You may have seen it in the movies or on television, or, horribly, in real life – when doctors or emergency personnel use an epinephrine (also called adrenaline) shot in an attempt to restore a heartbeat in a patient suffering cardiac arrest. This is a traditional procedure with paramedics, in hospitals, and emergency rooms, but new research is questioning its effectiveness and even its safety.
An American Heart Association study reports that around 350,000 Americans experience cardiac arrest outside of the hospital each year, and 89% of these events result in death. CPR and defibrillator shocks give them the best chance at survival. Adrenaline is a last resort, working by increasing blood flow to the heart.
However, it also reduces blood flow to the small blood vessels in the brain, which can cause brain damage. A recent study published in the New England Journal of Medicine in the U.K. found that approximately a third of heart attack survivors who received adrenaline ended up in a vegetative state, or were unable to care for themselves or walk unassisted, in comparison to about 18% who were given a placebo.
The trial’s summary findings were that using epinephrine injections to the heart nearly doubles the risk of serious neurological damage to cardiac arrest survivors, and does not significantly improve the rate of survival.
“We have found that the benefits of adrenaline are small—one extra survivor for every 125 patients treated—but the use of adrenaline almost doubles the risk of a severe brain damage amongst survivors,” said Gavin Perkins, professor of Critical Care Medicine in Warwick Medical School in the U.K. and lead author on the paper.
Methodology of the study
Adrenaline shots as a last-ditch effort to save lives became common practice about five decades ago. Its intent was to make CPR more effective, with the thought that epinephrine increases the blood pressure during chest compressions. The study focused on cardiac arrest incidents occurring outside the hospital.
During the study, paramedics in the U.K. were provided with pre-filled syringes with either a placebo or adrenaline to use for people in cardiac arrest. They were only to use the shots after initial and traditional attempts at resuscitation failed, like CPR or defibrillation. (Residents in the area of the study were informed and given the choice to wear “no study” wristbands if they did not wish to participate.)
Over the course of the study, 4,012 people were treated with adrenaline and 3,995 were given the placebo. From the patients given adrenaline, 130 (3.2%) were alive after 30 days, compared to 94 (2.4%) of the patients who were given a placebo. However, of the 128 patients who had been given adrenaline and survived to hospital discharge, 39 (30.1%) had severe brain damage, compared with only 16 (18.7%) of the 91 survivors who had a placebo.
Prof. Perkins suggests that an increased survival rate doesn’t necessarily make adrenaline worth the risk. “Patients may be less willing to accept burdensome treatments if the chances of recovery are small or the risk of survival with severe brain damage is high. Our own work with patients and the public before starting the trial identified survival without brain damage is more important to patients than survival alone. The findings of this trial will require careful consideration by the wider community and those responsible for clinical practice guidelines for cardiac arrest,” he said.
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