Epinephrine is not a defined standard treatment under the Trauma Cardiac Arrest Medical Directive. The cause for arrest in trauma is typically one of: hypovolemia due to hemorrhage, cardiogenic obstruction due to tension pneumothorax, pericardial tamponade or great vessel injury, hypoxia due to airway/breathing mechanism injury or hypothermia. These various causes of cardiac arrest in trauma require management of the underlying insult (blood products, control of bleeding source, relief of cardiac output obstruction, oxygenation and rewarming) in order to correct the arrest.

Epinephrine is indicated within the Medical Cardiac Arrest Medical Directive and acts by causing increased coronary perfusion pressure via alpha adrenergic effects. Epinephrine given in the setting of trauma may not effectively induce vasoconstriction as the vessels are likely already maximally constricted. Therefore, optimal management of the trauma arrest patient includes CPR, defibrillation (if indicated), rapid transport to the closest appropriate facility following the 1st rhythm analysis, and ensuring the patient does not meet the criteria for BHP Patch for Trauma TOR (see Treatment – Algorithm for Trauma Arrest).

If you feel that epinephrine may be of benefit, you may consider requesting further orders from the BHP for its administration (see Ask MAC 1-Mar-2012).

Note, however, that the evidence for benefit of epinephrine in cardiac arrest is not robust. There has been a single randomized controlled trial performed examining the outcomes for the use of epinephrine vs. placebo for all-cause out-of-hospital cardiac arrest. A study by Jacobs et al (2011) examined a total of 534 patients and found those receiving epinephrine had significantly higher rates of ROSC [64(23.5%) vs. 22 (8.4%)] with no statistically significant survival to discharge [5 (1.9%) vs. 11 (4.0%)]. These results were similar to a metanalysis by Atiksawedparit et al. (2014) looking at the outcomes of epinephrine given in the prehospital or in the ED settings for cardiac arrest, which found an increase in prehospital ROSC, but no significant difference in overall ROSC, hospital admission, or survival to discharge from hospital.

Therefore, ensure the listed management (see Treatment – Algorithm for Trauma Arrest is being optimized and you are transporting expediently before considering epinephrine administration en route.
Jacobs IG, Finn JC, Jelinek GA, et al. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation. 2011;82(9):1138-1143.

Atiksawedparit P, Rattanasiri S, McEvoy M, et al. Effects of prehospital adrenaline administration on out-of-hospital cardiac arrest outcomes: A systematic review and meta-analysis. Crit Care. 2014;18(4):463.

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