The use of epinephrine (EPI) in cardiac arrest has been a source of significant controversy for many years. Early studies of EPI, including the use of high-dose EPI, consistently showed improvements in rates of return of spontaneous circulation (ROSC) but failed to show improvements in subsequent survival or neurologic recovery. In fact, slight worsening of neurologic recovery was found in patients who received high-dose EPI or large cumulative doses of EPI.
The use of high-dose EPI was subsequently abandoned, but the use of regular-dose EPI in 1-mg IV boluses every 3-5 minutes was continually endorsed by the American Heart Association (AHA) with a Class IIb recommendation ("possibly helpful") since 2015, despite many authors who argued that there was insufficient evidence to continue to endorse the use of EPI.
On November 14, 2019, the AHA published a "Focused Update on Advanced Cardiac Life Support," addressing, among other topics, the use of EPI in cardiac arrest. This new update has elevated EPI to a Class I recommendation for use in patients with cardiac arrest. The AHA once again reiterated its prior statements recommending against the use of high-dose EPI.
In regard to the timing of the EPI, the AHA recommended the administration of
