UMEM Educational Pearls


In patients with persistent VT/VF cardiac arrest, giving epinephrine before the 2nd defibrillation attempt (which should follow initial shock and 2 minutes of CPR) is associated with decreased ROSC, decreased hospital survival, and decreased functional outcome. 

Take Home Point:

"Electricity before Epi" in patients with persistent VT/VF arrest, at least for the initial epinephrine dose.


Background Info:

While the ACLS algorithm does recommend initial defibrillation followed by 2 minutes of CPR and repeated shock if the shockable rhythm persists, the 2015 AHA Guidelines update admits that there is insufficient evidence to comment on “optimal timing” of epinephrine administration in these patients.

A 2016 study of 2794 patients across 310 hospitals looked at patients with cardiac arrest with initial shockable rhythm and found that compared to patients who received epinephrine after the second defibrillation attempt, patients who received epinephrine in the first 2 minutes before the 2nd shock had:

  • decreased rate of ROSC (67 v. 79%, p<0.001)
  • decreased rate of survival (31 v. 48%, p<0.001)
  • decreased functional outcome (25 vs. 41%, p<0.001)

The benefit of 2nd-shock-first was maintained when groups were matched using a propensity score accounting for baseline characteristics of the patients, events, and hospitals. 



Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Link MS, Berkow LC, Kudenchuk PJ, et al. Circulation. 2015;132(18 Suppl 2):S444-64.

Early administration of epinephrine (adrenaline) in patients with cardiac arrest with initial shockable rhythm in hospital: propensity score matched analysis. Andersen LW, Kurth T, Chase M, et al. BMJ. 2016;353:i1577.