What We Are Still Getting Wrong About Cardiac Arrest

Despite years of research and numerous advancements, cardiac arrest care remains riddled with persistent myths, and these myths are harming patients. Fewer than 7% of patients survive to discharge with a favorable neurologic outcome.1 To improve that number, we must scrutinize outdated practices, embrace high-quality evidence, and abandon interventions that don't move the needle. Before diving in, it's essential to define what “good outcomes” actually mean. ROSC is not the finish line; it's an immediate but often temporary success. Studies that carry the most weight focus on favorable neurologic function, as well as survival to hospital discharge or 30-day survival. For the purposes of this review, let's focus on these outcomes. Myth #1: More Epinephrine = More Lives Saved Epinephrine may improve coronary perfusion and oxygen delivery with its alpha-adrenergic activity, which may increase the likelihood of ROSC. The beta-adrenergic activity increases heart rate and contractility.2 However, epinephrine also increases myocardial oxygen demand, arrhythmogenicity, and potential cerebral vasoconstriction. The landmark PARAMEDIC-2 trial (>8,000 patients) demonstrated that when compared to placebo, epinephrine improves ROSC but does not improve survival with favorable neurologic outcome.3 Despite this, advanced cardiovascular life support (ACLS) still recommends 1 mg every 3-5 minutes.4 But in refractory ventricular fibrillation (VF) or ventricular tachycardia (VT), physiology tells us a different story. These patients already have a profound catecholamine surge, and adding more catecholamines via epinephrine may worsen myocardial irritability, impede defibrillation success, and worsen brain perfusion. Many experts now recommend stopping the epinephrine after 10-15 minutes in cases of refractory VT/VF. The current ACLS epinephrine dose is viewed by many as too high, too frequent, and possibly detrimental.5 More definitive studies are needed, but it is reasonable to consider halting epinephrine administration during refractory VF or VT after 10-15 minutes of resuscitation. Myth #2: Secure the Airway First All too often, a patient arrives in cardiac arrest, and the team becomes hyperfocused on intubation, sometimes even halting CPR to get the tube. Every pause in compressions, however brief, reduces the likelihood of recovery. It's clear that anytime CPR is withheld, favorable outcomes plummet. One study showed that every 5-second increase in pre- and peri-shock pause decreased the odds of survival to discharge by 15%.6 The AIRWAYS-2 trial sought to settle this debate, looking at 9,296 patients who received a supraglottic airway (SGA) versus endotracheal intubation (ETI). No difference in survival at 30 days or at hospital discharge was found, yet the SGA group had a higher first-attempt success and more reliable ventilation compared to ETI.7 This aligns with the physiology: in the first minute following non-asphyxial cardiac arrest, patients often have adequate oxygen reserve. Compressions and defibrillation matter more than airway control.8 Compression-only CPR has demonstrated equivalent survival outcomes compared to standard CPR in several studies.9 In cases of nonasphyxial cardiac arrest, one should perform the minimum airway intervention that allows oxygenation and ventilation until ROSC.6 Start with bag-valve-mask ventilation. As muscle tone is lost during arrest, airway collapse can occur. Knowing basic airway maneuvers can make a huge difference. Jaw thrust, head tilt oropharyngeal airway, moving toward an SGA is key. Intubation should never precede defibrillation or interrupt compressions—ever. Myth #3: Charge the Defibrillator After Pulse-Check Minimizing interruptions during CPR is the most impactful change we can make. A simple practice shift is pre-charging the defibrillator. Have the timekeeper announce 20 seconds before pulse check. Charge the defibrillator during compressions so that if a shockable rhythm is identified, the shock can be delivered immediately, with