• James M Burgert, Arthur D Johnson, Joseph C O'Sullivan, Wayne J Blalock, Brent C Duffield, Brian P Albright, Cory C Herzog, Matthew S Moore, Katelyn S Dempster, and Japeth W Rauch.
• College of Health Sciences, Midwestern University, 19555 N. 59th Ave., Glendale, AZ 85308, USA; The Geneva Foundation for Military Medical Research, 917 Pacific Ave. Suite 600, Tacoma, WA 98402, USA; Kellogg College, University of Oxford, 60 Banbury Road, Oxford, OX2 6PN, UK. Electronic address: james.burgert@alumni.bcm.edu.
• Am J Emerg Med. 2019 Nov 1; 37 (11): 2043-2050.

IntroductionLimited prospective data exist regarding epinephrine's controversial role in managing traumatic cardiac arrest (TCA). This study compared the maximum concentration (Cmax), time to maximum concentration (Tmax), plasma concentration over time, return of spontaneous circulation (ROSC), time to ROSC, and odds of ROSC of epinephrine administered by the endotracheal (ETT), intraosseous (IO), and intravenous (IV) routes in a swine TCA model.MethodsForty-nine Yorkshire-cross swine were assigned to seven groups: ETT, tibial IO (TIO), sternal IO (SIO), humeral IO (HIO), IV, CPR with defibrillation (CPRD), and CPR only. Swine were exsanguinated 31% of their blood volume and cardiac arrest induced. Chest compressions began 2 min post-arrest. At 4 min post-arrest, 1 mg epinephrine was administered, and blood specimens collected over 4 min. Resuscitation continued until ROSC or 30 min elapsed.ResultsThe Cmax of IV epinephrine was significantly higher than the TIO group (P = 0.049). No other differences in Cmax, Tmax, ROSC, and time to ROSC existed between the epinephrine groups (P > 0.05). Epinephrine levels were detectable in two of seven ETT swine. No significant difference in ROSC existed between the epinephrine groups and CPRD group (P > 0.05). Significant differences in ROSC existed between all groups and the CPR only group (P < 0.05). No significant differences in odds of ROSC were noted.ConclusionsThe pharmacokinetics of IV, HIO, and SIO epinephrine were comparable. Endotracheal epinephrine absorption was highly variable and unreliable compared to IV and IO epinephrine. Epinephrine appeared to have a lesser role than volume replacement in resuscitating TCA.Copyright © 2019 Elsevier Inc. All rights reserved.

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