title: Dynamic effects of adrenaline (epinephrine) in out-of-hospital cardiac arrest with initial pulseless electrical activity (PEA).
abstract: BACKGROUND
  In cardiac arrest, pulseless electrical activity (PEA) is a challenging clinical syndrome. In a randomized study comparing intravenous (i.v.) access and drugs versus no i.v. access or drugs during advanced life support (ALS), adrenaline (epinephrine) improved return of spontaneous circulation (ROSC) in patients with PEA. Originating from this study, we investigated the time-dependent effects of adrenaline on clinical state transitions in patients with initial PEA, using a non-parametric multi-state statistical model.
  
  
  RESULTS
  Patients with available defibrillator recordings were included, of whom 101 received adrenaline and 73 did not. There were significantly more state transitions in the adrenaline group than in the no-adrenaline group (rate ratio = 1.6, p<0.001). Adrenaline markedly increased the rate of transition from PEA to ROSC during ALS and slowed the rate of being declared dead; e.g. by 20 min 20% of patients in the adrenaline group had been declared dead and 25% had obtained ROSC, whereas 50% in the no-adrenaline group have been declared dead and 15% had obtained ROSC. The differential effect of adrenaline could be seen after approx. 10 min of ALS for most transitions. For both groups the probability of deteriorating from PEA to asystole was highest during the first 15 min. Adrenaline increased the rate of transition from PEA to ventricular fibrillation or -tachycardia (VF/VT), and from ROSC to VF/VT.
  
  
  CONCLUSIONS
  Adrenaline has notable clinical effects during ALS in patients with initial PEA. The drug extends the time window for ROSC to develop, but also renders the patient more unstable. Further research should investigate the optimal dose, timing and mode of adrenaline administration during ALS.
authors.affiliation: Dept of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway. trond.nordseth@ntnu.no
authors.forename: Trond
authors.initials: T
authors.lastname: Nordseth
authors.forename: Theresa Mariero
authors.initials: TM
authors.lastname: Olasveengen
authors.forename: Jan Terje
authors.initials: JT
authors.lastname: Kvaløy
authors.forename: Lars
authors.initials: L
authors.lastname: Wik
authors.forename: Petter Andreas
authors.initials: PA
authors.lastname: Steen
authors.forename: Eirik
authors.initials: E
authors.lastname: Skogvoll
mesh_terms: D000293:Adolescent; D000318:Adrenergic beta-Agonists / Q000627:therapeutic use*; D000328:Adult; D022561:Advanced Cardiac Life Support; D000368:Aged; D000369:Aged, 80 and over; D004562:Electrocardiography; D004837:Epinephrine / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D058687:Out-of-Hospital Cardiac Arrest / Q000188:drug therapy* / Q000503:physiopathology / Q000628:therapy; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000318:Adrenergic beta-Agonists; D004837:Epinephrine