Faiqa Qureshi

Part 13: Pediatric Basic Life Support 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest. Asphyxia begins with a variable period of systemic hypoxemia, hypercapnea, and acidosis, progresses to bradycardia and hypotension, and culminates with cardiac arrest.1 Another mechanism of cardiac arrest, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), is the initial cardiac rhythm in approximately 5% to 15% of pediatric in-hospital and out-of-hospital cardiac arrests;2,–,9 it is reported in up to 27% of pediatric in-hospital arrests at some point during the resuscitation.6 The incidence of VF/pulseless VT cardiac arrest rises with age.2,4 Increasing evidence suggests that sudden unexpected death in young people can be associated with genetic abnormalities in myocyte ion channels resulting in abnormalities in ion flow (see “Sudden Unexplained Deaths,” below). Since 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR),10 it seems appropriate to review the progressive improvement in outcome of pediatric resuscitation from cardiac arrest. Survival from in-hospital cardiac arrest in infants and children in the 1980s was around 9%.11,12 Approximately 20 years later, that figure had increased to 17%,13,14 and by 2006, to 27%.15,–,17 In contrast to those favorable results from in-hospital cardiac arrest, overall survival to discharge from out-of-hospital cardiac arrest in infants and children has not changed substantially in 20 years and remains at about 6% (3% for infants and 9% for children and adolescents).7,9 It is unclear why the improvement in outcome from in-hospital cardiac arrest has occurred, although earlier recognition and management of at-risk patients on general inpatient units …

Pediatric Advanced Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

For best survival and quality of life, pediatric basic life support (BLS) should be part of a community effort that includes prevention, early cardiopulmonary resuscitation (CPR), prompt access to the emergency response system, and rapid pediatric advanced life support (PALS), followed by integrated post–cardiac arrest care. These 5 links form the American Heart Association (AHA) pediatric Chain of Survival (Figure 1), the first 3 links of which constitute pediatric BLS. FIGURE 1. Pediatric Chain of Survival. Rapid and effective bystander CPR can be associated with successful return of spontaneous circulation (ROSC) and neurologically intact survival in children following out-of-hospital cardiac arrest.1,–,3 Bystander resuscitation may have the greatest impact for out-of-hospital respiratory arrest,4 because survival rates >70% have been reported with good neurologic outcome.5,6 Bystander resuscitation may also have substantial impact on survival from primary ventricular fibrillation (VF), because survival rates of 20% to 30% have been documented in children with sudden out-of-hospital witnessed VF.7 Overall about 6%8 of children who suffer an out-of-hospital cardiac arrest and 8% of those who receive prehospital emergency response resuscitation survive, but many suffer serious permanent brain injury as a result of their arrest.7,9,–,14 Out-of-hospital survival rates and neurological outcome can be improved with prompt bystander CPR,3,6,15,–,17 but only about one third to one half of infants and children who suffer cardiac arrest receive bystander CPR.3,9,12,18 Infants are less likely to survive out-of-hospital cardiac arrest (4%) than children (10%) or adolescents (13%), presumably because many infants included in the arrest figure are found dead after a substantial period of time, most from sudden infant death syndrome (SIDS).8 As in adults, survival is …

Acute headache in children and adolescents presenting to the emergency department.

Objectives.–Our goals were (1) to investigate the causes of acute headache in childhood from the emergency department perspective and (2) to search for clinical clues that might distinguish headache associated with serious underlying disease.

Efficacy of Nebulized Ipratropium in Severely Asthmatic Children

STUDY OBJECTIVE To determine the effect of adding the nebulized anticholinergic drug ipratropium bromide to standard therapy compared with standard therapy alone for acute severe asthma (peak expiratory flow rate [PEFR] < 50% of predicted) in children presenting to the emergency department. METHODS Ninety children aged 6 to 18 years were randomly assigned to two groups in a prospective, double-blind, placebo-controlled study performed in the ED of an urban childrens hospital. All children received nebulized albuterol solution (.15 mg/kg) every 30 minutes, and all received oral steroids with the second dose of albuterol. Children in group 1 received ipratropium bromide (500 micrograms/dose) with the first and third dose of albuterol those in group 2 received saline placebo instead of ipratropium. Pulmonary functions (PEFR and 1-second forced expiratory volume [FEV1]) and physiologic measurements were assessed every 30 minutes up to 120 minutes. By chance, the baseline values for percent of predicted PEFR and FEV1 differed between the two groups. Therefore a multivariate model accounting for both time and baseline effects was used to compare the response between groups. RESULTS On average, and adjusting for baseline measures, children in the ipratropium group had a significantly greater improvement in percent of predicted PEFR than did children in the placebo group at 60 minutes (P = .02), 90 minutes (P = .002), and 120 minutes (P < .0001). The improvement in percent predicted FEV1 was significantly greater for children in the ipratropium group only at 120 minutes (P = .013). Nine children (20%) from the ipratropium group and 14 (31.1%) from the control group were admitted (P = .33, chi 2). There were no significant adverse effects attributable to the ipratropium, and there was no relation between ipratropium use and changes in pulse, respiratory rate, blood pressure, or oxygen saturation. CONCLUSION We detected significant improvement in pulmonary function studies over 120 minutes in children with severe asthma who were given nebulized ipratropium combined with albuterol and oral steroids, compared with children who received the standard therapy. Further study is needed to determine whether early use of ipratropium decreases the need for hospitalization.

Efficacy of oral ketamine for providing sedation and analgesia to children requiring laceration repair.

A prospective, double-blind, placebo-controlled, randomized clinical trial was conducted to study the efficacy of oral ketamine for providing sedation and analgesia to children during laceration repair. Thirty children between the ages of one and seven years with lacerations that required suturing were randomly assigned to receive either oral ketamine (10 mg/kg) or an identically flavored placebo syrup prior to suturing. Patients were assessed by means of a tolerance score reflecting behavioral correlates of perceived pain at the time of both lidocaine injection and suturing. In addition, a sedation score for monitoring patient level of consciousness was used. The ketamine-treated group demonstrated a significantly greater tolerance to both lidocaine injection (P < 0.001) and suturing (P = 0.009) in comparison to the placebo-treated group. The ketamine-treated group also achieved a significantly greater degree of sedation (P = 0.012). No significant respiratory or circulatory adverse effects were seen in either group, although 26% of patients who received ketamine experienced minor, transient adverse effects. We conclude that oral ketamine in a dose of 10 mg/kg provides effective sedation and analgesia to young children undergoing wound repair.

Managing Headache in the Pediatric Emergency Department

Abstract Headache is a common complaint in children and adolescents. While the majority of headaches are self-limited and benign, headaches occasionally herald a life-threatening illness such as a brain tumor, intracranial hemorrhage, or meningitis. The emergency department physician has to distinguish between “benign” and “serious” headaches and therefore must have a rational, organized approach to the evaluation of these patients. This article will focus on a clinical classification system for childhood and adolescent headaches and discuss their emergency department evaluation and current recommended therapy.

EMERGENCY DEPARTMENT USE OF IPRATROPIUM IN SEVERE ASTHMATIC CHILDREN.|[bull]| 2321

Objective. To determine the effect of adding the nebulized anticholinergic drug, ipratropium bromide, to standard therapy for acute severe asthma (PEFR<50% of predicted) in children presenting to the emergency department. Study Design. Ninety children (ages 6-18 years) were randomized to two groups in a prospective, double-blind, placebo controlled study performed in the emergency department of an urban childrens hospital. All children received nebulized albuterol solution (0.15 mg/kg/dose) every 30 minutes. Those in group 1 received ipratropium bromide (500μg/dose) with the first and third dose of albuterol. The children in group 2 had saline substituted for the ipratropium. All patients received oral steroids with the second dose of albuterol. Pulmonary functions (PEFR and FEV1) were assessed every 30 minutes up to 120 minutes. Pulmonary functions, physiologic parameters (heart rate, respiratory rate, blood pressure) and demographics were compared by unpaired t-tests at baseline and at each time point. The total change in percent predicted PEFR and FEV1 over the 120 minute study period, and the occurrence of adverse effects and rate of hospital admissions were also compared. Results. The percent predicted FEV1 increased from a mean of 37.5% to 70.01% in the ipratropium group compared with a change from 31.1% to 57.9% in the saline group (p<0.05). The percent predicted PEFR increased from 34.2% to 67.9% in the ipratropium group compared to an increase of 29.5% to 53.6% in the saline group (p<0.001). Nine children were admitted from the ipratropium group and 14 were admitted from the control group (p=0.11 by Chi-square). There were no significant adverse effects attributable to the ipratropium.Conclusion. There was a significant improvement in pulmonary function studies over 120 minutes in children with severe asthma who were given combined albuterol and ipratropium therapy when compared to the children receiving only nebulized albuterol.