Timothy J. Mader^*, Ryan A. Coute, Adam R. Kellogg, Joshua L. Harris

Show more
Department of Emergency Medicine at Baystate Medical Center, Tufts University School of Medicine, Springfield, MA, USA.
Show less

Abstract: Background: This study was done to compare coronary perfusion pressure (CPP) prior to the first rescue shock (RS) among a group of animals that received intraosseous (IO) epinephrine 0.1 mg/ kg (high-dose epinephrine [HDE]) with a group that received intravenous (IV) epinephrine 0.01 mg/kg (standard-dose epinephrine [SDE]) during cardiac arrest resuscitation using a swine model of prolonged out-of-hospital ventricular fibrillation (VF) cardiac arrest. Methods: This was a secondary analysis of prospectively collected data from two IACUC approved protocols. Seventy-nine Yorkshire swine (25 - 35 kg) were surgically instrumented under anesthesia and VF was electrically induced. After 10 minutes of untreated VF in the IO study (n = 26) and 12 minutes of untreated VF in the IV study (n = 53), resuscitation commenced with closed chest compressions (CCC). A single dose of epinephrine (HDE IO or SDE IV, respectively) was given and flushed with saline. The CCC and RS attempts were standardized for all animals. The CPP was defined as aortic diastolic pressure minus right atrial diastolic pressure measured 2.5 minutes after medication delivery. Descriptive statistics were used to analyze the data. Results: Baseline group characteristics were mathematically the same. Just prior to the first RS, HDE IO resulted in a mean CPP of 33.2 mmHg (95%CI: 26.6, 39.9), while SDE IV resulted in a mean CPP of 25.0 mmHg (95%CI: 20.5, 29.4). Conclusion: This observation study reaffirms the assertion that HDE IO may be required to generate CPP values similar to SDE IV during resuscitation of prolonged VF.

Keywords: Cardiac Arrest Resuscitation; Coronary Perfusion Pressure; Intraosseous; Epinephrine

Cite this paper: Mader, T. , Coute, R. , Kellogg, A. and Harris, J. (2014) Coronary Perfusion Pressure Response to High-Dose Intraosseous versus Standard-Dose Intravenous Epinephrine Administration after Prolonged Cardiac Arrest. Open Journal of Emergency Medicine, 2, 1-7. doi: 10.4236/ojem.2014.21001.

References

[1]   Callaway, C.W. (2013) Epinephrine for Cardiac Arrest. Current Opinion in Cardiology, 28, 36-42. http://dx.doi.org/10.1097/HCO.0b013e32835b0979

[2]   Spivey, W.H., Crespo, S.G., Fuhs, L.R. and Schoffstall, J.M. (1992) Plasma Catecholamine Levels after Intraosseous Epinephrine Administration in a Cardiac Arrest Model. Annals of Emergency Medicine, 21, 127-131. http://dx.doi.org/10.1016/S0196-0644(05)80145-3

[3]   Neumar, R.W., Otto, C.W., Link, M.S., et al. (2010) Part 8: Adult Advanced Cardiovascular Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 122, S729-S767. http://dx.doi.org/10.1161/CIRCULATIONAHA.110.970988

[4]   Mader, T.J., Kellogg, A.R., Smith, J., et al. (2008) A Blinded, Randomized Controlled Evaluation of an Impedance Threshold Device During Cardiopulmonary Resuscitation in Swine. Resuscitation, 77, 387-394. http://dx.doi.org/10.1016/j.resuscitation.2008.01.007

[5]   Mader, T.J., Kellogg, A.R., Walterscheid, J.K., Lodding, C.C. and Sherman, L.D. (2010) A Randomized Comparison of Cardiocerebral and Cardiopulmonary Resuscitation Using a Swine Model of Prolonged Ventricular Fibrillation. Resuscitation, 81, 596-602. http://dx.doi.org/10.1016/j.resuscitation.2010.01.013

[6]   Weisfeldt, M.L. and Becker, L.B. (2002) Resuscitation after Cardiac Arrest: A 3-Phase Time-Sensitive Model. JAMA: The Journal of the American Medical Association, 288, 3035-3038. http://dx.doi.org/10.1001/jama.288.23.3035

[7]   Redding, J.S. and Pearson, J.W. (1963) Evaluation of Drugs for Cardiac Resuscitation. Anesthesiology, 24, 203-207. http://dx.doi.org/10.1097/00000542-196303000-00008

[8]   Babbs, C.F. (1980) New versus Old Theories of Blood Flow during CPR. Critical Care Medicine, 8, 191-195. http://dx.doi.org/10.1097/00003246-198003000-00026

[9]   Ditchey, R.V., Winkler, J.V. and Rhodes, C.A. (1982) Relative Lack of Coronary Blood Flow during Closed-Chest Resuscitation in Dogs. Circulation, 66, 297-302. http://dx.doi.org/10.1161/01.CIR.66.2.297

[10]   Sanders, A.B., Ewy, G.A., Alferness, C.A., Taft, T. and Zimmerman, M. (1982) Failure of One Method of Simultaneous Chest Compression, Ventilation, and Abdominal Binding during CPR. Critical Care Medicine, 10, 509-513. http://dx.doi.org/10.1097/00003246-198208000-00005

[11]   Michael, J.R., Guerci, A.D., Koehler, R.C., et al. (1984) Mechanisms by which Epinephrine Augments Cerebral and Myocardial Perfusion during Cardiopulmonary Resuscitation in Dogs. Circulation, 69, 822-835. http://dx.doi.org/10.1161/01.CIR.69.4.822

[12]   Niemann, J.T., Rosborough, J.P., Niskanen, R.A., Alferness, C. and Criley, J.M. (1985) Mechanical “Cough” Cardiopulmonary Resuscitation during Cardiac Arrest in dogs. The American Journal of Cardiology, 55, 199-204. http://dx.doi.org/10.1016/0002-9149(85)90328-5

[13]   Niemann, J.T., Criley, J.M., Rosborough, J.P., Niskanen, R.A. and Alferness, C. (1985) Predictive Indices of Successful Cardiac Resuscitation after Prolonged Arrest and Experimental Cardiopulmonary Resuscitation. Annals of Emergency Medicine, 14, 521-528. http://dx.doi.org/10.1016/S0196-0644(85)80774-5

[14]   Sanders, A.B., Kern, K.B., Atlas, M., Bragg, S. and Ewy, G.A. (1985) Importance of the Duration of Inadequate Coronary Perfusion Pressure on Resuscitation from Cardiac Arrest. Journal of the American College of Cardiology, 6, 113-118. http://dx.doi.org/10.1016/S0735-1097(85)80261-8

[15]   Kern, K.B., Ewy, G.A., Voorhees, W.D., Babbs, C.F. and Tacker, W.A. (1988) Myocardial Perfusion Pressure: A Predictor of 24-Hour Survival during Prolonged Cardiac Arrest in Dogs. Resuscitation, 16, 241-250. http://dx.doi.org/10.1016/0300-9572(88)90111-6

[16]   Paradis, N.A., Martin, G.B., Rivers, E.P., et al. (1990) Coronary Perfusion Pressure and the Return of Spontaneous Circulation in Human Cardiopulmonary Resuscitation. JAMA: The Journal of the American Medical Association, 263, 1106-1113. http://dx.doi.org/10.1001/jama.1990.03440080084029

[17]   Cobb, L.A., Fahrenbruch, C.E., Walsh, T.R., et al. (1999) Influence of Cardiopulmonary Resuscitation Prior to Defibrillation in Patients with Out-of-Hospital Ventricular Fibrillation. JAMA: The Journal of the American Medical Association, 281, 1182-1188. http://dx.doi.org/10.1001/jama.281.13.1182

[18]   Weisfeldt, M.L. and Becker, L.B. (2002) Resuscitation after Cardiac Arrest: A 3-Phase Time-Sensitive Model. JAMA: The Journal of the American Medical Association, 288, 3035-3038. http://dx.doi.org/10.1001/jama.288.23.3035

[19]   Wik, L., Hansen, T.B., Fylling, F., et al. (2003) Delaying Defibrillation to Give Basic Cardiopulmonary Resuscitation to Patients with Out-of-Hospital Ventricular Fibrillation: A Randomized Trial. JAMA: The Journal of the American Medical Association, 289, 1389-1395. http://dx.doi.org/10.1001/jama.289.11.1389

[20]   Berg, R.A., Hilwig, R.W., Ewy, G.A. and Kern, K.B. (2004) Precountershock Cardiopulmonary Resuscitation Improves Initial Response to Defibrillation from Prolonged Ventricular Fibrillation: A Randomized, Controlled Swine Study. Critical Care Medicine, 32, 1352-1357. http://dx.doi.org/10.1097/01.CCM.0000127780.01362.E5

[21]   Reynolds, J.C., Salcido, D.D. and Menegazzi, J.J. (2010) Coronary Perfusion Pressure and Return of Spontaneous Circulation after Prolonged Cardiac Arrest. Prehospital Emergency Care, 14, 78-84. http://dx.doi.org/10.3109/10903120903349796