021 at 3:49 pm

    F*ckin’ tremendous things here. I’m very happy to look your post.

    Thanks a lot and i am looking ahead to touch you. Will you please drop me a e-mail?

    my web-site :: Max Melt Keto Reviews (http://www.hltkd.tw/)

  34. Max Melt Keto Review on 18/09/2021 at 4:14 pm

    The very next time I read a blog, I hope that it does not disappoint
    me as much as this particular one. After all, Yes, it was my choice to read,
    but I really thought you would probably have something interesting to talk about.
    All I hear is a bunch of complaining about something that you can fix if you weren’t too busy seeking attention.

    my page … Max Melt Keto Review

  35. www.fotosombra.com.br on 18/09/2021 at 4:48 pm

    I’ve been surfing online more than 2 hours today, yet I never found any interesting article like yours.

    It’s pretty worth enough for me. Personally, if all web owners and bloggers made good content as
    you did, the internet will be much more useful than ever before.

    my blog post Extreme Keto EFX Review, http://www.fotosombra.com.br,

  36. data togel china on 18/09/2021 at 5:51 pm

    you ɑre trly ɑ just riցht ԝebmaster. The website loading velocity is incredible.
    It sort of feels that you are doіng аny distintive trick.
    In addition, Thee contents are masterworк.
    yoս have pеrformed a magnificent job iin this matter!

  37. bbs.cnction.com on 18/09/2021 at 6:31 pm

    May I simply just say what a relief to discover a person that
    truly understands what they’re talking about online.
    You definitely know how to bring a problem to light and make it important.
    A lot more people must read this and understand this side of your story.
    I was surprised you’re not more popular because you certainly have the gift.

    Look into my blog: Mega Male Enhancement (bbs.cnction.com)

  38. Pure CBD Softgels Cost on 18/09/2021 at 7:47 pm

    Thanks a ton for being my own coach on this matter. We enjoyed the article very much and most of all favored how
    you really handled the areas I regarded as being controversial.

    You happen to be always quite kind towards readers much like me and
    assist me in my everyday living. Thank you.

    Feel free to surf to my blog post: Pure CBD Softgels Cost

  39. Denisha on 19/09/2021 at 4:16 pm

    These are truly wonderful ideas in about blogging.

    You have touched some pleasant points here.
    Any way keep up wrinting.

  40. Arlie on 19/09/2021 at 10:16 pm

    When someone writes an post he/she maintains the image of a user in his/her mind
    that how a user can understand it. So that’s why this paragraph is perfect.
    Thanks!

  41. bắn cá online 3d on 20/09/2021 at 2:01 am

    Oh my goodness! Awesome article dude! Many thanks, However I am eencountering
    issues with your RSS. I don’t know why I can’t subscribe too it.
    Is there anybody having the same RSS problems? Anyone who knows the solution can you kindly respond?
    Thanks!!

    Here is my web page :: bắn cá online 3d

  42. Jewell on 20/09/2021 at 3:36 am

    Thanks for sharing your thoughts on website. Regards

  43. Donny on 20/09/2021 at 4:45 am

    What’s up, all the time i used to check blog posts here in the early hours in the dawn, for the reason that i like
    to learn more and more.

  44. Agnes on 20/09/2021 at 5:13 am

    At this moment I am going to do my breakfast, once having my breakfast coming again to read
    other news.

  45. Margo on 20/09/2021 at 8:12 am

    Excellent blog here! Additionally your website lots up fast!
    What host are you using? Can I am getting your affiliate link to your host?
    I wish my site loaded up as fast as yours lol

  46. Prince on 20/09/2021 at 8:38 am

    This is very interesting, You are a very professional blogger.

    I have joined your feed and sit up for seeking extra of your great
    post. Additionally, I’ve shared your web
    site in my social networks

  47. Temeka on 20/09/2021 at 9:53 am

    Undeniably imagine that that you said. Your favourite justification appeared to be on the
    internet the simplest thing to have in mind of.
    I say to you, I definitely get annoyed whilst other folks think about concerns that they just don’t recognise about.

    You controlled to hit the nail upon the highest and also defined out the entire thing without having side effect , other folks could take a signal.

    Will probably be again to get more. Thank you

  48. Fatima on 20/09/2021 at 10:50 am

    This is my first time pay a quick visit at here and i am actually pleassant to
    read everthing at alone place.

  49. Julian on 20/09/2021 at 11:57 am

    I am regular reader, how are you everybody? This post posted
    at this web site is genuinely pleasant.

  50. Karma on 20/09/2021 at 12:29 pm

    A person essentially lend a hand to make severely articles I’d
    state. This is the very first time I frequented your web page and up to now?
    I surprised with the research you made to create this actual
    put up extraordinary. Fantastic process!

  51. Vernon on 20/09/2021 at 12:30 pm

    I quite like reading through an article that will make people think.
    Also, thanks for allowing for me to comment!

  52. Jame on 06/10/2021 at 10:10 pm

    I loved as much as you’ll receive carried out right here.
    The sketch is attractive, your authored subject matter stylish.
    nonetheless, you command get bought an impatience over that you wish be delivering the following.
    unwell unquestionably come more formerly again as
    exactly the same nearly a lot often inside case you shield this hike.

Leave a Comment