Heart Association Resuscitation Guidelines Research Articles

Drugs Used to Treat Pediatric Emergencies.

This clinical report is a revision of "Preparing for Pediatric Emergencies: Drugs to Consider." It updates the list, indications, and dosages of medications used to treat pediatric emergencies in the prehospital, pediatric clinic, and emergency department settings. Although it is not an all-inclusive list of medications that may be used in all emergencies, this resource will be helpful when treating a vast majority of pediatric medical emergencies. Dosage recommendations are consistent with current emergency references such as the Advanced Pediatric Life Support and Pediatric Advanced Life Support textbooks and American Heart Association resuscitation guidelines.

Process Improvement and Adopting the 2015 American Heart Association Resuscitation Guidelines.

Process Improvement and Adopting the 2015 American Heart Association Resuscitation Guidelines.

Outcomes Similar With Interrupted and Continuous Chest Compressions in Cardiac Arrest

According to this study: * In patients treated by emergency medical services (EMS) providers for out-of-hospital cardiac arrest, rates of survival and favorable neurologic status were similar in those who received interrupted chest compressions and those who received continuous chest compressions. * An accompanying editorial suggests that, in light of these findings, the 2015 American Heart Association resuscitation guidelines for EMS providers may need to be revisited.

Abstract 302: Transthoracic Impedance Is Poorly Predicted by Patient Characteristics but Significantly Reduced by Placement of Defibrillator Pads in the Anteroposterior Position

Introduction The American Heart Association Resuscitation Guidelines advocate four pad positions to achieve defibrillation success following cardiac arrest. Transthoracic impedance (TTI) reflects the electrode-skin interface and patient impedance and affects current amplitude, energy delivered and defibrillation efficacy. Modern defibrillators utilise an impedance compensated waveform to account for changes in TTI to improve defibrillation success. However the effect of electrode pad position and patient characteristics on TTI remains unclear. Objective To evaluate the effect of patient characteristics and pad position on Transthoracic impedance (TTI). Methods Patients undergoing diagnostic cardiac catheterisation were recruited for the study following regional ethical approval. Standard self-adhesive defibrillator electrodes were applied to patients in both the anterolateral and anteroposterior positions and connected to Heartsine Samaritan defibrillators. TTI was measured by applying a 30kHz sinusoidal signal through the chest. The voltage was then converted to digital samples using an 8-bit microprocessor. The digital samples were then stored on the secure digital card to be retrieved using custom-made download data recovery software. TTI was measured at 10 second intervals in both positions for the duration of the clinical procedure. Results 32 patients (mean age 63), (66% male), were recruited. TTI measured at 10 seconds was significantly higher in the anterolateral position (88.3ohms vs 68.5ohms, p <0.001). Mean TTI reduction over 5 minutes was 2.4% in the anterolateral position and 1.9% in anteroposterior position. There was no significant correlation between TTI measured from either pad position and age, height, weight, body surface area and Haemoglobin (r<0.4 for all parameters). Conclusion TTI is significantly reduced by placement of defibrillator pads in the anteroposterior position. Furthermore patient characteristics are poorly predictive of TTI from either pad position. Patients suffering failed defibrillation attempts from pads positioned in the anterolateral position may benefit from prompt relocation to the anteroposterior position to improve defibrillation efficacy.

Impact of Changes in Resuscitation Practice on Survival and Neurological Outcome After Out-of-Hospital Cardiac Arrest Resulting From Nonshockable Arrhythmias

Out-of-hospital cardiac arrest (OHCA) claims millions of lives worldwide each year. OHCA survival from shockable arrhythmias (ventricular fibrillation/ tachycardia) improved in several communities after implementation of American Heart Association resuscitation guidelines that eliminated "stacked" shocks and emphasized chest compressions. "Nonshockable" rhythms are now the predominant presentation of OHCA; the benefit of such treatments on nonshockable rhythms is uncertain. We studied 3960 patients with nontraumatic OHCA from nonshockable initial rhythms treated by prehospital providers in King County, Washington, over a 10-year period. Outcomes during a 5-year intervention period after adoption of new resuscitation guidelines were compared with the previous 5-year historical control period. The primary outcome was 1-year survival. Patient demographics and resuscitation characteristics were similar between the control (n=1774) and intervention (n=2186) groups, among whom 471 of 1774 patients (27%) versus 742 of 2186 patients (34%), respectively, achieved return of spontaneous circulation; 82 (4.6%) versus 149 (6.8%) were discharged from hospital, 60 (3.4%) versus 112 (5.1%) with favorable neurological outcome; 73 (4.1%) versus 135 (6.2%) survived 1 month; and 48 (2.7%) versus 106 patients (4.9%) survived 1 year (all P≤0.005). After adjustment for potential confounders, the intervention period was associated with an improved odds of 1.50 (95% confidence interval, 1.29-1.74) for return of spontaneous circulation, 1.53 (95% confidence interval, 1.14-2.05) for hospital survival, 1.56 (95% confidence interval, 1.11-2.18) for favorable neurological status, 1.54 (95% confidence interval, 1.14-2.10) for 1-month survival, and 1.85 (95% confidence interval, 1.29-2.66) for 1-year survival. Outcomes from OHCA resulting from nonshockable rhythms, although poor by comparison with shockable rhythm presentations, improved significantly after implementation of resuscitation guideline changes, suggesting their potential to benefit all presentations of OHCA.

What’s new in pediatric resuscitation? A practical update for the anesthesiologist

The International Liaison Committee on Resuscitation (ILCOR) has members from the world’s major resuscitation councils, including the Heart and Stroke Foundation of Canada and the American Heart Association. ILCOR engages with resuscitation science experts to perform systematic reviews of the world’s resuscitation literature, and from these appraisals, it produces its Consensus on Science and Treatment Recommendations for Resuscitation (the CoSTR document) every five years. Individual resuscitation councils then work from this document to create resuscitation guidelines and educational programs specific to their local context, including Basic Life Support, Advanced Cardiac Life Support, Pediatric Advanced Life Support, and the Neonatal Resuscitation Program. The publication of the 2010 Resuscitation Guidelines was particularly notable as it marked the 50 anniversary of the introduction of modern cardiopulmonary resuscitation (CPR). The guidelines for the Neonatal Resuscitation Program are applicable to neonates being cared for in the delivery room. After discharge from the newborn nursery (whether it be to home or to hospital wards), emergent care for neonates is provided using Pediatric Advanced Life Support guidelines. Adolescents with signs of secondary sexual development should be resuscitated using Advanced Cardiac Life Support guidelines. Much of the 2010 Heart and Stroke Foundation of Canada/American Heart Association Resuscitation Guidelines are relevant to the perianesthetic setting and are important for anesthesiologists to know. Anesthesiologists should recognize particular patients at higher risk of cardiac arrest, including those requiring emergency surgery, American Society of Anesthesiologists’ physical status class III-V, pulmonary hypertension, and congenital heart disease. Prevention of cardiac arrest is dependent on healthcare providers’ early recognition of the infant or child at risk of imminent collapse. The creation of medical emergency teams or rapid response teams is an attempt to address this problem. An abundance of historical control (‘‘pre/ post’’) pediatric studies suggests possible benefit associated with their implementation, but there is an absence of well-controlled prospective randomized studies that conclusively support their use. Cardiac arrest can be surprisingly difficult to diagnose quickly, even for resuscitation experts. Anesthesiologists should recognize that the pulse check performed by pediatric healthcare providers may be inaccurate, with a pulse being mistakenly detected up to 25% of the time when none is actually present. A maximum of ten seconds should be taken to feel for a pulse in a patient without signs of life (unresponsive and with apnea or agonal respirations), and chest compressions should be initiated if a pulse cannot be felt or if its presence is uncertain. A sudden profound fall in end-tidal CO2 (EtCO2) or the absence of an EtCO2 waveform may assist in diagnosing intraoperative cardiac arrest. Conversely, a progressive significant rise in EtCO2 while chest compressions are ongoing may suggest the return of a spontaneous circulation (ROSC). Pediatric cardiac arrest is typically asphyxial and follows a prolonged period of respiratory failure or shock. The rhythm immediately preceding cardiac arrest is frequently sinus bradycardia with a pulse of 60 beats min. While A. de Caen, MD (&) Pediatric Critical Care Medicine, Stollery Children’s Hospital, University of Alberta, 8440 – 112 Street, Edmonton, AB T6G 2B7, Canada e-mail: allan.decaen@albertahealthservices.ca

The Utility of the HeartSaver Sticker for Maintaining Correct Hand Position during Chest Compressions

BackgroundThe importance of attaining correct hand position in cardiopulmonary resuscitation (CPR) instruction has not been emphasized as much as the significance of the compression performance. Study Objectives: This pilot study was performed to investigate the utility of a HeartSaver Sticker for maintaining correct hand position during chest compressions. MethodsFifty-one sophomore college students, training to become emergency medical technicians, were recruited. The students, having no previous experience using HeartSaver stickers, participated in this prospective, randomized simulation-based controlled study, which consisted of two groups: 1) with sticker (n=26), 2) without sticker (n=25). The 4×4-cm HeartSaver sticker marked with both vertical and horizontal center lines was used in this study. Proper sticker placement was such that the vertical line coincided with the mid-sternum of the chest, and the horizontal line aligned with the nipples. Participants performed adult basic life support by single rescuer according to the 2005 American Heart Association resuscitation guidelines. Skill assessment was also performed by these guidelines. ResultsGroup 1 participants placed the HeartSaver sticker on the correct landmark within 10 s of approaching the model. The compression rate and depth were not significantly different between the two groups. However, significant improvement in correct hand position was noticed when using the HeartSaver sticker. Correct hand position was 97.1% ± 7.4% in group 1 and 85.9% ± 21.5% in group 2 (p=0.002). ConclusionThe HeartSaver sticker was useful in maintaining correct hand position during the single-rescuer CPR scenario because it provided easy recognition of that position when compressing after ventilations.

Cardiologists' knowledge of the 2005 American Heart Association Resuscitation Guidelines: The Athens Study

Objective The study objective was to determine cardiologists’ theoretic knowledge of the 2005 American Heart Association (AHA) resuscitation guidelines. Methods The questionnaire consisted of demographic questions, resuscitation experience questions, a question regarding confidence in resuscitation skills, and 20 theoretic knowledge questions. Results For the theoretic knowledge questions, the participants’ overall mean score was 9.9 ± 4.6 (range 3-20). Participants who had received advanced cardiac life support (ACLS) training scored significantly higher. Furthermore, those who had attended the ACLS course in the preceding year scored significantly higher compared with those who had attended the ACLS course more than 1 year before the survey (19.1 ± .6 vs 16.7 ± .67, P = .001). Theoretic knowledge of resuscitation did not increase with seniority. Furthermore, no correlation was observed between the theoretic knowledge scores and participants’ self-appraisal of resuscitation knowledge. Conclusion Cardiologists have knowledge gaps in the 2005 AHA resuscitation guidelines. Resuscitation knowledge decay 1 year after the course is evident.

Stayin’ alive: The 2010 Heart and Stroke Foundation of Canada/American Heart Association resuscitation guidelines for newborns and older children

Five years have transpired since the most recent set of paediatric and neonatal resuscitation guidelines were jointly released by the Heart and Stroke Foundation of Canada (HSFC) and the American Heart Association. The recent publication of the 2010 resuscitation guidelines (1–3) prompts the following questions: What process led to the creation of the guidelines? What is new since 2005? What is our role in implementation? Guideline development has evolved from using consensus of experts, to the use of an evidence-based approach. Starting in 2000, the International Liaison Committee on Resuscitation (ILCOR), consisting of resuscitation councils from around the world (including the HSFC), has conducted regular systematic reviews of the resuscitation literature. These reviews resulted in the Consensus on Science and Treatment Recommendations (CoSTR). After the release of ILCOR’s 2005 CoSTR document, the paediatric and neonatal task forces reconvened, with international (including Canadian) representation. Each task force identified key questions requiring evidence evaluation, and assigned each question to two or more international resuscitation experts. After a rigorous literature search, relevant articles were independently identified, analyzed and graded by each worksheet author. With the assistance of an evidence evaluation expert, the scientific information surrounding a specific question was summarized and treatment recommendations were drafted based on this summary. The worksheet summaries (without treatment recommendations) were made available to the wider scientific community through the ILCOR website. Each worksheet author then presented his/her findings one final time to the paediatric or neonatal task forces, who debated and finalized the CoSTR statements (published in October 2010 [4,5]). Since that time, regional resuscitation councils (such as the HSFC and American Heart Association) have released their own resuscitation guidelines that have contextualized the CoSTR documents for their respective health care systems. A significant challenge for the world’s paediatric and neonatal resuscitation community continues to be the paucity of high-quality studies in the basic science, clinical and educational domains. Many resuscitation science recommendations are based on extrapolation from adult (human) studies or even animal data, whereas educational science largely consists of low-level studies of learner outcomes rather than patient outcomes. There is a pressing need for further study regarding how best to translate resuscitation science into practice, and how best to improve knowledge acquisition and retention by both lay rescuers and health care professionals over time. Studies are needed to compare traditional instructor-led courses with newer innovative approaches to teaching including Internet- and computer-based training, and low- or high-fidelity simulation. The rapid attrition of cognitive and technical skills within months of initial instruction suggests that we need to consider other approaches to continuing education, potentially including more frequent refresher courses, training sessions or simulations. The introduction of simulation and debriefing to neonatal resuscitation training will result in substantial changes to Neonatal Resuscitation Program (NRP) courses, presenting new challenges for our instructors and learners. These new methodologies will help us recognize the importance of teamwork competencies, and individual knowledge, skills and behaviours. Fortunately, the clinical science recommendations reinforce and build on practices introduced to Canada in 2006 (6), and will require relatively minor modifications. Outside the newborn population, clearer, simpler and more consistent messaging to the public regarding how to provide cardiopulmonary resuscitation (CPR) to individuals of all ages will hopefully ensure that bystanders act promptly, in contrast to the majority of out-of-hospital cardiac arrests in Canada, where no intervention is provided by lay rescuers. Starting the first cycle of CPR with chest compressions (chest compressions, airway, breathing), as opposed to the traditional order (airway, breathing, chest compressions) will ensure that rescuers immediately ‘do something (ie, at least chest compressions) as opposed to doing nothing’ for all cardiac arrest victims. This will maximize coronary perfusion and delay the provision of rescue breaths by only a few seconds. The challenge for paediatric and neonatal health care providers is to recognize our collective role and responsibility in optimizing resuscitative care for Canada’s infants and children. Although maintaining up-to-date CPR certification and/or NRP registration is an essential first step, our role extends to advocating CPR education for our own children and families, and getting the “stayin’ alive” message out to the public through our patients, their families and the community. It is time for us, as paediatricians, to approach paediatric cardiac arrest as a preventable disease, in the same way that we successfully advanced seatbelt and bicycle helmet education programs. Similarly, perinatal teams should view newborn compromise as predictable in many circumstances and, therefore, assess risk and prepare for resuscitation before every delivery. Finally, it is incumbent on us to cultivate resuscitation-based scientific research to fill the knowledge gaps in basic, clinical and educational science, and inform future CoSTR cycles.

Take Heart America: A comprehensive, community-wide, systems-based approach to the treatment of cardiac arrest*

To determine out-of-hospital cardiac arrest survival rates before and after implementation of the Take Heart America program (a community-based initiative that sequentially deployed all of the most highly recommended 2005 American Heart Association resuscitation guidelines in an effort to increase out-of-hospital cardiac arrest survival). Out-of-hospital cardiac arrest patients in Anoka County, MN, and greater St. Cloud, MN, from November 2005 to June 2009. Two sites in Minnesota with a combined population of 439,692 people (greater St. Cloud and Anoka County) implemented: 1) widespread cardiopulmonary resuscitation and automated external defibrillator skills training in schools and businesses; 2) retraining of all emergency medical services personnel in methods to enhance circulation, including minimizing cardiopulmonary resuscitation interruptions, performing cardiopulmonary resuscitation before and after single-shock defibrillation, and use of an impedance threshold device; 3) additional deployment of automated external defibrillators in schools and public places; and 4) protocols for transport to and treatment by cardiac arrest centers for therapeutic hypothermia, coronary artery evaluation and treatment, and electrophysiological evaluation. More than 28,000 people were trained in cardiopulmonary resuscitation and automated external defibrillator use in the two sites. Bystander cardiopulmonary resuscitation rates increased from 20% to 29% (p = .086, odds ratio 1.7, 95% confidence interval 0.96-2.89). Three cardiac arrest centers were established, and hypothermia therapy for admitted out-of-hospital cardiac arrest victims increased from 0% to 45%. Survival to hospital discharge for all patients after out-of-hospital cardiac arrest in these two sites improved from 8.5% (nine of 106, historical control) to 19% (48 of 247, intervention phase) (p = .011, odds ratio 2.60, confidence interval 1.19-6.26). A financial analysis revealed that the cardiac arrest centers concept was financially feasible, despite the costs associated with high-quality postresuscitation care. The Take Heart America program doubled cardiac arrest survival when compared with historical controls. Study of the feasibility of generalizing this approach to larger cities, states, and regions is underway.

Abstract P89: Take Heart America ™ : A Community-based Sudden Cardiac Arrest Survival Initiative is Saving Lives by Implementing the Most Highly Recommended 2005 American Heart Association Resuscitation Guidelines

Introduction: Take Heart America (THA) is a community-based initiative intended to improve survival from sudden, out-of-hospital cardiac arrest (OHCA) in four US communities: St. Cloud (MN), Anoka County (MN), Columbus (OH) and Austin (TX). Hypothesis: Implementing a continuum of resuscitation care that includes the most highly recommended 2005 AHA resuscitation guidelines will improve survival from OHCA. Methods: In Phase I, the two MN sites (population: greater St. Cloud: ~160K; Anoka Co: ~320K) implemented: a) widespread CPR training in schools and businesses; b) retraining of all EMS personnel in methods to enhance circulation including minimizing CPR interruptions, performing CPR prior to and after single shock defibrillation, and use of an impedance threshold device; c) more widespread deployment of AEDs in schools and public places; and d) transport to and treatment by Level One Cardiac Arrest Centers that provide: therapeutic hypothermia (applied to all comatose patients regardless of initial arrest rhythm), coronary artery evaluation and treatment, and widespread electrophysiological evaluation. During Phase II, Austin and Columbus will implement these same steps. A Standard Chi-Square analysis was performed. Results: From 2006 –2007 in the two MN sites, >12,000 people were trained in CPR, bystander CPR rates increased by ~5%, three Level One Cardiac Arrest Centers were established, and interventions a–d above were fully implemented. Survival in all patients following OCHA improved from 9.3% (14/151) in 2005 (historical control) to 17% (31/181) (P=0.0373) in 2007 in these two sites. Conclusions: In conclusion, when OHCA patients were treated with a continuum of prehospital and inhospital interventions intended to optimize defibrillation and circulation during CPR, and preserve heart and brain function following cardiac arrest, survival rates nearly doubled when compared to historical controls. The THA initiative is effective in mid-size communities, but regular retraining of EMS personnel is needed to assure full implementation of the key aspects of the program. Phase II is underway to determine if the program can be successfully implemented with similar positive results in communities with populations of 500 –1000K.

Preparing for Pediatric Emergencies: Drugs to Consider

This clinical report provides current recommendations regarding the selection and use of drugs in preparation for pediatric emergencies. It is not intended to be a comprehensive list of all medications that may be used in all emergencies. When possible, dosage recommendations are consistent with those used in current emergency references such as the Advanced Pediatric Life Support and Pediatric Advanced Life Support textbooks and the recently revised American Heart Association resuscitation guidelines.

The Role of Intraosseous Vascular Access in the Out-of-Hospital Environment (Resource Document to NAEMSP Position Statement)

Thousands of critically ill emergency patients are treated in the out-of-hospital setting in the United States every year. In many patients intravenous (IV) therapy cannot be initiated because of inadequate access to peripheral veins. In some cases, this lack of vascular access may limit benefit of medications because of late administration.[[]] Both speed andoverall success of vascular access are important when evaluating potential methodologies for their use in the out-of-hospital environment. Insertion of an IV cannula has been reported to require substantial time in the prehospital environment, with a recent study reporting an average successful intravenous line placement time of 4.4 ± 2.8 minutes.[[]] In critically ill pediatric patients, vascular access may present substantial difficulties to the provide.[[]] Intraosseous access may provide a significant time saving which may benefit many critically ill patients, both by decreasing the time to achieve access andby decreasing the time to administration of indicated medications.[[]] Achieving rapid administration of medications may facilitate the care of critically ill patients.[[]] Devices are now available that permit rapid, accurate access to the intraosseous space. Recent changes in the American Heart Association's resuscitation guidelines state that the intraosseous route should be the first alternative to difficult or delayed intravenous access.[[]] With these considerations, the role of intraosseous vascular access in the out-of-hospital environment should be reemphasized.

Terlipressin for refractory hypotension following angiotensin‐II receptor antagonist overdose

A 54-year-old female presented to the Emergency Department following the ingestion of 32 tablets containing a combination of irbesartan 300 mg and hydrochlorothiazide 12.5 mg (CoAprovel, Bristol-Myers Squibb, Uxbridge, UK) and an unknown quantity of diazepam, paracetamol and alcohol. She had a past history of hypertension and alcohol dependency. On admission her arterial pressure was 95/50 mmHg and she had a sinus tachycardia (105 min−1). Seven hours after ingestion she became profoundly hypotensive and despite 2 litres of fluid her arterial pressure was 72/35 mmHg, with a central venous pressure of 13 mmHg. The patient developed 4 mm ST segment depression in leads V2-V5 but remained asymptomatic. She was administered ephedrine 30 mg with no response, and was transferred to ICU, where an infusion of phenylephrine 0.6 μg.kg−1.min−1 was started, with little improvement. The phenylephrine was stopped and norepinephrine and dobutamine were commenced, but despite increasing these to 0.25 μg.kg−1.min−1 and 10 μg.kg−1.min−1, respectively, she remained hypotensive. We decided to administer terlipressin 1 mg (Glypressin, Ferring, Malmö, Sweden) by slow intravenous bolus. Within 2 h her arterial pressure was within normal limits and she could be weaned off all vasopressors and inotropes. She remained normotensive, enabling transfer to the ward the following day, during which her observations were satisfactory. She was discharged home 2 days later after a psychiatric consultation. Patients who have been chronically treated with angiotensin receptor antagonists (AIIR1) have been shown to exhibit hypotension after induction of anaesthesia, which is often refractory to classical vasoconstrictor therapy [1]. As both the sympathetic and renin-angiotensin systems are blunted, the role of the vasopressin in restoring arterial pressure in these cases has been proposed [2]. Arginine-vasopressin, a postpituitary nine amino-acid peptide, stimulates vasopressin receptors – notably the vascular V1a receptors, to cause marked arterial constriction and has been used for septic and catecholamine resistant shock [3, 4]. It has also been shown to improve cerebral blood flow in resuscitation and is included in American Heart Association resuscitation guidelines [5, 6]. Terlipressin (triglycycl–lysine vasopressin) is a drug precursor slowly metabolised to lysine-vasopressin by plasma esterases. It has been reported to be effective in the treatment of vasodilatory shock secondary to calcium-channel blocker overdose and bupivacaine intoxication [7, 8]. Terlipressin was shown to be effective in rapidly restoring arterial pressure with no concomitant impairment in the left ventricular function in patients chronically treated with AIIR1 antagonists who presented with refractory hypotension after induction of anaesthesia [2]. Although our patient was not under general anaesthesia, the normal physiological mechanisms involved in maintaining blood pressure were blunted by the supranormal dose of AIIR1 antagonists. The resulting hypotension would have been caused by vasodilation and decrease in vascular adrenergic receptor sensitivity limiting the clinical effect of adrenergic drugs. Terlipressin results in limited postoperative hypertension and tachycardia [3]. A report of cardiac ischaemia following terlipressin used for treating intra-operative hypotension was associated with an acute increase in left ventricular afterload [9]. We feel that myocardial ischaemia on ECG in our patient was caused by a decrease in perfusion pressure in the coronary arteries. Following the administration of terlipressin there was resolution of the ST segment depression and a cardiac troponin assay was negative, indicating absence of significant myocardial ischaemic injury in this case. In conclusion, we suggest terlipressin may be used for the treatment of refractory hypotension secondary to angiotensin receptor antagonist overdose if conventional vasopressors have been unsuccessful.