Pediatric Advanced Life Support Research Articles

Special consideration in neonatal resuscitation

Delivery room resuscitation of neonates is performed according to evidence-based neonatal resuscitation guidelines. Neonatal resuscitation guidelines focus on the resuscitation of newborns suffering from perinatal asphyxia. Special considerations are needed when resuscitating newborns in locations other than the delivery room and for newborns with congenital anomalies. In this review, we examine the resuscitation of newborns at home and in the emergency department and highlight special considerations for resuscitating newborns with specific congenital anomalies. In addition, we explore the resuscitation of neonates in the neonatal intensive care unit and discuss the potential use of pediatric advanced life support guidelines. Finally, we highlight the importance of simulation to prepare teams for neonatal resuscitations. This review aims to prepare healthcare professionals in all disciplines caring for neonates at risk for requiring resuscitation under special circumstances.1Evidence-based neonatal resuscitation guidelines focus on resuscitation newborns suffering from perinatal asphyxia in the delivery room.2Modification of neonatal resuscitation guidelines is needed for newborn resuscitations outside the delivery room and to address certain congenital anomalies.3When resuscitating critically ill neonates in the intensive care unit suffering from arrest etiologies not covered in neonatal guidelines, teams may consider using pediatric advanced life support guidelines.4Simulation is a central part of neonatal resuscitation training and should be used to prepare for neonatal resuscitation in all circumstances.5With preparation and practice for special circumstances, healthcare teams can improve the quality of resuscitation for all neonates.

Adding age-adjusted shock index to the American College of Surgeons' trauma team activation criteria to predict severe injury in children.

The American College of Surgeons (ACS) requires trauma centers to use six minimum criteria (ACS-6) for full trauma team activation. Our goal was to evaluate the effect of adding age-adjusted shock index (SI) to the ACS-6 for the prediction of severe injury among pediatric trauma patients with the hypothesis that SI would significantly improve sensitivity with an acceptable decrease in specificity. We performed a secondary analysis of prospectively collected EMS and trauma registry data from two urban pediatric trauma centers. Age-adjusted SI thresholds were calculated as heart rate divided by systolic blood pressure using 2020 Pediatric Advanced Life Support SI vital sign ranges and previously published Shock Index, Pediatric Adjusted (SIPA) thresholds. The primary outcome was a composite of emergency operative (within 1 hour of arrival) or emergency procedural intervention (EOPI) or Injury Severity Score (ISS) greater than 15. Sensitivities, specificities, and 95% CIs were calculated for the ACS-6 alone and in combination with age-adjusted SI. There were 8,078 patients included; 20% had an elevated age-adjusted SI and 17% met at least one ACS minimum criterion; 1% underwent EOPI; and 17% had ISS >15. Sensitivity and specificity of the ACS-6 for EOPI or ISS > 5 were 45% (95% confidence interval [CI], 41-50%) and 89% (95% CI, 81-96%). Inclusion of Pediatric Advanced Life Support-SI and SIPA resulted in sensitivities of 51% (95% CI, 47-56%) and 69% (95% CI, 65-72%), and specificities of 80% (95% CI, 71-89%) and 60% (95% CI, 53-68%), respectively. Similar trends were seen for each secondary outcome. In this cohort of pediatric trauma registry patients, the addition of SIPA to the ACS-6 for trauma team activation resulted in significantly increased sensitivity for EOPI or ISS greater than 15 but poor specificity. Future investigation should explore using age-adjusted shock index in a two-tiered trauma activation system, or in combination with novel triage criteria, in a population-based cohort. Diagnostic Tests or Criteria; Level II.

Pediatric Advanced Life Support in a Neonatal Context.

Pediatric Advanced Life Support in a Neonatal Context.

An In Situ Mock Code Program in the Pediatric Intensive Care Unit: A Multimodal Nurse-Led Quality Improvement Initiative.

Lifesaving resuscitation is required for approximately 1 in 100 patients in the pediatric intensive care unit. Certification renewal alone is insufficient to guarantee adequate knowledge, skills, and confidence among staff members involved in infrequent resuscitation events. Knowledge and skill gaps were identified in pediatric intensive care unit staff members involved in patient resuscitation events. The primary aim of this quality improvement project was to optimize patient resuscitations through improved staff performance and coordination between interdisciplinary roles. A multidisciplinary committee was created to develop, implement, and evaluate a mock code program. Surveys were administered before and after the intervention to assess self-perceived resuscitation performance and program effectiveness. Code sheets were analyzed for documentation quality and adherence to pediatric advanced life support guidelines. The committee used a multimodal approach to education, including high-and low-fidelity in situ mock code simulations and supplemental educational events. From September 2018 through January 2020, the committee conducted 65 events for almost 500 participants. Nurses' levels of self-reported confidence in initiating pediatric advanced life support interventions and identifying cardiac rhythms increased, as did perceived level of competence and knowledge. Most unit staff members considered the mock code program to be "very to extremely effective" in increasing resuscitation competence, confidence, communication, teamwork, and role clarity. Adherence to recommended resuscitation behaviors improved, as did code sheet documentation quality. An in situ mock code program using a multimodal approach to education can be a successful educational adjunct to biennial pediatric advanced life support certification.

Belhassen Tachycardia in a Pediatric Patient: A Simulation for Pediatric Emergency Medicine Fellows.

Ventricular tachycardia in pediatric emergency department patients is a high-risk, low-frequency event well suited for education through simulation. This technical report describes a simulation-based curriculum for Pediatric Emergency Medicine fellows and senior residents involving the evaluation and management of a 10-year-old female presenting with palpitations who is ultimately diagnosed with Belhassen tachycardia. The curriculum highlights the features that differentiate Belhassen tachycardia (idiopathic left posterior fascicular ventricular tachycardia) from supraventricular or other tachycardias, building upon foundational pediatric resuscitation skills and Pediatric Advanced Life Support (PALS) algorithms for advanced learners.

Alternative shock index cutoffs for pediatric patients outperform the Shock Index Pediatric Age-adjusted (SIPA) on strength of association with adverse outcomes in pediatric trauma patients

BackgroundThe shock index is a tool for evaluating critically ill patients that is defined as the ratio of their heart rate divided by systolic blood pressure. The SI is associated with outcomes in adult trauma patients. The Shock Index Pediatric Age-adjusted was developed as a pediatric-specific tool to account for the physiologic differences of children of varying ages. There is growing interest in Shock Index Pediatric Age-adjusted, which is associated with adverse outcomes in pediatric trauma. We hypothesized that alternative shock index cutoffs based on the Advanced Trauma Life Support or the Pediatric Advanced Life Support vital sign reference ranges would outperform Shock Index Pediatric Age-adjusted. MethodsWe analyzed a retrospective cohort of pediatric trauma patients (age 1 to 16 years old) in the American College of Surgeons Trauma Quality Programs Participant Use File from 2010 to 2018. The primary outcome measure was in-hospital mortality. The Shock Index Pediatric Age-adjusted was compared to an Advanced Trauma Life Support–based and a Pediatric Advanced Life Support–based shock index cutoff system. Our findings were subsequently confirmed with a separate, internal validation data set. ResultsA total of 598,830 Trauma Quality Programs Participant Use File patients were included, 0.9% (n = 5,471) of whom died. For mortality, the Advanced Trauma Life Support–based system yielded the highest positive predictive value (15.8%; 95% confidence interval 15.0%–16.7%) compared with the Pediatric Advanced Life Support–based system (4.3%; 95% confidence interval 4.1%–4.5%). Both the Advanced Trauma Life Support–based and Pediatric Advanced Life Support–based systems achieved higher positive predictive values compared to Shock Index Pediatric Age-adjusted (2.6%; 95% confidence interval 2.5%–2.7%). The negative predictive values were not clinically different. Our findings were validated using a separate internal trauma database, in which the positive predictive value for mortality of the Advanced Trauma Life Support–based system was significantly higher than Shock Index Pediatric Age-adjusted (18.2% [95% confidence interval: 8.2%–32.7%] vs 2.9% [95% confidence interval: 1.6%–5.0%], P < .05). ConclusionAdvanced Trauma Life Support and Pediatric Advanced Life Support–based shock index cutoffs achieved higher positive predictive values and similar negative predictive values compared to Shock Index Pediatric Age-adjusted for adverse outcomes in pediatric trauma.

Early postoperative arrhythmias after pediatric congenital heart disease surgery: a 5-year audit from a lower- to middle-income country.

BackgroundArrhythmias are known complication after surgery for congenital heart disease (CHD). This study aimed to identify and discuss their immediate prevalence, diagnosis and management at a tertiary care hospital in Pakistan.MethodsA retrospective study was conducted at a tertiary care hospital in Pakistan between January 2014 and December 2018. All pediatric (<18 years old) patients admitted to the intensive care unit and undergoing continuous electrocardiographic monitoring after surgery for CHD were included in this study. Data pertaining to the incidence, diagnosis, and management of postoperative arrhythmias were collected.ResultsAmongst 812 children who underwent surgery for CHD, 185 (22.8%) developed arrhythmias. Junctional ectopic tachycardia (JET) was the most common arrhythmia, observed in 120 patients (64.9%), followed by complete heart block (CHB) in 33 patients (17.8%). The highest incidence of early postoperative arrhythmia was seen in patients with atrioventricular septal defects (64.3%) and transposition of the great arteries (36.4%). Patients were managed according to the Pediatric Advanced Life Support guidelines. JET resolved successfully within 24 hours in 92% of patients, while 16 (48%) patients with CHB required a permanent pacemaker.ConclusionsMore than one in five pediatric patients suffered from early postoperative arrhythmias in our setting. Further research exploring predictive factors and the development of better management protocols of patients with CHB are essential for reducing the morbidity and mortality associated with postoperative arrhythmia.

Принципи надання допомоги хворим і постраждалим дітям в умовах відділення екстреної (невідкладної) медичної допомоги (огляд літератури)

У статті наведені нормативно-правові засади надання медичної допомоги хворим і постраждалим дітям в умовах відділення екстреної (невідкладної) медичної допомоги. Підкреслено значення симуляційного навчання лікарів медицини невідкладних станів за програмою Advanced Paediatric Life Support (APLS) при клінічних станах, що є загрозливими для життя хворих або постраждалих дітей. Наведено доцільність використання стрічки Брозлоу у дітей в умовах відділення екстреної (невідкладної) медичної допомоги.

Preparedness for paediatric cardiopulmonary resuscitation amongst medical doctors working in primary health care facilities in Cape Town, South Africa.

BackgroundCardiopulmonary resuscitation (CPR) is the principal medical intervention used to reduce the high mortality associated with the cardiorespiratory arrest. There is a paucity of literature on the preparedness for paediatric cardiopulmonary resuscitation (pCPR) amongst doctors in Cape Town. This study aimed to assess the preparedness for pCPR of doctors working in Western Cape Provincial Government primary health care facilities (PHCFs) in Cape Town with regard to knowledge, confidence and doctors’ knowledge of equipment availability.MethodsA cross-sectional study using a questionnaire to collect quantitative data from a sample of 206 doctors working in Cape Town PHCFs.ResultsThe questionnaire was completed by 173 doctors (84% response rate). The majority (81.8%) had not undergone pCPR training (Paediatric Advanced Life Support or Advanced Paediatric Life Support). Basic life support was done by 88.3%: 28% greater than two years ago. The average pCPR knowledge score was 61% (standard deviation [s.d.]: 20.3, range: 8.3% – 100%). Doctors in their community service and internship years had significantly higher knowledge scores compared to grade 3 Medical officers (p = 0.001 and p = 0.010, respectively). Eleven per cent had performed pCPR > 10 times in the past year; 20% had never performed pCPR and 35% did not feel confident performing pCPR. More than 35% of doctors were uncertain about the availability of equipment in their facility.ConclusionDoctors working in Cape Town PHCFs have poor knowledge, have low confidence levels and are poorly prepared to perform pCPR. Urgent attention needs to be given to ensuring formal pCPR training and acquaintance with equipment availability and location in Cape Town PHCFs.

Characteristics of Paediatric Patients Transported by Emergency Care Personnel in a Government Tertiary Care Centre, Mysuru, India: A Cross-sectional Study

Introduction: Emergency Medical Service (EMS) systems have been well established and designed largely to cater to the needs of the cardiac and trauma related emergencies in adult patients. Paediatric emergencies are different; the benefits and outcomes of paediatric EMS have been assumed but without much evidence. With the emergence of paediatric and neonatal Advanced Life Support (ALS); it is imperative to have data that define the problems encountered in the prehospital care setting and also their outcome. This analysis may also provide insights into any modifications that may be required in the EMS system that exists to transport sick children. Aim: To characterise the paediatric prehospital care with emphasis on demography, presenting symptoms, treatment given, prehospital times, vitals monitoring and interventions done during EMS transport affiliated to Emergency Medical Service Agency. Materials and Methods: This descriptive cross-sectional study was conducted from July 2018 to June 2019 in Cheluvamba Hospital, a tertiary care referral teaching hospital attached to Mysore Medical College and Research Institute, Mysuru, India. The study included 147 children who were provided EMS by the 108 ambulance affiliated to the state/central government. Data pertaining to demography, presenting symptoms, vital sign monitoring, treatment given, various prehospital times, and interventions done during transport was obtained and analysed. Inpatient diagnosis with the duration of hospital stay and outcome in these childrens were also described. Results: Among the 147 children included; 3 were brought dead, hence the studied population comprised of 144 children. Amongst them, 42 were neonates and the remaining 102 belonged to the general paediatric population (older children). Overall, 61.8% were males and 57.64% hailed from a rural background. Mean ‘on- scene’ time was 12.12±2.34 minutes and 5.50±5.01 minutes, and ‘transport time’ was 33.79±16.78 minutes, and 26.11±14.2 minutes for neonates and older children, respectively. Respiratory distress was the most common presenting symptom. The mean Heart Rate (HR, beats/min), Respiratory Rate (RR, cycles/min) and temperature (°C) in neonates was 129.86±27.91, 59.90±15.40 and 36.14±0.84 whereas in older children it was 112.81±28.39, 34.87±14.86, and 37.40±0.96, respectively. Mean systolic blood pressure (SBP mmHg) in children aged more than 10 years was 116.67±8.61. Of the 39 children aged more than 6 years, 36 (92.30%) had a Glasgow Coma Scale (GCS) between 13-15. The most common intervention done was administering oxygen in 84.02% (121/144) of children; 34.02% (49/144) of children were unstable at admission; 127 (88.2%) were discharged; remaining 17 (11.8%) succumbed to their illness. On- scene time of more than 15 minutes, transport time of more than 30 minutes and factors such as hypoxia, respiratory failure and shock at admission were significantly associated with mortality (p&lt;0.001). Conclusion: Majority of the EMS transports were related to medical conditions. Basic Life Support (BLS) interventions were done albeit mostly in older children. Emergency Medical Technicians (EMT)/paramedics delivering EMS need special training to orient themselves to the special needs of critically ill children and to improve their outcome.

A case of SVT: response to the third dose of Adenosine

Background: Supraventricular tachycardia (SVT), manifested as rapid and regular heartbeat, is the most frequent symptomatic tachyarrhythmia requiring medical intervention in children. SVT occurs in 1 in every 250-1,000 children. The heart rate can be as high as 180 beats/minute in children and 220 beats/minute in Infants. Evidence suggests that the primary dose of adenosine should be given as 0.1 mg/kg, administered in an intravenous bolus with a dose up to 6 mg. If the primary dose is insufficient, then the amount is increased by 0.1 mg/kg-0.2 mg/kg to a maximum of 12 mg. Our case demonstrates the response to adenosine after the third dose. Case presentation: A 12-year-old boy, previously diagnosed with recurrent SVT, presented with a complaint of palpitation for the last 30 minutes. There was no obvious trigger for his palpitation on history and examination. He was conscious, well looking with normal blood pressure, and good perfusion. We started the management in accordance with pediatric advanced life support guidelines, in which we noted a partial response after the administration of the second dose of adenosine. Subsequently, a third dose of adenosine of 0.2 mg/kg was administered, terminating SVT and regaining a normal sinus rhythm in the patient. Conclusion: After reviewing recent evidence regarding stable SVT management and adenosine side effects, we found that there is no evidence limiting the use of adenosine to only two doses, especially in a case of short or minimal response following the second dose.

198 A Novel ‘Virtual Simulation’ for The Advanced Life Support Group, Making a Dream a Reality: A Beginner’s Guide

In the UK, it is a requirement for staff involved in paediatric critical care to remain up to date with advanced paediatric life support (APLS). To do so there is an expectation to participate in face-to-face courses on a four-yearly basis. The Advanced Life Support Group (ALSG), an organization dedicated to supporting professional education, sought to add to their resources in line with advances in online capabilities. With stakeholder input, the goal emerged to develop an engaging, interactive and entirely novel educational product. Here we present the pilot stages of our project.The aim of this project was to produce an educationally effective and novel product that learners of APLS would engage with and enjoy.Stage 1 involved determining clearly defined learning objectives mapped to the APLS curriculum. At a round table with stakeholders, educationalists, and a technologist an outline of the project was formed and the scenario of a sick baby with bronchiolitis chosen for a pilot. Informed by literature on serious game design, a branching narrative was created. Stage 2 involved collating resources. A photoshoot at Leicester Royal Infirmary A&amp;E (Accident and Emergency) created a set of images. A video shoot at the Royal London Hospital A&amp;E generated a series of videos. These were then edited and used to create a Microsoft PowerPoint slide set. Voiceovers to text, sound effects to add a hospital atmosphere and questions were then added. Stage 3 involved taking this draft and translating it into an interactive final product utilizing Articulate Software. This enabled its usage across smartphone, desktop, and laptop devices. Testing followed with anonymous online feedback informed by the 7Is framework We launched the pilot version at the RCPCH (Royal College of Paediatrics and Child Health) Conference 2021. Feedback was collected from delegates and continues to be collected via online participants. It is hoped that ongoing quality improvement cycles will assist in assuring a finished fully functional online virtual advanced paediatric life support simulation for release in 2022. Further stakeholder review is pending. Thus far it has been met with universal approval, i.e. all learners questioned expressed that they would like to utilize this novel style of education again. The average duration to complete the virtual simulation was 15 minutes. All learners rated their knowledge and skills in APLS to be either unchanged/revised or improved. Finally, interactivity online was felt to need improvement by most participants. Interactivity is key if high levels of engagement are to be achieved. Future testing will determine whether any educational impact is maintained across time. The current pilot version can be accessed at the following webpage

Pediatric Hospitalist Resuscitation Skills Refresher Training With Pauses for Deliberate Practice.

IntroductionPediatric hospitalists are expected to lead resuscitative efforts for cardiopulmonary arrests, but the infrequency of these events and pediatric advanced life support (PALS) re-certifications are insufficient to maintain skill proficiency.We created a novel resuscitation refresher curriculum for pediatric hospitalists with strategic pauses during simulations for expert and peer coaching of procedural skills.MethodsIn a tertiary care academic pediatric hospital between September 2018 to June 2019, pediatric hospitalists and fellows voluntarily participated in a series of three quarterly two-hour training sessions taught by expert peer facilitators. Sessions focused on the thirty-second rapid cardiopulmonary assessment and each of the pediatric advanced life support (PALS) algorithms. Scenarios were strategically paused to practice critical hands-on skills. Cases centered on the themes of shock, respiratory, and cardiac emergencies and took place in a high-fidelity simulation lab requiring a technician and expert peer facilitator. Participants anonymously completed Likert scale-based evaluations after each session and again at the end of the year that focused on participants’ own perceived change in their comfort levels in performing various resuscitation skills and in knowing basic resuscitation steps. As part of our institutional and personal assessment of the curriculum, an end-of-year survey additionally asked participants to reflect on the overall simulation curriculum and resultant changes in their clinical practice.ResultsComfort in all skills practiced across the three sessions increased. The end-of-year survey showed a significant rise in comfort above baseline but some decrements when compared to that immediately post-training. Ninety-six percent of pediatric hospitalists rated the overall quality of the training “better” or “much better” than other resuscitation training (including PALS classes and traditional simulations with skills training after the scenario). The overall effect of the curriculum on perceived knowledge, skills, and confidence levels was significant (p <0.0001).ConclusionSerial resuscitation skills refreshers with expert peer coaching and strategic pauses for hands-on skills practice can result in significant improvements in perceived knowledge and comfort with skill performance as well as the leadership role among pediatric hospitalists.

NRP Versus PALS for Infants Outside the Delivery Room: Not If, but When?

Both the Neonatal Resuscitation Program and Pediatric Advanced Life Support guidelines can be used for infants requiring cardiopulmonary resuscitation outside the delivery room. Each set of guidelines has supporting algorithms for resuscitation; however, there are no current recommendations for transitioning older infants outside the delivery room. To provide background information on the algorithms in the Neonatal Resuscitation Program and Pediatric Advanced Life Support guidelines and to discuss the role that nurses and advanced practice nurses play in advancing scientific research on resuscitation. Summaries of both sets of guidelines, differences in practices, and recommendations for practice changes will be discussed. Provider preference and unit practice determine which guidelines are used for infants outside the delivery room. Providers in pediatric intensive care units and pediatric cardiac intensive care units often use the Pediatric Advanced Life Support guidelines, whereas providers in neonatal intensive care units use the Neonatal Resuscitation Program guidelines for infants of the same age. The variation in resuscitation practices for infants outside the delivery room can negatively affect resuscitation outcomes.

How to Maintain Safety and Maximize the Efficacy of Cardiopulmonary Resuscitation in COVID-19 Patients: Insights from the Recent Guidelines

Since December 2019, the novel coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has remained a challenge for governments and healthcare systems all around the globe. SARS-CoV-2 infection is associated with increased rates of hospital admissions and significant mortality. The pandemic increased the rate of cardiac arrest and the need for cardiopulmonary resuscitation (CPR). COVID-19, with its pathophysiology and detrimental effects on healthcare, influenced the profile of patients suffering from cardiac arrest, as well as the conditions of performing CPR. To ensure both the safety of medical personnel and the CPR efficacy for patients, resuscitation societies have published modified guidelines addressing the specific reality of the COVID-19 pandemic. In this review, we briefly describe the transmission and pathophysiology of COVID-19, present the challenges of CPR in SARS-CoV-2-infected patients, summarize the current recommendations regarding the algorithms of basic life support (BLS), advanced life support (ALS) and pediatric life support, and discuss other aspects of CPR in COVID-19 patients, which potentially affect the risk-to-benefit ratio of medical procedures and therefore should be considered while formulating further recommendations.

Abstract 13839: Knowledge, Attitude &amp; Practice of Health Care Workers Regarding Pediatric Early Warning System - A Cross Sectional Study in Karachi, Pakistan

Introduction: The Pediatrics Early Warning Scoring (PEWS) system is a quantitative instrument that measures the severity of the clinical situation of children aged 1 month to 18 years. Hypothesis: To assess the knowledge, attitude, and practices among nurses and doctors regarding the Pediatric Early Warning Signs (PEWS) system, in a pediatric ward at a tertiary care hospital in Karachi, Pakistan. Methods: A cross-sectional study design was used to address the study question. The universal sampling technique was used to recruit a total of 142 eligible nurses and doctors to explore the knowledge and attitude regarding the PEWS system. Medical records of patients who had a Pediatric Rapid Response Team (PRRT) request raised was reviewed for practice assessment of PEWS. The relationship between the study participants’ demographic characteristics and their knowledge and attitude regarding PEWS was assessed through Chi-square for categorical variables and one-way ANOVA for continuous variables. Results: The findings of the study revealed that out of 142 study participants, 50% participants had a low level of knowledge yet positive attitude towards the PEWS system. Professional qualification and age of participants were significantly associated with knowledge regarding the PEWS system. Profession, professional qualification, current position of the study participants and specialized training on PEWS had a significant association with attitude regarding the PEWS system. Medical records of 30 patients were eligible for practice assessment which revealed that 56.7% of the PEWS observations were documented in patient records which were either incomplete or inappropriate. About 50% showed a poor level of practice regarding PEWS. Conclusions: Our study revealed a knowledge and practice gap among the nurses and doctors while utilizing the PEWS system. Despite having a low level of knowledge, the participants had a positive attitude towards PEWS to enhance their PEWS knowledge and practices. PEWS should be incorporated in the Pediatric Advanced Life Support (PALS) certification course. Moreover, simulation-based teaching strategies should be planned to improve practice and knowledge regarding the system.

Utilizing High-fidelity Simulators in Improving Trainee Confidence and Competency in Code Management.

Introduction:Simulation training is central in preparing practitioners for code management that is free from patient harm.1 The purpose of this study was to determine if using a high-fidelity simulator in pediatric code education would improve trainee confidence and competency compared with the use of a traditional mannequin in the same setting.Methods:Fifty-third-year medical students participated in Pediatric Advanced Life Support code training, including a mock code scenario. Students were randomized into two groups and assigned to a simulator group: high-fidelity simulator (Group 1) or traditional mannequin (Group 2). To assess competency, trainees were evaluated using a checklist of required verbalized items or performed during the mock code scenario. To assess confidence, trainees completed pre- and postintervention confidence surveys, which were collected and compared.Results:Both Group 1 and Group 2 reported increased overall confidence in code management upon completion of their training. Although confidence increased universally, Group 1 reported increased confidence over that of Group 2 in three specific areas: ability to treat respiratory arrest, ability to run a code, and knowledge of the Pediatric Advanced Life Support algorithm. Group 1 also demonstrated increased competency in code management compared with Group 2 in four key code components: checking airway, checking breathing, checking pulses, and checking capillary refill.Conclusions:Trainee confidence increases after completion of Pediatric Advanced Life Support code training, regardless of simulator type utilized. However, trainees were more competent in code management when trained using a high-fidelity simulator compared with a traditional mannequin.

An Abnormal Echocardiogram and Telemetry Tracing in a Late Preterm Infant.

An Abnormal Echocardiogram and Telemetry Tracing in a Late Preterm Infant.

A Novel Code Team Leader Card to Improve Leader Identification.

Prompt and clear code team leader identification is vital in effective cardiopulmonary resuscitation (CPR), and pediatric trainees often have limited experience in these scenarios. This project sought to develop a tangible object that provided clear leader identification and assisted in code team management and simulated team training. A Code Team Leader Card (CTLC) was designed to provide clear leader identification while simultaneously providing a cognitive aid via integration of pediatric advanced life support (PALS) algorithms. Additionally, CTLC served to occupy the leader's hands to limit their ability to intervene on procedural tasks. The CTLC was incorporated into pediatric resident simulation training, and pre- and postintervention survey data were analyzed. Analysis particularly focused on whether "a leader was clearly identified by all team members." The relationship between CTLC implementation and consistent leader recognition was evaluated using chi-squared test, and secondary qualitative data were obtained via debriefing sessions. Pediatric residents completed 131 surveys prior to CTLC implementation and 41 surveys after implementation. Consistent code team leader recognition increased significantly from 61.8% (81 of 131) pre-CTLC to 80.5% (33 of 41) after introduction of CTLC (P=0.027). Participants commented on the benefits of CTLC during debriefing sessions. Use of a CTLC significantly improved leader recognition during simulated CPR. Inclusion of PALS algorithms led to normalization and increased utilization of these adjunct materials. The CTLC provided a secondary benefit of occupying the leader's hands, thereby allowing that person to focus on overseeing the team rather than assisting with procedural tasks.

FACTORS ASSOCIATED WITH ENDOTRACHEAL TUBE MALPOSITION AMONG PEDIATRIC PATIENTS WITH HEART DISEASE: A CROSS-SECTIONAL ANALYTICAL STUDY

TOPIC: Respiratory Care TYPE: Original Investigations PURPOSE: Several guidelines and formula for endotracheal tube depth insertion are being studied and used. These suggested formulas in computation for the endotracheal tube (ETT) size and depth are based on age, weight and height of those with normal growth and mostly of the Western population. These may not be applicable for those children with growth impairment in patients with cardiac diseases. Investigation of the incidence of inappropriate ETT size and ETT malposition is important to lessen pulmonary complications in these population. METHODS: This is a cross-sectional analytical study approved by the Institutional Review Board of the Philippine Heart Center. Review of charts of pediatric patients, neonates up to 18 years of age with heart disease, who has undergone endotracheal intubation between April 1, 2017 and December 31, 2019 was done. Age, gender, nutritional status, type of heart disease, setting of intubation, formula in computing for the ETT depth, and complications were all obtained from the charts of the patient. The actual ETT placement was compared with the computed ETT depth to identify which guideline specific formula was used. ETT placement, measured in centimeters, seen in chest radiograph taken in neutral position right after intubation was also obtained from the record of the patients. The chest radiographs were evaluated by a single identified radiologist to prevent inter-reader variation. RESULTS: A total of 99 patients with heart disease who underwent endotracheal intubation were included with age ranging from 4 days to 18 years and mean age of 87.71 months (±14.04). There is male preponderance (60.6%). From the review of the post-intubation chest radiographs, 51.52% endotracheal tubes were in place and 48.48% were misplaced. The presence of malnutrition was not a significant factor (p=0.52). However, from the different types of malnutrition, severe stunting (p=0.021) was a factor in the occurrence of malpositioned ETT. Patients with severe stunting, were 3.23 times more likely to have malpositioned ETT as compared to those with normal growth and to those with stunting. In the multivariate analysis, the use of guideline-specified formula was noted to be a significant factor in decreasing the likelihood of malpositioned ETT. Neonates intubated using the Neonatal Resuscitation Program (NRP) formula were 96.87% less likely to have malpositioned endotracheal tube. Furthermore, the NRP guideline was also utilized in infants up to 2 months old who weighed less than 4 kilograms. For those belonging to older age group, Internal Diameter (ID) estimation and Pediatric Advanced Life Support (PALS) formula were 75.33% and 70.88% less likely to have malpositioned ETT, respectively. Wheezing or bronchospasm was the most common complication followed by atelectasis of the left lung. CONCLUSIONS: There are several guidelines and recommendations in proper endotracheal tube insertion a mediical provider may choose and use; however, important factors and characteristics of the individual patient, such as his or her nutritional status should be taken into consideration. CLINICAL IMPLICATIONS: This important and life-saving emergency procedure should be further studied in the pediatric population with different growth patterns to decrease incidence of malpositoning and further pulmonary complications. DISCLOSURES: No relevant relationships by Karenne Somera, source=Web Response