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Pediatric cardiopulmonary resuscitation: The new AHA guidelines

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Abstract

The new guidelines for pediatric cardiopulmonary resuscitation are based on the best present in the literature. Although there are few studies in the pediatric population, recommendations have been made for lay-person basic life support (BLS), airway m MM gement, drugs, treatment of rhythm disturbances, mid newborn resuscitation.

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Pediatric resuscitation has been a topic of discussion for years. It is difficult to keep abreast of changing recommendations, especially for busy pediatricians who do not regularly use these skills. This review will focus on the most recent guidelines for resuscitation drugs. Three specific questions will be discussed: standard dose versus high-dose epinephrine, amiodarone use, and the future of vasopressin in pediatric resuscitation. The issue of using high-dose epinephrine for cardiopulmonary resuscitation refractory to standard dose epinephrine has been a topic of debate for many years. Recently, a prospective, double-blinded study was performed to help settle the debate. These results will be reviewed and compared with previous studies. Amiodarone is a medication that was added to the pediatric resuscitation algorithms with the most recent recommendations from the American Heart Association in 2000. Its use and safety will also be discussed. Another topic that is resurfacing in resuscitation is the use of vasopressin. Its mechanism and comparisons to other agents will be highlighted, although its use in the pediatric patient has not been thoroughly studied. Pediatric resuscitation is a constantly evolving subject that is on the mind of anyone taking care of sick children. Clinicians are continually searching for the most effective methods to resuscitate children in terms of short- and long-term outcomes. It is important to be familiar with not only the agents being used but also the optimal way to use them.
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Context Endotracheal intubation (ETI) is widely used for airway management of children in the out-of-hospital setting, despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome.Objective To compare the survival and neurological outcomes of pediatric patients treated with bag-valve-mask ventilation (BVM) with those of patients treated with BVM followed by ETI.Design Controlled clinical trial, in which patients were assigned to interventions by calendar day from March 15, 1994, through January 1, 1997.Setting Two large, urban, rapid-transport emergency medical services (EMS) systems.Participants A total of 830 consecutive patients aged 12 years or younger or estimated to weigh less than 40 kg who required airway management; 820 were available for follow-up.Interventions Patients were assigned to receive either BVM (odd days; n = 410) or BVM followed by ETI (even days; n = 420).Main Outcome Measures Survival to hospital discharge and neurological status at discharge from an acute care hospital compared by treatment group.Results There was no significant difference in survival between the BVM group (123/404 [30%]) and the ETI group (110/416 [26%]) (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.61-1.11) or in the rate of achieving a good neurological outcome (BVM, 92/404 [23%] vs ETI, 85/416 [20%]) (OR, 0.87; 95% CI, 0.62-1.22).Conclusion These results indicate that the addition of out-of-hospital ETI to a paramedic scope of practice that already includes BVM did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system. Figures in this Article Although bag-valve-mask ventilation (BVM) and endotracheal intubation (ETI) are both widely used in the out-of-hospital setting in caring for critically ill or injured children, there has been no controlled study comparing the outcomes of pediatric or adult patients treated with these 2 procedures. In 1 out-of-hospital study, BVM did compare favorably to non-ETI advanced airway management techniques (pharyngeal tracheal lumen, laryngeal mask, and esophageal tracheal combination esophageal-tracheal tube) among adults and children, as measured by PO2 and PCO2 values on arrival in the emergency department (ED), frequency of vomiting, and patient outcome.1 There have been a number of descriptive studies of ETI in the out-of-hospital setting. Reported success rates of pediatric ETI vary from 50% to 100%, depending on the patient's presenting illness or injury, the age of the patient, education level of the health care provider, and use of neuromuscular blocking agents to facilitate intubation.2- 10 Major complications of ETI, such as esophageal intubation, have been reported in as little as 1.8% and as many as 17% of pediatric patients in the out-of-hospital setting.7,10 One study reported an overall complication rate of 22.6%, using succinylcholine to facilitate intubation.10 Despite the fact that retrospective studies comparing the survival of patients treated with BVM and ETI have generally found no difference, some investigators have suggested that ETI may be beneficial in certain patient subgroups, such as those with submersion injury and cardiopulmonary arrest.4,6,11- 13 Moreover, despite limited comparative data for BVM and ETI, and the high complication rates reported for pediatric ETI in the out-of-hospital setting, pediatric ETI is taught in 97% of paramedic training schools and widely used by out-of-hospital providers.14 This study compared the survival and neurological outcomes of pediatric patients assigned to receive BVM with those of patients assigned to receive ETI in the out-of-hospital setting.
Article
Animal studies suggest that the standard dose of epinephrine (SDE) for treatment of cardiac arrest in human beings may be too low. We compared the outcome after SDE with that after high-dose epinephrine (HDE) in children with refractory cardiac arrest. Prospective intervention versus historic control groups. Two similar groups of 20 consecutive patients each (median ages, 2.5 and 3 years) with witnessed cardiac arrest who remained in arrest after at least two SDEs (0.01 mg/kg). Treatment with an additional SDE versus HDE (0.2 mg/kg). The rates of return of spontaneous circulation and long-term survival were compared. Fourteen of the HDE group (70%) had return of spontaneous circulation, whereas none of the SDE group did (P less than .001). Eight children survived to discharge after HDE, and three were neurologically intact at follow-up. No significant toxicity from HDE was observed. HDE provided a higher return of spontaneous circulation rate and a better long-term outcome than SDE in our series of pediatric cardiac arrest. HDE may warrant incorporation into standard resuscitation protocols at an early enough point to prevent irreversible brain injury.
Article
To evaluate retention of CPR skills by medical residents (MDs), registered nurses (RNs), we tested single-rescuer CPR skills of 21 MDs, 17 RNs, and 21 laypersons using recording manikin and American Heart Association criteria. All study participants had been trained from 4 to 12 months before testing. No MD or RN and only one layperson performed each step correctly and in proper sequence. If calls for assistance were eliminated, one additional layperson, two MDs, and two RNs performed correctly. There were no significant differences between the MDs and RNs. MDs and RNs did better (p less than .01) in assessment compared to laypersons, but some individuals in each group initiated ventilations and compressions without assessing need. There was no difference in the ability to perform ventilations; all three groups did poorly. MDs and RNs performed compression skills better than laypersons (p less than .01), but all had difficulty with rate and depth of compressions. Moreover, only one-third of the general public demonstrated correct hand placement. Despite more training and experience, MD and RN performance was comparable to layperson performance. These data suggest that improving basic life-support skills could save more lives.
Article
The instruction of cardiopulmonary resuscitation (CPR) faces new challenges. With the current poor resuscitation outcomes of victims of sudden death syndrome, the impetus to include early defibrillation as a basic skill for laypersons imposes the need to simplify CPR instruction and reduce the time required to teach this technique. The exploration of an alternative paradigm has gained both public and academic interest. Some of the constraints have evolved around the urgent need to bring both CPR and automated external defibrillation instruction to a much larger population segment and at the same time reduce the time needed to accomplish this task. Additional debate exists with respect to maintaining the current traditional training methods or the use of new media such as video-based instruction, interactive computer-based software, and public service announcements. To answer any one of these questions we are tasked with having to objectively document not only retention and performance of learned skills, but the ultimate impact that any of these elements have on survival and outcome. This has to balance against the ongoing scourge of sudden cardiac death, which claims the lives of 350,000 Americans each year.
Article
Little information is available about the effects of CPR in children, although it is known that the outcomes are dismal. Examples of unanswered questions include which advanced life support (ALS) procedures should be performed out-of-hospital, whether high-dose epinephrine improves survival, and the true prevalence of ventricular fibrillation as a presenting rhythm. Children differ from adults as to the cause and pathophysiology of cardiopulmonary arrest, but prehospital EMS and hospital resuscitation teams were initially designed for the care of adults. Because pediatric cardiopulmonary arrest is rare, prospective data are difficult to gather, and there are few large published studies. The purpose of this collective review was to review the current body of knowledge regarding survival rates and outcomes in pediatric CPR and, based on this review, to outline a course for future research.
Article
Policies of most neonatal intensive care units include teaching cardiopulmonary resuscitation (CPR) to parents or other caretakers prior to infant hospital discharge. However, little is known about CPR skills retention in this population or the outcome of parents' use of CPR. This is a study to measure CPR skills 6 months following CPR training to identify characteristics predicting successful performance and to determine if parents used CPR. A sample of 100 parents or related caretakers of infants at risk for an out-of-hospital respiratory or cardiac arrest 6 months following CPR training were asked to demonstrate CPR on an infant mannequin and 94 agreed to participate. Although they were excluded from the study if they had a CPR course within the past 2 years, 37% had taken CPR sometime in the past. Only one third of participants (n = 31, 33%) were able to perform satisfactory CPR. Those who demonstrated satisfactory CPR skills were more likely to have had previous CPR training and to have experienced higher levels of social support at the time of training than those who achieved unsatisfactory CPR performance ratings (p < .05). A logistic regression analysis revealed previous CPR training, social support, and level of anxiety at time of CPR training to be the most important predictors of CPR skills retention. Seven parents reported using CPR to resuscitate their infant who had suffered a respiratory arrest. All seven were successful. CPR skills decay is significant for caregivers of infants at high risk for cardiopulmonary arrest. Parents should be encouraged to review the steps of CPR frequently and to attend refresher classes. A significant proportion of parents of infants hospitalized in the neonatal intensive care unit are called upon to use CPR and are able to use it appropriately.
Article
Since the introduction around 1960 of external cardiopulmonary resuscitation (CPR) basic life support (BLS) without equipment, i.e. steps A (airway control)-B (mouth-to-mouth breathing)-C (chest (cardiac) compressions), training courses by instructors have been provided, first to medical personnel and later to some but not all lay persons. At present, fewer than 30% of out-of-hospital resuscitation attempts are initiated by lay bystanders. The numbers of lives saved have remained suboptimal, in part because of a weak or absent first link in the life support chain. This review concerns education research aimed at helping more lay persons to acquire high life supporting first aid (LSFA) skill levels and to use these skills. In the 1960s, Safar and Laerdal studied and promoted self-training in LSFA, which includes: call for the ambulance (without abandoning the patient) (now also call for an automatic external defibrillator); CPR-BLS steps A-B-C; external hemorrhage control; and positioning for shock and unconsciousness (coma). LSFA steps are psychomotor skills. Organizations like the American Red Cross and the American Heart Association have produced instructor-courses of many more first aid skills, or for cardiac arrest only-not of LSFA skills needed by all suddenly comatose victims. Self-training methods might help all people acquire LSFA skills. Implementation is still lacking. Variable proportions of lay trainees evaluated, ranging from school children to elderly persons, were found capable of performing LSFA skills on manikins. Audio-tape or video-tape coached self-practice on manikins was more effective than instructor-courses. Mere viewing of demonstrations (e.g. televised films) without practice has enabled more persons to perform some skills effectively compared to untrained control groups. The quality of LSFA performance in the field and its impact on outcome of patients remain to be evaluated. Psychological factors have been associated with skill acquisition and retention, and motivational factors with application. Manikin practice proved necessary for best skill acquisition of steps B and C. Simplicity and repetition proved important. Repetitive television spots and brief internet movies for motivating and demonstrating would reach all people. LSFA should be part of basic health education. LSFA self-learning laboratories should be set up and maintained in schools and drivers' license stations. The trauma-focused steps of LSFA are important for 'buddy help' in military combat casualty care, and natural mass disasters.
Statement by Ad Hoc Committee on Cardiopulmonary Resuscitation of the Division of Medical Sciences, National Academy of Sciences, National Research Council
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