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. 2025 Sep 22;25(1):182.
doi: 10.1186/s12873-025-01351-4.

The use of epinephrine in out-of-hospital cardiac arres : A retrospective study of the effects of administration timing and cumulative doses on outcome in a physician-staffed emergency medical service system

Tobias Gruebl  1   2 , Janine Jungblut  3   4 , Dennis Rupp  5 , Chung Shing Rex Ha  6 , Birgit Ploeger  4 , Dana Maresa Haag  7 , Davut Deniz Uzun  8 , Christoph Walter Jaenig  9 , Martin Christian Sassen  10 , Bernhard Schieffer  4   11 , Lars Timmermann  12 , Susanne Betz  4
Affiliations

The use of epinephrine in out-of-hospital cardiac arres : A retrospective study of the effects of administration timing and cumulative doses on outcome in a physician-staffed emergency medical service system

Tobias Gruebl et al. BMC Emerg Med. .

Abstract
in English, German

Background: Epinephrine administration during cardiopulmonary resuscitation (CPR) has been a long-standing recommendation, but the evidence is controversial. This study investigated effects of epinephrine administration in a physician-staffed emergency medical service (EMS) system and for the first time addressed the quality of chest compressions.

Methods: Complete datasets of adult patients who suffered out-of-hospital cardiac arrest (OHCA) and received CPR were retrospectively analysed. Factors (time of collapse, bystander CPR, EMS arrival, initial cardiac rhythm, suspected cause of OHCA, and for the first time also quality of chest compressions) that may influence outcome (return of spontaneous circulation [ROSC], survival to discharge, neurological status) and epinephrine administration (time of first administration, total dose, route of administration) were analysed after adjustment.

Results: A total of 1141 patients were identified; 1090 patients were included. Patient data (age, gender, pre-existing conditions, initial electrocardiographic rhythm, suspected cause) were comparable to those reported in international studies. Mean chest compression depth was 5.5 cm (SD: 0.8 cm). Median compression rate was 115/min (SD: 12/min). The first epinephrine dose was administered after a mean period of 6:43 min after EMS arrival (SD: 9:30 min) and 18:23 min after collapse (SD: 11:13 min). Earlier epinephrine administration was associated with increased rates of ROSC and survival to discharge. Patients who achieved ROSC and survived to discharge received less than 6 mg of epinephrine. Early administration was associated with improved outcomes, especially in patients with asystole. Neurological outcomes, however, deteriorated with increasing epinephrine doses.

Conclusions: This study supports the benefit of early administration of limited doses of epinephrine in OHCA patients. Higher epinephrine doses may be associated with poorer outcomes. Further randomised controlled studies that investigate the administration of medications within fifteen minutes after collapse and also address the quality of basic life support measures are required to assess the actual benefits of epinephrine during CPR.

Supplementary Information: The online version contains supplementary material available at 10.1186/s12873-025-01351-4.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The study was approved by the Ethics Committee of the Medical School of Philipps University of Marburg (No. 97/20) and was conducted in accordance with the Declaration of Helsinki. Consent from individual participants was not required for this retrospective study of routinely collected, anonymized clinical data. Consent of publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Time from collapse to epinephrine administration in minutes (min) and outcome
Fig. 2
Fig. 2
Probability of ROSC and total dose of epinephrine administered
Fig. 3
Fig. 3
Probability of survival and total dose of epinephrine administered
Fig. 4
Fig. 4
Neurological status at discharge and total dose of epinephrine administered or time from collapse to first epinephrine administration
See this image and copyright information in PMC

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