Cardiopulmonary resuscitation for in-hospital events in the emergency department: A comparison of adult and pediatric outcomes and care processes

The Reliability of the Resuscitation Assessment Tool (RAT) in Assessing Emergency Medicine Resident Competence in Pediatric Resuscitation Scenarios: A Prospective Observational Pilot Study

Introduction Emergency medicine (EM) postgraduate medical education in Canada has transitioned from traditional time-based training to competency-based medical education (CBME). In order to promote residents through stages of training, simulated assessments are needed to evaluate residents in high-stakes but low-frequency medical emergencies. There remains a gap in the literature pertaining to the use of evaluative tools in simulation, such as the Resuscitation Assessment Tool (RAT) in the new CBME curriculum design. Methods We completed a pilot study of resident physicians in one Canadian EM training program to evaluate the effectiveness and reliability of a simulation-based RAT for pediatric resuscitation. We recorded 10 EM trainees completing simulated scenarios and had nine EM physicians use the RAT tool to evaluate their performances. Generalizability theory was used to evaluate the reliability of the RAT tool. Results The mean RAT score for the management of pediatric myocarditis, cardiac arrest, and septic shock (appendicitis) across raters was 3.70, 3.73, and 4.50, respectively. The overall generalizability coefficient for testing simulated pediatric performance competency was 0.77 for internal consistency and 0.75 for absolute agreement. The performance of senior participants was superior to that of junior participants in the management of pediatric myocarditis (p = 0.01) but not statistically significant in the management of pediatric septic shock (p=0.77) or cardiac arrest (p =0.61). Conclusion Overall, our findings suggest that with an appropriately chosen simulated scenario, the RAT tool can be used effectively for the simulation of high-stakes and low-frequency scenarios for practice to enhance the new CBME curriculum in emergency medicine training programs.

Ultrasound-guided versus traditional method for peripheral venous access: an umbrella review

Background

Short peripheral catheters (SPC) insertion technique has a high failure rate, one of the reasons why the ultrasound (US)-guided method has been proposed as a valid alternative to traditional technique in SPC insertion. This umbrella review aims to synthesize the available evidence comparing the US-guided method with the traditional method on SPC insertion in terms of effectiveness, safety and patient satisfaction.

Methods

An umbrella review addressing the comparison between US-guided versus traditional method for SPC insertion in which only systematic reviews of all comparative study designs were eligible was carried out. Previous systematic reviews and meta-analyses were systematically searched in MEDLINE, EMBASE, Web of Science and Cochrane Library. Methodological quality was assessed with AMSTAR-2 tool. The quality of evidence per association was assessed using the GRADE criteria and was stablished as high, moderate, low and very low.

Results

Twelve systematic reviews with a range of 75–1860 patients were included. Moderate certainty evidence supports the positive effect of US-guided method on first-attempt success rate and number of attempts. There is moderate certainty evidence that US-guided method does not reduce the time spent in SPC insertion. Low certainty evidence supports that US-guided method improves both overall success rates and patient satisfaction. Emergency department was the main hospital department where these findings were reported.

Conclusions

The best current evidence indicates that US-guided method for SPC insertion is postulated as a valid alternative for both adult and pediatric population, especially in patients with difficult venous access and in hospital departments where optimal vascular access in the shortest time possible is critical.

Trial registration

PROSPERO: CRD42021290824.

Pediatric Cardiac Arrest Outcomes in the United States: A Nationwide Database Cohort Study

Background

Knowledge about the causes and outcomes of pediatric cardiac arrest in the emergency department is limited. The aim of our study was to evaluate the characteristics and outcomes of pediatric cardiac arrest in the emergency department (EDCA) and inpatient (IPCA) settings in the United States using a large database designed to provide nationwide estimates.

Methods

We performed a retrospective cohort study using the Nationwide Emergency Department Sample (NEDS), a database that includes both ED and inpatient encounters. The NEDS was analyzed for episodes of cardiac arrest between 2016-2018 in patients aged ≤18 years. Patients with cardiac arrest were identified using the International Classification of Diseases, 10th revision codes.

Results

A total of 15,348 pediatric cardiac arrest events with cardiopulmonary resuscitation were recorded, of which 13,239 had EDCA and 2,109 had IPCA. A lower survival rate of 19% was observed for EDCA compared to 40.4% for IPCA. While more than half of the EDCA events had no associated diagnoses, trauma (15.6%), respiratory failure (5%), asphyxiation (2.7%), acidosis (2.4%), and ventricular arrhythmia (1.4%) were associated with the remaining events. In comparison, the most frequently associated diagnoses for IPCA were respiratory failure (75.8%), acidosis (43.9%), acute kidney injury (27.2%), trauma (27.1%), and sepsis (22.5%). 

Conclusions

Survival rates for EDCA were less than half of that for IPCA. The low survival rates along with the distinctive characteristics of EDCA events suggest the need for further research in this area to identify remediable factors and improve survival.

Serum Lactate for Predicting Cardiac Arrest in the Emergency Department

Objectives: Early recognition and prevention of in-hospital cardiac arrest (IHCA) play an increasingly important role in the Chain of Survival. However, clinical tools for predicting IHCA in the emergency department (ED) are scanty. We sought to evaluate the role of serum lactate in predicting ED-based IHCA. Methods: Data were retrieved from 733,398 ED visits over a 7-year period in a tertiary medical centre. We selected one ED visit per person and excluded out-of-hospital cardiac arrest, children, or those without lactate measurements. Patient demographics, computerised triage information, and serum lactate levels were extracted. The initial serum lactate levels were grouped into normal (≤2 mmol/L), moderately elevated (2 < lactate ≤ 4), and highly elevated (>4 mmol/L) categories. The primary outcome was ED-based IHCA. Results: A total of 17,392 adult patients were included. Of them, 342 (2%) developed IHCA. About 50% of the lactate levels were normal, 30% were moderately elevated, and 20% were highly elevated. In multivariable analysis, the group with highly elevated lactate had an 18-fold increased risk of IHCA (adjusted odds ratio [OR], 18.0; 95% confidence interval [CI], 11.5-28.2), compared with the normal lactate group. In subgroup analysis, the poor lactate-clearance group (<2.5%/h) was associated with a 7.5-fold higher risk of IHCA (adjusted OR, 7.5; 95%CI, 3.7-15.1) compared with the normal clearance group. Conclusions: Elevated lactate levels and poor lactate clearance were strongly associated with a higher risk of ED-based IHCA. Clinicians may consider a more liberal sampling of lactate in patients at higher risk of IHCA with follow-up of abnormal levels.

Cardiac Arrest Survival Postresuscitation In-Hospital (CASPRI) Score Predicts Neurological Favorable Survival in Emergency Department Cardiac Arrest

Background: This study was conducted to identify the predictive factors for survival and favorable neurological outcome in patients with emergency department cardiac arrest (EDCA). Methods: ED patients who suffered from in-hospital cardiac arrest (IHCA) from July 2014 to June 2019 were enrolled. The electronic medical records were retrieved and data were extracted according to the IHCA Utstein-style guidelines. Results: The cardiac arrest survival post-resuscitation in-hospital (CASPRI) score was associated with survival, and the CASPRI scores were lower in the survival group. Three components of the CASPRI score were associated with favorable neurological survival, and the CASPRI scores were lower in the favorable neurological survival group of patients who were successfully resuscitated. The independent predictors of survival were presence of hypotension/shock, metabolic illnesses, short resuscitation time, receiving coronary angiography, and TTM. Receiving coronary angiography and low CASPRI score independently predicted favorable neurological survival in resuscitated patients. The performance of a low CASPRI score for predicting favorable neurological survival was fair, with an AUROCC of 0.77. Conclusions: The CASPRI score can be used to predict survival and neurological status of patients with EDCA. Post-cardiac arrest care may be beneficial for IHCA, especially in patients with EDCA.

Real-time audio-visual feedback with handheld nonautomated external defibrillator devices during cardiopulmonary resuscitation for in-hospital cardiac arrest: A meta-analysis

Objective:

Restoring cardiopulmonary circulation with effective chest compression remains the cornerstone of resuscitation, yet real-time compressions may be suboptimal. This project aims to determine whether in patients with in-hospital cardiac arrest (IHCA; population), chest compressions performed with free-standing audiovisual feedback (AVF) device as compared to standard manual chest compression (comparison) results in improved outcomes, including the sustained return of spontaneous circulation (ROSC), and survival to the intensive care unit (ICU) and hospital discharge (outcomes).

Methods:

Scholarly databases and relevant bibliographies were searched, as were clinical trial registries and relevant conference proceedings to limit publication bias. Studies were not limited by date, language, or publication status. Clinical randomized controlled trials (RCT) were included that enrolled adults (age ≥ 18 years) with IHCA and assessed real-time chest compressions delivered with either the standard manual technique or with AVF from a freestanding device not linked to an automated external defibrillator (AED) or automated compressor.

Results:

Four clinical trials met inclusion criteria and were included. No ongoing trials were identified. One RCT assessed the Ambu CardioPump (Ambu Inc., Columbia, MD, USA), whereas three assessed Cardio First Angel™ (Inotech, Nubberg, Germany). No clinical RCTs compared AVF devices head-to-head. Three RCTs were multi-center. Sustained ROSC (4 studies, n = 1064) was improved with AVF use (Relative risk [RR] 1.68, 95% confidence interval [CI] 1.39–2.04), as was survival to hospital discharge (2 studies, n = 922; RR 1.78, 95% CI 1.54–2.06) and survival to hospital discharge (3 studies, n = 984; RR 1.91, 95% CI 1.62–2.25).

Conclusion:

The moderate-quality evidence suggests that chest compressions performed using a non-AED free-standing AVF device during resuscitation for IHCA improves sustained ROSC and survival to ICU and hospital discharge.

Trial Registration:

PROSPERO (CRD42020157536).

Updated Approaches to Cardiac Electrical Stimulation and Pacing in Pediatrics

Cardiac electrical stimulation is a rarely used but required skill for pediatric emergency physicians. Children who are in cardiac arrest or who demonstrate evidence of hypoperfusion because of cardiac reasons require rapid diagnosis and intervention to minimize patient morbidity and mortality. Both hospital- and community-based personnel must have sufficient access to, and knowledge of, appropriate equipment to provide potentially lifesaving defibrillation, cardioversion, or cardiac pacing. In this review, we will discuss the primary clinical indications for cardioelectrical stimulation in pediatric patients, including the use of automated external defibrillators, internal defibrillators, and pacemakers. We discuss the types of devices that are currently available, emergency management of internal defibrillation and pacemaker devices, and the role of advocacy in improving delivery of emergency cardiovascular care of pediatric patients in the community.

Healthcare providers' perspectives on family presence during resuscitation in the emergency departments of the Kingdom of Bahrain

BACKGROUND

Worldwide, policies exist on family presence during resuscitation (FPDR), however, this is still lacking in the Gulf Corporation Countries (GCC) in general and in the Kingdom of Bahrain in particular. The aim of this study is to assess the perspectives of healthcare providers (HP) on FPDR among those working in the emergency departments (EDs) in the Kingdom.

METHODS

A self-administered anonymous electronic survey was collected from 146 HPs (emergency physicians and nurses) working in the three major EDs in the Kingdom of Bahrain. Besides demographic data, 18 items measuring HPs' perceptions of FPDR were generated using the 5-point Likert scale.

RESULTS

Surveys (n = 146) from physicians and nurses were analysed (45.9% vs. 54.1%, respectively). There were significant differences between physicians and nurses in terms of personal beliefs, FPDR enhancing professional satisfaction and behaviour, and the importance of a support person and saying goodbye (p < 0.001). However, general responses demonstrated that the majority of HPs encouraged and supported FPDR, but with greater support from physicians than nurses.

CONCLUSION

The study reflects that many HPs in EDs participated in and are familiar with FPDR, with the majority of ED physicians supporting it. Further studies should investigate the reasons for the lack of support from nurses. Results may contribute to the development of hospital ED policies that allow FPDR in the region.

Predicting cardiac arrest in the emergency department

In-hospital cardiac arrest remains a leading cause of death: roughly 300,000 in-hospital cardiac arrests occur each year in the United States, ≈10% of which occur in the emergency department. ED-based cardiac arrest may represent a subset of in-hospital cardiac arrest with a higher proportion of reversible etiologies and a higher potential for neurologically intact survival. Patients presenting to the ED have become increasingly complex, have a high burden of critical illness, and face crowded departments with thinly stretched resources. As a result, patients in the ED are vulnerable to unrecognized clinical deterioration that may lead to ED-based cardiac arrest. Efforts to identify patients who may progress to ED-based cardiac arrest have traditionally been approached through identification of critically ill patients at triage and the identification of patients who unexpectedly deteriorate during their stay in the ED. Interventions to facilitate appropriate triage and resource allocation, as well as earlier identification of patients at risk of deterioration in the ED, could potentially allow for both prevention of cardiac arrest and optimization of outcomes from ED-based cardiac arrest. This review will discuss the epidemiology of ED-based cardiac arrest, as well as commonly used approaches to predict ED-based cardiac arrest and highlight areas that require further research to improve outcomes for this population.

Epidemiology of pediatric cardiopulmonary resuscitation

OBJECTIVE

To analyze the main epidemiological aspects of prehospital and hospital pediatric cardiopulmonary resuscitation and the impact of scientific evidence on survival.

SOURCE OF DATA

This was a narrative review of the literature published at PubMed/MEDLINE until January 2019 including original and review articles, systematic reviews, meta-analyses, annals of congresses, and manual search of selected articles.

SYNTHESIS OF DATA

The prehospital and hospital settings have different characteristics and prognoses. Pediatric prehospital cardiopulmonary arrest has a three-fold lower survival rate than cardiopulmonary arrest in the hospital setting, occurring mostly at home and in children under 1year. Higher survival appears to be associated with age progression, shockable rhythm, emergency medical care, use of automatic external defibrillator, high-quality early life support, telephone dispatcher-assisted cardiopulmonary resuscitation, and is strongly associated with witnessed cardiopulmonary arrest. In the hospital setting, a higher incidence was observed in children under 1year of age, and mortality increased with age. Higher survival was observed with shorter cardiopulmonary resuscitation duration, occurrence on weekdays and during daytime, initial shockable rhythm, and previous monitoring. Despite the poor prognosis of pediatric cardiopulmonary resuscitation, an increase in survival has been observed in recent years, with good neurological prognosis in the hospital setting.

CONCLUSIONS

A great progress in the science of pediatric cardiopulmonary resuscitation has been observed, especially in developed countries. The recognition of the epidemiological aspects that influence cardiopulmonary resuscitation survival may direct efforts towards more effective actions; thus, studies in emerging and less favored countries remains a priority regarding the knowledge of local factors.

Delays in Cardiopulmonary Resuscitation, Defibrillation, and Epinephrine Administration All Decrease Survival in In-hospital Cardiac Arrest

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

Rapid response to witnessed, pulseless cardiac arrest is associated with increased survival.

WHAT THIS ARTICLE TELLS US THAT IS NEW

Assessment of witnessed, pulseless cardiac arrests occurring at 538 hospitals during a 9-yr period indicates that CPR did not occur immediately at 0 min in 5.7% of patients despite guidelines for instantaneous initiation. Delay in initiation of CPR was associated with significantly decreased survival.Time to initiation of CPR and subsequent time to initiation of administration of defibrillation shock (for shockable arrhythmias) and epinephrine were both associated with reduced patient survival.

BACKGROUND

Because the extent to which delays in initiating cardiopulmonary resuscitation (CPR) versus the time from CPR to defibrillation or epinephrine treatment affects survival remains unknown, it was hypothesized that all three independently decrease survival in in-hospital cardiac arrest.

METHODS

Witnessed, index cases of cardiac arrest from the Get With The Guidelines-Resuscitation Database occurring between 2000 and 2008 in 538 hospitals were included in this analysis. Multivariable risk-adjusted logistic regression examined the association of time to initiation of CPR and time from CPR to either epinephrine treatment or defibrillation with survival to discharge.

RESULTS

In the overall cohort of 57,312 patients, there were 9,802 survivors (17.1%). Times to initiation of CPR greater than 2 min were associated with a survival of 14.7% (91 of 618) as compared with 17.1% (9,711 of 56,694) if CPR was begun in 2 min or less (adjusted odds ratio [95% CI], 0.68 [0.54 to 0.87]; P < 0.002). Times from CPR to either defibrillation or epinephrine treatment of 2 min or less were associated with a survival of 18.0% (7,654 of 42,475), as compared with 15.0% (1,680 of 11,227) for 3 to 5 min (reference, 0 to 2 min; adjusted odds ratios [95% CI], 0.83 [0.78 to 0.88]; P < 0.001), 12.8% (382 of 2,983) for 6 to 8 min (0.67 [0.60 to 0.76], P < 0.001), and 13.7% (86 of 627) for 9 to 11 min (0.54 [0.42 to 0.69], P < 0.001).

CONCLUSIONS

Delays in the initiation of CPR and from CPR to defibrillation or epinephrine treatment were each associated with lower survival.

Cardiopulmonary Resuscitation in the Pediatric Cardiac Catheterization Laboratory: A Report From the American Heart Association's Get With the Guidelines-Resuscitation Registry

OBJECTIVES

Hospitalized children with underlying heart disease are at high risk for cardiac arrest, particularly when they undergo invasive catheterization procedures for diagnostic and therapeutic interventions. Outcomes for children experiencing cardiac arrest in the cardiac catheterization laboratory remain under-reported with few studies reporting survival beyond the catheterization laboratory. We aim to describe survival outcomes after cardiac arrest in the cardiac catheterization laboratory while identifying risk factors associated with hospital mortality after these events.

DESIGN

Retrospective observational study of data from a multicenter cardiac arrest registry from November 2005 to November 2016. Cardiac arrest in the cardiac catheterization laboratory was defined as the need for chest compressions greater than or equal to 1 minute in the cardiac catheterization laboratory. Primary outcome was survival to discharge. Variables analyzed using generalized estimating equations for association with survival included age, illness category (surgical cardiac, medical cardiac), preexisting conditions, pharmacologic interventions, and event duration.

SETTING

American Heart Association's Get With the Guidelines-Resuscitation registry of in-hospital cardiac arrest.

PATIENTS

Consecutive patients less than 18 years old experiencing an index (i.e., first) cardiac arrest event reported to the Get With the Guidelines-Resuscitation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 203 patients met definition of index cardiac arrest in the cardiac catheterization laboratory composed primarily of surgical and medical cardiac patients (54% and 41%, respectively). Children less than 1 year old comprised the majority of patients, 58% (117/203). Overall survival to hospital discharge was 69% (141/203). No differences in survival were observed between surgical and medical cardiac patients (p = 0.15). The majority of deaths (69%, 43/62) occurred in patients less than 1 year old. Bradycardia (with pulse) followed by pulseless electrical activity/asystole were the most common first documented rhythms observed (50% and 27%, respectively). Preexisting metabolic/electrolyte abnormalities (p = 0.02), need for vasoactive infusions (p = 0.03) prior to arrest, and use of calcium products (p = 0.005) were found to be significantly associated with lower rates of survival to discharge on multivariable regression.

CONCLUSIONS

The majority of children experiencing cardiac arrest in the cardiac catheterization laboratory in this large multicenter registry analysis survived to hospital discharge, with no observable difference in outcomes between surgical and medical cardiac patients. Future investigations that focus on stratifying medical complexity in addition to procedural characteristics at the time of catheterization are needed to better identify risks for mortality after cardiac arrest in the cardiac catheterization laboratory.

Pediatric cardiac arrest in the emergency department: Outcome is related to the time of admission

Objectives:

Nights and weekends represent a potentially high-risk time for pediatric cardiac arrest (CA) patients in emergency departments. Data regarding night or weekend arrest and its impact on outcomes is controversial. The purpose of this study was to determine the relationship between cardiopulmonary resuscitation during the various emergency department shifts and survival to discharge.

Methods:

We conducted a retrospective, observational study of patients who had visited our Emergency Department for CAs from January 2014 to December 2016. Medical records and patient characteristics of 67 children with CA were retrieved from patient admission files.

Results:

The mean age was 54.7±7.3 months and 59% were male. Rates of survival to discharge 35% (11/31) within working hours’ vs. out of working hours 3% (1/36). Among the CAs presenting to the emergency department, the survival rates were higher for working hours than for non-working hours (OR: 37.6 (2.62-539.7), p: 008). The rate of return of spontaneous circulation within working hours was higher than that of non-working hours (71% vs.19%) (p<0.001). Patients who received chest compression for more than 10 minutes had the lowest survival rate (2%) (p<0.001), whereas better outcome was associated with in-hospital CA, younger age (less than 12 months) and respiratory failure.

Conclusion:

Survival rates from pediatric CAs were significantly lower during non-working hours. Poor outcome was associated with prolonged cardiopulmonary resuscitation, out of hospital CA and older age.

Real-time compression feedback for patients with in-hospital cardiac arrest: a multi-center randomized controlled clinical trial

Objective

To determine if real-time compression feedback using a non-automated hand-held device improves patient outcomes from in-hospital cardiac arrest (IHCA).

Methods

We conducted a prospective, randomized, controlled, parallel study (no crossover) of patients with IHCA in the mixed medical–surgical intensive care units (ICUs) of eight academic hospitals. Patients received either standard manual chest compressions or compressions performed with real-time feedback using the Cardio First Angel™ (CFA) device. The primary outcome was sustained return of spontaneous circulation (ROSC), and secondary outcomes were survival to ICU and hospital discharge.

Results

One thousand four hundred fifty-four subjects were randomized; 900 were included. Sustained ROSC was significantly improved in the CFA group (66.7% vs. 42.4%, P < 0.001), as was survival to ICU discharge (59.8% vs. 33.6%) and survival to hospital discharge (54% vs. 28.4%, P < 0.001). Outcomes were not affected by intra-group comparisons based on intubation status. ROSC, survival to ICU, and hospital discharge were noted to be improved in inter-group comparisons of non-intubated patients, but not intubated ones.

Conclusion

Use of the CFA compression feedback device improved event survival and survival to ICU and hospital discharge.

Trial registration

The study was registered with Clinicaltrials.gov (NCT02845011), registered retrospectively on July 21, 2016.

A novel depth estimation algorithm of chest compression for feedback of high-quality cardiopulmonary resuscitation based on a smartwatch

INTRODUCTION

High-quality cardiopulmonary resuscitation (CPR) is a key factor affecting cardiac arrest survival. Accurate monitoring and real-time feedback are emphasized to improve CPR quality. The purpose of this study was to develop and validate a novel depth estimation algorithm based on a smartwatch equipped with a built-in accelerometer for feedback instructions during CPR.

METHODS

For data collection and model building, researchers wore an Android Wear smartwatch and performed chest compression-only CPR on a Resusci Anne QCPR training manikin. We developed an algorithm based on the assumptions that (1) maximal acceleration measured by the smartwatch accelerometer and the chest compression depth (CCD) are positively correlated and (2) the magnitude of acceleration at a specific time point and interval is correlated with its neighboring points. We defined a statistic value M as a function of time and the magnitude of maximal acceleration. We labeled and processed collected data and determined the relationship between M value, compression rate and CCD. We built a model accordingly, and developed a smartwatch app capable of detecting CCD. For validation, researchers wore a smartwatch with the preinstalled app and performed chest compression-only CPR on the manikin at target sessions. We compared the CCD results given by the smartwatch and the reference using the Wilcoxon Signed Rank Test (WSRT), and used Bland-Altman (BA) analysis to assess the agreement between the two methods.

RESULTS

We analyzed a total of 3978 compressions that covered the target rate of 80-140/min and CCD of 4-7 cm. WSRT showed that there was no significant difference between the two methods (P = 0.084). By BA analysis the mean of differences was 0.003 and the bias between the two methods was not significant (95% CI: -0.079 to 0.085).

CONCLUSION

Our study indicates that the algorithm developed for estimating CCD based on a smartwatch with a built-in accelerometer is promising. Further studies will be conducted to evaluate its application for CPR training and clinical practice.

How to implement live video recording in the clinical environment: A practical guide for clinical services

BACKGROUND

The use of video in healthcare is becoming more common, particularly in simulation and educational settings. However, video recording live episodes of clinical care is far less routine.

AIM

To provide a practical guide for clinical services to embed live video recording.

MATERIALS AND METHODS

Using Kotter's 8-step process for leading change, we provide a 'how to' guide to navigate the challenges required to implement a continuous video-audit system based on our experience of video recording in our emergency department resuscitation rooms.

RESULTS

The most significant hurdles in installing continuous video audit in a busy clinical area involve change management rather than equipment. Clinicians are faced with considerable ethical, legal and data protection challenges which are the primary barriers for services that pursue video recording of patient care.

DISCUSSION

Existing accounts of video use rarely acknowledge the organisational and cultural dimensions that are key to the success of establishing a video system. This article outlines core implementation issues that need to be addressed if video is to become part of routine care delivery.

CONCLUSION

By focussing on issues such as staff acceptability, departmental culture and organisational readiness, we provide a roadmap that can be pragmatically adapted by all clinical environments, locally and internationally, that seek to utilise video recording as an approach to improving clinical care.

Amiodarone Versus Lidocaine for Pediatric Cardiac Arrest Due to Ventricular Arrhythmias: A Systematic Review

OBJECTIVE

We performed a systematic review as part of the International Liaison Committee on Resuscitation process to create a consensus on science statement regarding amiodarone or lidocaine during pediatric cardiac arrest for the 2015 International Liaison Committee on Resuscitation's Consensus on Science and Treatment Recommendations.

DATA SOURCES

Studies were identified from comprehensive searches in PubMed, Embase, and the Cochrane Library.

STUDY SELECTION

Studies eligible for inclusion were randomized controlled and observational studies on the relative clinical effect of amiodarone or lidocaine in cardiac arrest.

DATA EXTRACTION

Studies addressing the clinical effect of amiodarone versus lidocaine were extracted and reviewed for inclusion and exclusion criteria by the reviewers. Studies were rigorously analyzed thereafter.

DATA SYNTHESIS

We identified three articles addressing lidocaine versus amiodarone in cardiac arrest: 1) a prospective study assessing lidocaine versus amiodarone for refractory ventricular fibrillation in out-of-hospital adults; 2) an observational retrospective cohort study of inpatient pediatric patients with ventricular fibrillation or pulseless ventricular tachycardia who received lidocaine, amiodarone, neither or both; and 3) a prospective study of ventricular tachycardia with a pulse in adults. The first study showed a statistically significant improvement in survival to hospital admission with amiodarone (22.8% vs 12.0%; p = 0.009) and a lack of statistical difference for survival at discharge (p = 0.34). The second article demonstrated 44% return of spontaneous circulation for amiodarone and 64% for lidocaine (odds ratio, 2.02; 1.36-3.03) with no statistical difference for survival at hospital discharge. The third article demonstrated 48.3% arrhythmia termination for amiodarone versus 10.3% for lidocaine (p < 0.05). All were classified as lower quality studies without preference for one agent.

CONCLUSIONS

The confidence in effect estimates is so low that International Liaison Committee on Resuscitation felt that a recommendation to use of amiodarone over lidocaine is too speculative; we suggest that amiodarone or lidocaine can be used in the setting of pulseless ventricular tachycardia/ventricular fibrillation in infants and children.