Paediatric Resuscitation Guidelines Research Articles

A novel tool for assessing pediatric emergency care in low- and middle-income countries: a pilot study

BackgroundGlobally, most children seek emergency care at general rather than specialized pediatric emergency departments. There remains significant variation in the provision of pediatric emergency care, particularly in resource-constrained settings. The objective of this study is to pilot a self-assessment tool to evaluate pediatric emergency care capabilities in low- and middle-income country (LMIC) hospitals on the African Continent.MethodsThis was a prospective cross-sectional descriptive study using a convenience sample of sub-Saharan African hospitals. The assessment tool was developed by operationalizing the technical contents of existing standards and guidelines from international bodies including the World Health Organization and International Federation of Emergency Medicine. The pilot was conducted at emergency departments located across different regions on the African continent. Descriptive statistics were used to evaluate different domains of pediatric emergency care capabilities including pediatric triage, protocols, staffing, training, equipment, consumables, and medicines.ResultsSixteen hospitals with emergency departments completed the assessment tool (participation rate of 76%). The hospitals were in nine different countries across four regions of sub-Saharan Africa. National/academic hospitals comprised 56.3% of the participating hospitals. The majority, 44%, of these hospitals saw pediatric patient volumes of 2,000–4,999 patients per year. Dedicated pediatric triage spaces and resuscitation spaces were available at 37.5% and 56.3%, respectively. Formal pediatric resuscitation guidelines were used at 62.5%. Doctors on the self-assessment teams came from primarily pediatrics and general practitioner training backgrounds (both 68.8%). Basic respiratory and airway support equipment (e.g. oxygen, bag-valve mask devices) were available in all participating hospitals, whereas advanced airway equipment (e.g. pediatric intubation equipment) was available in 37.5% of hospitals. Most medicines from the World Health Organization Essential Medicines list were available at participating hospitals.ConclusionsTo date, this is the first assessment tool dedicated to the comprehensive evaluation of pediatric emergency care in LMICs. This pilot provides a first approach to evaluate pediatric emergency healthcare capabilities in the hospital setting with future directions to improve the tool based on qualitative feedback.

Optimal Chest Compression Point During Pediatric Resuscitation: Implications for Pediatric Resuscitation Practice by CT Scans.

Current European guidelines for pediatric cardiopulmonary resuscitation (CPR) recommend the lower half of the sternum as the chest compression point (CP). In this study, we have used thoracic CT scans to evaluate recommended and optimal CP in relation to cardiac anatomy and structure. Analysis of routinely acquired thoracic CT scans acquired from 2000 to 2020. Single-center pediatric department in a German University Hospital. Imaging data were obtained from 290 patients of 3-16 years old. None. We measured and analyzed 14 thoracic metrics in each thoracic CT scan. In 44 of 290 (15.2%) scans, the recommended CP did not match the level of the cardiac ventricles. Anatomically, the optimal CP was one rib or one vertebral body lower than the recommended CP, that is, the optimal CP was more caudal to the level of the body of the sternum in 67 of 290 (23.1%) scans. The recommended compression depth appeared reasonable in children younger than 12 years old. At 12 years old or older, the maximum compression depth of 6 cm is less than or equal to one-third of the thoracic depth. In this study of thoracic CT scans in children 3-16 years old, we have found that optimal CP for CPR appears to be more caudal than the recommended CP. Therefore, it seems reasonable to prefer to use the lower part of the sternum for CPR chest compressions. At 12 years old or older, a compression depth similar to that used in adults-6 cm limit-may be chosen.

ILCOR pediatric life support recommendations translation to constituent council guidelines: An emphasis on similarities and differences

The International Liaison Committee on Resuscitation (ILCOR) performs rigorous scientific evidence evaluation and publishes Consensus on Science with Treatment Recommendations. These evidence-based recommendations are incorporated by ILCOR constituent resuscitation councils to inform regional guidelines, and further translated into training approaches and materials and implemented by laypersons and healthcare providers in- and out-of-hospital. There is variation in council guidelines as a result of the weak strength of evidence and interpretation. In this manuscript, we highlight ten important similarities and differences in regional council pediatric resuscitation guidelines, and further emphasize three differences that identify key knowledge gaps and opportunity for “natural experiments.”

Assessment of Adherence to Standard Operating Procedure in Blood Pressure Measurement of Children Above Three Years of Age Among Nurses Working in Paediatric Unit at Pondicherry Institute of Medical Sciences

Blood Pressure (BP) is the pressure of the blood flow which exerted against the wall of arteries when the ventricles contract. BP measurement based on guidelines is quality care and safe nursing practice. Adherence to guidelines reduces inaccuracies that may expose the patient to misdiagnosis and inappropriate care An infant may have a pretty common blood pressure of 80/45 mm of Hg, while that evaluation in an adult is considered low. A teenager may have a satisfactory blood pressure of 110/70 mm of Hg, but that value would be of apprehension in a toddler. Measurement of BP in children is more difficult than in adults because readings are likely to be falsely high in crying children, and an appropriately sized cuff may not be available. According to Paediatric resuscitation guidelines 2012, it is important to measure Blood Pressure while assessing a sick child to determine the circulatory and neurological status. Therefore, BP measurement based on guidelines becomes truly a valuable tool in screening for high-risk patients, early detection and control of hypertension, and prevention of complications. STATEMENT OF THE PROBLEM: “A Descriptive Study to assess adherence to the standard operating procedure in blood pressure measurement of children above three years of age among nurses working in the paediatric unit at Pondicherry institute of medical sciences” OBJECTIVES: 1. To determine the level of adherence among the staff nurses in following the standard operating procedure in blood pressure measurement in pediatric patients admitted to the Pondicherry Institute of Medical Sciences. 2. To identify the barriers in adhering to the standard operating procedure in blood pressure measurement. 3. To associate the demographic variables of staff Nurses with their level of adherence in following standard operating procedures for BPM. METHODOLOGY A descriptive non-experimental method was used to assess the level of adherence of standard operating procedures in blood pressure measurement of children above three years of age. The study was conducted in the pediatric ward, Pondicherry Institute of Medical Sciences, Pondicherry, in September 2019. Purposive sample method was used and the sample included 33 nurses. Each sample was observed three times using the observational checklist, which consists of twelve steps. Descriptive statistics were used to analyze the data. Frequency and percentage were used to assess the adherence level in following the standard operating procedure in blood pressure measurement. RESULT The result of the analysis of data shows that the majority of 32 (97 %) were female nurses, 31(94%) had B.Sc. Nursing degree and the majority of 27 (81.8 %) had work experience less than 4 years. Out of 33 participants, 6 (18.2 %) had adhered to the standard operating procedure in blood pressure measurement, 27 (81.8 %) were not able had adhered at all times while checking blood pressure with Aneroid BP Apparatus. Barriers related to adherence to SOP were related to lack of time, less manpower, workflow constraints, and some assumed that it is not necessary to follow each step every time, the cooperation of the child. CONCLUSION The result of the study showed that very few nurses adhered to each step in the SOP of blood pressure measurement. The study concludes that there is a need to conduct in-service education between regular intervals on the importance of SOP and skills and the importance of blood pressure measurement among nurses of PIMS Keywords: Standard Operating Procedure, Blood Pressure, Adherence, Nurses, Pediatric Unit

Considerations on the Use of Neonatal and Pediatric Resuscitation Guidelines for Hospitalized Neonates and Infants: On Behalf of the American Heart Association Emergency Cardiovascular Care Committee and the American Academy of Pediatrics.

Between 0.25% and 3% of admissions to the NICU, PICU, and PCICU receive cardiopulmonary resuscitation (CPR). Most CPR events occur in patients <1 year old. The incidence of CPR is 10 times higher in the NICU than at birth. Therefore, optimizing the approach to CPR in hospitalized neonates and infants is important. At birth, the resuscitation of newborns is performed according to neonatal resuscitation guidelines. In older infants and children, resuscitation is performed according to pediatric resuscitation guidelines. Neonatal and pediatric guidelines differ in several important ways. There are no published recommendations to guide the transition from neonatal to pediatric guidelines. Therefore, hospitalized neonates and infants can be resuscitated using neonatal guidelines, pediatric guidelines, or a hybrid approach. This report summarizes the current neonatal and pediatric resuscitation guidelines, considers how to apply them to hospitalized neonates and infants, and identifies knowledge gaps and future priorities. The lack of strong scientific data makes it impossible to provide definitive recommendations on when to transition from neonatal to pediatric resuscitation guidelines. Therefore, it is up to health care teams and institutions to decide if neonatal or pediatric guidelines are the best choice in a given location or situation, considering local circumstances, health care team preferences, and resource limitations.

Abstract 165: 21% Or 100% Oxygen During Cardiopulmonary Resuscitation in Asphyxiated Pediatric Piglets - A Randomized Controlled Animal Study

Background: Current pediatric resuscitation guidelines recommend 100% oxygen (O 2 ) during cardiopulmonary resuscitation (CPR), however the most effective O 2 concentration for pediatric patients remains unknown. Aim: To determine if 21%O 2 during CPR with either chest compression (CC) during sustained inflation (SI) (CC+SI) or continuous chest compression with asynchronized ventilation (CCaV) will reduce time to return of spontaneous circulation (ROSC) compared to 100%O 2 in pediatric piglets with asphyxia-induced cardiac arrest. Methods: Piglets (20-23 days of age, weighing 6.2-10.2 kg) were anesthetized, intubated, instrumented, and exposed to asphyxia. Cardiac arrest was defined as mean arterial blood pressure &lt;25 mmHg with bradycardia. After cardiac arrest, piglets were randomized to CC+SI or CCaV with either 21% or 100%O 2 or sham. Heart rate, arterial blood pressure, carotid blood flow, and respiratory parameters were continuously recorded. Results: There were no differences in baseline parameters or the duration and degree of asphyxiation. Median (interquartile range) time to ROSC was 107 (90-440) and 140 (105-200) sec with CC+SI 21% and 100%O 2 and 600 (50-600) and 600 (95-600)sec with CCaV 21% and 100%O 2 (p=0.27). Overall, 6 (86%) and 6 (86%) with CC+SI 21% and 100%O 2 and 3 (43%) and 3 (43%) achieved ROSC with CCaV 21% and 100%O 2 (p=0.13). Conclusions: In pediatric piglets resuscitated with 21% oxygen compared to 100% oxygen, using either CCaV or CC+SI had similar time to ROSC and survival. CPR using CC+SI had shorter time to ROSC and higher survival compared to CCaV. Clinical studies comparing 21% with 100%O 2 during pediatric CPR are warranted.

High dose of epinephrine does not improve survival of children with out-of-hospital cardiac arrest: Results from the French National Cardiac Arrest Registry.

ObjectivesThe pediatric resuscitation guidelines recommend the use of 0. 01 mg kg−1 epinephrine during a cardiac arrest; an epinephrine dose higher than that is not recommended. The first aim of this study was to determine the administration rate of high epinephrine dose during pediatric out-of-hospital cardiac arrest. The second aim was to compare the survival status in patients who received high or standard doses of epinephrine.MethodsThis was a multicenter comparative post-hoc study conducted between January 2011 and July 2021 based on the French National Cardiac Arrest Registry data. All prepubescent (boys < 12 years old, girls < 10 years old) victims of an out-of-hospital cardiac arrest were included. To compare survival status and control bias, patients who received a high epinephrine dose were matched with those who received a standard epinephrine dose using propensity score matching.ResultsThe analysis included 755 patients; 400 (53%) received a high dose and 355 (47%) received a standard dose of epinephrine. The median dose (mg kg−1) per bolus was higher in the high-dose group than that in the standard dose group (0.04 vs. 0.01 mg kg−1, P < 0.001). Before matching, there was no between-group difference in the 30-day survival rate or survival status at hospital discharge. Matching yielded 288 pairs; there was no between-group difference in the 30-day survival rate or survival at hospital discharge (High dose, n = 5; standard dose, n = 12; Odds ratios: 2.40, 95% confidence interval: 0.85–6.81). Only 2 patients in the standard dose group had a good neurological outcome.ConclusionMore than 50% of the patients did not receive the recommended epinephrine dose during resuscitation. There was no association between patients receiving a high dose or standard dose of epinephrine with the 30-day survival or survival status at hospital discharge. Collaboration across multiple cardiac arrest registries is needed to study the application of pediatric guidelines.

Use of an end-tidal carbon dioxide-guided algorithm during cardiopulmonary resuscitation improves short-term survival in paediatric swine

AimTo evaluate an algorithm that uses an end-tidal carbon dioxide (ETCO2) target of ≥ 30 torr to guide specific changes in chest compression rate and epinephrine administration during cardiopulmonary resuscitation (CPR) in paediatric swine. MethodsSwine underwent asphyxial cardiac arrest followed by resuscitation with either standard or ETCO2-guided algorithm CPR. The standard group received chest compressions at a rate of 100/min and epinephrine every 4 min during advanced life support consistent with the American Heart Association paediatric resuscitation guidelines. In the ETCO2-guided algorithm group, chest compression rate was increased by 10 compressions/min for every minute that the ETCO2 was < 30 torr, and the epinephrine administration interval was decreased to every 2 min if the ETCO2 remained < 30 torr. Short-term survival and physiologic data during active resuscitation were compared. ResultsShort-term survival was significantly greater in the ETCO2-guided algorithm CPR group than in the standard CPR group (16/28 [57.1%] versus 4/28 [14.3%]; p = 0.002). Additionally, the algorithm group had higher predicted mean ETCO2, chest compression rate, diastolic and mean arterial pressure, and myocardial perfusion pressure throughout resuscitation. Swine in the algorithm group also exhibited significantly greater improvement in diastolic and mean arterial pressure and cerebral perfusion pressure after the first dose of epinephrine than did those in the standard group. Incidence of resuscitation-related injuries was similar in the two groups. ConclusionsUse of a resuscitation algorithm with stepwise guidance for changes in the chest compression rate and epinephrine administration interval based on a goal ETCO2 level improved survival and intra-arrest hemodynamics in this porcine cardiac arrest model.

Singapore Paediatric Resuscitation Guidelines 2021.

We present the 2021 Singapore Paediatric Resuscitation Guidelines. The International Liaison Committee on Resuscitation's Pediatric Taskforce Consensus Statements on Science and Treatment Recommendations, which was published in October 2020, and the updated resuscitation guidelines from the American Heart Association and European Resuscitation Council, were reviewed and discussed by the committee. These recommendations were derived after deliberation of peer-reviewed evidence updates on paediatric resuscitation and took into consideration the local setting and clinical practice.

Abstract 132: Cardiopulmonary Resuscitation with Chest Compressions During Sustained Inflations in a Pediatric Porcine Model - A Randomized Control Animal Trial

Background: Pediatric resuscitation guidelines recommend continuous chest compressions (CC) with asynchronized ventilation (CCaV) during cardiopulmonary resuscitation (CPR) once an airway has been secured. However, the optimal CC technique remains unknown. Aim: To determine if CCs during sustained inflations (SI) improves return of spontaneous circulation (ROSC) of asphyxiated pediatric piglets compared to CCaV. Intervention and measurements: Piglets (age 20-23 days) were anesthetized, intubated, instrumented, and asphyxiated. Protocolized resuscitation was initiated when mean arterial blood pressure was &lt;25mmHg with bradycardia. Piglets (n=12/group) were randomized to receive CCaV resuscitation (CCaV group) according to the current resuscitation guidelines, or CC during SI (CC+SI group). The CC+SI group received a SI with a peak inflating pressure of 25 cmH 2 O for 30sec, CCs were provided at a rate of 100/min, and SI was interrupted after 30 sec for one second before a further 30sec SI was provided. CC and SI were continued until ROSC. Respiratory parameters, carotid blood flow, systemic artery pressures, and cerebral oxygenation were measured. Main results: Median (IQR) time to ROSC was significantly decreased in the CC+SI group compared to CCaV with 248 (41-346)sec vs. 720 (167-720)sec (p=0.049), respectively. CC+SI had a 100% higher rate of ROSC compared to CCaV with 10(83%) vs. 5(42%) (p=0.089), respectively. Piglets in the CC+SI group received a median (IQR) 3.5 (0-5.8) intravenous epinephrine boluses compared to 8.0 (1.8-11) in the CCaV group (p=0.123). Conclusions: Combining CC and SI significantly improved time to ROSC and survival in asphyxiated pediatric piglets when compared to the current standard of CCs with CCaV during pediatric CPR.

Evaluation of Chest Compression Quality and Appropriateness in the Pediatric Cardiopulmonary Resuscitation

Background/Objective: This study aimed to verify the quality and the appropriateness of pediatric CPR chest compressions according to 2015 Korean Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.Method/Statistical Analysis: The participants of this study were 64 EMT and nursing students who were quailified as BLS providers. Four sets of 5 CPR cycles were performed with one hand and two hands at the ratio of chest compression (30 times) to respiration (2 times), and fatigue was confirmed by NRS(numeral rating scale). Collected data were analyzed using frequency, descriptive statistics, paired t-test, and repeated measure ANOVA by SPSS 22.0.Findings: While the total number of chest compressions (629.6 times vs. 618.3 times, p=.016) and hands-off time (6.6 sec vs. 6.9 sec, p=.006) were effective for one-handed chest compression, average pressure depth (42.2mm vs. 43.8mm, p<.001), sufficient chest compression depth rate (83.0% vs. 89.1%, p=.038) and fatigue (7.0 points vs. 6.2 points, p=.040) were more effective in two-handed chest compressions. In addition, there were significant differences in the average chest compression depth over time(p=.003) and the total elapsed time (p=.332), but no significant difference in inappropriate chest compression.Improvements/Applications: Performing pediatric CPR according to the 2015 Guidelines for Pediatric Cardiopulmonary resuscitation is acceptable, but it is necessary to consider two-hand chest compression more than one hand compression.

The use of pressure-controlled mechanical ventilation in a swine model of intraoperative pediatric cardiac arrest.

Current pediatric resuscitation guidelines suggest that resuscitators using an advanced airway deliver 8-10 breaths per minute while carefully avoiding excessive ventilation. In the intraoperative setting, having a dedicated ventilation rescuer may be difficult because of limited personnel. Continuing pressure-controlled mechanical ventilation during resuscitation for intraoperative cardiac arrest reduces personnel needed and the risk of hyperventilation but might risk hypoventilation during chest compression delivery. To determine whether the use of pressure-controlled mechanical ventilation at prearrest settings provides normoxia and normocarbia during resuscitation from cardiac arrest. We retrospectively analyzed combined data from preclinical randomized controlled trials. Two-week-old swine (3-4kg) underwent asphyxia-induced cardiac arrest. Animals were resuscitated with periods of basic and advanced life support. During resuscitation, pressure-controlled mechanical ventilation was delivered at the prearrest respiratory rate, peak inspiratory pressure, and positive end-expiratory pressure. Arterial blood gases were measured prearrest, at 11minutes of asphyxia, and at 8 and 20minutes of cardiopulmonary resuscitation. Piglets (n=154) received pressure-controlled mechanical ventilation before and during cardiopulmonary resuscitation with a peak inspiratory pressure of 14-15cm H2 O, positive end-expiratory pressure of 4cm H2 O, 20 breaths/minute, and an inspiratory:expiratory ratio of 1:2. During asphyxia, the arterial blood gas showed the expected severe hypercarbia and hypoxia. Continuing pressure-controlled mechanical ventilation using prearrest parameters and increasing the FiO2 to 1.0 returned the PaCO2 to prearrest levels and slightly increased the partial pressure of arterial oxygen at 8 and 20minutes of cardiopulmonary resuscitation. In this piglet model of resuscitation from asphyxial arrest, pressure-controlled mechanical ventilation during cardiopulmonary resuscitation at the prearrest ventilator settings with an FiO2 of 1.0 provides adequate oxygenation and restores normocarbia. Clinical investigation is warranted to determine the benefits of continuing pressure-controlled mechanical ventilation at prearrest parameters during pediatric cardiopulmonary resuscitation.

Updated Guidelines for Neonatal and Pediatric Resuscitation

Sponsoring Organization: American Heart Association (AHA)Background and ObjectiveInstead of en bloc revisions, the AHA now releases focused updates

Abstract 215: Hemodynamics of Absolute, Proportional, and Adaptive Mechanical Chest Compression Strategies in a Swine Model of Pediatric Out-Of-Hospital Cardiac Arrest

Background: Guidelines for pediatric resuscitation recommend a depth of 1.5in or 1/3 anterior-posterior chest diameter for chest compressions (CC) despite little supporting evidence. Objective: To evaluate the hemodynamic effects of the two recommended depths and an adaptive strategy. Methods: Thirty-eight animals (mass ~25kg) were sedated, anesthetized, intubated, and ventilated. Micromanometer pressure sensors were installed in the aorta and right atrium via the right femoral artery and vein. Coronary perfusion pressure (CPP) was calculated as aortic minus right atrial pressure. An ultrasonic flow probe was secured around the right common carotid. Biosignals were recorded at 1000Hz. Animals were then re-paralyzed, followed by a fentanyl bolus, and the endotracheal tube was occluded for 9min. Each was randomized to absolute (Group 1: 1.5in &amp; 100/min), proportional (Group 2: 1/3 AP diameter &amp; 100/min), or stepwise adaptive (Group 3: 1.5in &amp; 100/min, adding 0.25in or 5/min q25s until CPP &gt; 25mmHg) CC using a robotic compressor. Epinephrine (0.1mg/kg) and sodium bicarbonate (1mEq/kg) were given after 4min, followed by epinephrine (0.15mg/kg) q3min. Defibrillation (150J) was attempted after 5min; CPR discontinued after 20min. Mean arterial pressure (MAP), CPP and carotid blood flow (CBF) were calculated for the first 10 minutes of CPR and compared between groups with generalized estimating equations (GEE). Results: In GEE models, MAP, CBF and CPP did not differ between groups over the first 10 minutes of resuscitation. Each measure differed significantly over time (p&lt;0.05). When considering only the first 5 minutes (early phase including first pressor), hemodynamic variables also did not differ. Conclusion: In a swine model of asphyxial cardiac arrest, CC methods based on current guidelines and an additional adaptive approach did not differ hemodynamically.

Current Guideline of Chest Compression Depth for Children of All Ages May Be Too Deep for Younger Children.

Aim To determine whether the chest compression depth of at least 1/3 of the Anteroposterior (AP) diameter of the chest and about 5 cm is appropriate for children of all age groups via chest computed tomography. Methods The AP diameter of the chest, anterior chest wall diameter, and compressible diameter (Cd) were measured at the lower half of the sternum for patients aged 1-18 years using chest computed tomography. The mean ratio of 5 cm compression to the Cd of adult patients was used as the lower limit, and the mean ratio of 6 cm compression to the Cd of adult patients was used as the upper limit. Also, the depth of chest compression resulting in a residual depth <1 cm was considered to cause internal injury potentially. With the upper and lower limits, the compression ratios to the Cd were compared when compressions were performed at a depth of 1/3 the AP diameter of the chest and 5 cm for patients aged 1-18 years. Results Among children aged 1-7 years, compressing 5 cm was deeper than 1/3 the AP diameter. Also, among children aged 1-5 years, 5 cm did not leave a residual depth of 1 cm, potentially causing intrathoracic injury. Conclusion Current pediatric resuscitation guidelines of chest compression depth for children were too deep for younger children aged 1-7 years.

Common Conditions Requiring Emergency Life Support.

1. Kelsey Fawcett, MD*,† 2. Nicole Gerber, MD*,† 3. Shweta Iyer, MD*,† 4. Guillermo De Angulo, MD, MPH*,† 5. Martin Pusic, MD, PhD* 6. Michael Mojica, MD*,†,‡ 1. *Department of Emergency Medicine and 2. †Department of Pediatrics, New York University School of Medicine, New York, NY 3. ‡Department of Emergency Medicine, Bellevue Hospital Center, New York, NY * Abbreviations: AHA: : American Heart Association CPR: : cardiopulmonary resuscitation CT: : computed tomography ED: : emergency department ICP: : intracranial pressure ROSC: : return of spontaneous circulation Providers should be up to date on the evidence-based current guidelines for pediatric resuscitation and be able to identify and manage life-threatening illness and injury. After completing this article, readers should be able to: 1. Understand the major changes in the 2015 American Heart Association guidelines for pediatric basic life support, advanced life support, and postresuscitation care. 2. Initiate the management and identify prognostic factors associated with near drowning. 3. Identify the signs and symptoms of life-threatening thoracic injuries, including pneumothorax, hemothorax, flail chest, and cardiac tamponade. 4. Identify and manage cerebral edema in the asphyxiated patient. There are common emergencies in pediatrics that any pediatrician needs to be equipped to handle. Common office emergencies include respiratory distress, dehydration, seizures, and anaphylaxis. However, pediatricians also need to be prepared for common conditions that require emergency life support. These include, but are not limited to, cardiac arrest, near drowning, thoracic injuries, and cerebral edema. This article focuses on these common conditions that require emergency life support. ### Introduction Cardiac arrest is rare in the pediatric population. In 2015, the American Heart Association (AHA) released updated recommendations for pediatric advanced life support. (1) These updated guidelines, incorporating the available evidence, can guide resuscitation efforts to continue to improve overall survival after pediatric cardiac arrest and, in particular, improve survival with a favorable neurologic outcome. ### Basic Life Support An estimated 6,000 children experience out-of-hospital cardiac arrest per year in the United States. (2) The survival to hospital discharge is 11.3%, and survival with a neurologically favorable outcome is …

Singapore Paediatric Resuscitation Guidelines 2016.

We present the revised 2016 Singapore paediatric resuscitation guidelines. The International Liaison Committee on Resuscitation's Pediatric Taskforce Consensus Statements on Science and Treatment Recommendations, as well as the updated resuscitation guidelines from the American Heart Association and European Resuscitation Council released in October 2015, were debated and discussed by the workgroup. The final recommendations for the Singapore Paediatric Resuscitation Guidelines 2016 were derived after carefully reviewing the current available evidence in the literature and balancing it with local clinical practice.

Prescribing an automated external defibrillator for children at increased risk of sudden arrhythmic death.

Automated external defibrillators can be life-saving in out-of-hospital cardiac arrest. Our aim was to review our experience of prescribing automated external defibrillators for children at increased risk of sudden arrhythmic death. We reviewed all automated external defibrillators issued by the Scottish Paediatric Cardiac Electrophysiology Service from 2005 to 2015. All parents were given resuscitation training according to the Paediatric Resuscitation Guidelines, including the use of the automated external defibrillator. A total of 36 automated external defibrillators were issued to 36 families for 44 children (27 male). The mean age at issue was 8.8 years. Diagnoses at issue included long QT syndrome (50%), broad complex tachycardia (14%), hypertrophic cardiomyopathy (11%), and catecholaminergic polymorphic ventricular tachycardia (9%). During the study period, the automated external defibrillator was used in four (9%) children, and in all four the automated external defibrillator correctly discriminated between a shockable rhythm - polymorphic ventricular tachycardia/ventricular fibrillation in three patients with one or more shocks delivered - and non-shockable rhythm - sinus rhythm in one patient. Of the three children, two of them who received one or more shocks for ventricular fibrillation/polymorphic ventricular tachycardia survived, but one died as a result of recurrent torsades de pointes. There were no other deaths. Parents can be taught to recognise cardiac arrest, apply resuscitation skills, and use an automated external defibrillator. Prescribing an automated external defibrillator should be considered for children at increased risk of sudden arrhythmic death, especially where the risk/benefit ratio of an implantable defibrillator is unclear or delay to defibrillator implantation is deemed necessary.

A new chest compression depth indicator would increase compression depth without increasing overcompression risk

PurposeAdequate chest compression (CC) depth is critical for effective cardiopulmonary resuscitation. Pediatric resuscitation guidelines recommend that CC be at least one-third of the anterior-posterior (AP) chest diameter or approximately 4 cm in infants and 5 cm in children. We aimed to find a better indicator of CC depth that maximizes CC depth while also minimizing injury. Basic proceduresChest computed tomographic images of patients aged 8 years and younger were measured for external diameter (ED) (AP distance from skin to skin) and internal diameter (AP distance between internal surface of anterior chest wall and anterior surface of vertebral body) at the midway of the lower half of the sternum. Compressible depth was defined as 1 cm short of internal diameter. We determined that up to a 10% estimated risk of overcompression is acceptable and approximated a quantile regression line for the 10th percentile of compressible depth on ED. After rounding coefficients, we used its equation as a new indicator. Main findingsA total of 426 images were analyzed. The new indicator had a slope of 0.5 and an intercept of −1.9 cm (1 fingerbreadth). Compared to one-third ED, the new indicator would provide deeper CC with average difference of 1.9 mm (95% confidence interval, 1.6-2.2 mm) without increasing the risk of overcompression (both 4.9%). Chest compression of 4/5 cm would provide deeper CC compared to the new indicator (difference, 3.5 mm; 95% confidence interval, 2.7-4.1 mm); however, its overcompression risk was too high (31.5%). Principal conclusionChest compression of one-half ED minus 1 fingerbreadth maximizes CC depth without increasing overcompression in pediatric population.

G574(P) Improving patient care through paediatric simulation and multi-disciplinary resuscitation training based upon previous serious incidents at a district general hospital

Context The quality improvement project was undertaken at a District General Hospital and included staff who care for seriously sick or injured children including doctors and nurses working in general paediatrics, accident and emergency and anaesthetics. The appropriate initial assessment and resuscitation of serious ill and injured children together with on-going reassessment and emergency management are essential for reducing morbidity and mortality. Problem There was no integrated multi-disciplinary team (MDT) paediatric resuscitation training and several paediatric serious incidents had involved more than one department. Simulation training increases the acquisition of skills and provides a platform to review performance and make errors without compromising patient safety. Both the Department of Health and RCPCH recognise the importance of simulation training in improving patient safety through reducing human and system errors. High fidelity manikins can be monitored which significantly adds to their realism. Assessment of problem and analysis of its causes A retrospective review was undertaken by a paediatric trainee of all the paediatric serious incidents during a ten year period to identify common themes and key recommendations. The development of MDT resuscitation training was one of the principle recommendations to improve the emergency assessment and care provided to children. Intervention MDT paediatric resuscitation training sessions involving healthcare assistants, nurses, doctors and other allied healthcare professionals from general paediatrics, accident and emergency and anaesthetics were planned several months in advance through a consultation process. Dates and times were chosen to maximise trainee availability and minimise disruption to routine services. For MDT training in accident and emergency, strategies were implemented to ensure patient safety at all times. Resuscitation officers provided support and resuscitation equipment. The hospital switch board was notified so a simulated paediatric crash call could be initiated through the hospital paging system. Scenarios were developed based upon previous paediatric serious incidents to review whether key recommendations had been successfully implemented and sustained. The focus was on familiarisation with paediatric resuscitation equipment, drugs and guidelines in real time as well as teamwork, communication and leadership skills and dynamics between and within the different specialties. A pilot paediatric simulation MDT training session was also undertaken in the Education Centre. Strategy for change MDT paediatric resuscitation training was coordinated through the paediatric and emergency departments as well as the hospital resuscitation committee. Anonymous feedback through questionnaires was collected from participants. Measurement of improvement The MDT paediatric resuscitation and simulation training received very positive feedback: Excellent scenario, felt more real than other simulated scenarios I have attended. Participants found the MDT simulation training much more realistic than weekly departmental resuscitation training with 79% strongly recommending the simulation training compared with just 33% for the weekly departmental training. Effects of changes MDT paediatric resuscitation training was successfully implemented. A business case was developed for the purchase of a paediatric simulation manikin to improve the reality of the training. Lessons learnt MDT paediatric resuscitation training is a very valuable tool for improving teamwork and paediatric resuscitation skills. Paediatric high fidelity simulation training can enhance this further through providing a more realistic experience. Message for others MDT resuscitation training should be routine practice in district general hospitals. Basing scenarios on previous serious incidents is a useful way to review previous key recommendations. A business case can be developed by demonstrating improved experience through a pilot high fidelity simulation trainer.