Part 14: Pediatric Advanced Life Support

Pre-hospital Predictors of Impaired ICP Trends in Continuous Monitoring of Paediatric Traumatic Brain Injury Patients

OBJECTIVE

Although secondary insults such as raised intracranial pressure (ICP) or cardiovascular compromise strongly contribute to morbidity, a growing interest can be noticed in how the pre-hospital management can affect outcomes after traumatic brain injury (TBI). The objective of this study was to determine whether pre-hospital co-morbidity has influence on patterns of continuously measured waveforms of intracranial physiology after paediatric TBI.

MATERIALS AND METHODS

Thirty-nine patients (mean age, 10 years; range, 0.5-15) admitted between 2002 and 2015 were used for the current analysis. Pre-hospital motor score, pupil reactivity, pre-hospital hypoxia (SpO₂ < 90%) and hypotension (mean arterial pressure < 70 mmHg) were documented. ICP and arterial blood pressure (ABP) were monitored continuously with an intraparenchymal microtransducer and an indwelling arterial line. Pressure monitors were connected to bedside computers running ICM+ software. Pressure reactivity was determined as the moving correlation between 30 10-s averages of ABP and ICP (PRx). The mean ICP and PRx were calculated for the whole monitoring period for each patient.

RESULTS

Those with pre-hospital hypotension were susceptible to higher ICP [20 (IQR 8) vs 13 (IQR 6) mmHg; p = 0.01] and more frequent ICP plateau waves [median = 0 (IQR 1), median = 4 (IQR 9); p = 0.001], despite having similar MAP, CPP and PRx during monitoring. Those with unreactive pupils tended to have higher ICP than those with reactive pupils (18 vs 14 mmHg, p = 0.08). Pre-hospital hypoxia, motor score and pupillary reactivity were not related to subsequent monitored intracranial or systemic physiology.

CONCLUSION

In paediatric TBI, pre-hospital hypotension is associated with increased ICP in the intensive care unit.

Bag Valve Mask Ventilation as a Perceptual-Cognitive Skill

Objective This study used a high-fidelity infant mannequin to examine the relationship between the quality of bag valve mask ventilation (BVMV) and how providers of varying levels of experience use visual feedback (e.g., electronic vital signs) to guide their performance. Background BVMV is a common and critical procedure for managing pediatric respiratory emergencies. However, providers do not consistently deliver effective BVMV. Efforts to improve BVMV have ignored the question of how providers effectively use feedback often available during BVMV. Method Six expert and six novice respiratory therapists completed two simulations of an infant requiring BVMV. In one, the technology failed to display SpO₂, an important but somewhat redundant visual cue. Eye movements, verbal reports, and ventilation rate (in breaths per minute) were measured in each simulation. Results Regardless of SpO₂ availability, eye movements and verbal reports suggested that novices depended strongly on electronic vital signs and when SpO₂ was absent ventilated at a faster rate (exceeding the recommended range of ventilation rates) than when SpO₂ was present. Experts' ventilation rates were comparable and within the recommended range in both conditions. When SpO₂ was absent, experts emphasized information from direct observation of the patient that novices neglected. Conclusion Individual differences in the use of feedback during BVMV contribute to the quality of BVMV. This work bears on the theoretical discussions involving the use of automation and nontechnological cues to guide performance. Application These results have the potential to expand the current understanding of factors underlying effective BVMV with implications for training novice providers.

Emergency Department Management of Pediatric Shock

Shock, a state of inadequate oxygen delivery to tissues resulting in anaerobic metabolism, lactate accumulation, and end-organ dysfunction, is common in children in emergency department. Shock can be divided into 4 categories: hypovolemic, distributive, cardiogenic, and obstructive. Early recognition of shock can be made with close attention to historical clues, physical examination and vital sign abnormalities. Early and aggressive treatment can prevent or reverse organ dysfunction and improve morbidity and mortality.

End-Tidal Carbon Dioxide Use for Tracheal Intubation: Analysis From the National Emergency Airway Registry for Children (NEAR4KIDS) Registry

OBJECTIVE

Waveform capnography use has been incorporated into guidelines for the confirmation of tracheal intubation. We aim to describe the trend in waveform capnography use in emergency departments and PICUs and assess the association between waveform capnography use and adverse tracheal intubation-associated events.

DESIGN

A multicenter retrospective cohort study.

SETTING

Thirty-four hospitals (34 ICUs and nine emergency departments) in the National Emergency Airway Registry for Children quality improvement initiative.

PATIENTS

Primary tracheal intubation in children younger than 18 years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patient, provider, and practice data for tracheal intubation procedure including a type of end-tidal carbon dioxide measurement, as well as the procedural safety outcomes, were prospectively collected. The use of waveform capnography versus colorimetry was evaluated in association with esophageal intubation with delayed recognition, cardiac arrest, and oxygen desaturation less than 80%. During January 2011 and December 2015, 9,639 tracheal intubations were reported. Waveform capnography use increased over time (39% in 2010 to 53% in 2015; p < 0.001), whereas colorimetry use decreased (< 0.001). There was significant variability in waveform capnography use across institutions (median 49%; interquartile range, 25-85%; p < 0.001). Capnography was used more often in emergency departments as compared with ICUs (66% vs. 49%; p < 0.001). The rate of esophageal intubation with delayed recognition was similar with waveform capnography versus colorimetry (0.39% vs. 0.46%; p = 0.62). The rate of cardiac arrest was also similar (p = 0.49). Oxygen desaturation occurred less frequently when capnography was used (17% vs. 19%; p = 0.03); however, this was not significant after adjusting for patient and provider characteristics.

CONCLUSIONS

Significant variations existed in capnography use across institutions, with the use increasing over time in both emergency departments and ICUs. The use of capnography during intubation was not associated with esophageal intubation with delayed recognition or the occurrence of cardiac arrest.

Spectrum of complications of severe DKA in children in pediatric Intensive Care Unit

Objectives:

To describe the spectrum of complications of Diabetic Ketoacidosis (DKA) observed in children admitted with severe DKA.

Methods:

Retrospective review of the medical records of all children admitted with the diagnosis of severe DKA in Pediatric Intensive Care Unit (PICU) of the Aga Khan University Hospital, from January 2010 to December 2015 was done. Data was collected on a structured proforma and descriptive statistics were applied.

Results:

Total 37 children were admitted with complicated DKA (1.9% of total PICU admission with 1.8% in 2010 and 3.4% in 2015). Mean age of study population was 8.1±4.6 years and 70% were females (26/37). Mean Prism III score was 9.4±6, mean GCS on presentation was 11±3.8 and mean lowest pH was 7.00±0.15. Complications observed included hyperchloremia (35.94%), hypokalemia (30.81%), hyponatremia (26.70%), cerebral edema (16.43%), shock (13.35%), acute kidney injury (10.27%), arrhythmias (3.8%), and thrombotic thrombocytopenic purpura (5.4%), while one patient had myocarditis and ARDS each. 13/37 children (35%) needed inotropic support, 11/37 (30%) required mechanical ventilation while only one patient required renal replacement therapy. Two patients (5.4%) died during their PICU stay.

Conclusion:

Hyperchloremia and other electrolyte abnormalities, cerebral edema and AKI are the most common complications of severe DKA.

Frequency of Desaturation and Association With Hemodynamic Adverse Events During Tracheal Intubations in PICUs

OBJECTIVES

Oxygen desaturation during tracheal intubation is known to be associated with adverse ICU outcomes in critically ill children. We aimed to determine the occurrence and severity of desaturation during tracheal intubations and the association with adverse hemodynamic tracheal intubation-associated events.

DESIGN

Retrospective cohort study as a part of the National Emergency Airway Registry for Children Network's quality improvement project from January 2012 to December 2014.

SETTING

International PICUs.

PATIENTS

Critically ill children younger than 18 years undergoing primary tracheal intubations in the ICUs.

INTERVENTIONS

tracheal intubation processes of care and outcomes were prospectively collected using standardized operational definitions. We defined moderate desaturation as oxygen saturation less than 80% and severe desaturation as oxygen saturation less than 70% during tracheal intubation procedures in children with initial oxygen saturation greater than 90% after preoxygenation. Adverse hemodynamic tracheal intubation-associated event was defined as cardiac arrests, hypo or hypertension requiring intervention, and dysrhythmia.

MEASUREMENTS AND MAIN RESULTS

A total of 5,498 primary tracheal intubations from 31 ICUs were reported. Moderate desaturation was observed in 19.3% associated with adverse hemodynamic tracheal intubation-associated events (9.8% among children with moderate desaturation vs 4.4% without desaturation; p < 0.001). Severe desaturation was observed in 12.9% of tracheal intubations, also significantly associated with hemodynamic tracheal intubation-associated events. After adjusting for patient, provider, and practice factors, the occurrence of moderate desaturation was independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 1.83 (95% CI, 1.34-2.51; p < 0.001). The occurrence of severe desaturation was also independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 2.16 (95% CI, 1.54-3.04; p < 0.001). Number of tracheal intubation attempts was also significantly associated with the frequency of moderate and severe desaturations (p < 0.001).

CONCLUSIONS

In this large tracheal intubation quality improvement database, we found moderate and severe desaturation are reported among 19% and 13% of all tracheal intubation encounters. Moderate and severe desaturations were independently associated with the occurrence of adverse hemodynamic events. Future quality improvement interventions may focus to reduce desaturation events.

Failure of Invasive Airway Placement on the First Attempt Is Associated With Progression to Cardiac Arrest in Pediatric Acute Respiratory Compromise

OBJECTIVES

The aim of this study was to describe the proportion of acute respiratory compromise events in hospitalized pediatric patients progressing to cardiopulmonary arrest, and the clinical factors associated with progression of acute respiratory compromise to cardiopulmonary arrest. We hypothesized that failure of invasive airway placement on the first attempt (defined as multiple attempts at tracheal intubation, and/or laryngeal mask airway placement, and/or the creation of a new tracheostomy or cricothyrotomy) is independently associated with progression of acute respiratory compromise to cardiopulmonary arrest.

DESIGN

Multicenter, international registry of pediatric in-hospital acute respiratory compromise.

SETTING

American Heart Association's Get with the Guidelines-Resuscitation registry (2000-2014).

PATIENTS

Children younger than 18 years with an index (first) acute respiratory compromise event.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 2,210 index acute respiratory compromise events, 64% required controlled ventilation, 26% had return of spontaneous ventilation, and 10% progressed to cardiopulmonary arrest. There were 762 acute respiratory compromise events (34%) that did not require an invasive airway, 1,185 acute respiratory compromise events (54%) with successful invasive airway placement on the first attempt, and 263 acute respiratory compromise events (12%) with failure of invasive airway placement on the first attempt. After adjusting for confounding variables, failure of invasive airway placement on the first attempt was independently associated with progression of acute respiratory compromise to cardiopulmonary arrest (adjusted odds ratio 1.8 [95% CIs, 1.2-2.6]).

CONCLUSIONS

More than 1 in 10 hospitalized pediatric patients who experienced an acute respiratory compromise event progressed to cardiopulmonary arrest. Failure of invasive airway placement on the first attempt is independently associated with progression of acute respiratory compromise to cardiopulmonary arrest.

Establishing and Sustaining an ECPR Program

The use of extracorporeal support after failed return of a spontaneous ciruculation during cardiopulmonary resuscitation (ECPR) is well described. There are 4 distinct phases for resuscitation with ECPR and the time spent in each phase is critical for successful outcome. Recommendations for ECPR previously published by the American Heart Association provide the context for implementing a consistent and well-rehearsed system for ECPR, by people with the knowledge, experience and resources to deploy ECPR in the most optimal time frame possible in selected patient populations. In this manuscript we review the current status of ECPR for acute cardiac failure and the components we believe are necessary to develop and sustain a reliable and resilient program.

A Quality Improvement Collaborative for Pediatric Sepsis: Lessons Learned

Background:

Sepsis is a leading cause of morbidity and mortality in children worldwide. Barriers exist for timely recognition and management in emergency care settings. This 1-year quality improvement collaborative sought to reduce mortality from sepsis.

Methods:

Fifteen hospitals participated initially. We included children with a spectrum of illness from sepsis to septic shock. The intervention bundle focused on recognition, escalation of care, and the first hour of resuscitation. We conducted monthly learning sessions and disseminated data reports of site-specific and aggregated metrics to drive rapid cycle improvement.

Results:

Seven sites contributed enough data to be analyzed. Of the 1,173 pediatric patients in the total cohort, 506 presented with severe sepsis/septic shock. Quarterly data demonstrated a mean improvement in initial clinical assessment from 46% to 60% (P < 0.001) and in adherence to the administration of first fluid bolus within 15 minutes from 38% to 46% (P < 0.015). There was no statistically significant improvement in other process metrics. There was no statistically significant improvement in mortality for the total cohort (sepsis to septic shock) or either of the subgroups in either 3- or 30-day mortality.

Conclusions:

A quality improvement collaborative focused on improving timely recognition and management of pediatric sepsis to septic shock led to some process improvements but did not show improvement in mortality. Future national efforts should standardize definitions and processes of care for sepsis to septic shock, including the identification of a “time zero” for measuring the timeliness of treatment.

Being Underweight Is an Independent Risk Factor for Poor Outcomes Among Acutely Critically Ill Children

BACKGROUND

Malnutrition is associated with impaired immune function; thus, nutrition status assessment is crucial in critical care medicine. We aimed to investigate the impact of being underweight or overweight on major sequelae and mortality among healthy children with an intensive care unit admission.

METHODS

In this retrospective study, 282 patients aged 1 month to 18 years were enrolled on intensive care unit admission between 2011 and 2012. Children were excluded if they had underlying chronic diseases and were transferred to other hospitals or discharged against medical advice. The patients were further categorized into 3 nutrition status groups according to the weight-for-age (W/A) z score.

RESULTS

The prevalence rates of being underweight and overweight, based on W/A z scores of ≤-2 and ≥2, were 8.2% and 5.7%, respectively. Patients who were underweight were younger and had a higher rate of mortality, poor outcomes, and longer duration of mechanical ventilation than those with a normal weight. The patients with mortality or major sequelae had significantly higher rates of being underweight, noninfectious diseases and hypotension, and higher Pediatric Index of Mortality 2 (PIM2) score and creatinine level (all P < .01). In multivariate logistic regression interpretation, the W/A z score ≤-2 (95% CI, 2.992-47.508; P < .001) and PIM2 score (95% CI, 1.094-1.413; P = .001) were independent risk factors for a poor outcome.

CONCLUSION

Being underweight and having a PIM2 score on admission were independent risk factors for poor clinical outcomes among critically ill children without underlying diseases.

Management of Supraventricular Tachycardia in Infants

Supraventricular tachycardia is the most common tachyarrhythmia encountered in infants. In older children and adults, definitive treatment of the supraventricular tachycardia substrate with catheter ablation is a common approach to management. However, in infants, the risks of catheter ablation are significantly higher, and the patients often outgrow the potential to experience episodes. Therefore, antiarrhythmic medications are often utilized to minimize the likelihood of experiencing episodes. This article reviews the common arrhythmia mechanisms encountered in infants and the medications used to treat these patients.

Competence in performing emergency skills: How good do doctors really think they are?

Introduction

Despite the differences in exposure and experience in dealing with medical emergencies, all doctors should nevertheless be competent to assist a patient in need of resuscitation. The objective of this study was to describe the level of self-assessed emergency skill competence that specialist trainees in various disciplines possessed as well as to identify factors that may have contributed to their level of self-perceived competence.

Methods

A prospective, cross-sectional, questionnaire study of various specialist trainees’ self-perceived levels of competence in emergency skills was conducted across three academic hospitals in Johannesburg, South Africa. Trainees from General Surgery and Internal Medicine (Clinical) and Psychiatry and Radiology (Non-Clinical) rated their self-perceived level of competence in a list of basic, intermediate and advanced emergency skills according to a five-point Likert ranking scale.

Results

Ninety-four specialist trainees participated in the study – a response rate of 36%. The overall median competence rating for cardiac arrest resuscitation was 3.0 [IQR 3.0, 4.0] (i.e. intermediate). The median competence rating for cardiac arrest resuscitation in the clinical group (4.0) [IQR 3.0, 4.0] was higher than in the non-clinical group (3.0) [IQR 2.0, 3.0] (p < 0.001). Current or expired certification in Paediatric Advanced Life Support (PALS) or Advanced Paediatric Life Support (APLS) courses increased perceived competence and delays in starting specialisation resulted in a decrease in overall competence composite scores for each year of delay after internship.

Discussion

General Surgery and Internal Medicine trainees had a higher level of self-perceived competence in various emergency skills than their non- clinical counterparts. Current certification in advanced life support courses had a positive impact on trainees’ self- perceived levels of competence in emergency skills. Specialist trainees who had less delay before starting their specialist training also demonstrated higher levels of perceived competence.

Development of Pediatric Neurologic Emergency Life Support Course: A Preliminary Report

BACKGROUND

Acute neurological emergencies (ANEs) in children are common life-threatening illnesses and are associated with high mortality and severe neurological disability in survivors, if not recognized early and treated appropriately. We describe our experience of teaching a short, novel course "Pediatric Neurologic Emergency Life Support" to pediatricians and trainees in a resource-limited country.

METHODS

This course was conducted at 5 academic hospitals from November 2013 to December 2014. It is a hybrid of pediatric advance life support and emergency neurologic life support. This course is designed to increase knowledge and impart practical training on early recognition and timely appropriate treatment in the first hour of children with ANEs. Neuroresuscitation and neuroprotective strategies are key components of this course to prevent and treat secondary injuries. Four cases of ANEs (status epilepticus, nontraumatic coma, raised intracranial pressure, and severe traumatic brain injury) were taught as a case simulation in a stepped-care, protocolized approach based on best clinical practices with emphasis on key points of managements in the first hour.

RESULTS

Eleven courses were conducted during the study period. One hundred ninety-six physicians including 19 consultants and 171 residents participated in these courses. The mean (SD) score was 65.15 (13.87%). Seventy percent (132) of participants were passed (passing score > 60%). The overall satisfaction rate was 85%.

CONCLUSIONS

Pediatric Neurologic Emergency Life Support was the first-time delivered educational tool to improve outcome of children with ANEs with good achievement and high satisfaction rate of participants. Large number courses are required for future validation.

Airtraq Laryngoscope Versus the Conventional Macintosh Laryngoscope During Pediatric Intubation Performed by Nurses: A Randomized Crossover Manikin Study With Three Airway Scenarios

OBJECTIVES

We hypothesized that the Airtraq laryngoscope (Airtraq LLC, Bonita Springs, Fla) is beneficial for intubation of pediatric manikins while performing cardiopulmonary resuscitation (CPR). In the present study, we evaluated the effectiveness of the Macintosh (MAC) laryngoscope (HEINE Optotechnik, Munich, Germany) and Airtraq in 3 simulated CPR scenarios.

METHODS

A randomized crossover simulation trial was designed. Eighty-three nurses intubated the trachea of a PediaSIM CPR training manikin (FCAE HealthCare, Sarasota, Fla) using the MAC and Airtraq in a normal airway scenario, normal airway with chest compression scenario, and difficult airway with chest compression scenario. The participants were directed to perform a maximum of 3 attempts in each scenario. The success rate, time to intubation, Cormack & Lehane grade, dental compression, and the ease of intubation were measured.

RESULTS

All participants performed successful intubation with the Airtraq in all 3 scenarios. In all scenarios, the success rate was significantly higher and the time to intubation was significantly shorter with the Airtraq than with the MAC. Glottic visualization using the Cormack-Lehane scale was also better when using Airtraq in all scenarios.

CONCLUSIONS

In this manikin study, we found that the Airtraq can be used successfully for the intubation of pediatric manikins with normal and difficult airways by medical staff without previous experience in pediatric intubation. Moreover, intubation can be achieved without interrupting chest compression. The use of the Airtraq compared with the MAC led to faster time to intubation. Nevertheless, we recommend that the performance of the Airtraq and the MAC during CPR should be further evaluated in a clinical setting.

Early Exercise in Critically Ill Youth and Children, a Preliminary Evaluation: The wEECYCLE Pilot Trial

OBJECTIVES

To determine the feasibility of conducting a full trial evaluating the efficacy of early mobilization using in-bed cycling as an adjunct to physiotherapy, on functional outcomes in critically ill children.

DESIGN

Single center, pilot, randomized controlled trial.

SETTING

Twelve-bed tertiary care, medical-surgical PICU at McMaster Children's Hospital, Hamilton, ON, Canada.

PATIENTS

Children 3-17 years old who were limited to bed-rest with an expected PICU stay of at least 48 hours. Patients were excluded if they were at their baseline level of function, already mobilizing out of bed or expected to do so within 24 hours.

INTERVENTIONS

Patients were randomized in a 2:1 ratio to early mobilization using in-bed cycling in addition to usual care physiotherapy (cycling arm) or to usual care physiotherapy alone (control). Usual care was according to institutional practice guidelines. The primary outcome was feasibility and safety.

MEASUREMENTS AND MAIN RESULTS

Thirty patients were enrolled (20 to the cycling and 10 to control) over a 12-month period, at a 93.7% consent rate. The median (interquartile range) time from PICU admission to mobilization was 1.5 days (1-3) in the cycling arm and 2.5 days (2-7) in the control arm. Total duration of mobilization therapy in PICU was 210 (152-380) and 136 minutes (42-314 min) in cycling and control arms, respectively. Total number of PICU days mobilized was 5.0 (3-6) with cycling and 2.5 (2-4.8) with usual care. No adverse events occurred in either arm. The main threat to feasibility of mobilization was the availability of physiotherapists or research personnel.

CONCLUSIONS

Early mobilization is safe and feasible in the PICU. In-bed cycling may facilitate greater duration and intensity of mobilization, in critically ill children. A full-scale randomized controlled trial is warranted to evaluate the efficacy of this intervention on PICU-acquired morbidities and functional outcomes in this population.

Fluid Bolus Over 15-20 Versus 5-10 Minutes Each in the First Hour of Resuscitation in Children With Septic Shock: A Randomized Controlled Trial

OBJECTIVES

To compare the effect of administration of 40-60 mL/kg of fluids as fluid boluses in aliquots of 20 mL/kg each over 15-20 minutes with that over 5-10 minutes each on the composite outcome of need for mechanical ventilation and/or impaired oxygenation-increase in oxygenation index by 5 from baseline in the initial 6 and 24 hours in children with septic shock.

DESIGN

Randomized controlled trial.

SETTING

Pediatric emergency and ICU of a tertiary care institute.

PATIENTS

Children (< 18 yr old) with septic shock.

INTERVENTIONS

We randomly assigned participants to 15-20 minutes bolus (study group) or 5-10 minutes bolus groups (control group).

MEASUREMENTS AND MAIN RESULTS

We assessed the composite outcomes in the initial 6 and 24 hours after fluid resuscitation in both groups. We performed logistic regression to evaluate factors associated with need for ventilation in the first hour. Data were analyzed using Stata 11.5. Of the 96 children, 45 were randomly assigned to "15-20 minutes group" and 51 to "5-10 minutes group." Key baseline characteristics were not different between the groups. When compared with 5-10 minutes group, fewer children in 15-20 minutes group needed mechanical ventilation or had an increase in oxygenation index in the first 6 hours (36% vs 57%; relative risk, 0.62; 95% CI, 0.39-0.99) and 24 hours (43% vs 68%; relative risk, 0.63; 95% CI, 0.42-0.93) after fluid resuscitation. We did not find any difference in secondary outcomes such as death (1.2; 0.70-2.03), length of stay (mean difference: 0.52; -1.72 to 2.7), or resolution of shock (0.98; 0.63-1.53).

CONCLUSION

Children receiving fluid boluses over 5-10 minutes each had a higher risk of intubation than those receiving boluses over 15-20 minutes each. Notwithstanding the lack of difference in risk of mortality and the possibility that a lower threshold of intubation and mechanical ventilation was used in the presence of fluid overload, our results raise concerns on the current recommendation of administering boluses over 5-10 minutes each in children with septic shock.

Promoters and Barriers to Implementation of Tracheal Intubation Airway Safety Bundle: A Mixed-Method Analysis

OBJECTIVES

To describe promoters and barriers to implementation of an airway safety quality improvement bundle from the perspective of interdisciplinary frontline clinicians and ICU quality improvement leaders.

DESIGN

Mixed methods.

SETTING

Thirteen PICUs of the National Emergency Airway Registry for Children network.

INTERVENTION

Remote or on-site focus groups with interdisciplinary ICU staff. Two semistructured interviews with ICU quality improvement leaders with quantitative and qualitative data-based feedbacks.

MEASUREMENTS AND MAIN RESULTS

Bundle implementation success (compliance) was defined as greater than or equal to 80% use for tracheal intubations for 3 consecutive months. ICUs were classified as early or late adopters. Focus group discussions concentrated on safety concerns and promoters and barriers to bundle implementation. Initial semistructured quality improvement leader interviews assessed implementation tactics and provided recommendations. Follow-up interviews assessed degree of acceptance and changes made after initial interview. Transcripts were thematically analyzed and contrasted by early versus late adopters. Median duration to achieve success was 502 days (interquartile range, 182-781). Five sites were early (median, 153 d; interquartile range, 146-267) and eight sites were late adopters (median, 783 d; interquartile range, 773-845). Focus groups identified common "promoter" themes-interdisciplinary approach, influential champions, and quality improvement bundle customization-and "barrier" themes-time constraints, competing paperwork and quality improvement activities, and poor engagement. Semistructured interviews with quality improvement leaders identified effective and ineffective tactics implemented by early and late adopters. Effective tactics included interdisciplinary quality improvement team involvement (early adopter: 5/5, 100% vs late adopter: 3/8, 38%; p = 0.08); ineffective tactics included physician-only rollouts, lack of interdisciplinary education, lack of data feedback to frontline clinicians, and misconception of bundle as research instead of quality improvement intervention.

CONCLUSIONS

Implementation of an airway safety quality improvement bundle with high compliance takes a long time across diverse ICUs. Both early and late adopters identified similar promoter and barrier themes. Early adopter sites customized the quality improvement bundle and had an interdisciplinary quality improvement team approach.

Coming full circle: thirty years of paediatric fluid resuscitation

Fluid bolus therapy (FBT) is a cornerstone of the management of the septic child, but clinical research in this field is challenging to perform, and hard to interpret. The evidence base for independent benefit from liberal FBT in the developed world is limited, and the Fluid Expansion as Supportive Therapy (FEAST) trial has led to conservative changes in the World Health Organization-recommended approach to FBT in resource-poor settings. Trials in the intensive care unit (ICU) and emergency department settings post-FEAST have continued to explore liberal FBT strategies as the norm, despite a strong signal associating fluid accumulation with pulmonary pathology in the paediatric population. Modern clinical trial methodology may ameliorate the traditional challenges of performing randomised interventional trials in critically ill children. Such trials could examine differing strategies of fluid resuscitation, or compare early FBT to early vasoactive agent use. Given the ubiquity of FBT and the potential for harm, appropriately powered examinations of the efficacy of FBT compared to alternative interventions in the paediatric emergency and ICU settings in the developed world appear justified and warranted.

The Use of Extracorporeal Membrane Oxygenation-Cardiopulmonary Resuscitation in Prolonged Cardiac Arrest in Pediatric Patients: Is it Time to Expand It?

Extracorporeal membrane oxygenation was instituted as an aid to in-hospital cardiopulmonary resuscitation (E-CPR) nearly 23 years ago, this led to remarkable improvement in survival considering the mortality rate associated with conventional cardiopulmonary resuscitation (CPR). Given this success, one begins to wonder whether the time has come for expanding the use of E-CPR to outside hospital cardiac arrests especially in the light of development of newer extracorporeal life support devices that are small, mobile, and easy to assemble. This editorial will review recent studies on this subject and address some key guidelines and limitations of this evolving and promising technology.

Transport-related Adverse Events in Critically-ill Children: The Role of a Dedicated Transport Team

OBJECTIVE

To compare the frequency of transport-related adverse events in children during specialized, non-specialized or unassisted transports.

METHODS

Patients were grouped based on transport team involved - specialized (Group-1); non-specialized (Group-2); unassisted transport (Group-3). Demographics, events during transport and condition on arrival were recorded.

RESULTS

Group-1 children had a lower incidence of adverse events compared to Group-2 and Group-3 (4.3%, 82.6% and 85.4% respectively; P<0.001). At arrival, children in Group-1 had a lower incidence of respiratory distress and airway compromise (P< 0.001).

CONCLUSION

Transport of critically ill children by a specialized transport team is associated with fewer transport-related adverse events.

Assessing the global reach and value of a provider-facing healthcare app using large-scale analytics

BACKGROUND

The rapid global adoption of mobile health (mHealth) smartphone apps by healthcare providers presents challenges and opportunities in medicine. Challenges include ensuring the delivery of high-quality, up-to-date and optimised information. Opportunities include the ability to study global practice patterns, access to medical and surgical care and continuing medical education needs.

METHODS

We studied users of a free anaesthesia calculator app used worldwide. We combined traditional app analytics with in-app surveys to collect user demographics and feedback.

RESULTS

31 173 subjects participated. Users were from 206 countries and represented a spectrum of healthcare provider roles. Low-income country users had greater rates of app use (p<0.001) and ascribed greater importance of the app to their practice (p<0.001). Physicians from low-income countries were more likely to adopt the app (p<0.001). The app was used primarily for paediatric patients. The app was used around the clock, peaking during times typical for first start cases.

CONCLUSIONS

This mHealth app is a valuable decision support tool for global healthcare providers, particularly those in more resource-limited settings and with less training. App adoption and use may provide a mechanism for measuring longitudinal changes in access to surgical care and engaging providers in resource-limited settings. In-app surveys and app analytics provide a window into healthcare provider behaviour at a breadth and level of detail previously impossible to achieve. Given the potentially immense value of crowdsourced information, healthcare providers should be encouraged to participate in these types of studies.

Effectiveness of interventions to improve medication use during rapid-sequence intubation in a pediatric emergency department

PURPOSE

Results of a study to determine whether checklist-based interventions improved the selection and administration of rapid-sequence intubation (RSI) medications in a pediatric emergency department (ED) are reported.

METHODS

A retrospective study of data collected during a quality-improvement project was conducted. Data sources included the electronic health record and video review. The central intervention was use of a 21-item RSI checklist, which included guidance for the physician team leader on medication selection and timing. A quick-reference card was developed to guide staff in preparing RSI medications. The main outcomes were (1) standard selection, defined as administration of indicated medications and avoidance of medications not indicated, and (2) efficient administration, defined as an interval of <30 seconds from sedative to neuromuscular blocker (NMB) infusion.

RESULTS

A total of 253 consecutive patients underwent RSI during 3 consecutive periods: the historical (preimprovement) period (n = 136), the checklist only period (n = 68), and the checklist/card period (n = 49). The rate of standard selection of 3 RSI medications (atropine, lidocaine, and rocuronium) did not improve. The rate of efficient sedative and NMB administration improved from 56% in the historical period to 88% in the checklist period (p = 0.005). The median duration of RSI medication administration decreased from 28 seconds (interquartile range [IQR], 23-44 seconds) in the historical period to 19 seconds (IQR, 15-25 seconds) in the checklist/card period (p = 0.004).

CONCLUSION

In a quality-improvement project in a pediatric ED, a checklist-based intervention improved RSI medication administration technique but not selection.

High-dose adenosine for refractory supraventricular tachycardia: a case report and literature review

Supraventricular tachycardia is the most common significant arrhythmia in children. If prolonged, it may cause heart failure and progress to cardiogenic shock warranting prompt treatment. The recommended interventions following vagal manoeuvres are intravenous adenosine and in the unstable patient electrical cardioversion. We present an infant with an unstable supraventricular tachycardia that was resistant to electrical cardioversion and recommended doses of adenosine. He reverted to sinus rhythm with a higher dose of adenosine, suggesting that such doses may be required in refractory supraventricular tachycardia.

Capnography Use During Intubation and Cardiopulmonary Resuscitation in the Pediatric Emergency Department

OBJECTIVE

Capnography is indicated as a guide to assess and monitor both endotracheal intubation and cardiopulmonary resuscitation (CPR). Our primary objective was to determine the effect of the 2010 American Heart Association (AHA) guidelines on the frequency of capnography use during critical events in children in the emergency department (ED). Our secondary objective was to examine associations between patient characteristics and capnography use among these patients.

METHODS

A retrospective chart review was performed on children aged 0 to 21 years who were intubated or received CPR in 2 academic children's hospital EDs between January 2009 and December 2012. Age, sex, time of arrival, medical or traumatic cause, length of CPR, return of spontaneous circulation (ROSC), documented use of capnography and colorimetry, capnography values, and adverse events were recorded.

RESULTS

Two hundred ninety-two patients were identified and analyzed. Intubation occurred in 95% of cases and CPR in 30% of cases. Capnography was documented in only 38% of intubated patients and 13% of patients requiring CPR. There was an overall decrease in capnography use after publication of the 2010 AHA recommendations (P = 0.05). Capnography use was associated with a longer duration of CPR and return of spontaneous circulation.

CONCLUSIONS

Despite the 2010 AHA recommendations, a minority of critically ill children are being monitored with capnography and an unexpected decrease in documented use occurred among our sample. Further education and implementation of capnography should take place to improve the use of this monitoring device for critically ill pediatric patients in the ED.

Catecholaminergic Polymorphic Ventricular Tachycardia

Catecholaminergic polymorphic ventricular tachycardia is a rare cause of exercise-induced arrhythmia and sudden cardiac death in the pediatric patient. This arrhythmia is difficult to diagnose in the emergency department, given the range of presentations; thus, a familiarity with and high index of suspicion for this pathology are crucial. Furthermore, recognition of the characteristic electrocardiogram findings and knowledge of the management of the symptomatic patient are necessary, given the risk of arrhythmia recurrence and cardiac arrest. In this review, we discuss the presentation, differential diagnosis, and management of catecholaminergic polymorphic ventricular tachycardia for the emergency care provider.

Adherence to AHA Guidelines When Adapted for Augmented Reality Glasses for Assisted Pediatric Cardiopulmonary Resuscitation: A Randomized Controlled Trial

Background

The American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) are nowadays recognized as the world’s most authoritative resuscitation guidelines. Adherence to these guidelines optimizes the management of critically ill patients and increases their chances of survival after cardiac arrest. Despite their availability, suboptimal quality of CPR is still common. Currently, the median hospital survival rate after pediatric in-hospital cardiac arrest is 36%, whereas it falls below 10% for out-of-hospital cardiac arrest. Among emerging information technologies and devices able to support caregivers during resuscitation and increase adherence to AHA guidelines, augmented reality (AR) glasses have not yet been assessed. In order to assess their potential, we adapted AHA Pediatric Advanced Life Support (PALS) guidelines for AR glasses.

Objective

The study aimed to determine whether adapting AHA guidelines for AR glasses increased adherence by reducing deviation and time to initiation of critical life-saving maneuvers during pediatric CPR when compared with the use of PALS pocket reference cards.

Methods

We conducted a randomized controlled trial with two parallel groups of voluntary pediatric residents, comparing AR glasses to PALS pocket reference cards during a simulation-based pediatric cardiac arrest scenario—pulseless ventricular tachycardia (pVT). The primary outcome was the elapsed time in seconds in each allocation group, from onset of pVT to the first defibrillation attempt. Secondary outcomes were time elapsed to (1) initiation of chest compression, (2) subsequent defibrillation attempts, and (3) administration of drugs, as well as the time intervals between defibrillation attempts and drug doses, shock doses, and number of shocks. All these outcomes were assessed for deviation from AHA guidelines.

Results

Twenty residents were randomized into 2 groups. Time to first defibrillation attempt (mean: 146 s) and adherence to AHA guidelines in terms of time to other critical resuscitation endpoints and drug dose delivery were not improved using AR glasses. However, errors and deviations were significantly reduced in terms of defibrillation doses when compared with the use of the PALS pocket reference cards. In a total of 40 defibrillation attempts, residents not wearing AR glasses used wrong doses in 65% (26/40) of cases, including 21 shock overdoses >100 J, for a cumulative defibrillation dose of 18.7 Joules per kg. These errors were reduced by 53% (21/40, P<.001) and cumulative defibrillation dose by 37% (5.14/14, P=.001) with AR glasses.

Conclusions

AR glasses did not decrease time to first defibrillation attempt and other critical resuscitation endpoints when compared with PALS pocket cards. However, they improved adherence and performance among residents in terms of administering the defibrillation doses set by AHA.

Prospective Study of Adenosine on Atrioventricular Nodal Conduction in Pediatric and Young Adult Patients After Heart Transplantation

BACKGROUND

Supraventricular tachycardia is common after heart transplantation. Adenosine, the standard therapy for treating supraventricular tachycardia in children and adults without transplantation, is relatively contraindicated after transplantation because of a presumed risk of prolonged atrioventricular block in denervated hearts. This study tested whether adenosine caused prolonged asystole after transplantation and if it was effective in blocking atrioventricular nodal conduction in these patients.

METHODS

This was a single-center prospective clinical study including healthy heart transplant recipients 6 months to 25 years of age presenting for routine cardiac catheterization during 2015 to 2016. After catheterization, a transvenous pacing catheter was placed and adenosine was given following a dose-escalation protocol until atrioventricular block was achieved. The incidence of clinically significant asystole (≥12 seconds after adenosine) was quantified. The effects of patient characteristics on adenosine dose required to produce atrioventricular block and duration of effect were also measured.

RESULTS

Eighty patients completed adenosine testing. No patient (0%; 95% confidence interval, 0-3) required rescue ventricular pacing. Atrioventricular block was observed in 77 patients (96%; 95% confidence interval, 89-99). The median longest atrioventricular block was 1.9 seconds (interquartile range, 1.4-3.2 seconds), with a mean duration of adenosine effect of 4.3±2.0 seconds. No patient characteristic significantly predicted the adenosine dose to produce atrioventricular block or duration of effect. Results were similar across patient weight categories.

CONCLUSIONS

Adenosine induces atrioventricular block in healthy pediatric and young adult heart transplant recipients with minimal risk when low initial doses are used (25 μg/kg; 1.5 mg if ≥60 kg) and therapy is gradually escalated.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02462941.

General dentists' awareness of how to cope with medical emergencies in paediatric dental patients

BACKGROUND

General dentists (GDs) should be aware of the symptoms, signs, diagnoses and treatment of medical emergencies in paediatric patients.

AIM

To evaluate the knowledge of GDs in coping with medical emergencies, and to identify whether they are confident to diagnose and treat medical emergencies in paediatric patients.

DESIGN

The questionnaire was conducted immediately before the beginning of national dental meetings and continuing education seminars in Croatia, attended by the GDs, in order to obtain a representative sample.

RESULTS

Of a total of 498 GDs who returned the questionnaire with valid data, 51.2% reported that a medical history was regularly taken. A high proportion (81.3%) of the GDs had never received any basic life support (BLS) training and education for paediatric patients during their undergraduate studies. After graduation, this value rose to 86.1% of GDs. However, more than two-thirds (68.7%) had experienced some emergency situation in their practice. The most frequent emergency was vasovagal syncope (83.6%) and the most rare was cardiac arrest (8.2%). One-fifth (20.5%) of GDs experienced some emergency but could not make a diagnosis. The more BLS training undergone by a GD, the more self-confident s/he felt in an emergency situation.

CONCLUSIONS

Most GDs have a lack of knowledge to cope with medical emergencies in paediatric patients, and do not feel confident to diagnose and treat emergency situations in children. It is suggested that adequate training and education should be provided for all GDs to address this shortcoming.

Rapid Identification of Psychoactive Drugs in Drained Gastric Lavage Fluid and Whole Blood Specimens of Drug Overdose Patients Using Ambient Mass Spectrometry

Psychoactive drug overdoses are life-threatening and require prompt and proper treatment in the emergency room to minimize morbidity and mortality. Prompt identification of the ingested psychoactive drugs is challenging, since witness recall is unreliable and patients' symptoms do not necessarily explain their loss of consciousness. Gas and liquid chromatography mass spectrometric analyses have been the traditionally employed methods to detect and identify abused substances; however, these techniques are time-consuming and labor-intensive. In this study, thermal desorption electrospray ionization mass spectrometry, an ambient mass spectrometric technique, was applied to rapidly characterize flunitrazepam, lysergic acid diethylamide, and 3,4-methylenedioxy-methamphetamine in drained gastric lavage fluid, and ketamine, cocaine, amphetamine and norketamine in whole blood samples. No pretreatment of the gastric lavage fluid specimens was required and the entire analytical process took less than 30 s per specimen. Liquid-liquid extraction, followed by centrifugation, was performed on the whole blood samples. The corresponding compounds were identified through matching the obtained mass spectrometric data with those provided by commercial databases. The limits-of-detection of the tested drugs in both drained gastric lavage fluid and whole blood samples are at sub ppm levels. This is sensitive enough for emergency medical application, since the quantities of medications ingested by overdosed abusers are much higher than the amounts that were tested.

Oesophageal heat exchangers with a diameter of 11mm or 14.7mm are equally effective and safe for targeted temperature management

BACKGROUND

Targeted temperature management (TTM) is widely used in critical care settings for conditions including hepatic encephalopathy, hypoxic ischemic encephalopathy, meningitis, myocardial infarction, paediatric cardiac arrest, spinal cord injury, traumatic brain injury, ischemic stroke and sepsis. Furthermore, TTM is a key treatment for patients after out-of-hospital cardiac-arrest (OHCA). However, the optimal cooling method, which is quick, safe and cost-effective still remains controversial. Since the oesophagus is adjacent to heart and aorta, fast heat-convection to the central blood-stream could be achieved with a minimally invasive oesophageal heat exchanger (OHE). To date, the optimal diameter of an OHE is still unknown. While larger diameters may cause thermal- or pressure-related tissue damage after long-term exposure to the oesophageal wall, smaller diameter (e.g., gastric tubes, up to 11mm) may not provide effective cooling rates. Thus, the objective of the study was to compare OHE-diameters of 11mm (OHE11) and 14.7mm (OHE14.7) and their effects on tissue and cooling capability.

METHODS

Pigs were randomized to OHE11 (N = 8) or OHE14.7 (N = 8). After cooling, pigs were maintained at 33°C for 1 hour. After 10h rewarming, oesophagi were analyzed by means of histopathology. The oesophagus of four animals from a separate study that underwent exactly the identical preparation and cooling protocol described above but received a maintenance period of 24h were used as histopathological controls.

RESULTS

Mean cooling rates were 2.8±0.4°C°C/h (OHE11) and 3.0±0.3°C °C/h (OHE14.7; p = 0.20). Occasional mild acute inflammatory transepithelial infiltrates were found in the cranial segment of the oesophagus in all groups including controls. Deviations from target temperature were 0.1±0.4°C (OHE11) and 0±0.1°C (OHE14.7; p = 0.91). Rewarming rates were 0.19±0.07°C °C/h (OHE11) and 0.20±0.05°C °C/h (OHE14.7; p = 0.75).

CONCLUSIONS

OHE with diameters of 11 mm and 14.7 mm achieve effective cooling rates for TTM and did not cause any relevant oesophageal tissue damage. Both OHE demonstrated acceptable deviations from target temperature and allowed for an intended rewarming rate (0.25°C/h).

A comparison between the two methods of chest compression in infant and neonatal resuscitation. A review according to 2010 CPR guidelines

AIM

The quality of chest compression (CC) delivered during neonatal and infant cardiopulmonary resuscitation (CPR) is identified as the most important factor to achieve the increase of survival rate without major neurological deficit to the patients. The objective of the study was to systematically review all the available studies that have compared the two different techniques of hand placement on infants and neonatal resuscitation, from 2010 to 2015 and to highlight which method is more effective.

METHODS

A review of the literature using a variety of medical databases, including Cochrane, MEDLINE, and SCOPUS electronic databases. The following MeSH terms were used in the search: infant, neonatal, CPR, CC, two-thumb (TT) technique/method, two-finger (TF) technique/method, rescuer fatigue, thumb/finger position/placement, as well as combinations of these.

RESULTS

Ten studies met the inclusion criteria; nine observational studies and a randomized controlled trial. All providers performed either continuous TF or TT technique CCs and the majority of CPR performance was taken place in infant trainer manikin.

CONCLUSIONS

The majority of the studies suggest the TT method as the more useful for infants and neonatal resuscitation than the TF.

Effect of prehospital advanced airway management for pediatric out-of-hospital cardiac arrest

BACKGROUND

Respiratory care may be important in pediatric out-of-hospital cardiac arrest (OHCA) due to the asphyxial nature of the majority of events. However, evidence of the effect of prehospital advanced airway management (AAM) for pediatric OHCA is scarce.

METHODS

This was a nationwide population-based study of pediatric OHCA in Japan from 2011 to 2012 based on data from the All-Japan Utstein Registry. We included pediatric OHCA patients aged between 1 and 17 years old. The primary outcome was one-month neurologically favorable survival defined as a Glasgow-Pittsburgh cerebral performance category (CPC) score of 1-2 (corresponding to a Pediatric CPC score of 1-3).

RESULTS

A total of 2157 patients were included in the final cohort; 365 received AAM and 1792 received bag-valve-mask (BVM) ventilation only. Among the 2157 patients, 213 (9.9%) survived with favorable neurological outcomes (CPC of 1-2) one month after OHCA. There were no significant differences in neurologically favorable survival between the AAM and BVM groups after adjusting for potential confounders, although there was a tendency favoring BVM ventilation: propensity score matching, OR 0.74 (95%CI 0.35-1.59), and multivariable logistic regression modeling, OR_adjusted 0.55 (95%CI 0.24-1.14). Subgroup analyses demonstrated that there were no subgroups in which AAM was associated with neurologically favorable survival, including the non-cardiac (primarily asphyxial) etiology group.

CONCLUSIONS

In pediatric OHCA, prehospital AAM was not associated with an increased chance of neurologically favorable survival compared with BVM-only ventilation. However, careful consideration is required to interpret the findings, as there may be unmeasured residual confounders and selection bias.

Ultrasonography for endotracheal tube position in infants and children

Ultrasonography (US) has been shown to be effective for verifying endotracheal tube (ETT) position in adults but has been less studied in infants and children. We review the literature regarding US for ETT positioning in the pediatric population. A literature search was conducted using the Ovid and MEDLINE databases with search terms regarding US relating to ETT intubation and positioning in infants and children. Most studies in neonates and infants used the midsagittal suprasternal view. Studies reported >80% visualization of the ETT tip by US, and US interpretation of the ETT position correlated with the XR position in 73-100% of cases. Studies of older children used the suprasternal views, substernal views, and mid-axillary intercostal views. US appears comparable to XR and capnography in determining ETT position in this population.

CONCLUSION

US for ETT verification appears to be well tolerated in infants and children and may augment determination of proper ETT position in combination with other ETT verification modalities. Further studies are needed regarding technique and training. What is Known: • Point-of-care ultrasonography is realizing increased availability and use in several pediatric specialties. • Ultrasonography has been shown to be effective for verifying ETT position in adults but have been less studied in infants and children. What is New: • Ultrasonography for endotracheal tube verification appears to be well tolerated in infants and children. • Ultrasonography may augment determination of proper endotracheal tube position in combination with other verification modalities such as radiography and capnography in the pediatric population.

Early Fluid Overload Prolongs Mechanical Ventilation in Children With Viral-Lower Respiratory Tract Disease

OBJECTIVES

Viral-lower respiratory tract disease is common in young children worldwide and is associated with high morbidity. Acute respiratory failure due to viral-lower respiratory tract disease necessitates PICU admission for mechanical ventilation. In critically ill patients in PICU settings, early fluid overload is common and associated with adverse outcomes such as prolonged mechanical ventilation and increased mortality. It is unclear, however, if this also applies to young children with viral-lower respiratory tract disease induced acute respiratory failure. In this study, we aimed to investigate the relation of early fluid overload with adverse outcomes in mechanically ventilated children with viral-lower respiratory tract disease in a retrospective dataset.

DESIGN

Retrospective cohort study.

SETTING

Single, tertiary referral PICU.

PATIENTS

One hundred thirty-five children (< 2 yr old) with viral-lower respiratory tract disease requiring mechanical ventilation admitted to the PICU of the Academic Medical Center, Amsterdam between 2008 and 2014.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The cumulative fluid balance on day 3 of mechanical ventilation was compared against duration of mechanical ventilation (primary outcome) and daily mean oxygen saturation index (secondary outcome), using uni- and multivariable linear regression. In 132 children, the mean cumulative fluid balance on day 3 was + 97.9 (49.2) mL/kg. Higher cumulative fluid balance on day 3 was associated with a longer duration of mechanical ventilation in multivariable linear regression (β = 0.166; p = 0.048). No association was found between the fluid status and oxygen saturation index during the period of mechanical ventilation.

CONCLUSIONS

Early fluid overload is an independent predictor of prolonged mechanical ventilation in young children with viral-lower respiratory tract disease. This study suggests that avoiding early fluid overload is a potential target to reduce duration of mechanical ventilation in these children. Prospective testing in a clinical trial is warranted to support this hypothesis.

Acute pesticide ingestion managed with yohimbine as a rescue therapy

Amitraz is used as a pesticide in agricultural and veterinary medicine. It is primarily a central α2 adrenergic agonist and known to cause central nervous system depression, convulsions, respiratory depression, and bradycardia on severe intoxication. We report a case of a 3-year-old child who presented with accidental ingestion of amitraz solution with signs of severe poisoning. There is no specific antidote of amitraz poisoning in humans, however, animal experiments with α2 adrenergic antagonists such as yohimbine and atimepazole have been successful. The child was managed besides intensive management with enteral yohimbine, and he regained consciousness in 18 h and was successfully weaned off mechanical ventilation.

Endotracheal tube placement confirmation: 100% sensitivity and specificity with sustained four-phase capnographic waveforms in a cadaveric experimental model

BACKGROUND

Waveform capnography is considered the gold standard for verification of proper endotracheal tube placement, but current guidelines caution that it is unreliable in low-perfusion states such as cardiac arrest. Recent case reports found that long-deceased cadavers can produce capnographic waveforms. The purpose of this study was to determine the predictive value of waveform capnography for endotracheal tube placement verification and detection of misplacement using a cadaveric experimental model.

METHODS

We conducted a controlled experiment with two intubated cadavers. Tubes were placed within the trachea, esophagus, and hypopharynx utilizing video laryngoscopy. We recorded observations of capnographic waveforms and quantitative end-tidal carbon dioxide (ETCO₂) values during tracheal versus extratracheal (i.e., esophageal and hypopharyngeal) ventilations.

RESULTS

106 and 89 tracheal ventilations delivered to cadavers one and two, respectively (n=195) all produced characteristic alveolar waveforms (positive) with ETCO₂ values ranging 2-113mmHg. 42 esophageal ventilations (36 to cadaver one and 6 to cadaver two), and 6 hypopharyngeal ventilations (4 to cadaver one and 2 to cadaver two) all resulted in non-alveolar waveforms (negative) with ETCO₂ values of 0mmHg. Esophageal and hypopharyngeal measurements were categorized as extratracheal (n=48). A binary classification test showed no false negatives or false positives, indicating 100% sensitivity (NPV 1.0, 95%CI 0.98-1.00) and 100% specificity (PPV 1.0, 95%CI 0.93-1.00).

CONCLUSION

Though current guidelines question the reliability of waveform capnography for verifying endotracheal tube location during low-perfusion states such as cardiac arrest, our findings suggest that it is highly sensitive and specific.

Compassionate Options for Pediatric EMS (COPE): Addressing Communication Skills

INTRODUCTION

Each year, 16,000 children suffer cardiopulmonary arrest, and in one urban study, 2% of pediatric EMS calls were attributed to pediatric arrests. This indicates a need for enhanced educational options for prehospital providers that address how to communicate to families in these difficult situations. In response, our team developed a cellular phone digital application (app) designed to assist EMS providers in self-debriefing these events, thereby improving their communication skills. The goal of this study was to pilot the app using a simulation-based investigative methodology.

METHODS

Video and didactic app content was generated using themes developed from a series of EMS focus groups and evaluated using volunteer EMS providers assessed during two identical nonaccidental trauma simulations. Intervention groups interacted with the app as a team between assessments, and control groups debriefed during that period as they normally would. Communication performance and gap analyses were measured using the Gap-Kalamazoo Consensus Statement Assessment Form.

RESULTS

A total of 148 subjects divided into 38 subject groups (18 intervention groups and 20 control groups) were assessed. Comparison of initial intervention group and control group scores showed no statistically significant difference in performance (2.9/5 vs. 3.0/5; p = 0.33). Comparisons made during the second assessment revealed a statistically significant improvement in the intervention group scores, with a moderate to large effect size (3.1/5 control vs. 4.0/5 intervention; p < 0.001, r = 0.69, absolute value). Gap analysis data showed a similar pattern, with gaps of -0.6 and -0.5 (values suggesting team self-over-appraisal of communication abilities) present in both control and intervention groups (p = 0.515) at the initial assessment. This gap persisted in the control group at the time of the second assessment (-0.8), but was significantly reduced (0.04) in the intervention group (p = 0.013, r = 0.41, absolute value).

CONCLUSION

These results suggest that an EMS-centric app containing guiding information regarding compassionate communication skills can be effectively used by EMS providers to self-debrief after difficult events in the absence of a live facilitator, significantly altering their near-term communication patterns. Gap analysis data further imply that engaging with the app in a group context positively impacts the accuracy of each team's self-perception.