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Ames SG, Workman JK, Olson JA, Korgenski EK, Masotti S, Knackstedt ED, Bratton SL, Larsen GY. Infectious Etiologies and Patient Outcomes in Pediatric Septic Shock. J Pediatric Infect Dis Soc 2017; 6:80-86. [PMID: 26837956 DOI: 10.1093/jpids/piv108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 12/15/2015] [Indexed: 11/12/2022]
Abstract
BACKGROUND Septic shock remains an important cause of death and disability in children. Optimal care requires early recognition and treatment. METHODS We evaluated a retrospective cohort of children (age <19) treated in our emergency department (ED) for septic shock during 2008-2012 to investigate the association between timing of antibiotic therapy and outcomes. The exposures were (1) receipt of empiric antibiotics in ≤1 hour and (2) receipt of appropriate antibiotics in ≤1 hour. The primary outcome was development of new or progressive multiple system organ dysfunction syndrome (NP-MODS). The secondary outcome was mortality. RESULTS Among 321 patients admitted to intensive care, 48% (n = 153) received empiric antibiotics in ≤1 hour. These patients were more ill at presentation with significantly greater median pediatric index of mortality 2 (PIM2) scores and were more likely to receive recommended resuscitation in the ED (61% vs 14%); however, rates of NP-MODS (9% vs 12%) and hospital mortality (7% vs 4%) were similar to those treated later. Early, appropriate antibiotics were administered to 33% (n = 67) of patients with identified or suspected bacterial infection. These patients had significantly greater PIM2 scores but similar rates of NP-MODS (15% vs 15%) and hospital mortality (10% vs 6%) to those treated later. CONCLUSIONS Critically ill children with septic shock treated in a children's hospital ED who received antibiotics in ≤1 hour were significantly more severely ill than those treated later, but they did not have increased risk of NP-MODS or death.
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Affiliation(s)
| | | | | | - E Kent Korgenski
- Pediatric Clinical Program, Intermountain Healthcare, Salt Lake City, Utah
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Abstract
OBJECTIVE Recent Pediatric Advanced Life Support (PALS) guidelines have deemphasized the use of advanced airways in short transport. It is unclear if guideline recommendations have altered practice. We sought to determine if a temporal change exists in the number of prehospital pediatric trauma intubations since the 2005 PALS guidelines update. METHODS This is an institutional review board-approved, retrospective, single-center study. Reviewed all pediatric trauma activations where patients younger than 19 years were intubated at the scene, en route or at the level 1 trauma center during 2006 to 2011. Specific complications collected were esophageal intubations, mainstem intubations and need for re-intubations. RESULTS There were 1012 trauma activations, 1009 pediatric patients, 300 (29.7%) intubated during transport to Children's Hospital of Wisconsin Pediatric Trauma Center (PTC) or upon arrival. Mean age of 9.5 ± 5.9 years. Fifty-seven percent (n = 172) were intubated before PTC, 31.7% (n = 95) field intubations, 25.7% (n = 77) outside facility intubations. 44% (n = 132) at PTC. Age was not a significant variable. There was no difference in the proportion of injured children requiring intubation who were intubated before arrival to the PTC. Those intubated in the field versus a facility had significantly increased mortality (P = 0.0002), longer hospital days (P = 0.0004) including intensive care unit days (P = 0.0003) and ventilator days (P = 0.0003) even when adjusted for illness severity. CONCLUSIONS There was no significant change in the proportion of pretrauma room intubations following the 2005 PALS guidelines even when adjusted for illness or injury severity. Children injured farther from the PTC and more severely injured children were more likely to be intubated before arrival at the PTC.
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Wolfe H, Morgan RW, Donoghue A, Niles DE, Kudenchuk P, Berg RA, Nadkarni VM, Sutton RM. Quantitative analysis of duty cycle in pediatric and adolescent in-hospital cardiac arrest. Resuscitation 2016; 106:65-9. [PMID: 27353289 DOI: 10.1016/j.resuscitation.2016.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 05/17/2016] [Accepted: 06/02/2016] [Indexed: 10/21/2022]
Abstract
AIMS Quality cardiopulmonary resuscitation (CPR) is associated with improved outcomes during cardiac arrest. Duty cycle (DC) represents an understudied element of CPR quality. Our objective was to quantitatively analyze DC during actual pediatric and adolescent in-hospital cardiac arrest (IHCA). METHODS Prospective observational study of IHCA at a large academic children's hospital. CPR variables included DC (%) up to the first 10min of recorded chest compressions (CCs). American Heart Association (AHA) DC compliance was prospectively defined as an average event DC of 50±5%. Percentage of events compliant with AHA DC was compared to a priori hypothesized compliance percentage of 25% using chi-square. Association between DC quartiles and categories of depth (<38, 38-49, ≥50mm) and rate (<100, 100-120, >120min(-1)) were analyzed by chi-square test for trend. RESULTS Between October 2006 and June 2015, 97 events in 87 patients were analyzed. Mean DC for events was 40±2.8%. DC quartiles: Q1 (DC ≤38.3%), Q2 (>38.3-40.1%), Q3 (>40.1-42.1%), Q4 (>42.1%). Only 5 (5.2%) events met AHA DC compliance, significantly less than the a priori hypothesis of 25% (p<0.001). Average CC rates trended higher across DC quartiles: (Q1) 105±9; (Q2) 106±9; (Q3) 112±8; and (Q4) 118±14min(-1); p<0.001. Other CPR quality variables were not associated with DC. There was no association between DC and survival. CONCLUSIONS Compression DC during resuscitation of actual child and adolescent IHCA met AHA recommendations in only 5% of events. In this series we found no association of DC with CC depth or survival.
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Affiliation(s)
- Heather Wolfe
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | - Ryan W Morgan
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Aaron Donoghue
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Dana E Niles
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Peter Kudenchuk
- The University of Washington, Department of Medicine, Division of Cardiology, Seattle, WA 98195-6422, United States
| | - Robert A Berg
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Vinay M Nadkarni
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Robert M Sutton
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States
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Southerland JH, Brown LR. Conscious Intravenous Sedation in Dentistry: A Review of Current Therapy. Dent Clin North Am 2016; 60:309-346. [PMID: 27040288 DOI: 10.1016/j.cden.2015.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Several sedation options are used to minimize pain, anxiety, and discomfort during oral surgery procedures. Minimizing or eliminating pain and anxiety for dental care is the primary goal for conscious sedation. Intravenous conscious sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate as well as cardiovascular function. Patients must retain their protective airway reflexes, and respond to and understand verbal communication. The drugs and techniques used must therefore carry a broad margin of safety.
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Affiliation(s)
- Janet H Southerland
- Department of Oral and Maxillofacial Surgery, Meharry Medical College School of Dentistry, 1005 Dr. DB Todd Jr. Boulevard, Nashville, TN 37208, USA.
| | - Lawrence R Brown
- Dadeland Oral Surgery Associates, 8950 S.W. 74th Court, Suite 1610, Miami Florida 33156; Baptist Hospital Of Miami, 8900 North Kendall Drive, Miami Florida 33176
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Khan M, Brown N, Mian AI. Point-of-care lactate measurement in resource-poor settings. Arch Dis Child 2016; 101:297-8. [PMID: 26582825 DOI: 10.1136/archdischild-2015-309484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 10/23/2015] [Indexed: 11/03/2022]
Affiliation(s)
- Muhammad Khan
- Department of Emergency Medicine, Aga Khan University (AKU), Karachi, Pakistan
| | - Nick Brown
- Department of Paediatric Medicine, Salisbury District Hospital, Wiltshire, UK Department of Child Health and Epidemiology, AKU, Karachi, Pakistan
| | - Asad I Mian
- Department of Emergency Medicine, Paediatrics and Child Health, AKU, Karachi, Pakistan
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Badawy SM, Thompson AA, Sand M. In-flight emergencies: Medical kits are not good enough for kids. J Paediatr Child Health 2016; 52:363-5. [PMID: 27145496 DOI: 10.1111/jpc.13118] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 11/04/2015] [Accepted: 11/25/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Sherif M Badawy
- Department of Pediatrics, Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine at Northwestern University, Chicago, Illinois, United States.,Department of Pediatrics, Division of Hematology and Oncology, Faculty of Medicine at Zagazig University, Zagazig, Egypt
| | - Alexis A Thompson
- Department of Pediatrics, Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine at Northwestern University, Chicago, Illinois, United States
| | - Michael Sand
- Dermatologic Surgery Unit, Department of Dermatology, Venereology and Allergology, Ruhr-University Bochum, Bochum.,Department of Plastic Surgery, St. Josef Hospital, Catholic Clinics of the Ruhr Peninsula, Essen, Germany
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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Antiarrhythmics. Pediatr Crit Care Med 2016; 17:S49-58. [PMID: 26945329 DOI: 10.1097/pcc.0000000000000620] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Arrhythmias are a common occurrence in critically ill pediatric patients. Pharmacotherapy is a usual modality for treatment and prevention of arrhythmias in this patient population. This review will highlight particular arrhythmias in the pediatric critical care population and discuss salient points of pharmacotherapy of these arrhythmias. The mechanisms of action for the various agents, potential adverse events, place in therapy, and evidence for their use will be summarized. DATA SOURCES The literature was searched for articles related to the topic. Expertise of the authors and a consensus of the editors were additional sources of data in the article. DATA SYNTHESIS The author team synthesized the current pharmacology and recommendations and present them in this review. Tables were generated to summarize the state of the art evidence-based practice. CONCLUSION Specialized knowledge as to the safe and effective use of the antiarrhythmic pharmacotherapy in the intensive care setting can lead to safe and effective rhythm management in patients with complex heart disease.
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A pragmatic checklist to identify pediatric ICU patients at risk for cardiac arrest or code bell activation. Resuscitation 2015; 99:33-7. [PMID: 26703460 DOI: 10.1016/j.resuscitation.2015.11.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 11/08/2015] [Accepted: 11/26/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND In-hospital cardiac arrest is a rare event associated with significant morbidity and mortality. The ability to identify the ICU patients at risk for cardiac arrest could allow the clinical team to prepare staff and equipment in anticipation. METHODS This pilot study was completed at a large tertiary care pediatric intensive care unit to determine the feasibility of a simple checklist of clinical variables to predict deterioration. The daily checklist assessed patient risk for critical deterioration defined as cardiac arrest or code bell activation within 24h of the checklist screen. The Phase I checklist was developed by expert consensus and evaluated to determine standard diagnostic test performance. A modified Phase II checklist was developed to prospectively test the feasibility and bedside provider "number needed to train". RESULTS For identifying patients requiring code bell activation, both checklists demonstrated a sensitivity of 100% with specificity of 76.0% during Phase I and 97.7% during Phase II. The positive likelihood ratio improved from 4.2 to 43.7. For identifying patients that had a cardiac arrest within 24h, the Phase I and II checklists demonstrated a sensitivity of 100% with specificity again improving from 75.7% to 97.6%. There was an improved positive likelihood ratio from 4.1 in Phase I to 41.9 in Phase II, with improvement of "number needed to train" from 149 to 7.4 providers. CONCLUSIONS A novel high-risk clinical indicators checklist is feasible and provides timely and accurate identification of the ICU patients at risk for cardiac arrest or code bell activation.
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Khursheed M, Bhatti J, Parukh F, Feroze A, Naeem S, Khawaja H, Razzak J. Dead on arrival in a low-income country: results from a multicenter study in Pakistan. BMC Emerg Med 2015; 15 Suppl 2:S8. [PMID: 26689125 PMCID: PMC4682389 DOI: 10.1186/1471-227x-15-s2-s8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND This study assessed the characteristics of dead on arrival (DOA) patients in Pakistan. METHODS Data about the DOA patients were extracted from Pakistan National Emergency Department Surveillance study (Pak-NEDS). This study recruited all ED patients presenting to seven tertiary care hospitals during a four-month period between November 2010 and March 2011. This study included patients who were declared dead-on-arrival by the ED physician. RESULTS A total of 1,557 DOA patients (7 per 1,000 visits) were included in the Pak-NEDS. Men accounted for two-thirds (64%) of DOA patients. Those aged 20-49 years accounted for about 46% of DOA patients. Nine percent (n = 72) of patients were brought by ambulance, and most patients presented at a public hospital (80%). About 11% of DOA patients had an injury. Factors significantly associated (p < 0.05) with ambulance use were men (adjusted odds ratio [aOR] = 2.72), brought to a private hospital (OR = 2.74), and being injured (aOR = 1.89). Cardiopulmonary resuscitation (CPR) was performed on 6% (n = 42) of patients who received treatment. Those brought to a private hospital were more likely to receive CPR (aOR = 2.81). CONCLUSION This study noted a higher burden of DOA patients in Pakistan compared to other resourceful settings (about 1 to 2 per 1,000 visits). A large proportion of patients belonging to productive age groups, and the low prevalence of ambulance and CPR use, indicate a need for improving the prehospital care and basic life support training in Pakistan.
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De Luca D, Romain O, Yousef N, Andriamanamirija D, Shankar-Aguilera S, Walls E, Sgaggero B, Aube N, Tissières P. Monitorages physiopathologiques en réanimation néonatale. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.jpp.2015.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Li R, Dong W, He W, Liu Y. Chinese dental students' knowledge and attitudes toward HIV/AIDS. J Dent Sci 2015; 11:72-78. [PMID: 30894949 PMCID: PMC6395151 DOI: 10.1016/j.jds.2015.09.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 08/25/2015] [Indexed: 11/28/2022] Open
Abstract
Background/purpose Oral care is vital to human immunodeficiency virus (HIV)-positive individuals. As future dentists, it is pertinent that dental students have sufficient knowledge and a positive approach toward this disease. The purpose of this study was to assess HIV/AIDS-related knowledge and attitudes among clinical dental students in central China. Materials and methods This survey was conducted on 103 dental students in the final year of a 5-year program. A structured questionnaire with 50 questions examining their knowledge under various categories and 17 questions examining their attitudes toward the disease was employed. Results The survey was completed by 92.2% (95/103) of the students. The results revealed that more than half of the respondents demonstrated a good level of knowledge, although few exhibited an excellent level. The mean scores on knowledge was 79.41 ± 6.3 out of a maximum possible score of 100, and there was no significant difference regarding sex. Despite their good level of knowledge, the majority (93.68%) displayed a negative attitude (nonprofessional attitude) toward HIV/AIDS. Conclusion These findings might help to define strategies to improve the quality of education among Chinese dental students and suggests that there is a need to address student misconceptions and attitudes toward the disease.
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Affiliation(s)
- Rui Li
- Department of Stomatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, PR China
| | - Wenhang Dong
- Department of Stomatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, PR China
| | - Wei He
- Department of Stomatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, PR China
| | - Yiming Liu
- Department of Stomatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, PR China
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Bélondrade P, Lefort H, Bertho K, Perrochon JC, Jost D, Tourtier JP, Chabernaud JL. Guidelines for care of the newborn baby at birth knowledge by prehospital emergency physicians. Anaesth Crit Care Pain Med 2015; 35:17-23. [PMID: 29610057 DOI: 10.1016/j.accpm.2015.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 06/16/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION In 2010, the International Liaison Committee On Resuscitation (ILCOR) guidelines for care of the newborn baby immediately after birth were published. MATERIALS AND METHODS Using a questionnaire that was distributed to a sample of 44 prehospital emergency physicians (April 2014), we assessed knowledge of these guidelines, in particular specificities for newborns as compared to adults. Twenty-five questions, starting with a birth with no problems to one resulting in neonatal distress, were used to profile the practice of the surveyed physicians. RESULTS Among the solicited physicians, 30 responded to the questionnaire (68%). Priority was given to efficient respiratory resuscitation during the first minutes of extrauterine life and the difficulties of newborn respiratory adaptation are well-known, but their implementation remains imperfectly understood. The assessment showed very mixed results, partly explained by the low frequency of newborn scenarios experienced by the practitioners who responded to the questionnaire. CONCLUSION To move from guidelines to their practical implementation is always delicate, with room for improvement such as continuing education, knowledge assessment and practice in the context of a quality approach. Well accepted, this evaluation process could be renewed upon publication of the next guidelines on this subject, thus contributing to their knowledge.
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Affiliation(s)
- Pascal Bélondrade
- Service des urgences/Samu, Centre hospitalier de Cayenne, rue des Flamboyants, BP 6006, 97300 Cayenne, France
| | - Hugues Lefort
- Service médical d'urgence, Brigade de sapeurs-pompiers de Paris, 1, place Jules-Renard, 75017 Paris, France.
| | - Kilian Bertho
- Antenne médicale spécialisée de Satory, 34, rue de la Martinière, 78000 Versailles, France
| | | | - Daniel Jost
- Service médical d'urgence, Brigade de sapeurs-pompiers de Paris, 1, place Jules-Renard, 75017 Paris, France
| | - Jean-Pierre Tourtier
- Service médical d'urgence, Brigade de sapeurs-pompiers de Paris, 1, place Jules-Renard, 75017 Paris, France
| | - Jean-Louis Chabernaud
- Smur pédiatrique (Samu 92), Pôle FAME, Hôpital Antoine-Béclère, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France
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Wolf RB, Edwards K, Grijalva CG, Self WH, Zhu Y, Chappell J, Bramley AM, Jain S, Williams DJ. Time to clinical stability among children hospitalized with pneumonia. J Hosp Med 2015; 10:380-3. [PMID: 25919391 PMCID: PMC4456292 DOI: 10.1002/jhm.2370] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 03/21/2015] [Accepted: 04/02/2015] [Indexed: 01/05/2023]
Abstract
We evaluated the performance of time to clinical stability (TCS), a longitudinal outcome measure using 4 physiologic parameters (temperature, heart rate, respiratory rate, and use of supplemental oxygen), among children enrolled in a prospective study of pneumonia hospitalizations. We calculated the time from admission to normalization for each of the 4 parameters individually along with various combinations of these parameters (≥2 parameters). We assessed for agreement between the combined TCS measures and both hospital length of stay and an ordinal severity scale (nonsevere, severe, and very severe). Overall, 323 (96.7%) of 334 included children had ≥1 parameter abnormal on admission; 70 (21%) children had ≥1 parameter abnormal at discharge. For the 4 combined measures, median TCS decreased with increasing age. Increasing TCS was associated with both longer length of stay and increasing disease severity. The simplest combined measure incorporating only respiratory rate and need for supplemental oxygen performed similarly to more complex measures including additional parameters. Our study demonstrates that longitudinal TCS measures may be useful in children with pneumonia, both in clinical settings to assess recovery and readiness for discharge, and as an outcome measure in research and quality assessments. Additional study is needed to further validate our findings.
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Affiliation(s)
- Rachel B Wolf
- The Monroe Carell Jr. Children's Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Kathryn Edwards
- The Monroe Carell Jr. Children's Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Yuwei Zhu
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - James Chappell
- Department of Pathology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Anna M Bramley
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Seema Jain
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Derek J Williams
- The Monroe Carell Jr. Children's Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
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Thakur A, Saluja S, Modi M, Kler N, Garg P, Soni A, Kaur A, Chetri S. T-piece or self inflating bag for positive pressure ventilation during delivery room resuscitation: An RCT. Resuscitation 2015; 90:21-4. [DOI: 10.1016/j.resuscitation.2015.01.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 12/22/2014] [Accepted: 01/19/2015] [Indexed: 10/24/2022]
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Sutton RM, Case E, Brown SP, Atkins DL, Nadkarni VM, Kaltman J, Callaway C, Idris A, Nichol G, Hutchison J, Drennan IR, Austin M, Daya M, Cheskes S, Nuttall J, Herren H, Christenson J, Andrusiek D, Vaillancourt C, Menegazzi JJ, Rea TD, Berg RA. A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality--A report from the ROC epistry-cardiac arrest. Resuscitation 2015; 93:150-7. [PMID: 25917262 DOI: 10.1016/j.resuscitation.2015.04.010] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/20/2015] [Accepted: 04/11/2015] [Indexed: 10/23/2022]
Abstract
AIM High-quality cardiopulmonary resuscitation (CPR) may improve survival. The quality of CPR performed during pediatric out-of-hospital cardiac arrest (p-OHCA) is largely unknown. The main objective of this study was to describe the quality of CPR performed during p-OHCA resuscitation attempts. METHODS Prospective observational multi-center cohort study of p-OHCA patients ≥ 1 and < 19 years of age registered in the Resuscitation Outcomes Consortium (ROC) Epistry database. The primary outcome was an a priori composite variable of compliance with American Heart Association (AHA) guidelines for both chest compression (CC) rate and CC fraction (CCF). Event compliance was defined as a case with 60% or more of its minute epochs compliant with AHA targets (rate 100-120 min(-1); depth ≥ 38 mm; and CCF ≥ 0.80). In a secondary analysis, multivariable logistic regression was used to evaluate the association between guideline compliance and return of spontaneous circulation (ROSC). RESULTS Between December 2005 and December 2012, 2564 pediatric events were treated by EMS providers, 390 of which were included in the final cohort. Of these events, 22% achieved AHA compliance for both rate and CCF, 36% for rate alone, 53% for CCF alone, and 58% for depth alone. Over time, there was a significant increase in CCF (p < 0.001) and depth (p = 0.03). After controlling for potential confounders, there was no significant association between AHA guideline compliance and ROSC. CONCLUSIONS In this multi-center study, we have established that there are opportunities for professional rescuers to improve prehospital CPR quality. Encouragingly, CCF and depth both increased significantly over time.
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Affiliation(s)
- Robert M Sutton
- The Children's Hospital of Philadelphia, 34th Street, Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | - Erin Case
- Resuscitations Outcome Consortium, 1107 NE 45th Street, Suite 505, Seattle, WA 98105-4680, United States.
| | - Siobhan P Brown
- Resuscitations Outcome Consortium, 1107 NE 45th Street, Suite 505, Seattle, WA 98105-4680, United States.
| | - Dianne L Atkins
- University of Iowa Carver College of Medicine, Stead Family Department of Pediatrics, Iowa City, IA 52242, United States.
| | - Vinay M Nadkarni
- The Children's Hospital of Philadelphia, 34th Street, Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | - Jonathan Kaltman
- National Heart, Lung, and Blood Institute, 6701 Rockledge Drive, Bethesda, MD 20817, United States.
| | - Clifton Callaway
- University of Pittsburgh, 400A Iroquois, 3600 Forbes Avenue, Pittsburgh, PA 15260, United States.
| | - Ahamed Idris
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8579, United States.
| | - Graham Nichol
- Resuscitation Outcome Consortium Clinical Trial Center, University of Washington, Seattle, WA 98104, United States.
| | - Jamie Hutchison
- The Hospital for Sick Children, 555 University Avenue, Toronto, ON, Canada M5G 1X8.
| | - Ian R Drennan
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, Canada M5B 1W8.
| | - Michael Austin
- University of Ottawa, The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, ON, Canada K1Y 4E9.
| | - Mohamud Daya
- Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mailcode CDW-EM, Portland, OR 97239-3098, United States.
| | - Sheldon Cheskes
- Sunnybrook Center for Prehospital Medicine, 77 Browns Line, Toronto, ON, Canada M8W 3S2.
| | - Jack Nuttall
- Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, United States.
| | - Heather Herren
- Resuscitations Outcome Consortium, 1107 NE 45th Street, Suite 505, Seattle, WA 98105-4680, United States.
| | - James Christenson
- Department of Emergency Medicine, University of British Columbia Faculty of Medicine, Room 3300 3rd Floor, 910 West 10th Avenue, Vancouver, BC, Canada V5Z 1M9.
| | - Dug Andrusiek
- School of Medical Sciences, Faculty of Health, Engineering and Science, Edith Cowan University, Building 19, Room 129d, 270 Joondalup Dr. Joondalup, Western Australia 6023, Australia.
| | - Christian Vaillancourt
- University of Ottawa, The Ottawa Hospital Research Institute, The Ottawa Hospital, Civic Campus, Room F649, 1053 Carling Avenue, Ottawa, ON, Canada K1Y 4E9.
| | - James J Menegazzi
- University of Pittsburgh, 3600 Forbes Avenue, Pittsburgh, PA 15261, United States.
| | - Thomas D Rea
- University of Washington, 206 3rd Avenue South, Seattle, WA 98104, United States.
| | - Robert A Berg
- The Children's Hospital of Philadelphia, 34th Street, Civic Center Boulevard, Philadelphia, PA 19104, United States.
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Abstract
BACKGROUND Therapeutic hypothermia (TH) has been shown to be effective in resuscitation of some adults following cardiac arrest and infants with hypoxic ischemic encephalopathy, but has not been well studied in children. OBJECTIVES The purpose of this systematic review/meta-analysis was to examine mortality, neurologic outcomes, and adverse events in children following use of TH. RESULTS A search of PubMed, the Cumulative Index to Nursing and Allied Health Literature, and the Institute for Scientific Information's Web of Knowledge from 1946 to 2014 yielded 6 studies (3 retrospective and 3 prospective cohort studies) that met our inclusion criteria. Quantitative synthesis of mortality following TH (136 subjects) was 44% (95% confidence interval, 32-57) with 28% (95% confidence interval, 11-53) of survivors (42 subjects) demonstrating poor neurologic outcome. The most frequently reported adverse events were electrolyte imbalances and pneumonia. CONCLUSIONS Evidence is insufficient to support the advantage of TH compared with normothermia in pediatric resuscitation. The adverse event profile appears to be different than that reported in adults. Further studies are needed before TH may be considered a standard protocol for children after cardiac arrest.
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Hosono S, Tamura M, Kunikata T, Wada M, Kusakawa I, Ibara S. Survey of delivery room resuscitation practices at tertiary perinatal centers in Japan. Pediatr Int 2015; 57:258-62. [PMID: 25208847 DOI: 10.1111/ped.12496] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 07/25/2014] [Accepted: 08/20/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to determine the current neonatal resuscitation practices for term infants in Japan, immediately before the 2010 publication of the international neonatal resuscitation consensus. METHODS In January 2010, a 26-question survey was mailed to neonatal department directors. RESULTS A total of 287 neonatal departments were identified. Four surveys were returned as undeliverable. A total of 191 surveys were returned completed, but four departments had no labor and delivery rooms (66.6% response rate, 65.2% survey available response rate). Flow-inflating bags were most commonly used (63.2%), followed by self-inflating bags (35.8%), and T-piece resuscitators (1.0%). Among the participants, 42.1% used oxygen blenders, 56.2% used pure oxygen for initial resuscitation, and 79.5% used a pulse oximeter to change the fraction of inspired oxygen. Among the participants, 45.3% used carbon dioxide detectors to confirm intubation, 42.5% routinely used the detectors, and 55.2% used them when confirming a difficult intubation. In addition, 42.5% of the participants used continuous positive airway pressure to treat breathing problems, most commonly with flow-inflating bags (93.2%). CONCLUSIONS The equipment and techniques used in Japanese perinatal center delivery room resuscitation practices are highly varied. Further research is required to determine which devices and techniques are appropriate for this important and common intervention.
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Affiliation(s)
- Shigeharu Hosono
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
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Two-thumb–encircling hands technique is more advisable than 2-finger technique when lone rescuer performs cardiopulmonary resuscitation on infant manikin. Am J Emerg Med 2015; 33:531-4. [DOI: 10.1016/j.ajem.2015.01.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 01/13/2015] [Accepted: 01/14/2015] [Indexed: 11/22/2022] Open
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Kasdorf E, Laptook A, Azzopardi D, Jacobs S, Perlman JM. Improving infant outcome with a 10 min Apgar of 0. Arch Dis Child Fetal Neonatal Ed 2015; 100:F102-5. [PMID: 25342246 DOI: 10.1136/archdischild-2014-306687] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Asystole at birth and extending through 10 min is rare, with current international recommendations stating it may be appropriate to consider discontinuation of resuscitation in this clinical scenario. These recommendations are based on small case series of both term and preterm infants, where death or abnormal outcome was nearly universal. Study objective was to determine recent outcome of infants with an Apgar score of 0 at 10 min despite cardiopulmonary resuscitation, treated with therapeutic hypothermia or standard treatment, in randomised cooling studies. DESIGN Outcome studies of infants with an Apgar of 0 at 10 min subsequently resuscitated and treated with hypothermia or standard treatment were reviewed and combined with local outcome data of infants treated with hypothermia. RESULTS Four recent studies (n=81) and local data (n=9) yielded a total of 90 infants with an Apgar of 0 at 10 min, with 56 treated with hypothermia and 34 controls. Primary outcome of death or abnormal neurodevelopmental outcome (18-24 months) occurred in 73% cooled and 79.5% normothermic infants (p=0.61). IMPLICATIONS Although poor, the outcome for infants with an Apgar of 0 at 10 min of life has improved substantially in recent years. This may be related to treatment with hypothermia, enhanced resuscitation techniques and/or other supportive management. Current recommendations to consider discontinuation of resuscitation without a detectable heart rate at 10 min should consider these findings.
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Affiliation(s)
- Ericalyn Kasdorf
- Department of Pediatrics, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Abbot Laptook
- Department of Pediatrics, Women & Infants' Hospital of Rhode Island, Providence, Rhode Island, USA
| | - Dennis Azzopardi
- Division of Clinical Sciences and Medical Research Council Clinical Sciences Centre, Hammersmith Hospital, Imperial College London, London, UK
| | - Susan Jacobs
- Neonatal Services, Royal Women's Hospital, Parkville, Victoria, Australia
| | - Jeffrey M Perlman
- Department of Pediatrics, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
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Hunt EA, Duval-Arnould JM, Nelson-McMillan KL, Bradshaw JH, Diener-West M, Perretta JS, Shilkofski NA. Pediatric resident resuscitation skills improve after “Rapid Cycle Deliberate Practice” training. Resuscitation 2014; 85:945-51. [DOI: 10.1016/j.resuscitation.2014.02.025] [Citation(s) in RCA: 212] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 02/25/2014] [Accepted: 02/25/2014] [Indexed: 11/28/2022]
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Opiyo N, Molyneux E, Sinclair D, Garner P, English M. Immediate fluid management of children with severe febrile illness and signs of impaired circulation in low-income settings: a contextualised systematic review. BMJ Open 2014; 4:e004934. [PMID: 24785400 PMCID: PMC4010848 DOI: 10.1136/bmjopen-2014-004934] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate the effects of intravenous fluid bolus compared to maintenance intravenous fluids alone as part of immediate emergency care in children with severe febrile illness and signs of impaired circulation in low-income settings. DESIGN Systematic review of randomised controlled trials (RCTs), and observational studies, including retrospective analyses, that compare fluid bolus regimens with maintenance fluids alone. The primary outcome measure was predischarge mortality. DATA SOURCES AND SYNTHESIS We searched PubMed, The Cochrane Library (to January 2014), with complementary earlier searches on, Google Scholar and Clinical Trial Registries (to March 2013). As studies used different clinical signs to define impaired circulation we classified patients into those with signs of severely impaired circulation, or those with any signs of impaired circulation. The quality of evidence for each outcome was appraised using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Findings are presented as risk ratios (RRs) with 95% CIs. RESULTS Six studies were included. Two were RCTs, one large trial (n=3141 children) from a low-income country and a smaller trial from a middle-income country. The remaining studies were from middle-income or high-income settings, observational, and with few participants (34-187 children). SEVERELY IMPAIRED CIRCULATION The large RCT included a small subgroup with severely impaired circulation. There were more deaths in those receiving bolus fluids (20-40 mL/kg/h, saline or albumin) compared to maintenance fluids (2.5-4 mL/kg/h; RR 2.40, 95% CI 0.84 to 6.88, p=0.054, 65 participants, low quality evidence). Three additional observational studies, all at high risk of confounding, found mixed effects on mortality (very low quality evidence). ANY SIGNS OF IMPAIRED CIRCULATION The large RCT included children with signs of both severely and non-severely impaired circulation. Overall, bolus fluids increased 48 h mortality compared to maintenance fluids with an additional 3 deaths per 100 children treated (RR 1.45, 95% CI 1.13 to 1.86, 3141 participants, high quality evidence). In a second small RCT from India, no difference in 72 h mortality was detected between children who received 20-40 mL/kg Ringers lactate over 15 min and those who received 20 mL over 20 min up to a maximum of 60 mL/kg over 1 h (147 participants, low quality evidence). In one additional observational study, resuscitation consistent with Advanced Paediatric Life Support (APLS) guidelines, including fluids, was not associated with reduced mortality in the small subgroup with septic shock (very low quality evidence). SIGNS OF IMPAIRED CIRCULATION, BUT NOT SEVERELY IMPAIRED Only the large RCT allowed an analysis for children with some signs of impaired circulation who would not meet the criteria for severe impairment. Bolus fluids increased 48 h mortality compared to maintenance alone (RR 1.36, 95% CI 1.05 to 1.76, high quality evidence). CONCLUSIONS Prior to the publication of the large RCT, the global evidence base for bolus fluid therapy in children with severe febrile illness and signs of impaired circulation was of very low quality. This large study provides robust evidence that in low-income settings fluid boluses increase mortality in children with severe febrile illness and impaired circulation, and this increased risk is consistent across children with severe and less severe circulatory impairment.
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Affiliation(s)
- Newton Opiyo
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Elizabeth Molyneux
- Department of Paediatrics, College of Medicine and Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - David Sinclair
- International Health Group, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Paul Garner
- International Health Group, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine and Department of Paediatrics, University of Oxford, Oxford, UK
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Gurabi Z, Koncz I, Patocskai B, Nesterenko VV, Antzelevitch C. Cellular mechanism underlying hypothermia-induced ventricular tachycardia/ventricular fibrillation in the setting of early repolarization and the protective effect of quinidine, cilostazol, and milrinone. Circ Arrhythm Electrophysiol 2014; 7:134-42. [PMID: 24429494 DOI: 10.1161/circep.113.000919] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hypothermia has been reported to induce ventricular tachycardia and fibrillation (VT/VF) in patients with early repolarization (ER) pattern. This study examines the cellular mechanisms underlying VT/VF associated with hypothermia in an experimental model of ER syndrome and examines the effectiveness of quinidine, cilostazol, and milrinone to prevent hypothermia-induced arrhythmias. METHODS AND RESULTS Transmembrane action potentials were simultaneously recorded from 2 epicardial and 1 endocardial site of coronary-perfused canine left ventricular wedge preparations, together with a pseudo-ECG. A combination of NS5806 (3-10 μmol/L) and verapamil (1 μmol/L) was used to pharmacologically model the genetic mutations responsible for ER syndrome. Acetylcholine (3 μmol/L) was used to simulate increased parasympathetic tone, which is known to promote ER. In controls, lowering the temperature of the coronary perfusate to induce mild hypothermia (32°C-34°C) resulted in increased J-wave area on the ECG and accentuated epicardial action potential notch but no arrhythmic activity. In the setting of ER, hypothermia caused further accentuation of the epicardial action potential notch, leading to loss of the action potential dome at some sites but not others, thus creating the substrate for development of phase 2 reentry and VT/VF. Addition of the transient outward current antagonist quinidine (5 μmol/L) or the phosphodiesterase III inhibitors cilostazol (10 μmol/L) or milrinone (5 μmol/L) diminished the ER manifestations and prevented the hypothermia-induced phase 2 reentry and VT/VF. CONCLUSIONS Hypothermia leads to VT/VF in the setting of ER by exaggerating repolarization abnormalities, leading to development of phase 2 reentry. Quinidine, cilostazol, and milrinone suppress the hypothermia-induced VT/VF by reversing the repolarization abnormalities.
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Cantrill RM, Creedy DK, Cooke M, Dykes F. Effective suckling in relation to naked maternal-infant body contact in the first hour of life: an observation study. BMC Pregnancy Childbirth 2014; 14:20. [PMID: 24423381 PMCID: PMC3898526 DOI: 10.1186/1471-2393-14-20] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 01/09/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Best practice guidelines to promote breastfeeding suggest that (i) mothers hold their babies in naked body contact immediately after birth, (ii) babies remain undisturbed for at least one hour and (iii) breastfeeding assistance be offered during this period. Few studies have closely observed the implementation of these guidelines in practice. We sought to evaluate these practices on suckling achievement within the first hour after birth. METHODS Observations of seventy-eight mother-baby dyads recorded newborn feeding behaviours, the help received by mothers and birthing room practices each minute, for sixty minutes. RESULTS Duration of naked body contact between mothers and their newborn babies varied widely from 1 to 60 minutes, as did commencement of suckling (range = 10 to 60 minutes). Naked maternal-infant body contact immediately after birth, uninterrupted for at least thirty minutes did not predict effective suckling within the first hour of birth. Newborns were four times more likely to sustain deep rhythmical suckling when their chin made contact with their mother's breast as they approached the nipple (OR 3.8; CI 1.03 - 14) and if their mothers had given birth previously (OR 6.7; CI 1.35 - 33). Infants who had any naso-oropharyngeal suctioning administered at birth were six times less likely to suckle effectively (OR .176; CI .04 - .9). CONCLUSION Effective suckling within the first hour of life was associated with a collection of practices including infants positioned so their chin can instinctively nudge the underside of their mother's breast as they approach to grasp the nipple and attach to suckle. The best type of assistance provided in the birthing room that enables newborns to sustain an effective latch was paying attention to newborn feeding behaviours and not administering naso-oropharyngeal suction routinely.
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Affiliation(s)
- Ruth M Cantrill
- Metro South Hospital and Health Service, Queensland Health, PO Box 7254, Redland Bay, Queensland 4165, Australia
| | - Debra K Creedy
- Griffith Health Institute Griffith University, Nathan, Queensland 4111, Australia
| | - Marie Cooke
- Griffith Health Institute Griffith University, Nathan, Queensland 4111, Australia
| | - Fiona Dykes
- Maternal and Infant Nutrition and Nurture Unit (MIANN), University of Central Lancashire, Lancashire, UK
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Ross JC, Trainor JL, Eppich WJ, Adler MD. Impact of simulation training on time to initiation of cardiopulmonary resuscitation for first-year pediatrics residents. J Grad Med Educ 2013; 5:613-9. [PMID: 24455010 PMCID: PMC3886460 DOI: 10.4300/jgme-d-12-00343.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 06/03/2013] [Accepted: 06/24/2013] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Pediatrics residents have few opportunities to perform cardiopulmonary resuscitation (CPR). Enhancing the quality of CPR is a key factor to improving outcomes for cardiopulmonary arrest in children and requires effective training strategies. OBJECTIVE To evaluate the effectiveness of a simulation-based intervention to reduce first-year pediatrics residents' time for 3 critical actions in CPR: (1) call for help, (2) initiate bag-mask ventilation, and (3) initiate chest compressions. METHODS A prospective study involving 31 first-year pediatrics residents at a children's hospital assigned to an early or late (control) intervention group. Residents underwent baseline assessment followed by repeat evaluations at 3 and 6 months. Time to critical actions was scored by video review. A 90-minute educational intervention focused on skill practice was conducted following baseline evaluation for the early-intervention group and following 3-month evaluation for the late-intervention group. Primary outcome was change in time to initiating the 3 critical actions. Change in time was analyzed by comparison of Kaplan-Meier curves, using the log-rank test. A 10% sample was timed by a second rater. Agreement was assessed using intraclass correlation (ICC). RESULTS There was a statistically significant reduction in time for all 3 critical actions between baseline and 3-month evaluation in the early intervention group; this was not observed in the late (control) group. Rater agreement was excellent (ICC ≥ 0.99). CONCLUSIONS A simulation-based educational intervention significantly reduced time to initiation of CPR for first-year pediatrics residents. Simulation training facilitated acquisition of critical CPR skills that have the potential to impact patient outcome.
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Rovamo LM, Mattila MM, Andersson S, Rosenberg PH. Testing of midwife neonatal resuscitation skills with a simulator manikin in a low-risk delivery unit. Pediatr Int 2013; 55:465-71. [PMID: 23461735 DOI: 10.1111/ped.12083] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 12/27/2012] [Accepted: 02/13/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Expertise in neonatal resuscitation is essential for personnel involved in the care of newborns. In this observational cohort study the skills of 52 midwives in a simulated scenario were assessed. METHODS A total of 52 midwives in a low-risk unit and five specialist nurses in a high-risk unit were tested to establish their competence in newborn resuscitation. The 52 midwives were divided into groups 1 (n = 39; no pretest training) and 2 (n = 13; 1 day training prior to study). The video-recorded test scenario was a newborn with asphyxia. Thirty items were graded by a neonatologist and nursing team in real time. Using the Angoff method, a pass score was 18.71 for skills that were graded 0 or 1. RESULTS The average score of specialist nurses was 26 (range, 23-29). A total of 49% of midwives in group 1 and 92% in group 2 passed the test. The average score was 17.7 (range, 9-25) in group 1 and 21.9 (range, 17-27) in group 2. A total of 27% and 77% of midwives in groups 1 and 2, respectively, carried out ventilation at a frequency as per the algorithm. Mask leakage was higher in group 1 (44%) versus group 2 (23%). Five and three midwives in groups 1 and 2, respectively, overexpanded the lungs. CONCLUSION Many midwives had imperfect resuscitation skills. A 1 day course improved such skills. The standard scenario is an objective and useful performance marker in assessing and documenting improvements in competence in delivery room resuscitation.
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Affiliation(s)
- Liisa M Rovamo
- Children's Hospital, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland.
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Abstract
Early recognition of sepsis and septic shock in children relies on obtaining an attentive clinical history, accurate vital signs, and a physical examination focused on mental status, work of breathing, and circulatory status. Laboratory tests may support the diagnosis but are not reliable in isolation. The goal of septic shock management is reversal of tissue hypoperfusion. The therapeutic end point is shock reversal. Mortality is significantly better among children when managed appropriately. Every physician who cares for children must strive to have a high level of suspicion and keen clinical acumen for recognizing the rare but potentially seriously ill child.
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Affiliation(s)
- Patrick J Maloney
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver Health Medical Center, 660 Bannock Street, MC 0108, Denver, CO 80204, USA.
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Evaluation of the 2010 American Heart Association Guidelines for infant CPR finger/thumb positions for chest compression: A study using computed tomography. Resuscitation 2013; 84:766-9. [DOI: 10.1016/j.resuscitation.2012.11.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 11/07/2012] [Accepted: 11/09/2012] [Indexed: 11/19/2022]
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Abstract
As recently as the year 2000, 100% oxygen was recommended to begin resuscitation of depressed newborns in the delivery room. However, the most recent recommendations of the International Liaison Committee on Resuscitation counsel the prudent use of oxygen during resuscitation. In term and preterm infants, oxygen therapy should be guided by pulse oximetry that follows the interquartile range of preductal saturations of healthy term babies after vaginal birth at sea level. This article reviews the literature in this context, which supports the radical but judicious curtailment of the use of oxygen in resuscitation at birth.
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Affiliation(s)
- Jay P Goldsmith
- Department of Pediatrics, Tulane University, 1430 Tulane Avenue, SL37, New Orleans, LA 70112, USA.
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Orcesi S, Olivieri I, Longo S, Perotti G, La Piana R, Tinelli C, Spinillo A, Balottin U, Stronati M. Neurodevelopmental outcome of preterm very low birth weight infants born from 2005 to 2007. Eur J Paediatr Neurol 2012; 16:716-23. [PMID: 22709626 DOI: 10.1016/j.ejpn.2012.05.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Revised: 05/08/2012] [Accepted: 05/19/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate short-term neurodevelopmental outcome (at 24 months of corrected age) and correlations with obstetric and neonatal factors in a sample of preterm very low birth weight infants born and admitted to an Italian tertiary centre between 2005 and 2007. METHODS 156 infants with a birth weight ≤ 1500 g (gestational age, range: 27-31 weeks) were followed at regular intervals through neurodevelopmental (neurological and psychomotor) assessment up to 24 months of corrected age. A statistical analysis was conducted in order to look for correlations between pre- and perinatal variables and neuropsychomotor outcome at 24 months. RESULTS 131 children were classified as normal and the other 25 presented sequelae classified as "minor" in 17 cases and as "major" in eight. The most significant risk factors for a poor outcome were preterm premature rupture of the membranes, bronchodysplasia, late-onset sepsis, postnatal steroid therapy and male gender. The presence of severe abnormalities on brain ultrasound scan and of an abnormal neurological assessment at 40 weeks at term equivalent age were strong predictors of poor outcome. CONCLUSIONS Our study is one of the few investigating the short-term outcome of preterm VLBW Italian children born in the second half of the 2000s. Neurodevelopmental assessment at 24 months revealed a marked reduction in major sequelae. Several risk factors for a poor neurodevelopmental outcome identified in children born in earlier periods were confirmed in these children born in recent years.
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Affiliation(s)
- Simona Orcesi
- Child Neurology and Psychiatry Unit, IRCCS C. Mondino National Institute of Neurology Foundation, Pavia, Italy.
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Sutton RM, French B, Nishisaki A, Niles DE, Maltese MR, Boyle L, Stavland M, Eilevstjønn J, Arbogast KB, Berg RA, Nadkarni VM. American Heart Association cardiopulmonary resuscitation quality targets are associated with improved arterial blood pressure during pediatric cardiac arrest. Resuscitation 2012; 84:168-72. [PMID: 22960227 DOI: 10.1016/j.resuscitation.2012.08.335] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 08/22/2012] [Accepted: 08/29/2012] [Indexed: 11/16/2022]
Abstract
AIM To evaluate the association between cardiopulmonary resuscitation (CPR) quality and hemodynamic measurements during in-hospital pediatric cardiac arrest. We hypothesized that AHA recommended CPR rate and depth targets would be associated with systolic blood pressures≥80mmHg and diastolic blood pressures≥30mmHg. METHODS In children and adolescents <18 years of age who suffered a cardiac arrest with an invasive arterial catheter in place, a CPR monitoring defibrillator collected CPR data which was synchronized to arterial blood pressure (BP) tracings. Chest compression (CC) depths were corrected for mattress deflection. Generalized least squares regression estimated the association between BP and CPR quality, treated as continuous variables. Mixed-effects logistic regression estimated the association between systolic BP≥80mmHg/diastolic BP≥30mmHg and the AHA targets of depth≥38mm and/or rate≥100/min. RESULTS Nine arrests resulted in 4156 CCs. The median mattress corrected depth was 32mm (IQR 28-38); median rate was 111CC/min (IQR 103-120). AHA depth was achieved in 1090/4156 (26.2%) CCs; rate in 3441 (83.7%). Systolic BP≥80mmHg was attained in 2516/4156 (60.5%) compressions; diastolic≥30mmHg in 2561/4156 (61.6%). A rate≥100/min was associated with systolic BP≥80mmHg (OR 1.32; CI(95) 1.04, 1.66; p=0.02) and diastolic BP≥30mmHg (OR 2.15; CI(95) 1.65, 2.80; p<0.001). Exceeding both (rate≥100/min and depth≥38mm) was associated with systolic BP≥80mmHg (OR 2.02; CI(95) 1.45, 2.82; p<0.001) and diastolic BP≥30mmHg (OR 1.48; CI(95) 1.01, 2.15; p=0.042). CONCLUSIONS AHA quality targets (rate≥100/min and depth≥38mm) were associated with systolic BPs≥80mmHg and diastolic BPs≥30mmHg during CPR in children.
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Affiliation(s)
- Robert M Sutton
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Kheir JN, Scharp LA, Borden MA, Swanson EJ, Loxley A, Reese JH, Black KJ, Velazquez LA, Thomson LM, Walsh BK, Mullen KE, Graham DA, Lawlor MW, Brugnara C, Bell DC, McGowan FX. Oxygen Gas-Filled Microparticles Provide Intravenous Oxygen Delivery. Sci Transl Med 2012; 4:140ra88. [DOI: 10.1126/scitranslmed.3003679] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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McInnes AD, Sutton RM, Nishisaki A, Niles D, Leffelman J, Boyle L, Maltese MR, Berg RA, Nadkarni VM. Ability of code leaders to recall CPR quality errors during the resuscitation of older children and adolescents. Resuscitation 2012; 83:1462-6. [PMID: 22634433 DOI: 10.1016/j.resuscitation.2012.05.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 05/09/2012] [Accepted: 05/14/2012] [Indexed: 10/28/2022]
Abstract
AIM Performance of high quality CPR is associated with improved resuscitation outcomes. This study investigates code leader ability to recall CPR error during post-event interviews when CPR recording/audiovisual feedback-enabled defibrillators are deployed. PATIENTS AND METHODS Physician code leaders were interviewed within 24h of 44 in-hospital pediatric cardiac arrests to assess their ability to recall if CPR error occurred during the event. Actual CPR quality was assessed using quantitative recording/feedback-enabled defibrillators. CPR error was defined as an overall average event chest compression (CC) rate <95/min, depth < 38 mm, ventilation rate >10/min, or any interruptions in CPR >10s. We hypothesized that code leaders would recall error when it actually occurred ≥ 75% of the time when assisted by audiovisual alerts from a CPR recording feedback-enabled defibrillators (analysis by χ(2)). RESULTS 810 min from 44 cardiac arrest events yielded 40 complete data sets (actual and interview); ventilation data was available in 24. Actual CPR error was present in 3/40 events for rate, 4/40 for depth, 32/40 for interruptions >10s, and 17/24 for ventilation frequency. In post-event interviews, code leaders recalled these errors in 0/3 (0%) for rate, 0/4 (0%) for depth, and 19/32 (59%) for interruptions >10s. Code leaders recalled these CPR quality errors less than 75% of the time for rate (p=0.06), for depth (p<0.01), and for CPR interruption (p=0.04). Quantification of errors not recalled: missed rate error median=94 CC/min (IQR 93-95), missed depth error median=36 mm (IQR 35.5-36.5), missed CPR interruption >10s median=18s (IQR 14.4-28.9). Code leaders did recall the presence of excessive ventilation in 16/17 (94%) of events (p=0.07). CONCLUSION Despite assistance by CPR recording/feedback-enabled defibrillators, pediatric code leaders fail to recall important CPR quality errors for CC rate, depth, and interruptions during post-cardiac arrest interviews.
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Affiliation(s)
- Andrew D McInnes
- The Children's Hospital of Philadelphia, Department of Anesthesia and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States.
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Blain H, Bonnafous M, Grovallet N, David M, Jonquet O. Manœuvre de la table : une nouvelle procédure à tenter en cas d’asphyxie sur fausse-route après échec des traitements conventionnels. Presse Med 2012; 41:439-40. [DOI: 10.1016/j.lpm.2011.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Revised: 08/12/2011] [Accepted: 08/25/2011] [Indexed: 11/25/2022] Open
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Evaluation of quantitative debriefing after pediatric cardiac arrest. Resuscitation 2012; 83:1124-8. [PMID: 22306665 DOI: 10.1016/j.resuscitation.2012.01.021] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 12/07/2011] [Accepted: 01/16/2012] [Indexed: 12/21/2022]
Abstract
AIM Our primary objective was to describe and determine the feasibility of implementing a care environment targeted pediatric post-cardiac arrest debriefing program. A secondary objective was to evaluate the usefulness of debriefing content items. We hypothesized that a care environment targeted post-cardiac arrest debriefing program would be feasible, well-received, and result in improved self-reported knowledge, confidence and performance of pediatric providers. METHODS Physician-led multidisciplinary pediatric post-cardiac arrest debriefings were conducted using data from CPR recording defibrillators/central monitors followed by a semi-quantitative survey. Eight debriefing content elements divided, a priori, into physical skill (PS) related and cognitive skill (CS) related categories were evaluated on a 5-point Likert scale to determine those most useful (5-point Likert scale: 1=very useful/5=not useful). Summary scores evaluated the impact on providers' knowledge, confidence, and performance. RESULTS Between June 2010 and May 2011, 6 debriefings were completed. Thirty-four of 50 (68%) front line care providers attended the debriefings and completed surveys. All eight content elements were rated between useful to very useful (Median 1; IQR 1-2). PS items scored higher than CS items to improve knowledge (Median: 2 (IQR 1-3) vs. 1 (IQR 0-2); p<0.02) and performance (Median: 2 (IQR 1-3) vs. 1 (IQR 0-1); p<0.01). CONCLUSIONS A novel care environment targeted pediatric post-cardiac arrest pediatric debriefing program is feasible and useful for providers regardless of their participation in the resuscitation. Physical skill related elements were rated more useful than cognitive skill related elements for knowledge and performance.
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Sanders W, Fringer R, Swor R. Management of an extremely premature infant in the out-of-hospital environment. PREHOSP EMERG CARE 2011; 16:303-7. [PMID: 22150626 DOI: 10.3109/10903127.2011.616258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The rate of premature infant mortality has decreased over the last several decades, with an accompanying decrease in the gestational age of premature infants who survive to hospital discharge. Emergency medical services (EMS) providers are sometimes called to provide prehospital care for infants born at the edge of viability. Such extremely premature infants (EPIs) present medical and ethical challenges. In this case report, we describe an infant born at 24 weeks into a toilet by a mother who thought she had miscarried. The EMS providers evaluated the infant as nonviable and placed him in a plastic bag for transport to a local emergency department (ED). The ED staff found the infant to have a bradycardic rhythm, initiated resuscitation, and admitted him to the neonatal intensive care unit. The infant died seven days later. We review the literature for recommendations in resuscitation of EPIs and discuss the ethics regarding their management in the prehospital setting.
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Affiliation(s)
- William Sanders
- Department of Emergency Medicine, Oakland University/William Beaumont School of Medicine, Royal Oak, Michigan, USA
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87
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Abstract
OBJECTIVE The authors had previously found flaws in resuscitation after severe neonatal asphyxia in cases selected on the grounds of suspected malpractice and financial compensation claims. The aim of the present study was to evaluate neonatal resuscitation in the general obstetric population in a setting with skilled attendance at birth. DESIGN Observational study. SETTING AND PATIENTS All infants born in the Stockholm County during 2004-2006 with a gestational age of ≥33 weeks, planned as vaginal delivery, with a normal cardiotocographic recording on admission to hospital and with an Apgar score of <7 at 5 min were included. MAIN OUTCOME MEASURES Adherence to guidelines for neonatal resuscitation. RESULTS Documentation was unsatisfactory in 142 (45%) infants. Other important shortcomings identified were delayed initiation of extensive resuscitation due to late paging or late arrival of attending paediatrician/neonatologist (n=48), and unsatisfactory ventilation related to late intubation and late securing of free airway (n=15). CONCLUSIONS Substandard care in neonatal resuscitation is not limited to cases of severe asphyxia related to claims for medical malpractice. The overall documentation of neonatal resuscitation needs to be much better to enable accurate and reliable evaluation. Obvious actions to improve standards of care include the paging of skilled personnel at an earlier stage in cases of complicated deliveries and team and skills training in neonatal ventilation.
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Affiliation(s)
- Sophie Berglund
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.
| | - Mikael Norman
- Department for Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Blain H, Bonnafous M, Grovallet N, David M, Jonquet O. La manœuvre de la table : une manœuvre qui peut sauver la vie en cas de fausse route asphyxique. Rev Med Interne 2011; 32:527-8. [DOI: 10.1016/j.revmed.2011.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 06/08/2011] [Indexed: 11/30/2022]
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Sutton RM, Niles D, Meaney PA, Aplenc R, French B, Abella BS, Lengetti EL, Berg RA, Helfaer MA, Nadkarni V. Low-dose, high-frequency CPR training improves skill retention of in-hospital pediatric providers. Pediatrics 2011; 128:e145-51. [PMID: 21646262 PMCID: PMC3387915 DOI: 10.1542/peds.2010-2105] [Citation(s) in RCA: 174] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To investigate the effectiveness of brief bedside cardiopulmonary resuscitation (CPR) training to improve the skill retention of hospital-based pediatric providers. We hypothesized that a low-dose, high-frequency training program (booster training) would improve CPR skill retention. PATIENTS AND METHODS CPR recording/feedback defibrillators were used to evaluate CPR quality during simulated arrest. Basic life support-certified, hospital-based providers were randomly assigned to 1 of 4 study arms: (1) instructor-only training; (2) automated defibrillator feedback only; (3) instructor training combined with automated feedback; and (4) control (no structured training). Each session (time: 0, 1, 3, and 6 months after training) consisted of a pretraining evaluation (60 seconds), booster training (120 seconds), and a posttraining evaluation (60 seconds). Excellent CPR was defined as chest compression (CC) depth ≥ one-third anterior-posterior chest depth, rate ≥90 and ≤120 CC per minute, ≤20% of CCs with incomplete release (>2500 g), and no flow fraction ≤ 0.30. MEASUREMENTS AND MAIN RESULTS Eighty-nine providers were randomly assigned; 74 (83%) completed all sessions. Retention of CPR skills was 2.3 times (95% confidence interval [CI]: 1.1-4.5; P=.02) more likely after 2 trainings and 2.9 times (95% CI: 1.4-6.2; P=.005) more likely after 3 trainings. The automated defibrillator feedback only group had lower retention rates compared with the instructor-only training group (odds ratio: 0.41 [95% CI: 0.17-0.97]; P = .043). CONCLUSIONS Brief bedside booster CPR training improves CPR skill retention. Our data reveal that instructor-led training improves retention compared with automated feedback training alone. Future studies should investigate whether bedside training improves CPR quality during actual pediatric arrests.
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Affiliation(s)
| | - Dana Niles
- Center for Simulation, Advanced Education, and Innovation, and
| | | | - Richard Aplenc
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | | | - Benjamin S. Abella
- Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, ,Center for Simulation, Advanced Education, and Innovation, and
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Universally poor outcomes of pediatric traumatic arrest: a prospective case series and review of the literature. Pediatr Emerg Care 2011; 27:616-21. [PMID: 21712745 DOI: 10.1097/pec.0b013e31822255c9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Few data are available on traumatic cardiopulmonary arrest in children. Efforts at resuscitation typically result in heavy utilization of finite resources with little understanding of which characteristics, if any, may be associated with success. The objectives of this study were to describe the outcome of children in traumatic cardiac arrest and to identify patients for whom aggressive resuscitation may or may not be warranted. METHODS Data were analyzed from a previous study of prehospital pediatric airway management in Los Angeles and Orange Counties, Calif, over a 33-month period. Patients included in this secondary analysis were younger than 13 years and found pulseless and apneic after having had an injury. Data sources included prospective, phone interviews with paramedics after transfer of care to the receiving facility, and chart review to determine outcome. Two main outcomes were assessed: survival and neurological function as measured by the Pediatric Cerebral Performance Category. RESULTS The emergency medical services responded to 118 traumatic arrests during the study period. Of these victims, only 6 (5%) survived. Median Injury Severity Score was 25 with an interquartile range of 16 to 75. The survivors all were neurologically impaired with a median Pediatric Cerebral Performance Category of 5 (interquartile range, 4-5). CONCLUSIONS Children who had trauma resulting in cardiac arrest have universally poor outcomes, and survivors have severe neurological compromise. We are unable to identify a subset of patients for whom aggressive resuscitation is indicated. This is the largest prospective study of pediatric traumatic arrest to date.
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91
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Briassoulis G, Briassoulis P, Briassouli E. Educational polymorphisms of basic life support algorithms. J Eval Clin Pract 2011; 17:462-70. [PMID: 20553365 DOI: 10.1111/j.1365-2753.2010.01450.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND A systematic review of the pooled effect of articles presenting current basic life support (BLS) algorithms for the treatment of cardiac arrest has never been carried. AIMS We aimed to record and classify potential inherent factors influencing simplicity negatively in teaching, learning and retention of cardiopulmonary resuscitation (CPR) delivered by health care providers or lay persons. METHODS We performed a search of the relevant literature exploring MEDLINE, COCHRANE LIBRARY and SCOPUS databases. Potential inhibitory factors in the structure of available algorithms influencing simplicity in teaching, learning and retention of BLS were recorded and stratified accordingly. In a second phase of this study, we tested the hypothesis that different options of a BLS algorithm might influence CPR retention negatively, by asking 348 health care provider participants of our CPR seminars to describe their predicted response in an emergency to: (1) a real-time model implicating the various victims and rescuers; and (2) a hypothetical challenging 'all-in-one' BLS algorithm model. RESULTS Fifteen articles presenting current BLS algorithms evidenced 163 suggestions that produced 23 different CPR options: five contrasting algorithms (21.8%); three two-option models (13%); six vague technical or scientific suggestions (26%); and nine multiple choices of action (39.1%). Identified references contributed differently in the development of educationally polymorphic BLS options in each of the four categories (P < 0.0001) and were all brought about by variants of victims and rescuers. Participants of CPR seminars answered that in an emergency they could remember the hypothetical BLS model (90%, P = 0.007) rather than a current BLS algorithm for adults (42.2%) or children (36%). CONCLUSIONS Educational polymorphisms of BLS algorithms could build unpredictable barriers between rescuers and cardiac arrest victims and might seriously limit instructors' educational effectiveness. These findings might support an alternative trial hypothesis of a simple 'all-in-one algorithm' educational approach in future.
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Affiliation(s)
- George Briassoulis
- School of Health Sciences, University of Crete, Heraklion, Crete, Greece.
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92
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"Booster" training: evaluation of instructor-led bedside cardiopulmonary resuscitation skill training and automated corrective feedback to improve cardiopulmonary resuscitation compliance of Pediatric Basic Life Support providers during simulated cardiac arrest. Pediatr Crit Care Med 2011; 12:e116-21. [PMID: 20625336 PMCID: PMC3717252 DOI: 10.1097/pcc.0b013e3181e91271] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To investigate the effectiveness of brief bedside "booster" cardiopulmonary resuscitation (CPR) training to improve CPR guideline compliance of hospital-based pediatric providers. DESIGN Prospective, randomized trial. SETTING General pediatric wards at Children's Hospital of Philadelphia. SUBJECTS Sixty-nine Basic Life Support-certified hospital-based providers. INTERVENTION CPR recording/feedback defibrillators were used to evaluate CPR quality during simulated pediatric arrest. After a 60-sec pretraining CPR evaluation, subjects were randomly assigned to one of three instructional/feedback methods to be used during CPR booster training sessions. All sessions (training/CPR manikin practice) were of equal duration (2 mins) and differed only in the method of corrective feedback given to participants during the session. The study arms were as follows: 1) instructor-only training; 2) automated defibrillator feedback only; and 3) instructor training combined with automated feedback. MEASUREMENTS AND MAIN RESULTS Before instruction, 57% of the care providers performed compressions within guideline rate recommendations (rate >90 min(-1) and <120 min(-1)); 71% met minimum depth targets (depth, >38 mm); and 36% met overall CPR compliance (rate and depth within targets). After instruction, guideline compliance improved (instructor-only training: rate 52% to 87% [p .01], and overall CPR compliance, 43% to 78% [p < .02]; automated feedback only: rate, 70% to 96% [p = .02], depth, 61% to 100% [p < .01], and overall CPR compliance, 35% to 96% [p < .01]; and instructor training combined with automated feedback: rate 48% to 100% [p < .01], depth, 78% to 100% [p < .02], and overall CPR compliance, 30% to 100% [p < .01]). CONCLUSIONS Before booster CPR instruction, most certified Pediatric Basic Life Support providers did not perform guideline-compliant CPR. After a brief bedside training, CPR quality improved irrespective of training content (instructor vs. automated feedback). Future studies should investigate bedside training to improve CPR quality during actual pediatric cardiac arrests.
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93
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Inamasu J, Nakatsukasa M, Suzuki M, Miyatake S. Therapeutic hypothermia for out-of-hospital cardiac arrest: an update for neurosurgeons. World Neurosurg 2011; 74:120-8. [PMID: 21300001 DOI: 10.1016/j.wneu.2010.02.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Accepted: 02/20/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Neurosurgeons have been familiar with the idea that hypothermia is protective against various types of brain injuries, including traumatic brain injury (TBI). Recent randomized controlled trials, however, have failed to demonstrate the efficacy of therapeutic hypothermia (TH) in patients with TBI. On the other hand, TH becomes popular in the treatment of out-of-hospital cardiac arrest (OHCA) survivors, after randomized controlled trials have shown that survival rate and functional outcome is improved with the use of TH in selected patients. We believe that knowledge on the recent progress in TH for OHCA is useful for neurosurgeons, because feedback of information obtained in the treatment of OHCA may revitalize the interest in TH for neurosurgical disorders, particularly TBI. METHODS A review of the literature was conducted with the use of PubMed. RESULTS Various cooling techniques and devices have been developed and trialed in the treatment of OHCA survivors, including prehospital cooling with bolus ice-cold saline, endovascular cooling catheters, and new generation surface cooling devices, some of which have already been known to neurosurgeons. The efficacy of these new methods and devices has been demonstrated in many preliminary studies, and phase III trials are also expected. CONCLUSIONS Neurosurgeons and critical care medicine physicians pursue the same goal of rescuing the brain from the secondary injury despite the difference in etiology (focal trauma vs. global ischemia), with the presumption that earlier and faster implementation of TH will result in better outcome. Thoughtful application of knowledge and techniques obtained in OHCA to TBI under a rigorously controlled situation will make a small, but significant difference in the outcome of TBI victims.
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Affiliation(s)
- Joji Inamasu
- Department of Neurosurgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan.
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Tofil NM, Benner KW, Zinkan L, Alten J, Varisco BM, White ML. Pediatric intensive care simulation course: a new paradigm in teaching. J Grad Med Educ 2011; 3:81-7. [PMID: 22379527 PMCID: PMC3186272 DOI: 10.4300/jgme-d-10-00070.1] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Revised: 06/16/2010] [Accepted: 10/11/2010] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE True pediatric emergencies are rare. Because resident work hours are restricted and national attention turns toward patient safety, teaching methods to improve physician performance and patient care are vital. We hypothesize that a critical-care simulation course will improve resident confidence and performance in critical-care situations. INTERVENTIONS We developed a monthly pediatric intensive care unit simulation course for second-year pediatric residents that consisted of weekly 1-hour sessions during both of the residents' month-long pediatric intensive care unit rotations. All scenarios used high-fidelity pediatric simulators and immediate videotape-assisted debriefing sessions. In addition, simulated intraosseous line insertion and endotracheal intubations were also performed. RESULTS All residents improved their comfort level and confidence in performing individual key resuscitation tasks. The largest improvements were seen with their perceived ability to intubate children and place intraosseous lines. Both of these skills improved from baseline and compared to third-year-resident controls who had pediatric intensive care unit rotations but no simulations (P = .05 and P = .07, respectively). Videotape reviews showed only 54% ± 12% of skills from a scenario checklist performed correctly. CONCLUSIONS Our simulation-based pediatric intensive care unit training course improves second-year pediatric residents' comfort level but not performance during codes, as well as their perceived intubation and intraosseous ability. Videotape reviews show discordance between objective performance and self-assessment. Further work is necessary to elucidate the reasons for this difference as well as the appropriate role for simulation in the new graduate medical education climate, and to create new teaching modalities to improve resident performance.
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Affiliation(s)
- Nancy M Tofil
- Corresponding author: Nancy M. Tofil, MD, MEd, Department of Pediatrics, 1600 7th Ave, South ACC 504, Birmingham, AL 35233, 205.939.9387,
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95
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Préparation des services d’accueil d’urgences (SAU) français à la prise en charge des urgences vitales de l’enfant. ANNALES FRANCAISES DE MEDECINE D URGENCE 2011. [DOI: 10.1007/s13341-010-0005-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bussières JF, Lebel D, Voytenko S, Marquis C, Bailey B. A pilot study to assess an online training module to quickly identify drugs on resuscitation trays. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2011; 30:31-36. [PMID: 21146350 DOI: 10.1016/j.annfar.2010.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Accepted: 11/02/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To measure the median time required for healthcare professionals to identify drugs on resuscitation trays and to assess the usefulness of an online training module used to identify drugs on resuscitation trays. STUDY DESIGN This is a descriptive pilot study conducted in a mother-child university hospital center with a convenience sample of physicians, residents, nurses, pharmacists, pharmacy students or pharmacy technicians (10/group). METHOD Participants were given a questionnaire before and after using a simulation module to identify drugs on resuscitation drug trays (30 questions on the full trays with 43 drugs and 15 questions on the partial trays with 21 drugs). The identification times were measured for each drug and for each tray. RESULTS The median time to identify the drugs varied from 4s (range 2-46) for dextrose to 18s (range 4-78) for epinephrine. The median times to locate a drug on full and partial trays were, respectively: pharmacists 7 (2-103) and 6 (1-31), physicians 10 (3-78) and 7 (2-61) and nurses 10 (3-83) and 7 (2-53). All 60 participants strongly agreed that the online simulation module was a good tool for healthcare staff and that it would allow them to locate drugs more quickly in emergency situations. CONCLUSION The online simulation module can be used by various groups of professionals and it can allow them to locate drugs on resuscitation tray more rapidly during an emergency.
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Affiliation(s)
- J-F Bussières
- Pharmacy department and Pharmacy Practice Research Unit (PPRU), CHU Sainte-Justine, 3175, chemin Côte-Sainte-Catherine, Montréal, Québec, Canada.
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Genzel-Boroviczény O, Hempelman J, Zoppelli L, Martinez A. Predictive value of the 1-min Apgar score for survival at 23-26 weeks gestational age. Acta Paediatr 2010; 99:1790-4. [PMID: 20670306 DOI: 10.1111/j.1651-2227.2010.01937.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM Is a 1-min Apgar score ≤1 predictive of mortality in resuscitated extremely premature infants? METHODS A retrospective case-control review of all infants with gestational ages < 27 weeks over a 5-year period. All values as median [75% CI]. RESULTS Of 237 infants, 29 had 1-min Apgar scores ≤1 (Group 1) and 208 had scores >1 (Group 2). Despite earlier and more frequent intubation (2 min [2.3; 6.7] vs. 5 min [7.5; 10] and 93% vs. 77%, p = 0.04), mortality was higher in Group 1 (62% vs. 17%; p < 0.0001). Age at death did not differ (Group 1: 3.5days [1; 30] vs. Group 2: 6 days [6; 44]). Birth weight and sex were the best predictors of survival. With a 1-min Apgar score of 1, a male infant at 23 weeks and 500g had a mortality rate of 92%. CONCLUSION Despite successful resuscitation, infants between 23 and 26 weeks have a very poor prognosis for survival when presenting with bradycardia, cyanosis and no respiratory efforts (1-min Apgar = 1) at birth. According to our data, initiating active treatment for an infant at 23 weeks with bradycardia and apnoea is almost always unsuccessful, whereas by 26 weeks gestation, the chance of survival is higher than the probability of death.
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Affiliation(s)
- O Genzel-Boroviczény
- Department of Gynecology and Obstetrics, University Children's Hospital, University of Munich, IS, Munich, Germany.
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98
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Blain H, Bonnafous M, Grovalet N, Jonquet O, David M. The table maneuver: a procedure used with success in four cases of unconscious choking older subjects. Am J Med 2010; 123:1150.e7-9. [PMID: 20870197 DOI: 10.1016/j.amjmed.2010.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Revised: 06/26/2010] [Accepted: 07/03/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND confronted with an unconscious choking victim, it is recommended to call an ambulance and start mouth-to-mouth and cardiopulmonary resuscitation (CPR). We describe a procedure called the "table maneuver" that was successful in relieving foreign-body airway obstruction in 4 cases of choking in unconscious elderly patients over a 6-year period in the same long-term care facility. METHODS the patients ranged in age from 70 to 89 years and were cyanosed and unconscious after choking while having a meal at a table. In a first attempt in 1 case, after failure of the Heimlich maneuver in 2 cases, and in combination with CPR in 1 person in cardiac arrest, the choking person was laid down on the table in prone position with the head facing downwards, with the arms hanging over the table, and then given sharp blows between the scapulas with the heel of the hand. RESULTS after a few back blows in 3 cases, and in combination with CPR in 1 case, the patients forcefully spit out the foreign body (pieces of beets, Brussels sprouts, a croissant soaked in milk, or pieces of banana) without either early or late complications. CONCLUSION these 4 case reports show that the table maneuver is a potentially life-saving technique that could be applied to patients with severe choking caused by foreign-body airway obstruction who fail to respond to the Heimlich maneuver and other conventional treatments.
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Affiliation(s)
- Hubert Blain
- Department of Internal Medicine and Geriatrics, University Hospital of Montpellier, and EUROMOV, University Montpellier 1, Montpellier, France.
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Wall SN, Lee ACC, Carlo W, Goldenberg R, Niermeyer S, Darmstadt GL, Keenan W, Bhutta ZA, Perlman J, Lawn JE. Reducing intrapartum-related neonatal deaths in low- and middle-income countries-what works? Semin Perinatol 2010; 34:395-407. [PMID: 21094414 DOI: 10.1053/j.semperi.2010.09.009] [Citation(s) in RCA: 165] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Each year, 814,000 neonatal deaths and 1.02 million stillbirths result from intrapartum-related causes, such as intrauterine hypoxia. Almost all of these deaths are in low- and middle-income countries, where women frequently lack access to quality perinatal care and may delay care-seeking. Approximately 60 million annual births occur outside of health facilities, and most of these childbirths are without a skilled birth attendant. Conditions that increase the risk of intrauterine hypoxia--such as pre-eclampsia/eclampsia, obstructed labor, and low birth weight--are often more prevalent in low resource settings. Intrapartum-related neonatal deaths can be averted by a range of interventions that prevent intrapartum complications (eg, prevention and management of pre-eclampsia), detect and manage intrapartum problems (eg, monitoring progress of labor with access to emergency obstetrical care), and identify and assist the nonbreathing newborn (eg, stimulation and bag-mask ventilation). Simple, affordable, and effective approaches are available for low-resource settings, including community-based strategies to increase skilled birth attendance, partograph use by frontline health workers linked to emergency obstetrical care services, task shifting to increase access to Cesarean delivery, and simplified neonatal resuscitation training (Helping Babies Breathe(SM)). Coverage of effective interventions is low, however, and many opportunities are missed to provide quality care within existing health systems. In sub-Saharan Africa, recent health services assessments found only 15% of hospitals equipped to provide basic neonatal resuscitation. In the short term, intrapartum-related neonatal deaths can be substantially reduced by improving the quality of services for all childbirths that occur in health facilities, identifying and addressing the missed opportunities to provide effective interventions to those who seek facility-based care. For example, providing neonatal resuscitation for 90% of deliveries currently taking place in health facilities would save more than 93,000 newborn lives each year. Longer-term strategies must address the gaps in coverage of institutional delivery, skilled birth attendance, and quality by strengthening health systems, increasing demand for care, and improving community-based services. Both short- and long-term strategies to reduce intrapartum-related mortality should focus on reducing inequities in coverage and quality of obstetrical and perinatal care.
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Affiliation(s)
- Stephen N Wall
- Saving Newborn Lives, Save the Children, Washington, DC, USA and Cape Town, South Africa
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Abstract
BACKGROUND The goal of this investigation is to determine the success rate of aggressive cardiorespiratory resuscitation in children who experience blunt cranial trauma of sufficient magnitude to quickly cause cardiac arrest. METHODS The records of all the children who, within a 6-year period, suffered cardiac arrest at the scene of injury, during transport or in the emergency department of a level one pediatric trauma center, as a consequence of blunt cranial trauma, form the basis of this study. RESULTS One of the 40 children who met the inclusion criteria survived. Their ages ranged from 1 month to 16 years, and all had a Glasgow Coma Score of 3 at the scene of injury. Forty-two percent were passengers in motor vehicles, and 32% were victims of nonaccidental trauma. Eleven of the 17 children in the motor vehicle crash were not properly restrained. Eleven of the unrestrained children plus two who were properly restrained were ejected at the time of impact. The average cardiopulmonary resuscitation time was 36 (2-107) minutes. A sinus rhythm was established in 50% but was not sustained in most. The sole survivor was an 8-year-old boy who was ejected and had asystole at the scene. At discharge, he was walking well but had cranial nerve deficits and learning disability. CONCLUSION Survival in 40 consecutive children with documented cardiac arrest caused by blunt cranial trauma was 2.5%. This series, when combined with other published reports, is supportive of the position that aggressive resuscitation is rarely successful after 10 minutes and futile after 20 minutes.
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