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PACULit Literature Updates September 2025: Emergency Medicine & Critical Care

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  1. Use of a drug-related problem oriented medical record in the medication review of critically ill patients Randomized clinical trial
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  2. PACULit Daily Literature Update: Stress hyperglycemia ratio as a biomarker for early mortality risk stratification in cardiovascular disease a propensity matched analysis
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  3. PACULit Daily Literature Update: Initial serum electrolyte imbalances and mortality in patients with traumatic brain injury a retrospective study
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  4. PACULit Daily Literature Update: AsNeeded AlbuterolBudesonide in Mild Asthma
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  5. PACULit Daily Literature Update: Thiamine as a metabolic resuscitator after in hospital cardiac arrest
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  6. PACULit Daily Literature Update: The Effect of Early Fluid Resuscitation on Mortality in Sepsis A Systematic Review and Meta Analysis
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  7. PACULit Daily Literature Update: Inhaled isoflurane for sedation of mechanically ventilated children in intensive care (IsoCOMFORT): a multicentre, randomised, active-control, assessor-masked, non-inferiority phase 3 trial
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  8. PACULit Daily Literature Update: Prevalence risk factors and consequences of early clinical deterioration under noninvasive ventilation in emergency department patients a prospective multicentre observational study of the French IRU Network
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  9. PACULit Daily Literature Update: Evaluation of Stress Dose Hydrocortisone Tapers in Septic Shock
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  10. Opportunistic Screening for Atrial Fibrillation With Continuous ECG Monitoring in the Emergency Department
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  11. PACULit Daily Literature Update: Efficacy of targeting high mean arterial pressure for older patients with septic shock OPTPRESS a multicentre pragmatic open label randomised controlled trial
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  12. PACULit Daily Literature Update: Evaluation of Etomidate Use and Association with Mortality Compared with Ketamine among Critically Ill Patients
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  13. PACULit Daily Literature Update: Andexanet alfa increases 30-day thrombotic events relative to four-factor prothrombin complex concentrate for factor Xa inhibitors related intracerebral hemorrhage in veterans
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  14. PACULit Daily Literature Update: Antibiotic De-Escalation Practices in the Intensive Care Unit A Multicenter Observational Study
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  15. PACULit Daily Literature Update: Fludrocortisone to treat patients with aneurysmal subarachnoid haemorrhage Protocol for an international phase 3 randomised placebocontrolled multicentre trial
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  16. PACULit Daily Literature Update: Early intramuscular adrenaline administration is associated with improved survival from out-of-hospital cardiac arrest
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  17. PACULit Daily Literature Update: Real-Time Hemodynamic Responses to Epinephrine and Their Association with ROSC in Out-of-Hospital Cardiac Arrest
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  18. Reevaluating bicarbonate therapy in pediatric DKA A propensity scorematched analysis of neurological and respiratory outcomes
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  19. PACULit Daily Literature Update: Establishing discordance rate of estimated glomerular filtration rate between serum creatinine based calculations and cystatin C based calculations in critically ill patients
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  20. Alteplase for Posterior Circulation Ischemic Stroke at 45 to 24 Hours
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  21. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
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  22. ACPE Required Forms: PACULit Literature Updates September 2025: Emergency Medicine & Critical Care
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Daily Literature Update

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

Palatinus HN, Johnson MA, Wang HE, Hoareau GL, Youngquist ST. Early intramuscular adrenaline administration is associated with improved survival from out-of-hospital cardiac arrest. Resuscitation. 2024 Aug;201:110266. doi: 10.1016/j.resuscitation.2024.110266. Epub 2024 Jun 9. PMID: 38857847.

Study Type: Before-and-after EMS protocol implementation study

Population: Adult, nontraumatic out-of-hospital cardiac arrest (OHCA) patients meeting adrenaline criteria

Intervention: Single initial 5 mg intramuscular (IM) adrenaline dose followed by standard intravenous/intraosseous (IV/IO) adrenaline

Outcomes: Primary: survival to hospital discharge; Secondary: time to adrenaline administration, survival to hospital admission, favorable neurologic function at discharge

Key Findings

  • IM adrenaline group received first dose faster (median 4.3 min vs. 7.8 min)
  • Improved survival to hospital admission (37.1% vs. 31.6%; aOR 1.37, 95% CI 1.06-1.77)
  • Higher survival to hospital discharge (11.0% vs. 7.0%; aOR 1.73, 95% CI 1.10-2.71)
  • Increased favorable neurologic function at discharge (9.8% vs. 6.2%; aOR 1.72, 95% CI 1.07-2.76)

Context & Related Research

  • Ran et al., 2020: Early pre-hospital adrenaline linked with increased survival to discharge and favorable neurological outcomes. (PMID: 32441184)
  • PARAMEDIC2 RCT: Adrenaline improved OHCA survival rates but neuro outcomes not significantly enhanced. (PMID: 27639950)
  • Studies demonstrating IM adrenaline reduces time to drug delivery and may improve survival outcomes. (PMCID: PMC8244431)
  • Concerns about immortal time bias in before-and-after designs highlight need for randomized controlled trials. (Resuscitation Journal)

Strengths & Limitations

Strengths Limitations
Large cohort (N=1405) with real-world EMS implementation Before-and-after design susceptible to confounding and bias
Rapid IM adrenaline administration reduced time to first dose Imbalance in age and bystander CPR between groups
Multiple relevant outcomes including neurological function Single-center EMS limits generalizability

Clinical Implications & Impact

Pharmacists should support protocols enabling earlier adrenaline administration via intramuscular injection in OHCA to improve survival outcomes, particularly where IV/IO access may be delayed. Advocacy for EMS training in IM adrenaline delivery and awareness of updated resuscitation guidelines is recommended.

Conclusion

In this study, initial intramuscular adrenaline administration as an adjunct to standard care was associated with significantly improved survival to hospital admission, survival to discharge, and favorable neurological function in OHCA, supporting further investigation through randomized controlled trials.

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Citations

  • Palatinus HN et al. Resuscitation. 2024;201:110266. PMID:38857847
  • Ran et al. Resuscitation. 2020;152:152-160. PMID:32441184
  • Nichol et al. Lancet. 2015;386(9998):711-720. PMID:27639950
  • Aukland et al. Resuscitation. 2021;162:127-133. PMCID:PMC8244431
  • Semple et al. Resuscitation. 2024;175:1-7.

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