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| Image Credit: Wikimedia |
Author: Kasha Bornstein, MSc Pharm, EMT-P, MSIII
University of Miami Miller School of Medicine MD/MPH Program
AAEM/RSA Modern Resident Blog Copy Editor
Introduction
In late 2019, the International Liaison Committee on Resuscitation (ILCOR) released its updated guidelines for adult and pediatric resuscitation, informing the United States-based American Heart Association (AHA)/Advanced Cardiac Life Support (ACLS) focused protocol update.[1]
Significant changes this year in ILCOR recommendations focus on:
– Vasopressor use
– Advanced airway interventions and extracorporeal cardiopulmonary resuscitation (ECPR) in adult and pediatric cardiac arrest
– Targeted temperature management (TTM) in pediatric cardiac arrest This short article will address the salient details regarding each of these updates. Vasopressor Use Epinephrine, the old standby for the all-cause pulseless patient, has undergone significant review in recent years. Multiple large-scale retrospective and placebo-controlled randomized-controlled prospective studies have probed the efficacy and safety of epinephrine in cardiac arrest.[2,3] The majority of these studies find that while epinephrine may increase return of spontaneous circulation (ROSC), the effect size is small versus placebo and no difference is seen in favorable neurologic outcome. Many aspects surrounding best practices in epinephrine use remain unknown. These include optimal timing for administration in patients with shockable rhythms, efficacious dosing, and dose/effect relationships. However, alternative interventions are limited, overall survival for patients with non-shockable rhythms (asystole, pulseless electrical activity) is low, and no other pharmacologic intervention has demonstrated improved ROSC in these cases.
Take home: 1. Despite research suggesting low efficacy in improving positive ultimate outcomes beyond improved ROSC and survival to hospital, epinephrine is still “strongly recommended” as the evidence is not strong enough to indicate removing it from routine use.
– Advanced airway interventions and extracorporeal cardiopulmonary resuscitation (ECPR) in adult and pediatric cardiac arrest
– Targeted temperature management (TTM) in pediatric cardiac arrest This short article will address the salient details regarding each of these updates. Vasopressor Use Epinephrine, the old standby for the all-cause pulseless patient, has undergone significant review in recent years. Multiple large-scale retrospective and placebo-controlled randomized-controlled prospective studies have probed the efficacy and safety of epinephrine in cardiac arrest.[2,3] The majority of these studies find that while epinephrine may increase return of spontaneous circulation (ROSC), the effect size is small versus placebo and no difference is seen in favorable neurologic outcome. Many aspects surrounding best practices in epinephrine use remain unknown. These include optimal timing for administration in patients with shockable rhythms, efficacious dosing, and dose/effect relationships. However, alternative interventions are limited, overall survival for patients with non-shockable rhythms (asystole, pulseless electrical activity) is low, and no other pharmacologic intervention has demonstrated improved ROSC in these cases.
Take home: 1. Despite research suggesting low efficacy in improving positive ultimate outcomes beyond improved ROSC and survival to hospital, epinephrine is still “strongly recommended” as the evidence is not strong enough to indicate removing it from routine use.
a. However, epinephrine is no panacea, so maintain focus on high quality basic life support (e.g., recognize cardiac arrest early, defibrillate early and minimize interruptions in compressions). Aggressively find and treat reversible causes of arrest. 2. Administer epinephrine early in non-shockable rhythms. 3. In shockable rhythms, consider administration of epinephrine after initial defibrillation attempts are unsuccessful during CPR.
Advanced Airway Interventions ILCOR evaluated recent research on outcomes associated with different airway management strategies. Endotracheal intubation is regarded as the gold standard in securing a patient’s airway. However, large-scale trials have found little difference in outcomes among adult patients receiving airway management using intubation, supraglottic airway (SGA) insertion, or bag-mask ventilation (BMV), in any setting. ILCOR recommends that emergency medical services agencies should maintain quality control with tracking of intubation attempts and outcomes and plan for continuous improvement.
No studies have shown endotracheal intubation to improve critical outcomes (survival to discharge, favorable neurological function) in pediatric out-of-hospital cardiac arrest (OHCA). Some evidence has demonstrated worse critical outcomes for pediatric OHCA patients receiving endotracheal intubation. No good quality evidence supports or discourages endotracheal intubation vs. SGA for pediatric patients who experience in-hospital cardiac arrest (IHCA). Take home: 1. Airway management utilizing endotracheal intubation has been deemphasized. As before, chest compressions should not be interrupted for placement of an endotracheal tube, particularly if alternative strategies are available and effective. 2. There is not enough good evidence to direct choice between airway management strategies in pediatric cardiac arrest patients in the in-hospital setting.
a. BMV alone may be reasonable. b. Consider local expert guidance. ECPR Extracorporeal membrane oxygenation (ECMO) and other forms of ECPR are a hot topic in resuscitation as evidence, skills, and ability to implement ECPR has grown substantially in recent years. ECPR is increasingly used as a salvage therapy for patients in cardiac arrest refractory to conventional resuscitation efforts. Many questions still remain as to the optimal implementation, including knowledge gaps around who is most likely to benefit from ECPR, timing, and post-arrest strategies for patients resuscitated with ECPR. Nonetheless, ECPR may be utilized as a rescue therapy to support organ perfusion while potentially reversible conditions are addressed, and where it can be “expeditiously implemented and supported by skilled providers.” Similar knowledge gaps exist for ECPR use in pediatric patients, as the evidence is not yet well established. The main source of data is derived from pediatric patients with congenital heart disease experiencing IHCA, so the ILCOR/AHA guidance is more closely hewn to that. ILCOR authors suggest venoarterial ECMO may be considered during active CPR or for patients with intermittent ROSC in pediatric patients with cardiac diagnoses and IHCA where it can be rapidly deployed. There is no existing high-quality data indicating ECPR use for pediatric cardiac arrest among the general population.
a. BMV alone may be reasonable. b. Consider local expert guidance. ECPR Extracorporeal membrane oxygenation (ECMO) and other forms of ECPR are a hot topic in resuscitation as evidence, skills, and ability to implement ECPR has grown substantially in recent years. ECPR is increasingly used as a salvage therapy for patients in cardiac arrest refractory to conventional resuscitation efforts. Many questions still remain as to the optimal implementation, including knowledge gaps around who is most likely to benefit from ECPR, timing, and post-arrest strategies for patients resuscitated with ECPR. Nonetheless, ECPR may be utilized as a rescue therapy to support organ perfusion while potentially reversible conditions are addressed, and where it can be “expeditiously implemented and supported by skilled providers.” Similar knowledge gaps exist for ECPR use in pediatric patients, as the evidence is not yet well established. The main source of data is derived from pediatric patients with congenital heart disease experiencing IHCA, so the ILCOR/AHA guidance is more closely hewn to that. ILCOR authors suggest venoarterial ECMO may be considered during active CPR or for patients with intermittent ROSC in pediatric patients with cardiac diagnoses and IHCA where it can be rapidly deployed. There is no existing high-quality data indicating ECPR use for pediatric cardiac arrest among the general population.
Take home: 1. Where ECPR is available, consider it as a rescue modality for patients in which conventional CPR is failing and a reversible cause of arrest can be managed.
2. For pediatric cardiac arrest patients with history of congenital heart disease, ECPR is more strongly supported by the literature base. Targeted Temperature Management in Pediatric Cardiac Arrest Therapeutic hypothermia has been suggested since the very first edition of ACLS guidelines in 1974. More recently has been demonstrated to improve neurologic recovery in adult patients post-ROSC. Improved neurologic function resulting from post-resuscitation hypothermia hinges upon inhibition of inflammatory mediators, which play a role in neurologic inflammation and intracranial edema. Knowledge gaps exist as to the role of targeted temperature management in the pediatric post-ROSC setting and effects on survival and neurologic outcome. Recent studies have examined these knowledge gaps, finding no statistically significant benefit of maintaining core temperatures at 32°C to 34°C compared with 36°C to 37.5°C in survival, recurrent arrest, or short, intermediate or long-term [one year] neurologic recovery. However, no increase in adverse outcomes was seen either. Take home: 1. More data is needed on pediatric TTM. 2. Consider implementing TTM in the post–cardiac arrest period to maintain core temperature <37.5°C.
References 1. Soar J, Perkins GD, Maconochie I, et al. European Resuscitation Council Guidelines for Resuscitation: 2018 Update – Antiarrhythmic drugs for cardiac arrest. Resusc. 2019;134:99-103. 2. Perkins GD, Kenna C, Ji C, et al. The effects of adrenaline in out of hospital cardiac arrest with shockable and non-shockable rhythms: Findings from the PACA and PARAMEDIC-2 randomised controlled trials. Resusc. 2019;140:55-63. 3. Skjeflo GW, Skogvoll E, Loennechen JP, Olasveengen TM, Wik L, Nordseth T. The effect of intravenous adrenaline on electrocardiographic changes during resuscitation in patients with initial pulseless electrical activity in out of hospital cardiac arrest. Resusc. 2019;136:119-25.