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Could the survival and outcome benefit of adrenaline also be dependent upon the presence of gasping upon arrival of emergency rescuers?

Eric M Rottenberg
American Journal of Emergency Medicine 2014, 32 (9): 1074-6
25034496
A recent systematic review and meta-analysis of randomized controlled trials of adrenaline use during resuscitation of out-of-hospital cardiac arrest found no benefit of adrenaline in survival to discharge or neurological outcomes. It did, however, find an advantage of standard dose adrenaline (SDA) over placebo and high dose adrenaline over SDA in overall survival to admission and return of spontaneous circulation (ROSC), which was also consistent with previous reviews. As a result, the question that remains is "Why is there no difference in the rate of survival to discharge when there are increased rates of ROSC and survival to admission in patients who receive adrenaline?" It was suggested that the lack of efficacy and effectiveness of adrenaline may be confounded by the quality of cardiopulmonary resuscitation (CPR) during cardiac arrest, which has been demonstrated in animal models. CPR quality was not measured or reported in the included randomized controlled trials. However, the survival and outcome benefit of adrenaline may also depend upon the presence of witnessed gasping and/or gasping upon arrival of emergency rescuers, which is a critical factor not accounted for in the analyses of the cited animal studies that allowed gasping but showed the survival and neurological outcome benefits of adrenaline use. Moreover, without the aid of gasping, very few rescuers can provide high-quality CPR. Also, age and the absence of gasping observed by bystanders and/or upon arrival of emergency- rescuers may be important factors in the determination of whether vasopressin instead of adrenaline should be used first.

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