Mary Fran Hazinski

Paediatric life support. An advisory statement by the Paediatric Life Support Working Group of the International Liaison Committee on Resuscitation.

This document reflects the deliberations of ILCOR. The epidemiology and outcome of paediatric cardiopulmonary arrest and the priorities, techniques and sequence of paediatric resuscitation assessments and interventions differ from those of adults. The working group identified areas of conflict and controversy in current paediatric basic and advanced life support guidelines, outlined solutions considered and made recommendations by consensus. The working group was surprised by the degree of conformity already existing in current guidelines advocated by the American Heart Association (AHA), the Heart and Stroke Foundation of Canada (HSFC), the European Resuscitation Council (ERC), the Australian Resuscitation Council (ARC), and the Resuscitation Council of Southern Africa (RCSA). Differences are currently based upon local and regional preferences, training networks and customs, rather than scientific controversy. Unresolved issues with potential for future universal application are highlighted. This document does not include a complete list of guidelines for which there is no perceived controversy and the algorithm/decision tree figures presented attempt to follow a common flow of assessments and interventions, in coordination with their adult counterparts. Survival following paediatric prehospital cardiopulmonary arrest occurs in only approximately 3-17% and survivors are often neurologically devastated. Most paediatric resuscitation reports have been retrospective in design and plagued with inconsistent resuscitation definitions and patient inclusion criteria. Careful and thoughtful application of uniform guidelines for reporting outcomes of advanced life support interventions using large, randomized, multicenter and multinational clinical trials are clearly needed. Paediatric advisory statements from ILCOR will, by necessity, be vibrant and evolving guidelines fostered by national and international organizations intent on improving the outcome of resuscitation for infants and children worldwide.

Children's Traffic Safety Program: Influence of Early Elementary School Safety Education on Family Seat Belt Use

HYPOTHESISnYoung children can learn safety behavior in the public school system. These children will modify family seat belt use. SETTING DESIGN: This is a prospective cohort analytic study conducted in a 50,000 square mile regionalized trauma center referral area.nnnMETHODSnA school-based injury prevention program targeting kindergarten through second-grade (K-2) students addressed four aspects of traffic safety: seat belt use, pedestrian and bicycle safety, school bus safety, and unsafe rides. After inservice instruction, teachers taught the program over a 10-week period. A simultaneous community traffic safety program was conducted through the media. Family seat belt use was monitored by blinded observation at six study schools and one control school. Income level of schools was characterized as low or high, based on student use of federal lunch subsidies. School program implementation was defined as good or poor, based on adherence to teaching protocol.nnnRESULTSnA total of 68,650 K-2 students have completed this traffic safety program during 1990 to 1994. During the study year (1992 to 1993), 25,900 students completed the program taught by 1,400 teachers in 95 schools. A total of 5,936 observations of seat belt use were made in seven schools. Income stratification delineated a subset of these schools in which seat belt use increased by 86% (p = 0.01). Half of the schools failed to follow protocol, and no change in seat belt use was observed.nnnCONCLUSIONSn(1) School K-2 safety education improves family seat belt use, (2) low income schools should be targeted, and (3) strict adherence to the teaching protocol is essential.

Is Pediatric Resuscitation Unique? Relative Merits of Early CPR and Ventilation Versus Early Defibrillation for Young Victims of Prehospital Cardiac Arrest

See related articles, p 484 and 492. [Hazinski ME: Is pediatric resuscitation unique? Relative merits of early CPR and ventilation versus early defibrillation for young victims of cardiac arrest. Ann Emerg Med April 1995;25:540-543.]

Cardiopulmonary resuscitation: special considerations for infants and children with cardiac disease

Pulseless cardiac arrest, defined as the cessation of cardiac mechanical activity, determined by unresponsiveness, apneoa, and the absence of a palpable central pulse, accounts for around one-twentieth of admissions to paediatric intensive care units, be they medical or exclusively cardiac. Such cardiac arrest is higher in children admitted to a cardiac as opposed to a paediatric intensive care unit, but the outcome of these patients is better, with just over two-fifths surviving when treated in the cardiac intensive care unit, versus between one-sixth and one-quarter of those admitted to paediatric intensive care units. Children who receive chest compressions for bradycardia with pulses have a significantly higher rate of survival to discharge, at 60%, than do those presenting with pulseless cardiac arrest, with only 27% surviving to discharge. This suggests that early resuscitation before the patient becomes pulseless, along with early recognition and intervention, are likely to improve outcomes. Recently published reports of in-hospital cardiac arrests in children can be derived from the multi-centric National Registry of Cardiopulmonary Resuscitation provided by the American Heart Association. The population is heterogeneous, but most arrests occurred in children with progressive respiratory insufficiency, and/or progressive circulatory shock. During the past 4 years at the Childrens Hospital of Philadelphia, 3.1% of the average 1000 annual admissions to the cardiac intensive care unit have received cardiopulmonary resuscitation. Overall survival of those receiving cardiopulmonary resuscitation was 46%. Survival was better for those receiving cardiopulmonary resuscitation after cardiac surgery, at 53%, compared with survival of 33% for pre-operative or non-surgical patients undergoing resuscitation. Clearly there is room for improvement in outcomes from cardiac resuscitation in children with cardiac disease. In this review, therefore, we summarize the newest developments in paediatric resuscitation, with an expanded focus upon the unique challenges and importance of anticipatory care in infants and children with cardiac disease.

Cardiopulmonary resuscitation techniques and instruction: when does evidence justify revision?

Abstract [Cummins RO, Hazinski MF: Cardiopulmonary resuscitation techniques and instruction: When does evidence justify revision? Ann Emerg Med December 1999;34:780-784.]

Effect of Defibrillation Energy Dose During In-Hospital Pediatric Cardiac Arrest

OBJECTIVE: To examine the effectiveness of initial defibrillation attempts. We hypothesized that (1) an initial shock dose of 2 ± 10 J/kg would be less effective for terminating fibrillation than suggested in published historical data and (2) a 4 J/kg shock dose would be more effective. PATIENTS AND METHODS: This was a National Registry of Cardiopulmonary Resuscitation prospective, multisite, observational study of in-hospital pediatric (aged ≤18 years) ventricular fibrillation or pulseless ventricular tachycardia cardiac arrests from 2000–2008. Termination of ventricular fibrillation or pulseless ventricular tachycardia and event survival after initial shocks of 2 J/kg were compared with historic controls and a 4 J/kg shock dose. RESULTS: Of 266 children with 285 events, 173 of 285 (61%) survived the event and 61 of 266 (23%) survived to discharge. Termination of fibrillation after initial shock was achieved for 152 of 285 (53%) events. Termination of fibrillation with 2 ± 10 J/kg was much less frequent than that seen among historic control subjects (56% vs 91%; P < .001), but not different than 4 J/kg. Compared with 2 J/kg, an initial shock dose of 4 J/kg was associated with lower rates of return of spontaneous circulation (odds ratio: 0.41 [95% confidence interval: 0.21–0.81]) and event survival (odds ratio: 0.42 [95% confidence interval: 0.18–0.98]). CONCLUSIONS: The currently recommended 2 J/kg initial shock dose for in-hospital cardiac arrest was substantially less effective than previously published. A higher initial shock dose (4 J/kg) was not associated with superior termination of ventricular fibrillation or pulseless ventricular tachycardia or improved survival rates. The optimal pediatric defibrillation dose remains unknown.

Background and Epidemiology of Pediatric Cardiac Arrest

Pediatric cardiac arrest is not a single problem. Although most episodes of pediatric cardiac arrest occur as complications and progressions of respiratory failure and shock, sudden cardiac arrest may result from sudden arrhythmias. With better understanding of the epidemiology of pediatric cardiac arrest, clinicians can better tailor therapy to optimize outcome.

The Initiative on Subspecialty Clinical Training and Certification (SCTC): Background and Recommendations

* Abbreviations:n ABP — : American Board of Pediatricsn ABMS — : American Board of Medical Specialtiesn ACGME — : Accreditation Council for Graduate Medical Educationn CBME — : competency-based medical educationn EPA — : entrustable professional activityn FOPO — : Federation of Pediatric Organizationsn MOC — : Maintenance of Certificationn SCTC — : Subspecialty Clinical Training and CertificationnnThe American Board of Pediatrics (ABP) certifies general pediatricians and pediatric subspecialists based on standards of excellence that lead to high-quality health care during infancy, childhood, adolescence, and the transition into adulthood. Thus, central to the ABP’s mission is assurance to the public that a general pediatrician or pediatric subspecialist has successfully completed accredited training and fulfills the continuous evaluation requirements that encompass the 6 core competencies of the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS). The ABP’s quest for excellence is evident in its rigorous evaluation process and in new initiatives undertaken that not only continually improve the standards of its certification but also advance the science, education, study, and practice of pediatrics.nnThe ABP’s responsibilities and authorities in standard setting and evaluation overlap through interest and influence the responsibilities and authorities assumed by the ACGME through its Pediatric Review Committee in the area of training, as well as those of the American Academy of Pediatrics and the subspecialty societies with respect to advocacy and education. Although the respective organizations have distinct missions and roles, they often work in collaboration and synergy regarding training and advocacy. Nonetheless, standard setting, evaluation, and certification remain the sole purview of the ABP. Because of the centrality of accredited training to certification, a decision by the ABP to offer a subspecialty certificate leads to a petition to the ACGME to accredit training programs. The ABP provides substantial input to the development of initial subspecialty program requirements and periodic revisions through its respective subboards, and the ABP standards for certification heavily influence the content of program requirements.nnIn the late 1990s, the ACGME and ABMS introduced the concept of competency-based medical education (CBME) with the establishment of 6 domains of competence: patient care, medical knowledge, practice-based … nnAddress correspondence to David K. Stevenson, MD, Harold K. Faber Professor of Pediatrics, Stanford University School of Medicine, Medical School Office Building, 1265 Welch Rd, X157, Stanford, CA 94305. E-mail: dstevenson{at}stanford.edu

Resuscitations From Pulseless Electrical Activity and Asystole: How Big a Piece of the Survivors’ Pie?

Abstract [Cummins RO, Hazinski MF: Resuscitations from pulseless electrical activity and asystole: How big a piece of the survivors pie? Ann Emerg Med October 1998;32:490-492.]

ILCOR Scientific Knowledge Gaps and Clinical Research Priorities for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: A Consensus Statement

Despite significant advances in the field of resuscitation science, important knowledge gaps persist. Current guidelines for resuscitation are based on the International Liaison Committee on Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, which includes treatment recommendations supported by the available evidence. The writing group developed this consensus statement with the goal of focusing future research by addressing the knowledge gaps identified during and after the 2015 International Liaison Committee on Resuscitation evidence evaluation process. Key publications since the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations are referenced, along with known ongoing clinical trials that are likely to affect future guidelines.