**2. Medications used in cardiac arrest**

The 2015 PALS guidelines discussed three drugs used during resuscitation in children: epinephrine, amiodarone, and lidocaine [24]. **Table 2** highlights these medications, comparing recommendations from the 2015 PALS update and most recent literature that has been published since then. The 2015 PALS guidelines state that it is reasonable to use epinephrine during cardiac arrest. This guideline was based on two pediatric observational studies that were inconclusive and one adult study showing increased ROSC and survival to admission but no change in SHD [24]. Since the 2015 guidelines, an analysis of nonshockable pediatric cardiac arrests in the GWTG registry showed a delay in epinephrine administration was associated with decreased likelihood of survival to admission, ROSC, SHD, and survival with FNO [38]. Another GWTG analysis looked at the intervals between epinephrine administration. Guidelines currently state to give epinephrine every 3–5 min during CPR. This study showed that compared to intervals of 1–5 min as the reference, longer intervals were associated with improved SHD [39]. For shock refractory VF or pulseless VT, the 2015 guidelines changed to state that either amiodarone or lidocaine was acceptable. Previous guidelines had recommended amiodarone as the preferred drug over lidocaine. This is based on pediatric retrospective data that shows lidocaine is associated with improved ROSC and 24-h survival; however, there is no change in SHD [24]. The 2018 update to the PALS guidelines continued


#### **Table 2.**

*Medications used during pediatric cardiac arrest: Current guidelines vs. most recent literature.*

to reaffirm the 2015 guidelines. No new pediatric data was available for the updated review; however, the committee did not consider extrapolated adult data [40].
