Background: Beneficial effect of epinephrine during resuscitation of cardiopulmonary arrest (CPA) has been inconclusive and potential harm was suggested particularly in trauma victims. Although no significant improvement of neurological outcome has been clarified among resuscitated patients using epinephrine, including trauma patients, the use of epinephrine is recommended in the advanced trauma life support (ATLS) protocol. Given that the use of vasopressors was reported to be associated with increased mortality in patients with massive bleeding, undesired effect of epinephrine in the resuscitation of traumatic CPA should be elucidated. We hypothesized that resuscitation with epinephrine would increase mortality in patients with CPA following trauma.
Methods: In a prospective, multicenter, observational study, 1,125 adults with out-of-hospital cardiac arrest following trauma were identified between January 2012 and March 2013. Patient data were divided into epinephrine or no-epinephrine groups depending on the use of epinephrine during resuscitation at hospital. Propensity scores were developed to estimate the probability of being assigned to the epinephrine group, using multivariate logistic regression analyses adjusted for known survival predictors. The primary outcomes were survival at 7 days after injury and compared among the two groups after propensity score matching.
Results: A total of 1,030 patients were included in this study after 29 were excluded due to missing data on primary outcome or the use of epinephrine. Of those patients, 822 (79.8%) were resuscitated using epinephrine, and 1.1% (9/822) in the epinephrine group and 5.3% (11/208) in the no-epinephrine group survived at 7 days after injury. The use of epinephrine was significantly associated with decreased 7-day survival (odds ratio, 0.20; 95% CI, 0.08–0.48; P<0.01) and this was confirmed by propensity score-matching analyses, in which 178 matched pairs were examined (adjusted odds ratio, 0.11; 95% CI, 0.01–0.85; P=0.02)
Conclusion: The relationship between the use of epinephrine during resuscitation and decreased 7-day survival was revealed in patients with CPA following trauma, and the propensity score-matching analyses validated the results. The resuscitation without epinephrine in traumatic CPA should be further studied in a randomized controlled trial.