Pediatric Resuscitation Research Articles

Comparison of video-assisted education and traditional classroom education in pediatric cardiopulmonary resuscitation education of nursing students

AimThis research aimed to compare the effectiveness of traditional classroom education and video-assisted education methods used in Pediatric (CPR) education and determine students' level of satisfaction with the education methods used. MethodThis research had a randomized, experimental, pretest-posttest design. The research was completed with 98 students (54 in the video-assisted education group and 44 in the traditional classroom education group). The traditional classroom education group received pediatric CPR education through traditional classroom education. On the other hand, the video-assisted education group watched the pediatric CPR education video prepared by the researchers. The level of knowledge of pediatric CPR, the level of pediatric CPR practice skills, and the satisfaction score of each student were evaluated. ResultsWhen the skills levels of the groups were compared, it was determined that there was no statistical difference between the test results. In both groups, the students' mean knowledge and skill scores in the first and second posttests were significantly higher than their pretest knowledge scores. The satisfaction scores of the students in both groups were similar. ConclusionBoth methods effectively improve students' pediatric CPR-related knowledge, skills, and satisfaction. Implications for practiceAs support for traditional education, using video-assisted visual education materials that nursing students can constantly access when needed is important.

Prediction of Return of Spontaneous Circulation in a Pediatric Swine Model of Cardiac Arrest Using Low-Resolution Multimodal Physiological Waveforms.

Monitoring physiological waveforms, specifically hemodynamic variables (e.g., blood pressure waveforms) and end-tidal CO2 (EtCO2), during pediatric cardiopulmonary resuscitation (CPR) has been demonstrated to improve survival rates and outcomes when compared to standard depth-guided CPR. However, waveform guidance has largely been based on thresholds for single parameters and therefore does not leverage all the information contained in multimodal data. We hypothesize that the combination of multimodal physiological features improves the prediction of the return of spontaneous circulation (ROSC), the clinical indicator of short-term CPR success. We used machine learning algorithms to evaluate features extracted from eight low-resolution (4 samples per minute) physiological waveforms to predict ROSC. The waveforms were acquired from the 2nd to 10th minute of CPR in pediatric swine models of cardiac arrest (N = 89, 8-12 kg). The waveforms were divided into segments with increasing length (both forward and backward) for feature extraction, and machine learning algorithms were trained for ROSC prediction. For the full CPR period (2nd to 10th minute), the area under the receiver operating characteristics curve (AUC) was 0.93 (95% CI: 0.87-0.99) for the multivariate model, 0.70 (0.55-0.85) for EtCO2 and 0.80 (0.67-0.93) for coronary perfusion pressure. The best prediction performances were achieved when the period from the 6th to the 10th minute was included. Poor predictions were observed for some individual waveforms, e.g., right atrial pressure. In conclusion, multimodal waveform features carry relevant information for ROSC prediction. Using multimodal waveform features in CPR guidance has the potential to improve resuscitation success and reduce mortality.

Little Patients, Big Tasks - A Pediatric Emergency Medicine Escape Room.

Little Patients, Big Tasks - A Pediatric Emergency Medicine Escape Room.

Use of pediatric trauma simulations to facilitate exposure to pediatric trauma resuscitations during training

BackgroundPediatric traumas are often high-acuity but are low-frequency compared to adult trauma activations. This is reflected in the relatively limited experience with these events during training. Although some principles of trauma resuscitation are similar between adults and children, there are also important differences in physiology, injury patterns, and presentation. Therefore, simulation can be used to supplement trainee exposure and enhance their ability to respond to these high-stakes events. MethodsWe developed a multidisciplinary pediatric trauma resuscitation simulation curriculum to increase exposure to pediatric traumas at our institution. The intervention includes monthly sessions in the pediatric resuscitation bays, during which multidisciplinary teams complete 2 full pediatric trauma resuscitation simulations. This is supplemented with formal debriefing, simulation-specific teaching, and standardized trauma cognitive aids. The comprehensiveness of trauma evaluations and resuscitation efforts are evaluated using our institutional structured trauma resuscitation observation tool, and post-simulation surveys are used to assess the impact of the teaching interventions. ResultsNine simulation sessions were conducted with more than 100 participants, including surgical residents, emergency medicine residents, nursing staff, respiratory therapists, and medical students. Completeness of resuscitation efforts improved from 55% to 82% (P < .01) between initial and repeat simulations. Surveyed participants reported improvement in overall team performance on the Team Emergency Assessment Measure (P < .01). ConclusionImplementing a multidisciplinary pediatric trauma simulation curriculum with structured teaching interventions and standardized trauma scripts promotes teamwork and strengthens trainees’ ability to conduct comprehensive evaluations required for high-acuity pediatric traumas.

Implications of pediatric extracorporeal cardiopulmonary resuscitation simulation for intensive care team confidence and coordination: A pilot study.

Extracorporeal cardiopulmonary resuscitation (ECPR) is associated with improved outcomes in select populations, however, crisis resource management (CRM) in this setting is logistically challenging. This study evaluates the impact of ECPR simulation on self-perceived confidence and collaboration of intensive care unit team members. This is a prospective observational study analyzing data obtained between July 2018-December 2019. This study focused on non-surgical members of critical care team consisting of pediatric intensivists, resident physicians, registered nurses, respiratory therapists. Participants were expected to perform cardiopulmonary resuscitation (CPR) during the ECPR event, participate in code-team responsibilities and provide ancillary support during cannulation. Pre- and post-simulation surveys employed the Likert scale (1 = not at all confident, 5 = highly confident) to assess self-perceived scores in specified clinical competencies. Twenty-nine providers participated in the simulation; 38% had prior ECPR experience. Compared to mean pre-study Likert scores (2.4, 2.4, 2.5), post-simulation scores increased (4.2, 4.4, 4.3) when self-evaluating: confidence in assessing patients needing ECPR, confidence in participating in ECPR workflow and confidence in performing high-quality CPR, respectively. Post-simulation values of >3 were reported by 100% of participants in all domains (p < .0001). All participants indicated the clinical scenario and procedural environment to be realistic and appropriately reflective of situational stress. Additionally, 100% of participants reported the simulation to improve perceived team communication and teamwork skills. This study demonstrated preliminary feasibility of pediatric ECPR simulation in enhancing independent provider confidence and team communication. This self-perceived improvement may establish a foundation for cohesive CRM, in preparation for a real life ECPR encounter.

Resuscitation Team Members' Perceptions of Supporting Parents During Cardiopulmonary Resuscitation of Children: A Systematic Review.

Supporting parents is a crucial part of family-centered care in pediatric and neonate resuscitation. The aim of this systematic review was to appraise and synthesize studies conducted to determine resuscitation team members' perspectives of support for parents during pediatric and neonate resuscitation. The PRISMA model guided the systematic literature search of Google Scholar, PubMed, MEDLINE, CINAHL, Cochrane, and Scopus for studies published until May 2022. The authors independently screened all titles, abstracts, and full-text articles for eligibility. There was agreement about screened articles for inclusion. Full texts of all potentially relevant studies were evaluated for the rigor of the study design, sample, and analysis. This review included quantitative, qualitative, and mixed-methods studies. The quality of evidence across the included studies was assessed using the risk of bias in non-randomized studies of interventions (ROBINS-I) tool as part of GRADE's (Recommendations Assessment, Development, and Evaluations) certainty rating process. There were 978 articles located. After reviewing for relevancy, 141 full-text articles were assessed, and 13 articles met criteria and were included in this review (4 quantitative, 7 qualitative, and 2 mixed-methods design). Five themes were revealed to summarize resuscitation team members' perspectives of parental support in pediatric resuscitation: providing information to parents, family facilitator, emotional support, presence of parents during resuscitation, and spiritual and religious support. The results of this systematic review can be used to improve support for parents by informing the education of resuscitation team members and clarifying policies and guidelines of resuscitation team roles to include support for parents.

19: Epinephrine dosing during pediatric extracorporeal cardiopulmonary resuscitation (ECPR): A single center retrospective study assessing adherence to resuscitation guidelines.

19: Epinephrine dosing during pediatric extracorporeal cardiopulmonary resuscitation (ECPR): A single center retrospective study assessing adherence to resuscitation guidelines.

Mortality after emergency unit fluid bolus in febrile Ugandan children.

Pediatric fluid resuscitation in sub-Saharan Africa has traditionally occurred in inpatients. The landmark Fluid Expansion as Supportive Therapy (FEAST) trial showed fluid boluses for febrile children in this inpatient setting increased mortality. As emergency care expands in sub-Saharan Africa, fluid resuscitation increasingly occurs in the emergency unit. The objective of this study was to determine the mortality impact of emergency unit fluid resuscitation on febrile pediatric patients in Uganda. This retrospective cohort study used data from 2012-2019 from a single emergency unit in rural Western Uganda to compare three-day mortality for febrile patients that did and did not receive fluids in the emergency unit. Propensity score matching was used to create matched cohorts. Crude and multivariable logistic regression analysis (using both complete case analysis and multiple imputation) were performed on matched and unmatched cohorts. Sensitivity analysis was done separately for patients meeting FEAST inclusion and exclusion criteria. The analysis included 3087 febrile patients aged 2 months to 12 years with 1,526 patients receiving fluids and 1,561 not receiving fluids. The matched cohorts each had 1,180 patients. Overall mortality was 4.0%. No significant mortality benefit or harm was shown in the crude unmatched (Odds Ratio [95% Confidence Interval] = 0.88 [0.61-1.26] or crude matched (1.00 [0.66-1.50]) cohorts. Adjusted cohort analysis (including both complete case analysis and multiple imputation) and sensitivity analysis of patients meeting FEAST inclusion and exclusion criteria all also failed to show benefit or harm. Post-hoc power calculations showed the study was powered to detect the absolute harm seen in FEAST but not the relative risk increase. This study's primary finding is that fluid resuscitation in the emergency unit did not significantly increase or decrease three-day mortality for febrile children in Uganda. Universally aggressive or fluid-sparing emergency unit protocols are unlikely to be best practices, and choices about fluid resuscitation should be individualized.

One hand open palm technique for infant CPR

BackgroundThe guideline recommended chest compression depth, rate, and recoil are essential factors for the return of spontaneous circulation (ROSC) in cardiopulmonary resuscitation (CPR). A pediatric resuscitation collaboration recently demonstrated that healthcare providers fail to meet the American Heart Association (AHA) guidelines, with the greatest difficulty being in achieving chest compression depth targets in infants. We hypothesized that the use of the heel of one hand [open palm technique (OPT)] will increase chest compression depth in infants compared to standard CPR techniques [two-finger technique (TFT), two thumb-encircling hand technique (TTT)].MethodsA prospective, randomized, single-center study was completed using an infant manikin. Thirty pediatric critical care providers performed 2 min of CPR for each technique followed by 5 min of rest. Each participant completed a survey at the end that assessed the difficulty level in order to assess the feasibility of this new technique.ResultsThe mean chest compression depth for the OPT was significantly deeper compared to TFT (2.61± 0.63 cm vs. 2.25 ± 0.54 cm, p = 0.0004) but not significantly deeper compared to TTT (2.43 ± 0.46 cm, p = 0.0820). OPT was graded as the easiest technique, followed by TTT (2.20 ± 0.76 vs. 3.17 ± 0.95, p &amp;lt; 0.0001) and then TFT (3.38 ± 0.83, p &amp;lt; 0.0001).ConclusionThe use of OPT for infant CPR resulted in improved chest compression depth. OPT was considered the easiest technique compared to standard infant CPR techniques, thus making it feasible to perform. Importantly, all providers failed to meet the AHA infant chest compression depth goal of 4 cm, regardless of the technique. Future research is needed to optimize CPR technique and performance to achieve targeted chest compression depth in infants.

Association between the presence of an advanced airway and ventilation rate during pediatric CPR: A report from the Videography in Pediatric Resuscitation (VIPER) collaborative

ObjectiveTo determine the association between presence of an advanced airway during pediatric cardiopulmonary resuscitation (CPR) and ventilation rates. MethodsProspective observational study, January 2017 to June 2020. Patients ≤18 years receiving CC for ≥2 minutes were enrolled. Ventilation rate and type of airway (advanced airway (AA), either endotracheal tube (ETT) or supraglottic airway (SGA); or natural airway (NA)) were collected from video review and analyzed in ‘CPR segments’ (periods of CPR by individual providers). Ventilation rate (breaths per minute, bpm) was calculated for each segment; hyperventilation was defined as >12 bpm according to 2015 American Heart Association guidelines. Univariate analysis between airway type was done by χ2 testing. Multivariate regression was used to determine the association between the presence of AA with hyperventilation while controlling for within-patient covariance. Results779 CPR segments from 94 CPR event were analyzed. The mean ventilation rate per CPR segment across all events was 22 bpm (±16 bpm)). Mean ventilation rates were higher with AA, either ETT (24 ± 17 bpm) or SGA (34 ± 19 bpm), than with NA (17 ± 14, p < 0.001). Hyperventilation occurred more often with AA in place (ETT: 68%; SGA: 96%; NA: 43%; p < 0.001). The presence of AA was independently associated with hyperventilation (AOR 9.3, 95% CI 4.3–20.1). ConclusionsDuring pediatric CPR, hyperventilation occurs more often with an AA in place than during CPR with NA. Future research should focus on respiratory physiology during pediatric CPR to determine optimal ventilation rate(s) during pediatric cardiac arrest.

Trained Lifeguards Performing Pediatric Cardiopulmonary Resuscitation While Running: A Pilot Simulation Study.

The aim of this study was to compare the quality of standard infant CPR with CPR in motion (i.e., walking and running) via performing maneuvers and evacuating the infant from a beach. Thirteen trained lifeguards participated in a randomized crossover study. Each rescuer individually performed three tests of 2 min each. Five rescue breaths and cycles of 30 chest compressions followed by two breaths were performed. Mouth-to-mouth-and-nose ventilation was carried out, and chest compressions were performed using the two-fingers technique. The manikin was carried on the rescuer's forearm with the head in the distal position. The analysis variables included compression, ventilation, and CPR quality variables, as well as physiological and effort parameters. Significantly lower compression quality values were obtained in running CPR versus standard CPR (53% ± 14% versus 63% ± 15%; p = 0.045). No significant differences were observed in ventilation or CPR quality. In conclusion, lifeguards in good physical condition can perform simulated infant CPR of a similar quality to that of CPR carried out on a victim who is lying down in a fixed position.

Mortality after cardiac arrest in children less than 2 years: relevant factors

BackgroundThere are only scant studies of predicting outcomes of pediatric resuscitation due to lack of population-based data. This study aimed to determine variable factors that may impact the survival of resuscitated children aged under 24 months.MethodsThis is a retrospective study of 66 children under 24 months. Cardiopulmonary resuscitation (CPR) with pediatric advanced life support guideline was performed uniformly for all children. Linear regression analysis with variable factors was conducted to determine impacts on mortality.ResultFactors with statistically significant increases in mortality were the number of administered epinephrine (p value < 0.001), total CPR duration (p value < 0.001), in-hospital CPR duration of out-hospital cardiac arrest (p value < 0.001), and changes in cardiac rhythm (p value < 0.040). However, there is no statistically significant association between patient outcomes and remaining factors such as age, sex, underlying disease, etiology, time between last normal to CPR, initial CPR location, initial cardiac rhythm, venous access time, or inotropic usage.ConclusionMore than 10 times of epinephrine administration and CPR duration longer than 30 minutes were associated with a higher mortality rate, while each epinephrine administration and prolonged CPR time increased mortality.Impact statementThis study analyzed various factors influencing mortality after cardiac arrest in patients under 24 months.Increased number of administered epinephrine and prolonged cardiopulmonary resuscitation duration do not increase survival rate in patients under 24 months.In patients with electrocardiogram rhythm changes during CPR, mortality increased when the rhythm changed into asystole in comparison to no changes occurring in the rhythm.

A National Comparison of Volume and Acuity for Adult and Pediatric Trauma: A Trauma Quality Improvement Program Cohort Study

IntroductionMost injured children receive trauma care outside of a pediatric trauma center. Differences in physiology, dosing, and injury pattern limit extrapolation of adult trauma principles to pediatrics. We compare US trauma center experience with pediatric and adult trauma resuscitation. Materials and MethodsWe queried the 2019 Trauma Quality Improvement Program to describe the experience of US trauma centers with pediatric (<15 y) and adult trauma. We quantified blunt, penetrating, burn, and unspecified traumas and compared minor, moderate, severe, and critical traumas (ISS 1-8 Minor, ISS 9-14 Moderate, ISS 15-24 Severe, ISS 25+ Critical). We estimated center-level volumes for adults and children. Institutional identifiers were generated based on unique center specific factors including hospital teaching status, hospital type, verification level, pediatric verification level, state designation, state pediatric designation, and bed size. ResultsA total of 755,420 adult and 76,449 pediatric patients were treated for traumatic injuries. There were 21 times as many critical or major injuries in adults compared to children, 17 times more moderate injuries, and 6 times more minor injuries. Children and adults presented with similar rates of blunt trauma, but penetrating injuries were more common in adults and burn injuries were more common in children. Comparing center-level data, adult trauma exceeded pediatric for every severity and mechanism. ConclusionsThere is relatively limited exposure to high-acuity pediatric trauma at US centers. Investigation into pediatric trauma resuscitation education and simulation may promote pediatric readiness and lead to improved outcomes.

Rapid, selective and homogeneous brain cooling with transnasal flow of ambient air for pediatric resuscitation

Neurologic outcome from out-of-hospital pediatric cardiac arrest remains poor. Although therapeutic hypothermia has been attempted in this patient population, a beneficial effect has yet to be demonstrated, possibly because of the delay in achieving target temperature. To minimize this delay, we developed a simple technique of transnasal cooling. Air at ambient temperature is passed through standard nasal cannula with an open mouth to produce evaporative cooling of the nasal passages. We evaluated efficacy of brain cooling with different airflows in different size piglets. Brain temperature decreased by 3°C within 25 minutes with nasal airflow rates of 16, 32, and 16 L/min in 1.8-, 4-, and 15-kg piglets, respectively, whereas rectal temperature lagged brain temperature. No substantial spatial temperature gradients were seen along the neuroaxis, suggesting that heat transfer is via blood convection. The evaporative cooling did not reduce nasal turbinate blood flow or sagittal sinus oxygenation. The rapid and selective brain cooling indicates a high humidifying capacity of the nasal turbinates is present early in life. Because of its simplicity, portability, and low cost, transnasal cooling potentially could be deployed in the field for early initiation of brain cooling prior to maintenance with standard surface cooling after pediatric cardiac arrest.

Poor Concordance of One-Third Anterior-Posterior Chest Diameter Measurements With Absolute Age-Specific Chest Compression Depth Targets in Pediatric Cardiac Arrest Patients.

Background Current pediatric cardiac arrest guidelines recommend depressing the chest by one-third anterior-posterior diameter (APD), which is presumed to equate to absolute age-specific chest compression depth targets (4 cm for infants and 5 cm for children). However, no clinical studies during pediatric cardiac arrest have validated this presumption. We aimed to study the concordance of measured one-third APD with absolute age-specific chest compression depth targets in a cohort of pediatric patients with cardiac arrest. Methods and Results This was a retrospective observational study from a multicenter, pediatric resuscitation quality collaborative (pediRES-Q [Pediatric Resuscitation Quality Collaborative]) from October 2015 to March 2022. In-hospital patients with cardiac arrest ≤12 years old with APD measurements recorded were included for analysis. One hundred eighty-two patients (118 infants >28 days old to <1 year old, and 64 children 1 to 12 years old) were analyzed. The mean one-third APD of infants was 3.2 cm (SD, 0.7 cm), which was significantly smaller than the 4 cm target depth (P<0.001). Seventeen percent of the infants had one-third APD measurements within the 4 cm ±10% target range. For children, the mean one-third APD was 4.3 cm (SD, 1.1 cm). Thirty-nine percent of children had one-third APD within the 5 cm ±10% range. Except for children 8 to 12 years old and overweight children, the measured mean one-third APD of the majority of the children was significantly smaller than the 5 cm depth target (P<0.05). Conclusions There was poor concordance between measured one-third APD and absolute age-specific chest compression depth targets, particularly for infants. Further study is needed to validate current pediatric chest compression depth targets and evaluate the optimal chest compression depth to improve cardiac arrest outcomes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02708134.

Critical Care Unit Characteristics and Extracorporeal Cardiopulmonary Resuscitation Survival in the Pediatric Cardiac Population: Retrospective Analysis of the Virtual Pediatric System Database.

Existing literature provides limited data about ICU characteristics and pediatric extracorporeal cardiopulmonary resuscitation (E-CPR) outcomes. We aimed to evaluate the associations between patient and ICU characteristics, and outcomes after E-CPR in the pediatric cardiac population. Retrospective analysis of the Virtual Pediatric System database (VPS, LLC, Los Angeles, CA). PICUs categorized as either cardiac-only versus mixed ICU cohort type. Consecutive cardiac patients less than 18 years old experiencing cardiac arrest in the ICU and resuscitated using E-CPR. None. Event and time-stamp filtering identified E-CPR events. Patient, hospital, and event-related variables were aggregated for independent and multivariable mixed effects logistic regression to assess the association between ICU cohort type and survival. Among ICU admissions in the VPS database, 2010-2018, the prevalence of E-CPR was 0.07%. A total of 671 E-CPR events (650 patients) comprised the final cohort; congenital heart disease (84%) was the most common diagnosis versus acquired heart diseases. The majority of E-CPR events occurred in mixed ICUs (67%, n = 449) and in ICUs with greater than 20 licensed bed capacity (65%, n = 436). Survival to hospital discharge was 51% for the overall cohort. Independent logistic regression failed to reveal any association between survival to hospital discharge and ICU type (ICU type: cardiac ICU, odds ratio [OR], 1.01; 95% CI, 0.71-1.44; p = 0.95). However, multivariable logistic regression revealed an association between cardiac surgical patients and greater odds for survival (OR, 2.03; 95% CI, 1.40-2.95; p < 0.001). Also, there was an association between ICUs with capacity greater than 20 (vs not) and lower survival odds (OR, 0.65; 95% CI, 0.43-0.96). The overall prevalence of E-CPR among critically ill children with cardiac disease observed in the VPS database is low. We failed to identify an association between ICU cohort type and survival. Further investigation into organizational factors is warranted.

Paediatric cardiopulmonary resuscitation quality during simulation of in-hospital transport

In-hospital cardiac arrests that occur outside of the intensive care unit may require transportation during active cardiopulmonary resuscitation. Studies have shown that high-quality cardiopulmonary resuscitation is imperative for survival with preserved neurologic function. We sought to determine if high-quality cardiopulmonary resuscitation is maintained during simulated transportation of paediatric in-hospital cardiac arrest. Randomized crossover simulated study of paediatric in-hospital cardiac arrest with 10 teams composed of five providers (physicians, advanced practice providers, nurses and respiratory therapists). Teams remained in a simulation room or transported the mannequin between two rooms. The primary analysis compared chest compression fraction in stationary versus transport simulations. Secondary analyses included additional cardiopulmonary resuscitation quality metrics with comparison to the 2015 American Heart Association standards. There was no significant difference in chest compression fraction or rate between the transport and stationary groups. 92%, 72% and 26% of epochs met American Heart Association criteria for compression fraction, rate and depth, respectively. Stationary simulations were more likely to meet recommendations for combined quality metrics, including compression fraction and rate (77 vs. 53; Chest compression fraction was preserved during simulated in-hospital cardiac arrest with transport. However, the transport simulation was less likely to meet American Heart Association recommendations for combined metrics. Similar to previous cardiopulmonary resuscitation quality studies, both teams failed to meet depth requirements in the majority of simulations.

Transitioning Cognitive Aids into Decision Support Platforms: Requirements and Design Guidelines.

Digital cognitive aids have the potential to serve as clinical decision support platforms, triggering alerts about process delays and recommending interventions. In this mixed-methods study, we examined how a digital checklist for pediatric trauma resuscitation could trigger decision support alerts and recommendations. We identified two criteria that cognitive aids must satisfy to support these alerts: (1) context information must be entered in a timely, accurate, and standardized manner, and (2) task status must be accurately documented. Using co-design sessions and near-live simulations, we created two checklist features to satisfy these criteria: a form for entering the pre-hospital information and a progress slider for documenting the progression of a multi-step task. We evaluated these two features in the wild, contributing guidelines for designing these features on cognitive aids to support alerts and recommendations in time- and safety-critical scenarios.

Epinephrine dosing strategies during pediatric extracorporeal cardiopulmonary resuscitation reveal novel impacts on survival: A multicenter study utilizing time-stamped epinephrine dosing records

ObjectivesTo describe epinephrine dosing distribution using time-stamped data and assess the impact of dosing strategy on survival after ECPR in children. MethodsThis was a retrospective study at five pediatric hospitals of children <18 years with an in-hospital ECPR event. Mean number of epinephrine doses was calculated for each 10-minute CPR interval and compared between survivors and non-survivors. Patients were also divided by dosing strategy into a frequent epinephrine group (dosing interval of ≤5 min/dose throughout the first 30 minutes of the event), and a limited epinephrine group (dosing interval of ≤5 min/dose for the first 10 minutes then >5 min/dose for the time between 10 and 30 minutes). ResultsA total of 191 patients were included. Epinephrine was not evenly distributed throughout ECPR, with 66% of doses being given during the first half of the event. Mean number of epinephrine doses was similar between survivors and non-survivors the first 10 minutes (2.7 doses). After 10 minutes, survivors received fewer doses than non-survivors during each subsequent 10-minute interval. Adjusted survival was not different between strategy groups [OR of survival for frequent epinephrine strategy: 0.78 (95% CI 0.36–1.69), p = 0.53]. ConclusionsSurvivors received fewer doses than non-survivors after the first 10 minutes of CPR and although there was no statistical difference in survival based on dosing strategy, the findings of this study question the conventional approach to EPCR analysis that assumes dosing is evenly distributed.

Implementation of a North American pediatric emergency medicine simulation curriculum using the virtual resuscitation room.

Simulation provides consistent opportunities for residents to practice high-stakes, low-frequency events such as pediatric resuscitations. To increase standardization across North American residency programs, the Emergency Medicine Resident Simulation Curriculum for Pediatrics (EM ReSCu Peds) was developed. However, access to high-quality simulation/pediatric expertise is not uniform. As the concurrent COVID-19 pandemic necessitated new virtual simulation methods, we adapted the Virtual Resus Room (VRR) to teach EM ReSCu Peds. VRR is an award-winning, low-resource, open-access distance telesimulation platform we hypothesize will be effective and scalable for teaching this curriculum. EM residents completed six VRR EM ReSCu Peds simulation cases and received immediate facilitator-led teledebriefing. Learners completed retrospective pre-post surveys after each case. Learners and facilitators completed end-of-day surveys. Primary outcomes were learning effectiveness measured by a composite of the Simulation Effectiveness in Teaching Modified (SET-M) tool and self-reported changes in learner comfort with case objectives. Secondary outcome was VRR scalability to teach EM ReSCu Peds using a composite outcome of net promoter scores (NPS), resource utilization, open-text feedback, and technical issues. Learners reported significantly increased comfort with 95% (54/57) of EM ReSCu Peds-defined case objectives (91% cognitive, 9% psychomotor), with moderate (Cohen's d 0.71, 95% CI 0.67-0.76) overall effect size. SET-M responses indicated simulation effectiveness, particularly with debriefing. Ninety EM residents from three North American residency programs were taught by 59 pediatric faculty from six programs over 4 days-more than possible if simulations were conducted in person. Learners (39) and faculty (68) NPS were above software industry benchmarks (13). Minor, quickly resolved, technical issues were reported by 18% and 29% of learners and facilitators, respectively. Learners and facilitators report that the VRR is an effective and scalable platform to teach EM ReSCu Peds. This low-cost, accessible distance simulation intervention could increase equitable, global access to high-quality pediatric emergency education.