Renee Matos

Duration of Cardiopulmonary Resuscitation and Illness Category Impact Survival and Neurologic Outcomes for In-hospital Pediatric Cardiac Arrests

Background— Pediatric cardiopulmonary resuscitation (CPR) for >20 minutes has been considered futile after pediatric in-hospital cardiac arrests. This concept has recently been questioned, although the effect of CPR duration on outcomes has not recently been described. Our objective was to determine the relationship between CPR duration and outcomes after pediatric in-hospital cardiac arrests. Methods and Results— We examined the effect of CPR duration for pediatric in-hospital cardiac arrests from the Get With The Guidelines–Resuscitation prospective, multicenter registry of in-hospital cardiac arrests. We included 3419 children from 328 US and Canadian Get With The Guidelines–Resuscitation sites with an in-hospital cardiac arrest between January 2000 and December 2009. Patients were stratified into 5 patient illness categories: surgical cardiac, medical cardiac, general medical, general surgical, and trauma. Survival to discharge was 27.9%, but only 19.0% of all cardiac arrest patients had favorable neurological outcomes. Between 1 and 15 minutes of CPR, survival decreased linearly by 2.1% per minute, and rates of favorable neurological outcome decreased by 1.2% per minute. Adjusted probability of survival was 41% for CPR duration of 1 to 15 minutes and 12% for >35 minutes. Among survivors, favorable neurological outcome occurred in 70% undergoing <15 minutes of CPR and 60% undergoing CPR >35 minutes. Compared with general medical patients, surgical cardiac patients had the highest adjusted odds ratios for survival and favorable neurological outcomes, 2.5 (95% confidence interval, 1.8–3.4) and 2.7 (95% confidence interval, 2.0–3.9), respectively. Conclusions— CPR duration was independently associated with survival to hospital discharge and neurological outcome. Among survivors, neurological outcome was favorable for the majority of patients. Performing CPR for >20 minutes is not futile in some patient illness categories.

Increased mortality rates of young children with traumatic injuries at a US army combat support hospital in baghdad, Iraq, 2004

OBJECTIVE. The objective of this study was to determine whether age ≤8 y is an independent predictor of mortality in noncoalition trauma patients at a US combat support hospital. METHODS. A retrospective chart review was conducted of 1132 noncoalition trauma patients who were admitted to a combat support hospital between December 2003 and December 2004. Data on age, severity of injury indices, and in-hospital mortality rates were analyzed. All variables that were associated with death on univariate analysis were analyzed by multivariate logistic regression to determine independent associations with mortality. RESULTS. There were 38 young pediatric patients (aged ≤8 years) and 1094 older pediatric and adult patients (aged >8 years). Penetrating trauma accounted for 83% of all injuries. Young pediatric patients compared with older pediatric and adult patients had increased severity of injury indicated by decreased Glasgow Coma Scale score; increased incidence of hypotension, base deficit, and serum pH on admission; red blood cell transfusion amount; and increased injury severity scores on admission. Young pediatric patients compared with older pediatric and adult patients also had increased ICU lengths of stay (median 2 [interquartile range 0–5] vs median 0 [interquartile range 0–2] days) and in-hospital mortality rate (18% vs 4%), respectively. Multivariate logistic regression indicated that base deficit, injury severity score of ≥15, Glasgow Coma Scale score of ≤8, and age of ≤8 years were independently associated with mortality. CONCLUSIONS. Young children who present to a combat support hospital have increased severity of injury compared with older children and adults. In a population with primarily penetrating injuries, after adjustment for severity of injury, young children may also have an independent increased risk for death compared with older children and adults. Providing forward-deployed medical staff with pediatric-specific equipment and training in the acute care of young children with severe traumatic injuries may improve outcomes in this population.

Ten years of military pediatric care in Afghanistan and Iraq.

BACKGROUND Besides care for injured US military personnel, doctrine also requires life-, limb-, and eyesight-saving care to all injured casualties, including children. This study’s objective was to evaluate the burden and epidemiology of pediatric medical care during the past decade of military operations in Iraq and Afghanistan. METHODS Retrospective review of two military registries of all patients admitted to combat support hospitals and forward surgical teams from 2001 through 2011 was conducted. Pediatric (PED) patients were defined as younger than 18 years. Adult patients were divided into local civilian/noncoalition military (LOCAL) and coalition (COALITION) soldiers. RESULTS A total of 7,505 PED patients, 25,459 LOCAL adults, and 95,618 COALITION soldiers were analyzed in the primary registry. Children represented 5.8% of all admissions (11% bed days), LOCAL adults represented 20% (36% bed days), and COALITION soldiers represented 74% (53% bed days). PED median (interquartile range) length of stay was 3 days (1–7 days), longer than LOCAL with 2 days (1–6 days), and COALITION with 1 day (1–2 days) (p < 0.001). PED Injury Severity Score (ISS) was 9 (4–16), similar to LOCAL with 9 (4–16) but higher than COALITION with 5 (2–10) (p < 0.001). Mortality in trauma patients was highest in PED (8.5%) compared with LOCAL (7.1%) and COALITION (3%) (p < 0.01). Mechanisms of injury for PED trauma were blast (37%), penetrating (27%), blunt (23%), and burn (13%). Factors independently associated with PED mortality included ISS (odds ratio, 95% confidence interval) (1.08, 1.06–1.09), Glasgow Coma Scale (GCS) score (0.85, 0.82–0.88), base excess (0.87, 0.85–0.90), female sex (1.73, 1.18–2.52), age less than 8 years (1.43, 1.00–2.04), and burns (3.17, 1.89–5.32). CONCLUSION Deployed medical facilities not staffed or equipped to typical civilian standards have a high burden of pediatric casualties requiring care. The cause of increased mortality in pediatric versus adult populations despite similar severity of injury is potentially multifactorial. Military medical planners need to consider pediatric resources and training to improve outcomes for children injured during combat. LEVEL OF EVIDENCE Epidemiologic study, level III.

Isolated pediatric burn injury in Iraq and Afghanistan.

Objectives: To characterize the epidemiology of burn injury in pediatric patients and identify factors associated with mortality based on burn severity. Design: Retrospective cohort study. Setting: U.S. military combat support hospitals and forward surgical hospitals in Iraq and Afghanistan. Patients: Iraqi and Afghan children less than 18 years old admitted with isolated burn injury. Interventions: None. Measurements and Main Results: Burn severity was classified as mild, moderate, and severe based on external Abbreviated Injury Scale score. Patient characteristics and outcomes were described according to burn severity. A multivariate logistic regression was performed on univariate associations with mortality. Of 4,743 pediatric patients, 549 (11.6%) had isolated burn injury. Overall mortality was 13%, median external Abbreviated Injury Scale was 3 (interquartile range, 2–4), and 67% were male. Variables included in the logistic regression were external Abbreviated Injury Scale score, abnormal heart rate for age, hypotension, mechanical ventilation, transfusion, Glasgow Coma Scale, international normalized ratio, base deficit, hematocrit, and platelet count. Factors independently associated with mortality were international normalized ratio (odds ratio, 2.6; 95% CI, 1.2–5.8; p = 0.021) and external Abbreviated Injury Scale (odds ratio, 2.5; 95% CI, 1.3–4.7; p = 0.004). Mortality increased with burn severity: mild 1.7%, moderate 7.2%, and severe 47% (p < 0.001). Conclusions: This is the first in-depth study of pediatric burn injuries in combat. Children with severe burns (total body surface area > 39% or > 29% if < 5 yr) had a high mortality and required significant resources in a setting that is not primarily resourced for long-term care of severe pediatric burn injury. Extraordinary measures are therefore used for the long-term care of these burned children within the war zones of Iraq and Afghanistan.

The Effect of an Interdisciplinary Simulation Training Program on Translational Outcomes for In-Hospital Cardiopulmonary Arrests

Purpose: High-quality cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest (IHCA) is the primary component influencing return of circulation (ROSC) and survival to hospital discharge,...

262: IMPROVING COMPRESSION QUALITY AT A SINGLE INSTITUTION THROUGH REAL-TIME CPR FEEDBACK

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) cooled to 36°C. Methods: This was a retrospective, cohort study at an academic medical center. The study included patients cooled during a 14-month period prior to and after the update in the protocol: from February 2013 to March 2014 the therapeutic hypothermia (TH) cohort was cooled to 33°C and from August 2014 to September 2015 the targeted temperature management (TTM) cohort was cooled to 36°C. The primary outcome was the amount of sedation (propofol and/or midazolam) used within 24-hour intervals for a total of 96 hours from the time of admission. Midazolam was converted to propofol equivalents for direct comparison of the sedatives where 1 mg/hr of midazolam is equal to 10 mcg/kg/min of propofol equivalents. Secondary outcomes of this study included the time to comfort care orders, the number of days and patients who received neuromuscular blockers and acetaminophen, and the average use of fentanyl. Results: This study assessed 250 total patients, 126 patients cooled using the TH protocol and 124 patients cooled using the TTM protocol. There was no difference in the quantity of sedation used in the two cohorts, 8841+9791 mg of propofol equivalents in the TTM patients versus 7404+5820 mg propofol equivalents in the TH group (p= 0.23). Regarding secondary outcomes, the number of patients receiving neuromuscular blockers differed, with 60% of patients in the TTM group compared to 83% of patients in the TH group (p= 0.001). Conclusions: This study found there was no difference in the amount of sedation used between the two cohorts. A lower proportion of patients received neuromuscular blockers in the TTM group. Further research is needed to fully understand sedation practice in patients cooled after cardiac arrest.

Maternal Cautopyreiophagia as a Rare Cause of Neonatal Hemolysis: A Case Report

Hyperbilirubinemia in the first 24 hours of life in a newborn is pathologic, necessitating additional evaluation. We report the first case of hemolysis and subsequent hyperbilirubinemia in an otherwise normal term neonate resulting from oxidative stress in the form of maternal cautopyreiophagia: the ingestion of burnt matchstick heads. During the third trimester of pregnancy, the infant’s mother consumed more than 300 burnt matchstick heads weekly for 4 weeks. Matches contain potassium chlorate, a powerful oxidant that when ingested can ultimately lead to the destruction of erythrocytes, disseminated intravascular coagulation, kidney injury, or death. The infant’s bilirubin rose as high as 17 mg/dL at 22 hours of life; however, the infant did well with a brief course of phototherapy. This case highlights the importance of prenatal questioning about maternal ingestion of potentially oxidative substances and assessing the possible risk for the infant.