Susan Fuchs

2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: Pediatric advanced life support

This publication presents the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of the pediatric patient and the 2005 American Academy of Pediatrics/AHA guidelines for CPR and ECC of the neonate. The guidelines are based on the evidence evaluation from the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, hosted by the American Heart Association in Dallas, Texas, January 23–30, 2005. The “2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care” contain recommendations designed to improve survival from sudden cardiac arrest and acute life-threatening cardiopulmonary problems. The evidence evaluation process that was the basis for these guidelines was accomplished in collaboration with the International Liaison Committee on Resuscitation (ILCOR). The ILCOR process is described in more detail in the “International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.” The recommendations in the “2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care” confirm the safety and effectiveness of many approaches, acknowledge that other approaches may not be optimal, and recommend new treatments that have undergone evidence evaluation. These new recommendations do not imply that care involving the use of earlier guidelines is unsafe. In addition, it is important to note that these guidelines will not apply to all rescuers and all victims in all situations. The leader of a resuscitation attempt may need to adapt application of the guidelines to unique circumstances. The following are the major pediatric advanced life support changes in the 2005 guidelines: There is further caution about the use of endotracheal tubes. Laryngeal mask airways are acceptable when used by experienced providers. Cuffed endotracheal tubes may be used in infants (except newborns) and children in in-hospital settings provided that cuff inflation pressure is kept <20 cm H2O. Confirmation of tube placement requires clinical assessment and assessment of exhaled carbon dioxide (CO2); esophageal detector devices may be considered for use in children weighing >20 kg who have a perfusing rhythm. Correct placement must be verified when the tube is inserted, during transport, and whenever the patient is moved. During CPR with an advanced airway in place, rescuers will no longer perform “cycles” of CPR. Instead, the rescuer performing chest compressions will perform them continuously at a rate of 100/minute without pauses for ventilation. The rescuer providing ventilation will deliver 8 to 10 breaths per minute (1 breath approximately every 6–8 seconds). Timing of 1 shock, CPR, and drug administration during pulseless arrest has changed and now is identical to that for advanced cardiac life support. Routine use of high-dose epinephrine is not recommended. Lidocaine is de-emphasized, but it can be used for treatment of ventricular fibrillation/pulseless ventricular tachycardia if amiodarone is not available. Induced hypothermia (32–34°C for 12–24 hours) may be considered if the child remains comatose after resuscitation. Indications for the use of inodilators are mentioned in the postresuscitation section. Termination of resuscitative efforts is discussed. It is noted that intact survival has been reported following prolonged resuscitation and absence of spontaneous circulation despite 2 doses of epinephrine. The following are the major neonatal resuscitation changes in the 2005 guidelines: Supplementary oxygen is recommended whenever positive-pressure ventilation is indicated for resuscitation; free-flow oxygen should be administered to infants who are breathing but have central cyanosis. Although the standard approach to resuscitation is to use 100% oxygen, it is reasonable to begin resuscitation with an oxygen concentration of less than 100% or to start with no supplementary oxygen (ie, start with room air). If the clinician begins resuscitation with room air, it is recommended that supplementary oxygen be available to use if there is no appreciable improvement within 90 seconds after birth. In situations where supplementary oxygen is not readily available, positive-pressure ventilation should be administered with room air. Current recommendations no longer advise routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid. Endotracheal suctioning for infants who are not vigorous should be performed immediately after birth. A self-inflating bag, a flow-inflating bag, or a T-piece (a valved mechanical device designed to regulate pressure and limit flow) can be used to ventilate a newborn. An increase in heart rate is the primary sign of improved ventilation during resuscitation. Exhaled CO2 detection is the recommended primary technique to confirm correct endotracheal tube placement when a prompt increase in heart rate does not occur after intubation. The recommended intravenous (IV) epinephrine dose is 0.01 to 0.03 mg/kg per dose. Higher IV doses are not recommended, and IV administration is the preferred route. Although access is being obtained, administration of a higher dose (up to 0.1 mg/kg) through the endotracheal tube may be considered. It is possible to identify conditions associated with high mortality and poor outcome in which withholding resuscitative efforts may be considered reasonable, particularly when there has been the opportunity for parental agreement. The following guidelines must be interpreted according to current regional outcomes: When gestation, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated. Examples are provided in the guidelines. In conditions associated with a high rate of survival and acceptable morbidity, resuscitation is nearly always indicated. In conditions associated with uncertain prognosis in which survival is borderline, the morbidity rate is relatively high, and the anticipated burden to the child is high, parental desires concerning initiation of resuscitation should be supported. Infants without signs of life (no heartbeat and no respiratory effort) after 10 minutes of resuscitation show either a high mortality rate or severe neurodevelopmental disability. After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life.

Factors influencing posttraumatic seizures in children

&NA; The ideal treatment of children with head trauma would include prevention of posttraumatic seizures. Ninety‐two of 937 children with head injuries (9.8%) experienced posttraumatic seizures. In 94.5% of these patients (87 of 92), seizures developed within the first 24 hours after injury. Three children convulsed between 24 hours and 7 days, but only 2 children developed seizures after the 1st week. Factors found to influence the likelihood of seizures included severe head injury (GCS, 3 to 8), diffuse cerebral edema, and acute subdural hematoma (P < 0.001). Seizures occurred in 35% of severely head‐injured children compared to 5.1% with minor head injury (P < 0.001). A less significant correlation (P < 0.1) was noted between seizures and open, depressed skull fractures. We found no significant correlation between seizure occurrence and numerous other factors including age, sex, fracture location and type (other than open, depressed fractures), parenchymal injuries, fixed neurological deficits, and cranial operation. Based on our observations, we recommend the prophylactic use of anticonvulsants in children at higher risk for posttraumatic seizures: those with diffuse cerebral edema, acute subdural hematoma, open, depressed skull fracture with parenchymal damage, or severe head injury (GCS ≤ 8).

Part 6: Pediatric basic life support and pediatric advanced life support. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

The Pediatric Task Force reviewed all questions submitted by the International Liaison Committee on Resuscitation (ILCOR) member councils in 2010, reviewed all council training materials and resuscitation guidelines and algorithms, and conferred on recent areas of interest and controversy. We identified a few areas where there were key differences in council-specific guidelines based on historical recommendations, such as the A-B-C (Airway, Breathing, Circulation) versus C-A-B (Circulation, Airway, Breathing) sequence of provision of cardiopulmonary resuscitation (CPR), initial back blows versus abdominal thrusts for foreign-body airway obstruction, an upper limit for recommended chest compression rate, and initial defibrillation dose for shockable rhythms (2 versus 4 J/kg). We produced a working list of prioritized questions and topics, which was adjusted with the advent of new research evidence. This led to a prioritized palate of 21 PICO (population, intervention, comparator, outcome) questions for ILCOR task force focus. The 2015 process was supported by information specialists who performed in-depth systematic searches, liaising with pediatric content experts so that the most appropriate terms and outcomes and the most relevant publications were identified. Relevant adult literature was considered (extrapolated) in those PICO questions that overlapped with other task forces, or when there were insufficient pediatric data. In rare circumstances (in the absence of sufficient human data), appropriate animal studies were incorporated into reviews of the literature. However, these data were considered only when higher levels of evidence were not available and the topic was deemed critical. When formulating the PICO questions, the task force felt it important to evaluate patient outcomes that extend beyond return of spontaneous circulation (ROSC) or discharge from the pediatric intensive care unit (PICU). In recognition that the measures must have meaning, not only to clinicians but also to parents and caregivers, longer-term outcomes at 30 …

Skull fractures in infants and predictors of associated intracranial injury

Background. Emergency department (ED) management of skull fractures in children remains controversial. Because infants incurring head trauma have a high incidence of skull fracture, we chose to describe fractures in this subset of patients and to determine if there are clinical predictors of associated intracranial injury (ICI) that may have utility in developing more efficient management schemes in these patients. Methods. A retrospective medical record review was conducted on all awake patients < 13 months of age with an acute skull fracture from non-birth trauma, presenting to the ED of a university-affiliated childrens hospital during a three-year period. Clinical and radiographic data extracted were used to describe skull fractures in these patients. The ability of various characteristics to determine the presence of ICI was assessed by calculating sensitivity, specificity, positive predictive value, and negative predictive value for each. Results. The predominant mechanism of injury for the 102 infants was falls (91%). Suspicion of abuse was found in only one case. The parietal bone was fractured in 87 infants, and 34 had nonparietal fractures. The most prevalent fracture type was linear (92 infants), and 31 had >1 cranial bone fractured. CT scans obtained on 32 infants (CT group) revealed 21 ICIs in 15 patients. Two with temporoparietal fractures required emergent evacuation of epidural blood. In the CT group, seven of the 15 (47%) with ICI (ICI group) were lethargic compared to two of the 17 (12%) without ICI (No ICI group) (P=0.035). Five (33%) in the ICI group had temporal bone fractures compared to 0 in the No ICI group (P=0.015). The presence of any sign or symptom had a sensitivity and negative predictive value of 100%, but only a specificity of 35%. The presence of lethargy had a positive predictive value of 78%. The presence of temporal and frontal bone fractures had positive predictive values of 100 and 75%, respectively. Conclusion. This study reports a high prevalence of fracture characteristics often associated with inflicted injury in other studies when virtually all injuries in our sample were accidental. Several clinical characteristics were demonstrated to be potentially useful in predicting ICI associated with skull fracture;

Point-of-care ultrasonography by pediatric emergency medicine physicians

Emergency physicians have used point-of-care ultrasonography since the 1990s. Pediatric emergency medicine physicians have more recently adopted this technology. Point-of-care ultrasonography is used for various scenarios, particularly the evaluation of soft tissue infections or blunt abdominal trauma and procedural guidance. To date, there are no published statements from national organizations specifically for pediatric emergency physicians describing the incorporation of point-of-care ultrasonography into their practice. This document outlines how pediatric emergency departments may establish a formal point-of-care ultrasonography program. This task includes appointing leaders with expertise in point-of-care ultrasonography, effectively training and credentialing physicians in the department, and providing ongoing quality assurance reviews.

Part 6: Pediatric basic life support and pediatric advanced life support

The Pediatric Task Force reviewed all questions submitted by the International Liaison Committee on Resuscitation (ILCOR) member councils in 2010, reviewed all council training materials and resuscitation guidelines and algorithms, and conferred on recent areas of interest and controversy. We identified a few areas where there were key differences in council-specific guidelines based on historical recommendations, such as the A-B-C (Airway, Breathing, Circulation) versus C-A-B (Circulation, Airway, Breathing) sequence of provision of cardiopulmonary resuscitation (CPR), initial back blows versus abdominal thrusts for foreign-body airway obstruction, an upper limit for recommended chest compression rate, and initial defibrillation dose for shockable rhythms (2 versus 4 J/kg). We produced a working list of prioritized questions and topics, which was adjusted with the advent of new research evidence. This led to a prioritized palate of 21 PICO (population, intervention, comparator, outcome) questions for ILCOR task force focus. The 2015 process was supported by information specialists who performed in-depth systematic searches, liaising with pediatric content experts so that the most appropriate terms and outcomes and the most relevant publications were identified. Relevant adult literature was considered (extrapolated) in those PICO questions that overlapped with other task forces, or when there were insufficient pediatric data. In rare circumstances (in the absence of sufficient human data), appropriate animal studies were incorporated into reviews of the literature. However, these data were considered only when higher levels of evidence were not available and the topic was deemed critical. When formulating the PICO questions, the task force felt it important to evaluate patient outcomes that extend beyond return of spontaneous circulation (ROSC) or discharge from the pediatric intensive care unit (PICU). In recognition that the measures must have meaning, not only to clinicians but also to parents and caregivers, longer-term outcomes at 30 …

Policy statement - Consent for emergency medical services for children and adolescents

Parental consent generally is required for the medical evaluation and treatment of minor children. However, children and adolescents might require evaluation of and treatment for emergency medical conditions in situations in which a parent or legal guardian is not available to provide consent or conditions under which an adolescent patient might possess the legal authority to provide consent. In general, a medical screening examination and any medical care necessary and likely to prevent imminent and significant harm to the pediatric patient with an emergency medical condition should not be withheld or delayed because of problems obtaining consent. The purpose of this policy statement is to provide guidance in those situations in which parental consent is not readily available, in which parental consent is not necessary, or in which parental refusal of consent places a child at risk of significant harm.

Characteristics of the Pediatric Patients Treated by the Pediatric Emergency Care Applied Research Network's Affiliated EMS Agencies

Abstract Objective. To describe pediatric patients transported by the Pediatric Emergency Care Applied Research Networks (PECARNs) affiliated emergency medical service (EMS) agencies and the process of submitting and aggregating data from diverse agencies. Methods. We conducted a retrospective analysis of electronic patient care data from PECARNs partner EMS agencies. Data were collected on all EMS runs for patients less than 19 years old treated between 2004 and 2006. We conducted analyses only for variables with usable data submitted by a majority of participating agencies. The investigators aggregated data between study sites by recoding it into categories and then summarized it using descriptive statistics. Results. Sixteen EMS agencies agreed to participate. Fourteen agencies (88%) across 11 states were able to submit patient data. Two of these agencies were helicopter agencies (HEMS). Mean time to data submission was 378 days (SD 175). For the 12 ground EMS agencies that submitted data, there were 514,880 transports, with a mean patient age of 9.6 years (SD 6.4); 53% were male, and 48% were treated by advanced life support (ALS) providers. Twenty-two variables were aggregated and analyzed, but not all agencies were able to submit all analyzed variables and for most variables there were missing data. Based on the available data, median response time was 6 minutes (IQR: 4–9), scene time 15 minutes (IQR: 11–21), and transport time 9 minutes (IQR: 6–13). The most common chief complaints were traumatic injury (28%), general illness (10%), and respiratory distress (9%). Vascular access was obtained for 14% of patients, 3% received asthma medication, <1% pain medication, <1% assisted ventilation, <1% seizure medication, <1% an advanced airway, and <1% CPR. Respiratory rate, pulse, systolic blood pressure, and GCS were categorized by age and the majority of children were in the normal range except for systolic blood pressure in those under one year old. Conclusions. Despite advances in data definitions and increased use of electronic databases nationally, data aggregation across EMS agencies was challenging, in part due to variable data collection methods and missing data. In our sample, only a small proportion of pediatric EMS patients required prehospital medications or interventions.

An Evidence-based Guideline for Pediatric Prehospital Seizure Management Using GRADE Methodology

Abstract Objective. The objective of this guideline is to recommend evidence-based practices for timely prehospital pediatric seizure cessation while avoiding respiratory depression and seizure recurrence. Methods. A multidisciplinary panel was chosen based on expertise in pediatric emergency medicine, prehospital medicine, and/or evidence-based guideline development. The panel followed the National Prehospital EBG Model using the GRADE methodology to formulate questions, retrieve evidence, appraise the evidence, and formulate recommendations. The panel members initially searched the literature in 2009 and updated their searches in 2012. The panel finalized a draft of a patient care algorithm in 2012 that was presented to stakeholder organizations to gather feedback for necessary revisions. Results. Five strong and ten weak recommendations emerged from the process; all but one was supported by low or very low quality evidence. The panel sought to ensure that the recommendations promoted timely seizure cessation while avoiding respiratory depression and seizure recurrence. The panel recommended that all patients in an active seizure have capillary blood glucose checked and be treated with intravenous (IV) dextrose or intramuscular (IM) glucagon if <60 mg/dL (3 mmol/L). The panel also recommended that non-IV routes (buccal, IM, or intranasal) of benzodiazepines (0.2 mg/kg) be used as first-line therapy for status epilepticus, rather than the rectal route. Conclusions. Using GRADE methodology, we have developed a pediatric seizure guideline that emphasizes the role of capillary blood glucometry and the use of buccal, IM, or intranasal benzodiazepines over IV or rectal routes. Future research is needed to compare the effectiveness and safety of these medication routes.

A comparison of pediatric emergency medicine and general emergency medicine physicians' practice patterns: results from the Future of Pediatric Education II Survey of Sections Project.

Background This survey was conducted to obtain information about career and practice issues facing pediatric emergency medicine (PEM) physicians and general emergency medicine (GEM) physicians. We hypothesized that PEM physicians work fewer clinical hours and perform more teaching and research in their positions than GEM physicians. Methods Two surveys sponsored by the Future of Pediatric Education II Project were sent to 1545 emergency physicians identified by the American Board of Pediatrics, the American Academy of Pediatrics, and the American College of Emergency Physicians between October 1997 and February 1998. Data on demographics, job description, recent job changes, and career expectations were obtained and analyzed using Student t test or Welch analysis of variance for continuous variables and χ2 for categorical data. P values less than 0.05 were considered significant. Comparisons between PEM and GEM physicians were adjusted using analysis of covariance to control for the effect of medical school affiliation. Results Effective response rate was 934 (64%) of 1451. A total of 705 (75%) respondents identified themselves as a PEM physician, and 229 (25%) identified as a GEM physician. PEM physicians were younger (41.0 y vs 45.1 y) and more likely to be women (44% vs 15%, P < 0.0001 for both). Children younger than 18 years made up 80.9% and 28.6% of patients seen by PEM and GEM physicians, respectively (P < 0.001). Seventy-nine percent of PEM physicians and 42% of GEM physicians held an academic appointment (P < 0.0001). No differences were found for full-time equivalents per physician group (9.7 vs 9.1) or clinical hours spent in the emergency department (ED) (31.5 vs 32.7) when means were adjusted for academic appointment. During ED clinical activities, PEM physicians reported more time spent supervising trainees (34% vs 16%, P < 0.0001), and GEM physicians reported more time spent in direct patient care (77% vs 57%, P < 0.0001). Total clinical hours worked per week were greater for GEM physicians (37.9 vs 35.3, P < 0.05). PEM physicians spent more time than GEM physicians teaching (12% vs 8%, P < 0.005) and conducting clinical research (5% vs 2%, P < 0.0003). Of PEM and GEM physicians combined, 26% reported a job change in the past 3 years. Extended reduction of ED clinical duties occurred most commonly because of child care issues and was reported more commonly by women than men (53% vs 6%, P < 0.0001) irrespective of PEM or GEM practice. The likelihood of leaving emergency medicine practice within 5 years increased with age for both groups: 10% of PEM and GEM physicians under 40 years old anticipated leaving practice versus 30% of those older than 50 years (P < 0.0001). PEM physicians were more likely than GEM physicians to predict an increased need for additional pediatric subspecialists in general (60% vs 26%, P < 0.001) and for pediatric subspecialists in their discipline (54% vs 17%, P < 0.001). PEM subspecialists were twice as likely as GEM specialists to perceive competition in their subspecialty (60% vs 31%, P < 0.001). Conclusions According to our sample, GEM and PEM physicians worked the same number of clinical hours in the ED but reported significant differences in how those hours are spent. Job changes and extended leaves were common in both groups. These results suggest that PEM and GEM physicians face similar vocational challenges, especially in the areas of balancing of family time, clinical hours, and academic productivity. These data also have important implications for workforce projection for the PEM physician supply, given the current estimated attrition rate, frequency of leave from clinical duties, and projection for increased need for PEM physicians in the future.