Optimizing CPR

An article in today’s New York Times reminds us that the quality of cardiopulmonary resuscitation varies widely region-to-region in the US. As a result, survival rates after cardiac arrest also vary widely. Although advances in CPR research are ongoing, their adoption by citizens and providers vary by location.

The best evidence is synthesized every 5 years by the American Heart Association (AHA), and summarized in updated guidelines for resuscitation care.  The AHA’s 2015 Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care were released in October.

The following are the most important changes and reinforcements to the Pediatric Advanced Life Support recommendations (co-authored by my colleague Halden Scott) made in the 2010 Guidelines:

• There is new evidence that when treating pediatric septic shock in specific settings, the use of restricted volume of isotonic crystalloid leads to improved survival, contrasting with the long-standing belief that all patients benefit from aggressive volume resuscitation. New guidelines suggest a cautious approach to fluid resuscitation, with frequent patient reassessment, to better tailor fluid therapy and supportive care to children with febrile illness.

• New literature suggests limited survival benefit to the routine use of atropine as a premedication for emergency tracheal intubation of non-neonates, and that any benefit in preventing arrhythmias is controversial. Recent literature also provides new evidence suggesting there is no minimum dose required for atropine use.

• Children in cardiac arrest may benefit from the titration of CPR to blood pressure targets, but this strategy is suggested only if they already have invasive blood pressure monitoring in place.

• New evidence suggests that either amiodarone or lidocaine is acceptable for treatment of shock-refractory pediatric ventricular fibrillation and pulseless ventricular tachycardia.

• Recent literature supports the need to avoid fever when caring for children remaining unconscious after out of hospital cardiac arrest (OHCA).

• The writing group reviewed a newly published multicenter clinical trial of targeted temperature management that demonstrated that a period of either 2 days of moderate therapeutic hypothermia (32° to 34° C) or the strict maintenance of normothermia (36° to 37.5° C) were equally beneficial. As a result, the writing group feels either of these approaches is appropriate for infants and children remaining comatose after OHCA.

• Hemodynamic instability after cardiac arrest should be treated actively with fluids and/or inotropes/vasopressors to maintain systolic blood pressure greater than the fifth percentile for age. Continuous arterial pressure monitoring should be used when the appropriate resources are available.

To update your own CPR skills, visit the AHA’s website.