Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

More on Epinephrine in Cardiac Arrest.

In Epinephrine in Cardiac Arrest and Dead VT vs Not Quite Dead, Yet VT I wrote about some of the reasons that epinephrine may not be a good idea in cardiac arrest. It does improve ROSC (the Return Of Spontaneous Circulation – getting a pulse back).

If you were having a heart attack, but now are experiencing cardiac arrest, is epinephrine good for you?

Here is what AHA (American Heart Association) states about ACS (Acute Coronary Syndrome – heart attacks and related conditions).

Acute myocardial infarction (AMI) and unstable angina (UA) are part of a spectrum of clinical disease collectively identified as acute coronary syndromes (ACS).

Sudden cardiac death may occur with any of these conditions. ACS is the most common proximate cause of sudden cardiac death.6–10

“Everybody dead gets Epi,” is what I tell students. It seems to help them remember the initial part of the arrest algorithms. Things have changed with the use of vasopressin as an alternative to epinephrine. Still, the thought process that goes into giving epinephrine is as mindless as ever.

If epinephrine is the wonder drug in cardiac arrest, and “ACS is the most common proximate cause of sudden cardiac death.6–10″ Then why is there not a single mention of epinephrine in the treatment of ACS. Go, search the document. Nothing.

Cardiac arrest is part of the expected progression of the ACS.

Cardiac arrest appears to be happening most often to those with ACS.

Epinephrine is the first IV drug given for all cardiac arrests.

Why is there no consideration of treating ACS with epinephrine, even accidentally?

Even if ACS is not the cause of cardiac arrest, but only coincidentally present, this is an important consideration.

How do these ACS patients benefit from epinephrine?

AHA does not even mention epinephrine, when discussing ACS treatment.

Is a vasopressor, such as epinephrine, essential for resuscitation?

Although epinephrine has been used universally in resuscitation, there is a paucity of evidence to show that it improves survival in humans. Both beneficial and toxic physiologic effects of epinephrine administration during CPR have been shown in animal and human studies.44–50

To date no placebo-controlled trials have shown that administration of any vasopressor agent at any stage during management of pulseless VT, VF, PEA, or asystole increases the rate of neurologically intact survival to hospital discharge. There is evidence, however, that the use of vasopressor agents favors initial ROSC.

The placebo controlled trials of epinephrine in cardiac arrest have not shown any improvement in meaningful survival with epinephrine. So, epinephrine has not been shown to be better than a fake treatment.

Epinephrine is full of side effects. These are not considered to be good for ACS. It is not unreasonable to expect that most of the patients treated with epinephrine in cardiac arrest have ACS at the time of arrest.

Shouldn’t we be careful in giving epinephrine to these patients?

It may be that epinephrine does produce a long term benefit to some of these patients, but shouldn’t we find some way of discriminating among these patients to determine who might benefit?

Instead we indiscriminately give epinephrine to all patients in cardiac arrest.

The research does not support using epinephrine in cardiac arrest.

The physiology of giving epinephrine to someone with ACS is ignored.

(Circulation. 2005;112:IV-89 – IV-110.)
© 2005 American Heart Association, Inc.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Part 7.2: Management of Cardiac Arrest

Part 8: Stabilization of the Patient With Acute Coronary Syndromes


  1. […] arrhythmias. I describe problems with the use of epinephrine in Epinephrine in Cardiac Arrest, More on Epinephrine in Cardiac Arrest, and Dead VT vs Not Quite Dead, Yet […]