Impact of Delayed Epinephrine Administration on Return of Spontaneous Circulation During Pediatric Out-of-Hospital Cardiac Arrest

Introduction: Epinephrine is the only vasopressor associated with return of spontaneous circulation (ROSC). While current guidelines recommend rapid and frequent vasopressor administration during cardiac arrest, delays in administration in out-of-hospital cardiac arrest (OHCA) remain a concern. Consequently, this study evaluated the effect of vasopressor administration delay on field ROSC in pediatric OHCA. 

Methods: This was a retrospective analysis of electronic patient care records from the 2017 ESO research database. The 2017 research database contains patient care records for over five million EMS responses from more than 900 agencies across the United States and encompasses a broad range of practice settings from urban to rural. All patients aged less than 18 years who suffered a nontraumatic OHCA prior to EMS arrival and for whom resuscitation was attempted were included. Data were analyzed using univariate tests and logistic regression with p≤0.05 indicating significance.
Results: A total of 412 patients met inclusion criteria with a mean age of 5.0 (±6.5) years. Mean EMS response time was 9.1 (±6.1) minutes, 28.4% were witnessed arrests, 42.5% received bystander CPR, 8.3% had shockable initial rhythms, and 22.6% experienced ROSC. The mean and 90th-percentile call-receipt-to-pressor intervals were 31.0 and 51 minutes, respectively. Patients receiving advanced airway control prior to epinephrine administration had longer scene-arrival-to-pressor intervals (24.9 vs. 19.3 minutes, p<0.01). Significant adjusted odds ratios for ROSC included call-receipt-to-pressor interval (per minute; OR 0.97, p<0.01); patient age (per year; OR 1.06,p<0.01); non-Caucasian race (OR 0.43, p=0.01); and witnessed arrests (OR 2.88, p<0.01). In addition, compared to arrests of cardiac etiology, arrests of respiratory (OR 2.42, p=0.01) and other etiologies (OR 2.12, p=0.04) were more likely to attain ROSC. An increased likelihood of ROSC was associated with an initial ECG of VF/VT or shockable AED rhythm (OR 3.06, p<0.01), PEA (OR 5.97, p<0.01), and unknown AED nonshockable rhythm (OR 8.42, p=0.03) when compared to asystole.

Conclusion: The odds of ROSC decrease 3% per minute of call-receipt-to-drug-administration delay. Airway control procedures account for a substantial portion of the delay in epinephrine administration and reduce the likelihood of ROSC.