Does Faster Time to Epinephrine Improve Outcomes in Pediatric Pulseless Arrest with Nonshockable Rhythm?

A study completed from 2000 to 2014 by Andersen and colleagues used 15,959 pediatric patients in-hospital cardiac arrests. 1,558 children (9.8%) received epinephrine in at least one dose for nonshockable rhythms during cardiopulmonary resuscitation (CPR). 50% of these children received the medication during the same or next minute after the pulse was lost. 15% received the medication after 5 minutes.

740 patients were excluded because they did not receive epinephrine, 363 patients were excluded for having rapid return of spontaneous circulation (ROSC) within 2 minutes. For a variety of reasons, this study was different from a randomized clinical trial, which would be nearly impossible to initiate in a pediatric hospital for this condition.

This study reinforced that overall, pediatric patients with in-hospital cardiac arrests and nonshockable rhythms have poor overall prognosis. Fewer than 33% of patients survive to discharge and many have poor neurocognitive outcomes. The results of the study proved that epinephrine should be given within the first 5 minutes after CPR, as currently recommended. Since many patients reached ROSC within the first 2 minutes without receiving the medication, it cannot be determined that outcomes are better within 2 minutes.

JAMA. 2015;314(8):776-777. 

This article is interesting and shows the importance of providing efficient and correct care. Patients rely on health care providers to think and work quickly. Since it is impossible to do a randomized clinical trial in this setting, research is difficult. I think that despite the lack of research, clinicians should diagnose and administer the medication as quickly as possible. I believe that this would improve patient outcomes by increasing survival and decreasing poor neurocognitive outcomes. How can a pharmacist help the interprofessional team to improve pediatric patient outcomes? Are the guidelines different for adult patients?

Trial of Continuous or Interrupted Chest Compressions during CPR

In a study sponsored by the National Heart, Lung, and Blood Institute and many others, the effectiveness of continuous versus interrupted chest compressions during CPR was looked at. This research occurred at 114 EMS agencies and focused on adults with non-trauma-related out-of-hospital cardiac arrest. Agencies were randomly assigned to have its staff perform either continuous or interrupted chest compressions, and twice a year switched to the other resuscitation strategy. Continuous chest compressions were identified as the intervention group and would receive compressions at 100 compressions per minute with ventilations whenever possible at a rate of 10 ventilations per minute. Interrupted chest compressions (the control group) were defined as being at a rate of 100 compressions per minute, but having 2 ventilations after every 30 compressions. The kind of outcomes the study was looking for was whether the patient died or not, and if the patient experienced any neurologic damage.

23,711 patients were included for the final data analysis, with 12,653 in the intervention group and 11,058 in the control. 9% of the patients in the intervention group survived hospital discharge while 9.7% of patients in the control group did so. Among the patients with data on neurologic status, 7.7% of patients in the control group survived with favorable neurologic function compared the 7% of patients in the intervention group. Overall, there was not a significant difference in the survival rates or neurologic function between the strategies of continuous or interrupted chest compressions.

I found this study to be really interesting, because I sometimes hear about the proper way to provide CPR, whether or not rescue breaths are included in the process. According to the 2015 American Heart Association CPR guidelines, compressions should be given in all situations, and if a trained rescuer is able to, he or she should provide 2 rescue breaths for every 30 compressions. Their reasoning for this was that only compressions would be easy for the untrained, and that current research shows that there isn’t too much of a difference between the survival rates of compressions only versus compressions and rescue breath. This study supports the AHA’s claim and recommendations on how to perform CPR. I am really curious on what future studies may discover, especially in terms of what type of strategy will provide a significantly higher survival rate.

N Engl J Med. 2015;373:2203-14.