James S. Seidel

Pediatric Cardiopulmonary Resuscitation: A Collective Review

Little information is available about the effects of CPR in children, although it is known that the outcomes are dismal. Examples of unanswered questions include which advanced life support (ALS) procedures should be performed out-of-hospital, whether high-dose epinephrine improves survival, and the true prevalence of ventricular fibrillation as a presenting rhythm. Children differ from adults as to the cause and pathophysiology of cardiopulmonary arrest, but prehospital EMS and hospital resuscitation teams were initially designed for the care of adults. Because pediatric cardiopulmonary arrest is rare, prospective data are difficult to gather, and there are few large published studies. The purpose of this collective review was to review the current body of knowledge regarding survival rates and outcomes in pediatric CPR and, based on this review, to outline a course for future research.

A rapid method for estimating weight and resuscitation drug dosages from length in the pediatric age group

Drug dosages used during pediatric emergencies and resuscitation are often based on estimated body weight. The Broselow Tape, a tape measure that estimates weight and drug dosages for pediatric patients from their length, has been developed to facilitate proper dosing during emergencies. In our study, 937 children of known weight were measured with this tape. Weight estimates generated by the tape were found to be within 15% error for 79% of the children. The tape was found to be extremely accurate for children from 3.5 to 10 kg, and from 10 to 25 kg. Regression lines of estimated compared with actual weight for these children have slopes of 0.98 and 0.96, respectively, not significantly different from the ideal slope of 1.00 (P = 28 and .13). Accuracy was significantly decreased for measured children who weighed more than 25 kg. In a separate group of children (n = 53), the tape was shown to be more accurate than weight estimates made by residents and pediatric nurses (P less than .0001). Use of the Broselow Tape is a simple, accurate method of estimating pediatric weights and drug doses and eliminates the need for memorization and calculation.

Vital signs as part of the prehospital assessment of the pediatric patient: A survey of paramedics

Vital signs are an integral part of the field assessment of patients. A two-part study was undertaken to determine which vital signs are taken in the field assessment of pediatric patients and to determine whether the frequency of vital signs taken is influenced by base station contact, patients severity of illness or injury, or paramedic demographic factors such as parenting and field experience. An initial pilot study of prehospital care records (run sheets) from two base hospitals in Los Angeles County revealed that there were significant differences between field vital sign assessment in pediatric and adult patients (P less than .0001). A retrospective review of 6,756 pediatric run sheets from Los Angeles County showed that the frequency of vital sign assessment varied with the age of the pediatric patient (P less than .05) (ie, the frequency of vital sign assessment increased correspondingly with the age of the patient). Base hospital contact occurred in 26% of the runs; when contact was made, vital signs were more likely to be taken in all age groups studied. Vital signs often were not assessed in children less than 2 years old, even if the patients chief complaint suggested the possibility of a major illness or trauma. The second part of the study was a field assessment survey that was distributed to 1,253 active paramedics in Los Angeles County; the results showed that paramedics were less confident in their ability to assess vital signs in children less than 2 years old. Confidence increased with age of the patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Presentation and evaluation of sexual misuse in the emergency department

Children who have been sexually abused develop a variety of emotional and physical complaints, often unrelated to the genital area. Emergency department records of children diagnosed as being sexually abused were reviewed for the period covering January 1984 through June 1985. Of 26,000 patients seen, 300 cases of sexual abuse were identified. Of these, 57 were patients who presented with initial complaints other than sexual abuse. The data were analyzed for age, sex, chief complaint, time of presentation, physical findings, and person accompanying the child. The most common presenting complaints of these 57 patients were abdominal pain (26%) and vaginal symptoms (26%) The latter included pruritus, discharge, and bleeding. Other complaints included rectal bleeding or constipation (9%), chronic urinary tract infection (5%), straddle injury (4%), and suicide attempt (2%). The remaining 26% included fever, respiratory infections, sore throat, asthma, bronchitis, obesity, mastoiditis, and weight loss. Because resident physicians are instructed to conduct complete anal and genital examinations on all patients, sexual misuse was often diagnosed with seemingly unrelated complaints. A protocol developed for use in the emergency department is described

Priorities for research in emergency medical services for children: results of a consensus conference.

STUDY OBJECTIVE To arrive at a consensus on the priorities for future research in emergency medical services for children. METHODS A consensus group was convened using the Rand-UCLA Consensus Process. The group took part in a 3-phase process. Round 1 involved reviewing a compendium of relevant research articles and answering a mailed questionnaire. Panel members were asked to prioritize topics on the basis of the 1993 Institute of Medicine Report on Emergency Medical Services for Children. Participants were asked to rate each topic based on the significance of the research, and whether the topic would (1) improve general knowledge, (2) change behavior, (3) improve health, (4) decrease the cost of care, or (5) change public policy. A 4-point Likert scale was used. Participants were also asked if the research would require a multicenter study and if the research were feasible. Round 2 of the study involved a meeting of the panel, where the results of Round 1 were discussed and the topics were reprioritized. The topics were given a rank order and a final ranking was done in Round 3. RESULTS The panel considered a list of 32 topics; these were combined and reworded to give them more precise meaning. Several new topics were also added. Fifteen topics were given a rank order and placed within the 7 broad categories of the Institute of Medicine report. Clinical aspects of emergency care, systems organization, configuration, and operation and injury prevention were given high priority rankings. The first 5 topics were very close in point-rank order. CONCLUSION The panel was able to develop a list of important topics for future research in emergency medical services for children that can be used by foundations, governmental agencies, and others in setting a research agenda for such services.

Guidelines for pediatric equipment and supplies for emergency departments

[Committee on Pediatric Equipment and Supplies for Emergency Departments, National Emergency Medical Services for Children Resource Alliance: Guidelines for pediatric equipment and supplies for emergency departments. Ann Emerg Med January 1998;31: 54-57.].

Emergency medical services and the adolescent patient

A study of 10,493 prehospital care report forms from 11 counties in California demonstrated that the adolescent age group (ages 12 to 18 years) accessed prehospital care through the emergency medical service (EMS) system more frequently than other pediatric patients (5978 reports). They did so most commonly for trauma (87.6%), but also for behavioral emergencies such as suicide and psychiatric problems. The most common cause of injury was automobiles, and care rendered was most commonly wound care and splinting. The most common substances given to adolescents in the prehospital setting were naloxone and 50% dextrose. EMS systems need to address the need for triage and care of adolescent patients.

Significance of extreme leukocytosis in the evaluation of febrile children

Background: Emergency department evaluation of young febrile children often includes a white blood cell count. Although a high white blood cell count is associated with an increased likelihood of infection, the clinical significance of extreme leukocytosis (EL), defined as a white blood cell count of ≥25,000/mm3, has not been well-studied. Objective: To determine diagnoses associated with EL in febrile children evaluated in a pediatric emergency department and to compare rates of serious bacterial infection in those with EL and in those with more modest leukocytosis (LK) (15,000–24,999/mm3). Methods: A retrospective case-control study of children 2–24 months of age was performed. Those with EL were frequency age- and gender-matched to controls with LK. Results: Sixty-nine patients with EL and 94 patients with LK were included. The mean age was 9.9 months, and 91 (56%) patients were male. The diagnoses were similar between the 2 groups, with otitis media, viral syndrome and pneumonia being the most common. The rates of proven serious bacterial infection were similar between EL (25%; 95% confidence interval, 15–36%) and LK (17%; 95% confidence interval, 10–26%) patients. Using different white blood cell cutoff points did not distinguish between patients with and without serious bacterial infection. Conclusion: Young febrile children whose emergency department evaluation revealed EL had diagnoses and rates of serious bacterial infection similar to those of children with LK.

Education in Pediatric Basic and Advanced Life Support

Curricula in pediatric resuscitation must be based on adult learning principles. The Pediatric Basic and Advanced Life Support Courses (PBLS, PALS) should use educational strategies fostering positive interactions between the instructor and learners and should take into consideration the learners motivation for taking the course. Materials should be developed for a specific target audience; course design should be flexible to meet individual needs. The PBLS and PALS courses have different audiences. PBLS is targeted toward caretakers of children. This course will continue to emphasize primary injury prevention as the major strategy but also will give learners the knowledge and skills to perform CPR. To optimize retention of knowledge and skills, the course content must be simplified, and the sequencing of steps in basic life support must be modified. Health care providers caring for pediatric patients in acute care settings are the primary audience for the PALS course. This course already incorporates adult learning principles; only minor revisions are anticipated. Discussion of the trauma patient is limited in the PALS course; additional trauma education could be facilitated by the addition of a trauma module or by other educational courses. All aspects of the PBLS and PALS educational programs must be evaluated continually to determine whether learning objectives have been met and whether the teaching format is appropriate. The answers to evaluation questions will help determine the degree to which the American Heart Association is meeting its educational objectives and how to allocate resources for development and training.

Out-of-hospital care of pediatric patients.

The out-of-hospital care of children has seen significant changes in the past 10 years. Much work has yet to be done to research interventions and prevention strategies that have a positive effect on the outcome of children. Physicians, nurses, and out-of-hospital providers must serve as advocates for children in their communities.