Administration Of Epinephrine Research Articles

Liver electrical activity upon epinephrine action

The electrical potential of the liver is an integrative indicator the activity of the cells in this organ. Here we tried to elucidate a link between liver functional state and its electrical activity. For that, electrical potential of the liver, the content of bile acid and blood glucose concentration were measured in control conditions and after intravenous epinephrine administration. Epinephrine at dose 0.2 µg/kg body weight caused short-term increase in blood glucose concentration and a decrease in hydroxylation ratio of bile acids. The administration also resulted in an increase in power spectral density (PSD) of liver electric potential in a frequency range of 1.6-2.5 Hz. In addition, a trend to increasing in PSD at 0.6-1.5 and 2.6-10 Hz ranges and decreasing in conjugation ratio of bile acids were shown. Correlation between liver electrical activity and blood glucose concentration observed in control conditions vanished upon epinephrine administration. In contrast, epinephrine administration potentiated correlation between liver electrical activity and content of bile acids. Thus, we conclude that the liver electrical activity could reflect its secretory processes.

Frequency and Severity of Cow’s Milk Allergy Reactions in Children: A Prospective Audit

Milk ranks as the second most common allergen, following peanuts. Recent studies from Spain and theUSA reports an annual frequency of accidental allergic reactions (AAR) ranging from 34% to 40%. AAR severity is influenced by food allergens and the presence of atopic diseases such as asthma, eczema, hay-fever, and recurrent wheezing. This study aimed to determine the frequency of accidental allergic reactions in children with cow’s milk protein allergy between September 2011 to September 2012. The study design employed is missing. A structured questionnaire was used and the guardians of the patients were guided in answering by the research assistants (Students). The questionnaire was conducted on 62 patients (35 males, 27 females) with a median age of 67 months. The inquiries were about the number and locations of accidental reactions, their severity, other food allergies, and risk factors such as asthma, hay-fever, recurrent wheezing, and eczema. Symptoms were classified as mild, moderate, or severe, and previous and current skin prick test results were recorded. Between 2011 and 2012, the frequency of AAR was found to be 57% (inclusive of adults). Among the children, 37 (60%) experienced 51 accidental reactions in the past year, with 43% classified as mild, 19% as moderate, and 38% as severe. The majority of reactions (60%) occurred at home, and treatment primarily involved the use of Chlorphenamine [Piriton©] (79%). Three anaphylactic reactions occurred and were identified leading to hospitalization and administration of epinephrine. Oral exposure was the primary route (89%), with milk-containing products being the most common allergen sources (51%). The main cause of AAR was attributed to mislabeling and misreading of labels, especially in newly implemented recipes and non-packaged cereal products like homemade croissants sold in cafes and restaurants. Other causes included high levels of peanut traces and hazelnuts in cookies and chocolates. In conclusion, accidental allergic reactions are prevalent in children and are often caused by contamination, mislabeling, recipe changes by companies, misinterpretation by caregivers, and direct milk intake. Risk factors for AAR severity include hay fever, peanut allergy, multiple atopic diseases, and wheal size.

Valoración de la eficacia de la educación en el manejo de autoinyectores de adrenalina

Introduction: anaphylaxis is a medical emergency and early administration of adrenaline is essential to reduce morbidity and mortality. Adrenaline autoinjectors are available for patients with a diagnosis of anaphylaxis so they can receive the medication without delay. The main goal of our study was to evaluate parental knowledge about anaphylaxis and the use of autoinjectors and whether their knowledge improved after some training. Material and methods: pre- and post-intervention study. We analysed 6 primary care caseloads, selecting patients with a diagnosis of anaphylaxis who had adrenaline autoinjector prescriptions. Participants received 2 emails. The first one included a questionnaire about anaphylaxis and how to use the adrenaline autoinjector. The second one contained informational pages and videos and a second questionnaire. That way we compared parental knowledge before and after receiving some training. Results: food was the main cause of anaphylaxis. Only 56.3% of the participants carried the autoinjector at all times. Comparing the knowledge before and after the intervention, we found improvement in nearly every step of the administration of adrenaline. The improvement was statistically significant when it came to the correct identification of the safety release cap (p 0.018) and the awareness of the possibility of administering a second dose (p 0.006). There was a clear improvement in the knowledge of needing to massage the injection area, but it was not statistically significant (p 0.066) Conclusions: periodic training about how to use the autoinjectors is key to reduce morbidity and mortality in patients with anaphylaxis.

Development of neffy, an Epinephrine Nasal Spray, for Severe Allergic Reactions.

Epinephrine autoinjectors (EAIs) are used for the treatment of severe allergic reactions in a community setting; however, their utility is limited by low prescription fulfillment rates, failure to carry, and failure to use due to fear of needles. Given that delayed administration of epinephrine is associated with increased morbidity/mortality, there has been a growing interest in developing needle-free, easy-to-use delivery devices. neffy (epinephrine nasal spray) consists of three Food and Drug Administration (FDA)-approved components: epinephrine, Intravail A3 (absorption enhancer), and a Unit Dose Spray (UDS). neffy's development pathway was established in conjunction with the FDA and the European Medicines Agency and included multiple clinical trials to evaluate pharmacokinetic and pharmacodynamic responses under a variety of conditions, such as self-administration and allergic and infectious rhinitis, as well as an animal anaphylaxis model of severe hypotension, where neffy demonstrated a pharmacokinetic profile that is within the range of approved injection products and a pharmacodynamic response that is as good or better than injections. The increased pulse rate (PR) and blood pressure (BP) observed even one minute following the administration of neffy confirm the activation of α and β adrenergic receptors, which are the key components of epinephrine's mechanism of action. The results suggest that neffy will provide a safe and effective needle-free option for the treatment of severe allergic reactions, including anaphylaxis.

Kounis Syndrome: Myocardial Infarction After Wasp Bites

The presented clinical case describes a rather rare type II Kunis syndrome (SC) that occurred in a 69-year-old man with risk factors for coronary heart disease (CHD) after wasp bites and was accompanied by the development of acute myocardial infarction (MI) due to coronary artery thrombosis (CA). The diagnosis of MI was confirmed on the basis of laboratory and instrumental data: an increase in troponin levels (>10000 pg/ml), changes in the electrocardiogram (ECG) (elevation of the ST segment in II, III leads, aVF), revealed violations of the contractility of the left ventricle (LV) according to echocardiography (zone of akinesia of the basal lower segment LV, hypokinesia of the median inferior and anterolateral segments of the LV, the apical-lateral segment of the LV), the results of coronary angiography (acute occlusion with signs of parietal thrombosis in the right coronary artery). The cause of CA thrombosis could be either a pronounced immuno-inflammatory reaction or the administration of adrenaline to stop anaphylactic reaction. Currently, there are no clear criteria for the verification of SC, the diagnosis is confirmed on the basis of a comprehensive examination of a patient with acute coronary syndrome (ACS) and the presence of a pronounced allergic/anaphylactic reaction. Additionally, to confirm the SC, it is proposed to assess the level of histamine and tryptase in the blood, however, these markers are metabolized quite quickly and, in most cases, it is not possible to identify their elevated levels. This case once again underlines the importance of informing doctors about the risk of developing ACS against the background of a pronounced allergic reaction, as well as the need for further study of SC in order to develop tactics for the treatment and prevention of this group of patients.

Early intramuscular adrenaline administration is associated with improved survival from out-of-hospital cardiac arrest

BackgroundEarly administration of adrenaline is associated with improved survival after out-of-hospital cardiac arrest (OHCA). Delays in vascular access may impact the timely delivery of adrenaline. Novel methods for administering adrenaline before vascular access may enhance survival. The objective of this study was to determine whether an initial intramuscular (IM) adrenaline dose followed by standard IV/IO adrenaline is associated with improved survival after OHCA. Methods Study DesignWe conducted a before-and-after study of the implementation of an early, first-dose IM adrenaline EMS protocol for adult OHCAs. The pre-intervention period took place between January 2010 and October 2019. The post-intervention period was between November 2019 and May 2024. SettingSingle-center urban, two-tiered EMS agency. ParticipantsAdult, nontraumatic OHCA meeting criteria for adrenaline use. InterventionSingle dose (5 mg) IM adrenaline. All other care, including subsequent IV or IO adrenaline, followed international guidelines. Main Outcomes and MeasuresThe primary outcome was survival to hospital discharge. Secondary outcomes were time from EMS arrival to the first dose of adrenaline, survival to hospital admission, and favorable neurologic function at discharge. ResultsAmong 1405 OHCAs, 420 (29.9%) received IM adrenaline and 985 (70.1%) received usual care. Fifty-two patients received the first dose of adrenaline through the IV or IO route within the post-intervention period and were included in the standard care group analysis. Age was younger and bystander CPR was higher in the IM adrenaline group. All other characteristics were similar between IM and standard care cohorts. Time to adrenaline administration was faster for the IM cohort [(median 4.3 min (IQR 3.0–6.0) vs. 7.8 min (IQR 5.8–10.4)]. Compared with standard care, IM adrenaline was associated with improved survival to hospital admission (37.1% vs. 31.6%; aOR 1.37, 95% CI 1.06–1.77), hospital survival (11.0% vs 7.0%; aOR 1.73, 95% CI 1.10–2.71) and favorable neurologic status at hospital discharge (9.8% vs 6.2%; aOR 1.72, 95% CI 1.07–2.76). ConclusionIn this single-center before-and-after implementation study, an initial IM dose of adrenaline as an adjunct to standard care was associated with improved survival to hospital admission, survival to hospital discharge, and functional survival. A randomized controlled trial is needed to fully assess the potential benefit of IM adrenaline delivery in OHCA.

Remimazolam anaphylaxis in a patient not allergic to brotizolam: a case report and literature review

BackgroundRemimazolam is a recently developed, ultrashort-acting benzodiazepine that is used as a general anesthetic. Some cases of remimazolam anaphylaxis have been reported, but its characteristics are not fully understood. We present an interesting case report and review of the literature to better understand remimazolam anaphylaxis.Case presentationA 75-year-old man scheduled for robot-assisted gastrectomy was administered remimazolam for the induction of general anesthesia. After intubation, low end-expiratory CO2, high airway pressure and concurrent circulatory collapse were observed. Bronchoscopy revealed marked tracheal and bronchial edema, which we diagnosed as anaphylaxis. The patient suffered cardiac arrest after bronchoscopy but recovered immediately with intravenous adrenaline administration and chest compressions. We performed skin prick tests for the drugs used during induction except for remimazolam, considering the high risk of systemic adverse reactions to remimazolam. We diagnosed remimazolam anaphylaxis because the skin prick test results for the other drugs used during anesthesia were negative, and these drugs could have been used without allergic reactions during the subsequent surgery. Furthermore, this patient had experienced severe anaphylactic-like reactions when he underwent cardiac surgery a year earlier, in which midazolam had been used, but it was not thought to be the allergen at that time. Based on these findings, cross-reactivity to remimazolam and midazolam was suspected. However, the patient had previously received another benzodiazepine, brotizolam, to which he was not allergic, suggesting that cross-reactivity of remimazolam may vary among benzodiazepines. In this article, we reviewed the 11 cases of remimazolam anaphylaxis that have been described in the literature.ConclusionsRemimazolam is an ultrashort-acting sedative; however, it can cause life-threatening anaphylaxis. In addition, its cross-reactivity with other benzodiazepines is not fully understood. To increase the safety of this drug, further research and more experience in its use are needed.

Anaphylaxis in Practice: A Guide to the 2023 Practice Parameter Update

This review summarizes new research developments and clinical practice recommendations for the diagnosis and management of anaphylaxis presented in the Joint Task Force on Practice Parameters 2023 Anaphylaxis practice parameter Update. It is intended to serve as a high-level summary of the 2023 practice parameter, which makes clinically impactful recommendations based on evidence that has emerged since the 2015 practice parameter. We invite clinicians to explore the full 2023 practice parameter to understand the research methods and underlying evidence that have informed the recommendations summarized here. There are new and evolving diagnostic criteria for anaphylaxis, rules for defining elevated tryptase levels, and recognition of signs and symptoms particular to infants and toddlers. The administration of epinephrine should not be used as a surrogate to diagnose anaphylaxis. Risk factors for anaphylaxis should be assessed on a case-by-case basis. Patient counseling and shared decision-making are essential to support patients' treatment decisions and capacity to manage the risk of anaphylaxis at home and in other community settings. Activation of emergency medical services after home epinephrine administration may not be required in all cases, and patients should be engaged in shared decision-making to determine when home management may be appropriate.

Alpha-Gal syndrome as a novel food allergy: a case report study

Introduction and importance: Alpha-Gal syndrome (AGS), a distinct form of mammalian meat allergy, presents unique characteristics that set it apart from typical IgE-mediated food hypersensitivities. AGS induces an allergic response typically 3–6 h post-ingestion of mammalian meat, such as beef, pork, or lamb. This prolonged reaction time differentiates AGS from other food allergies, which usually provoke a more immediate response. Case presentation: The authors present a case of a 35-year-old male patient who, unbeknownst to him, had been experiencing symptoms consistent with Alpha-Gal allergy for several years. His symptoms only subsided upon the complete elimination of mammalian meat from his diet. It was only then that the possibility of AGS was considered. Complete abstinence from mammalian meat, meat by-products, and other α-Gal containing foods is the most effective preventative strategy for AGS. No definitive cure for AGS has been established as of now. Treatment protocols for hypersensitivity reactions are contingent upon the severity of the reaction, with therapies ranging from antihistamine medications to the administration of epinephrine. Conclusion: There is considerable variability among AGS patients concerning the consumption of dairy products. Some individuals with AGS can safely consume dairy products without any adverse reactions, while others are advised to abstain due to potential allergenic responses. This variability in dairy tolerance among AGS patients warrants further investigation.

Hemodynamic instability caused by pneumorrachis and pneumomediastinum following epidural analgesia: a case report

BackgroundPneumomediastinum and pneumorrachis are rare complications following epidural analgesia, that can either be asymptomatic or rarely can produce mild to moderate severity symptoms. Most reported cases regarding the presentation of these two entities with epidural analgesia concern asymptomatic patients, however there are cases reporting post-dural puncture headache and respiratory manifestations.Case presentationWe present a case where a combined lumbar epidural and spinal anesthesia was performed using the loss of resistance to air technique (LOR), on a 78-year-old Greek (Caucasian) male undergoing a total hip replacement. Despite being hemodynamically stable throughout the operation, two hours following epidural analgesia the patient manifested a sudden drop in blood pressure and heart rate that required the administration of adrenaline to counter. Pneumomediastinum, pneumorrachis and paravertebral soft tissue emphysema were demonstrated in a Computed Tomography scan. We believe that injected air from the epidural space and surrounding tissues slowly moved towards the mediastinum, stimulating the para-aortic ganglia causing parasympathetic stimulation and therefore hypotension and bradycardia.ConclusionAnesthesiologists should be aware that epidural analgesia using the LOR to technique injecting air could produce a pneumomediastinum and pneumorrachis, which in turn could produce hemodynamic instability via parasympathetic stimulation.

Effect of timing of advanced life support on out-of-hospital cardiac arrests at home

AimIn cases of out-of-hospital cardiac arrests (OHCA) occurring at home, Japanese emergency medical services personnel decide whether to provide treatment on the scene or during transport based on their judgment. This study aimed to evaluate the association between the timing of advanced life support (ALS) (i.e., endotracheal intubation [ETI] or adrenaline administration) for OHCA at home and prognosis. MethodThis retrospective cohort study used data from the Japan Utstein Registry and emergency transport data collected from patients who underwent pre-hospital ETI (n = 6806) and received adrenaline (n = 22,636) between 2016 and 2019. The timing of ETI or adrenaline administration was determined as “on the scene” or “in the ambulance.” Multiple logistic regression analysis was used to estimate the association among the timing of ALS implementation, pre-hospital return of spontaneous circulation (ROSC), and survival at 1 month. ResultETI on the scene was significantly positively associated with pre-hospital ROSC (adjusted odds ratio [AOR], 1.81; 95% confidence interval [CI], 1.57–2.09) and survival at 1 month (AOR, 1.81; 95% CI, 1.47–2.23). Adrenaline administration on the scene was significantly positively associated with pre-hospital ROSC (AOR, 2.51; 95% CI, 2.33–2.70) and survival at 1 month (AOR, 2.13; 95% CI, 1.89–2.40). ConclusionOur analysis suggests performing ALS on the scene was associated with pre-hospital ROSC and survival at 1 month. Further efforts are needed to increase the rate of ALS implementation on the scene by emergency life-saving technicians.

Pilot study to teach residents about EMS scope of practice through reverse role simulations

Objective: To improve emergency physician trainee understanding of Emergency Medical Services´ (EMS) scope of practice, and physician confidence in performing EMS skills by conducting a simulation role reversal workshop. Methods: EMS clinicians and physicians created and facilitated a role-reversal workshop for seven pediatric emergency medicine (PEM) fellows designed to emphasize scope of practice of EMS clinicians using basic life support (BLS) and advanced life support (ALS) skills. Fellows roleplayed using BLS or ALS skills in three different case scenarios. Medication preparation and delivery were assessed. Pre, post, and retention surveys (provided at 1 month post-intervention) were performed to assess scope of practice knowledge, and the EMS skill set confidence of the fellows. Results: Fellows reported the curriculum had an impact on their understanding of EMS scope of practice. Confidence in differentiating ALS and BLS scope of practice improved as did the subjective understanding of local EMS protocols. The confidence in preparing and administering multiple types of medications (i.e., intramuscular epinephrine administration, nebulized medication preparation) significantly improved as well (p<0.016 with Bonferroni adjustment). Conclusion: Given improved confidence scoring in understanding EMS scope of practice and medication administration, role reversal methodology may offer intangible affective and psychomotor benefits for emergency medicine trainees by generating a sense of a “lived-experience” when role-playing EMS skill sets. The workshop may serve as a model to use in teaching pre-hospital scope of practice and generating interprofessional understanding for physician trainees.

Traditional vs. modified Ringer lactate-based del Nido cardioplegia impacts on clinical outcomes in patients undergoing coronary artery bypass grafting: results from a clinical trial

Introduction: myocardial protection with cardioplegia solution is one of the precautions during coronary bypass grafting surgery (CABG) with cardiopulmonary bypass (CPB) to reduce myocardial damage and ischemia/reperfusion injuries. Unfortunately, the major component of the del Nido cardioplegia solution, Plasma-Lyte A, is unreachable in Iran due to high cost. Therefore, we have utilized lactate Ringer's solution as the base solution for our modified del Nido solution (LR DN). Study design and methods: the present clinical trial was performed on 18-75 year old patients (EF>35%) undergoing CABG with CPB in Imam Hossein hospital Tehran-Iran in 2021. Patients were randomly allocated to LR DN (modified del Nido cardioplegia) and PL DN (standard del Nido cardioplegia solution) groups. Serum level of cardiac troponin I (cTnI) at baseline, declamp, ICU admission, and 24 hours after admission, the type and dosage of inotrope agents, EF, rate of arrhythmia after clamp removal and lactate level were measured and compared between groups. Results: 109 patients were recruited. There were no statistically significant differences between the PL DN cardioplegia and LR DN groups for cardiopulmonary bypass times, cardiac enzymes, transfusion requirements, and arterial blood gases. However, postoperative serum levels of cTnI among patients in the LR DN group was significantly higher than patients of the PL DN group after ICU admission and 24 hours postoperatively. Also, more patients needed epinephrine administration in the operating room in the LR DN group (29.8% vs. 11.5%; p: 0.019 vs. PL DN group). Conclusion: we concluded that standard del Nido cardioplegia solution offers better myocardial protection compared with Ringer's lactate-based del Nido cardioplegia in adult patients undergoing CABG with CPB. We recommend using standard del Nido cardioplegia with a base of Plasma-Lyte A for patients presenting for CABG surgery.

Ward-based in situ simulation: lessons learnt from a UK District General Hospital

IntroductionIn situ simulation (ISS) enables multiprofessional healthcare teams to train for real emergencies in their own working environment and identify latent patient safety threats. This study aimed to determine ISS...

Comparison of Adult and Child Endotracheal Administration of Epinephrine in a Normovolemic Cardiac Arrest Model

Comparison of Adult and Child Endotracheal Administration of Epinephrine in a Normovolemic Cardiac Arrest Model

A novel preclinical model of fentanyl-induced cardiorespiratory collapse to investigate resuscitation outcomes

Introduction: Opioid-related morbidities have become a critical public health concern, with ultrapotent synthetic opioids (UPSO) such as fentanyl contributing to the rise in opioid-related fatalities. Respiratory depression is the cardinal trait of fentanyl overdose, leading to systemic hypoxia and subsequent cardiorespiratory collapse (CRC). There is growing recognition that fentanyl induced CRC (fiCRC) is unique from other forms of sudden CRC. Yet, the consequences of fiCRC and its reversal remain poorly understood. This is due in part to the limited preclinical studies investigating rescue from fiCRC. Objective: using a novel model of fiCRC and subsequent reversal, this ongoing study aims to define the impact of UPSO and naloxone rescue on in vivo survival outcomes. Methods and Results: Male and female C57BL/6J mice were used. UPSO fentanyl i.v. administration (30 to 500 mcg/kg) suppressed breathing and subsequently led to fiCRC. The return of spontaneous circulation (ROSC) was achieved by performing manual chest compressions in combination of epinephrine administration after 8 minutes of fiCRC. In subset of mice, naloxone was administered post ROSC. Outcomes after 72 hours were accessed. The latency of fiCRC (mean arterial pressure at 40 mmHg) exhibited a negative correlation with the doses of fentanyl administered. Resuscitation from fiCRC was unreliable across the dose spectrum, while naloxone consistently rescued the majority of fiCRC animals. Naloxone increased ROSC rate from 54% to 86% when the dose of fentanyl was 30 mcg/Kg (n=22). With naloxone rescue, we compared fiCRC with non-opioid-induced cardiac arrest followed by potassium chloride injection (0.8 mg/g). Both models showed severe lung edema as evidenced by Evans Blue staining. However, the lung wet/dry weight ratio was higher in fiCRC group than in the non-opioid treatment group (5.50±0.05 vs. 6.60±0.60, n=4, p<0.05). Survival in fiCRC group was significantly worse than in non-opioid treatment group (survival rate: 25% vs. 83%, n=17, p<0.05). Conclusions: Our study highlights two important findings. First, the reliable resuscitation of fiCRC necessitates the use of naloxone. Second, the likelihood of injury is significant following successful rescue from fiCRC by naloxone. Our continued work using this fiCRC model will lead to insights that can be leveraged for strategies to mitigate injury and improve survival following fentanyl overdose. R01 HL163965 & R01 DA057767. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Association between defibrillation-to-adrenaline interval and short-term outcomes in patients with out-of-hospital cardiac arrest and an initial shockable rhythm

AimThe optimal timing of adrenaline administration after defibrillation in patients with out-of-hospital cardiac arrest (OHCA) and an initial shockable rhythm is unknown. We investigated the association between the defibrillation-to-adrenaline interval and clinical outcomes. MethodsBetween 2011 and 2020, we enrolled 1,259,960 patients with OHCA into a nationwide prospective population-based registry in Japan. After applying exclusion criteria, 20,905 patients with an initial shockable rhythm documented at emergency medical services (EMS) arrival who received adrenaline after defibrillation were eligible for this study. Multivariable logistic regression analysis was used to predict favourable short-term outcomes: prehospital return of spontaneous circulation (ROSC), 30-day survival, or a favourable neurological outcome (Cerebral Performance Category 1 or 2) at 30 days. Patients were categorised into 2-minute defibrillation-to-adrenaline intervals up to 18 min, or more than 18 min. ResultsAt 30 days, 1,618 patients (8%) had a favourable neurological outcome. The defibrillation-to-adrenaline interval in these patients was significantly shorter than in patients with an unfavourable neurological outcome [8 (5–12) vs 11 (7–16) minutes; P < 0.001]. The proportion of patients with prehospital ROSC, 30-day survival, or a favourable neurological outcome at 30 days decreased as the defibrillation-to-adrenaline interval increased (P < 0.001 for trend). Multivariable analysis revealed that a defibrillation-to-adrenaline interval of > 6 min was an independent predictor of worse prehospital ROSC, 30-day survival, or neurological outcome at 30 days when compared with an interval of 4–6 min. ConclusionA longer defibrillation-to-adrenaline interval was significantly associated with worse short-term outcomes in patients with OHCA and an initial shockable rhythm.

Direct Umbilical Vein Injection of Epinephrine with Cut-Cord Milking in an Ovine Model of Neonatal Resuscitation.

An umbilical venous catheter (UVC) is the preferred route of epinephrine administration during neonatal resuscitation but requires specialized equipment, expertise, and time. Direct injection of epinephrine into the umbilical vein (UV) followed by milking a ~20 cm segment of cut umbilical cord to flush the epinephrine (DUV + UCM) will lead to a quicker administration and earlier return of spontaneous circulation (ROSC) compared with epinephrine given through a UVC. Eighteen near-term asphyxiated lambs were randomized to receive a low-UVC or DUV + UCM of epinephrine at 0.02 or 0.03 mg/kg doses. A total of 16/18 lambs achieved ROSC with a similar mean (±SEM) time to ROSC [DUV + UCM vs. low-UVC (4.67 ± 0.67 vs. 3.99 ± 0.58 min); p = 0.46]. Two out of ten lambs in the DUV + UCM group required UVC placement for additional epinephrine. The administration of the first dose of epinephrine was similar (DUV + UCM-2.97 ± 0.48 vs. UVC-4.23 ± 0.58 min; p = 0.12). Both methods yielded similar epinephrine concentrations (peak concentrations of 253 ± 63 and 328 ± 80 ng/mL for DUV + UCM and UVC EPI, respectively). DUV + UCM resulted in a ROSC success of 78% following the first epinephrine dose and showed similar epinephrine concentrations to UVC. Clinical studies evaluating DUV + UCM as an alternate route for epinephrine while intravenous access is being established are warranted.

Time Savings and Safety of EMS Administration of Antibiotics for Open Fractures

ABSTRACT Introduction Early administration of antibiotics for open fractures reduces serious bone and soft tissue infections. The effectiveness of antibiotics in reducing these infections is time-dependent, with various surgical associations recommending administration within one hour of injury, or within one hour of patient arrival to the emergency department (ED). The extent to which prehospital antibiotic administration in these situations might reduce the time to treatment has not been previously reported. The purpose of this study was to describe current prehospital use of antibiotics for traumatic injury, to assess the safety of prehospital antibiotic administration, and to estimate the potential time-savings associated with antibiotic administration by EMS clinicians. Methods This was a retrospective analysis of the 2019 through 2022 ESO Data Collaborative research data set. Included subjects were patients that had a linked ICD-10 code indicating an open extremity fracture and who received prehospital antibiotics. Time to antibiotic administration was calculated as the elapsed time from EMS dispatch until antibiotic administration. The minimum potential time saved by EMS antibiotic administration was calculated as the elapsed time from administration until ED arrival. To assess safety, epinephrine and diphenhydramine administration were used as proxies for the adverse events of anaphylaxis and minor allergic reactions. Results There were 523 patients meeting the inclusion criteria. The median (and interquartile range [IQR]) elapsed time from EMS dispatch until antibiotic administration was 31 (IQR: 24-41) minutes. The median potential time savings associated with prehospital antibiotic administration was 15 (IQR: 8-22) minutes. Notably, 144 (27.5%) of the patients who received prehospital antibiotics had total prehospital times exceeding one hour. None of the patients who received antibiotics also received epinephrine for presumed anaphylaxis. Conclusions EMS clinicians were able to safely administer antibiotics to patients with open fractures a median of 15 minutes before arrival at the hospital, and 99 percent of the patients receiving antibiotics had them administered within one hour of EMS dispatch. EMS administration of antibiotics may be a safe way to increase compliance with recommendations for early antibiotic administration for open fractures.

Use of Initial Endotracheal Versus Intravenous Epinephrine During Neonatal Cardiopulmonary Resuscitation in the Delivery Room: Review of a National Database

To assess whether initial epinephrine administration by endotracheal tube (ET) in newly born infants receiving chest compressions and epinephrine in the delivery room (DR) is associated with lower rates of return of spontaneous circulation (ROSC) than newborns receiving initial intravenous (IV) epinephrine. We conducted a retrospective review of neonates receiving chest compressions and epinephrine in the DR from the AHA Get With The Guidelines-Resuscitation registry from October 2013 through July 2020. Neonates were classified according to initial route of epinephrine (ET vs IV). The primary outcome of interest was ROSC in the DR. In total, 408 infants met inclusion criteria; of these, 281 (68.9%) received initial ET epinephrine and 127 (31.1%) received initial IV epinephrine. The initial ET epinephrine group included those infants who also received subsequent IV epinephrine when ET epinephrine failed to achieve ROSC. Comparing initial ET with initial IV epinephrine, ROSC was achieved in 70.1% vs 58.3% (adjusted risk difference 10.02; 95% CI 0.05-19.99). ROSC was achieved in 58.3% with IV epinephrine alone, and 47.0% with ET epinephrine alone, with 40.0% receiving subsequent IV epinephrine. This study suggests that initial use of ET epinephrine is reasonable during DR resuscitation, as there were greater rates of ROSC compared with initial IV epinephrine administration. However, administration of IV epinephrine should not be delayed in those infants not responding to initial ET epinephrine, as almost one-half of infants who received initial ET epinephrine subsequently received IV epinephrine before achieving ROSC.