With all due respect (not trying to be an ***, I just don't know), why is this not a valid trial to assess definitively whether or not epi should be used as per current ACLS guidelines? Is it because Japan has a different EMS system than the states?
No offense taken. This was a retrospective registry study without any controls. It also occurred over many years, including years where standards changed. For those reasons alone it is difficult to make definitive statements from it. Additionally, Japanese EMS is very much a run and gun BLS setup, although they've expanded their scope recently. In some respects it is hard to apply this research seeing how poor the overall survival to discharge numbers are. I have troubles directly applying research from areas that aren't already pushing the bounds on neuro intact survival.
Also, what type of trial would have to be implemented in order to be the definitive answer? Obviously, it has to be something very large and standardized but I would think that it would also have to account for non-cardiac etymologies and other causes of death/neurological impairment. I would also assume that it would have to attempt to match up specific patient "profiles" like this one does, I think.
A prospective, randomized controlled trial of epinephrine versus placebo. Yes, it would be large and yes it would cover a large swath of patients. Propensity matching may occur in subgroup analysis, but would not be required for this particular trial.
Great news, such a trial exists!
PARAMEDIC-2: Prehospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug administration In Cardiac arrest
1.2 Research Question
Is the use of adrenaline in out of hospital cardiac arrest clinically and cost effective?
...
2.2.1 Primary objective
The primary objective of this trial is to determine the clinical effectiveness of adrenaline in the
treatment of OHCA measured as primary outcome: 30 day survival.
2.2.2 Secondary objective
Secondary objectives of the trial are to evaluate the effects of adrenaline on survival, cognitive and
neurological outcomes of survivors and to establish the cost-effectiveness of using adrenaline.
They tried this trial in Australia, however, many services and hospitals pulled out because of a concern regarding the, "Standard of care". Thankfully that is not the case here.
Good questions all around!
