• 
• 

Three Part Question

In [patients in traumatic cardiac arrest] does [IV adrenaline] [improve survival]

Clinical Scenario

A 45 year old cyclist is brought up into resus after being knocked off his bicycle by a lorry. He is in traumatic cardiac arrest. ATLS is in progress you wonder whether IV adrenaline would improve his chances of survival?

Search Strategy

In [adults with traumatic cardiac arrest] does [IV Adrenaline] [improve survival?]
EMBASE, BNI, Medline, CINAHL

1. Traumatic.ti,ab
2. (cardiac AND arrest).ti,ab
3. Adrenaline.ti,ab
4. Epinephrine.ti,ab
5. Vasopressors.ti,ab
6. 1 AND 2
7. 3 OR 4 OR 5
8. 6 AND 7

Search Outcome

104 unique papers of which 3 answered the clinical question. On closer inspection 2 of the papers were the same cohort of patients with the earlier paper being a poster abstract.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Chiang et al 2015 Taiwan	514 patients >18 years old with traumatic cardiac arrest in Taiwan	Retrospective trauma registry review	Use of adrenaline	Survival to hospital- adjusted odds ratio 2.57 (95% CI 1.24-5.31)	Retrospective data. Only 43 (8.4%) of patients received IV adrenaline. Unclear why certain patients were given IV adrenaline and others not.
			Use of adrenaline	Survival to hospital discharge- adjusted odds ratio 3.53 (95%CI 0.84-15.47)
Sherren et al 2013 Australia		Suggested algorithm based on experience, expert opinion and review of the evidence.	Use of adrenaline in blunt traumatic cardiac arrest	Consider 10mcg/kg if cardiac motion seen on US with no pericardial effusion.	Some evidence for recommendations extracted from animal studies.
			Use of adrenaline in penetrating traumatic cardiac arrest.	Consider 10mcg/kg after clamshell thoracotomy if thoracotomy fails to restore ROSC and the heart is full.

Comment(s)

The use of adrenaline in cardiac arrests is controversial and most studies looking at its use exclude traumatic cardiac arrests. There were only 2 papers relevant to the three part question. In the paper by Chiang et al which suggested improved survival rates the patients receiving adrenaline were more likely to have had a witnessed collapse, initial 'shockable' rhythm, placement of advanced airway, longer total prehospital time and less blunt injury.

Clinical Bottom Line

The role of adrenaline in traumatic cardiac arrests needs further evaluation but there may be a role for it in certain circumstances.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Chiang et al Prehospital intravenous epinephrine may boost survival of patients with traumatic cardiac arrest: a retrospective cohort study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2015 Nov 19;23:102. doi: 10.1186/s13049-015-0181-4.
2. Sherren et al Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service