Out-of-Hospital Pediatric Cardiac Arrest: Where Are We Now and Where Do We Need to Go?

Impact of the privacy rule on the study of out-of-hospital pediatric cardiac arrest

INTRODUCTION

The Privacy Rule, a follow-up to the Health Insurance Portability and Accountability Act, limits distribution of protected health information. Compliance with the Privacy Rule is particularly challenging for prehospital research, because investigators often seek data from multiple emergency medical services (EMS) and receiving hospitals.

OBJECTIVE

To describe the impact of the Privacy Rule on prehospital research and to present strategies to optimize data collection in compliance with the Privacy Rule. Methods. The CanAm Pediatric Cardiopulmonary Arrest Study Group has previously conducted a multicentered observational study involving children with out-of-hospital cardiac arrest. In the current study, we used a survey to assess site-specific methods of compliance with the Privacy Rule and the extent to which such strategies were successful.

RESULTS

The previously conducted observational study included collection of data from a total of 66 EMS agencies (range of 1-37 per site). Data collection from EMS providers was complicated by the lack of a systematic approval mechanism for the research use of EMS records and by incomplete resuscitation records. Agencies approached for approval to release EMS data for study purposes included Department of Health Institutional Review Boards, Fire Commissioners, and Commissioners of Health. The observational study included collection of data from a total of 164 receiving hospitals (range of 1-63 per site). Data collection from receiving hospitals was complicated by the varying requirements of receiving hospitals for the release of patient survival data.

CONCLUSIONS

Obtaining complete EMS and hospital data is challenging but is vital to the conduct of prehospital research. Obtaining approval from city or state level IRBs or Privacy Boards may help optimize data collection. Uniformity of methods to adhere to regulatory requirements would ease the conduct of prehospital research.

The new American Heart Association cardiopulmonary resuscitation guidelines: should children and adults have to share?

PURPOSE OF REVIEW

The latest American Heart Association guidelines for pediatric cardiopulmonary resuscitation (CPR) were published in December 2005. Changes from the 2000 guidelines were directed toward simplifying CPR. Infants, children, and adults now share the same recommendation for the initial compression:ventilation ratio. This is a significant change for pediatricians trained in the importance of a respiratory etiology of pediatric cardiopulmonary arrest. The present review will focus on the rationale behind these guideline changes.

RECENT FINDINGS

The new guidelines for single rescuer CPR include a compression:ventilation ratio of 30: 2 for both adult and pediatric victims. The impetus for this recommendation is based on recent appreciation for the deleterious effects of hyperventilation as well as an attempt to increase bystander delivery of CPR. The physiologic results of hyperventilation are discussed. The new pediatric basic life support guideline changes are underscored. Research representing the spectrum of opinions on the optimal compression:ventilation ratio, including compression-only CPR, is presented.

SUMMARY

Although based primarily on adult, animal, and computational models, the new compression:ventilation ratio, recommended for both initial pediatric and adult CPR, is a reasonable recommendation. The simplified CPR guidelines released in 2005 will hopefully contribute to improved bystander delivery of CPR and improved outcome.

Is cardiopulmonary resuscitation warranted in children who suffer cardiac arrest post trauma?

The use of cardiopulmonary resuscitation (CPR) is accepted universally for patients with cardiovascular compromise. However, outcomes from CPR in subsets of trauma patients may not be as good as initially thought. This article reviews the literature on outcomes from traumatic arrest in both adults and children. Outcomes for adults and children are similar, although the types of injuries may differ. Patients with asystolic arrest at the scene have very poor survival, and those who do survive sustain severe neurological injury. Recognizing that most providers would feel uncomfortable at not attempting resuscitation, the length and degree of aggressiveness of CPR is addressed. Finally, we discuss possible reasons to resuscitate. Organ donation and the ethics of nontherapeutic ventilation and other strategies to increase the donor pool are discussed. We hope to stimulate discussion around a very difficult issue.