Today in JAMA there is a non-randomized observational study of epinephrine vs. no medicine in 417,188 EMS cardiac arrest patients. I will be writing about this study in more detail, but I have already written a lot about the earlier studies that demonstrate the harm of epinephrine in cardiac arrest.
We never had a good reason to make epinephrine the standard of care in cardiac arrest.
The goal of resuscitation is NOT to get a pulse back.
But . . . but . . . but . . . if we don’t get pulses back, we can’t resuscitate patients.
Yes, but that does not mean that it does not matter how much harm we do in order to get pulses back.
Just because epinephrine increases the rate of return of pulses does not mean that epinephrine increases the rate of survival to discharge.
In the treatment of cardiac arrest, nothing is more important than survival to discharge.
OK, survival to one month is more important. Survival to one year is more important. Survival to ten years is more important.
A pulse for a few days is not important. A pulse for a few hours is not important. A pulse for a few minutes is not important. There is a word to describe these patients who never leave the hospital – dead.
only 1.4% of patients in the epinephrine group had good neurological outcomes, despite a 5.4% survivalrate (Table 1). Thus, only about 25% of survivors had good neurological outcomes.
Thus, properly evaluating this traditional therapy now seems necessary and timely and should consist of a rigorously conducted and adequately powered clinical trial comparing epinephrine with placebo during cardiac arrest. Such a trial has previously seemed unethical, and investigators who have attempted to perform this comparison have received unwarranted criticism in their communities.17,19 
The only thing unethical has been the resistance from those defending the Standard Of Care, that was nothing more than a refusal to examine tradition.
While awaiting results of such a definitive trial, physicians and other practitioners involved in cardiac resuscitation must consider carefully whether continued use of epinephrine is justified.
How can we justify a treatment that has never been based on any study of survival? We do not have any good reason to expect that the results of a randomized placebo-controlled study will support continuing use of epinephrine.
Epinephrine should only be used in cardiac arrest as a part of controlled studies.
Expert recommendations must come with an expiration date.
If the expert recommendation is not followed by appropriate research, then the expert recommendation should not be treated better than the patients.
ROSC (Return Of Spontaneous Circulation) is nice, but ROSC is only a surrogate endpoint. If we are creating a dangerous condition by transporting the patient to the hospital; if the patient never wakes up; if we create false hope for the family; if we generate huge bills that may bankrupt the family; if we takes hospital staff away from the treatment of other patients – where is the benefit?
But . . . but . . . but . . . the family will be able to say goodbye to their loved one while the person has a pulse.
How many millions of dollars is that worth to make us feel good, regardless of what the family wants?
Why do we assume that this is what the family wants? Do we ask? Of course not – we don’t want to risk learning the truth.
50 years of tradition, unimpeded by progress.
Forget it, Jake. It’s Chinatown.
There is also audio of an interview with Dr. Calloway, who wrote the accompanying editorial.
Thank you to William Toon, PhD. of the EMS EduCast for bringing this to my attention.
 Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest.
Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S.
JAMA. 2012 Mar 21;307(11):1161-8. doi: 10.1001/jama.2012.294.
PMID: 22436956 [PubMed – indexed for MEDLINE]
 Questioning the use of epinephrine to treat cardiac arrest.
JAMA. 2012 Mar 21;307(11):1198-200. doi: 10.1001/jama.2012.313. No abstract available.
PMID: 22436961 [PubMed – indexed for MEDLINE]
On the right side of the page, to the right of the First Page Preview, is a section with the title Multimedia Related by Topic. Below that is Author Interview. Below that is some information about the edition, . . . , and below that is an embedded recording of the interview. Press on the arrow to play. That has the recording of the interview with Dr. Callaway.
This is definitely worth listening to.