CHEST Guidelines-Improving-CPR-Performance

Improving-CPR-Performance_chest

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The correspondence in the document addresses the role of prolonged CPR, especially in patients with cardiac arrest due to pulmonary embolism (PE). Dr. Carla Nobre and Dr. Boban Thomas highlight the importance of extended intense chest compressions alongside thrombolytic therapy, emphasizing their own success in treating patients with PE using this approach. They argue that prolonged CPR can modify the prothrombotic state of cardiopulmonary arrest and maintain circulation, allowing thrombolytic agents like tenecteplase to act effectively.<br /><br />They point out that even after achieving return of spontaneous circulation (ROSC), patients might still have low cardiac output, necessitating continued chest compressions. This viewpoint is based on their understanding of specific pathologies in congenital heart disease where the right ventricle struggles with sudden pressure increases, rendering prolonged CPR beneficial in such contexts.<br /><br />In response, the authors of the original CPR performance review, Drs. Nassar and Kerber, acknowledge the points made by Nobre and Thomas. They note the absence of clearly defined minimum resuscitation durations in AHA guidelines, while supporting the notion that extended resuscitation could be advantageous in certain scenarios. They recommend using quantitative physiological measures like end-tidal CO2 or diastolic blood pressure to decide on the continuation of resuscitative efforts, considering these as better indicators of CPR's effectiveness.<br /><br />The responders also mention that while advancements in diagnosing and treating PE have occurred for non-arrest situations, the same progress isn't mirrored in cases of fulminant PE leading to cardiac arrest. They understand the suggestions about continued chest compressions even after ROSC but express skepticism about its impact on augmenting cardiac output post-ROSC. They recognize the challenges in diagnosing PE during cardiac arrest, despite supportive evidence from case studies and observational reports.

Keywords

prolonged CPR

cardiac arrest

pulmonary embolism

thrombolytic therapy

chest compressions

tenecteplase

ROSC

AHA guidelines

end-tidal CO2

cardiac output