2017 American Heart Association Focused Update on Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

System for Predicting Neurological Outcomes Following Cardiac Arrest Based on Clinical Predictors Using a Machine Learning Method: The Neurological Outcomes After Cardiac Arrest Method

BACKGROUND

A multimodal approach may prove effective for predicting clinical outcomes following cardiac arrest (CA). We aimed to develop a practical predictive model that incorporates clinical factors related to CA and multiple prognostic tests using machine learning methods.

METHODS

The neurological outcomes after CA (NOCA) method for predicting poor outcomes were developed using data from 390 patients with CA between May 2018 and June 2023. The outcome was poor neurological outcome, defined as a Cerebral Performance Category score of 3-5 at discharge. We analyzed 31 variables describing the circumstances at CA, demographics, comorbidities, and prognostic studies. The prognostic method was developed based on an extreme gradient-boosting algorithm with threefold cross-validation and hyperparameter optimization. The performance of the predictive model was evaluated using the receiver operating characteristic curve analysis and calculating the area under the curve (AUC).

RESULTS

Of the 390 total patients (mean age 64.2 years; 71.3% male), 235 (60.3%) experienced poor outcomes at discharge. We selected variables to predict poor neurological outcomes using least absolute shrinkage and selection operator regression. The Glasgow Coma Scale-M (best motor response), electroencephalographic features, the neurological pupil index, time from CA to return of spontaneous circulation, and brain imaging were found to be important key parameters in the NOCA score. The AUC of the NOCA method was 0.965 (95% confidence interval 0.941-0.976).

CONCLUSIONS

The NOCA score represents a simple method for predicting neurological outcomes, with good performance in patients with CA, using a machine learning analysis that incorporates widely available variables.

A study on the impact of open source metaverse immersive teaching method on emergency skills training for medical undergraduate students

BACKGROUND

In recent years, the traditional simulation-based medical teaching approach has faced challenges in meeting the requirements of practical emergency medicine education. This study utilized open-source tools and software to develop immersive panoramic videos using virtual reality technology for emergency medical teaching. It aims to investigate the efficacy of this novel teaching methodology. This transformation shifted the focus from physical simulation to virtual simulation in medical education, establishing a metaverse for emergency medical teaching.

METHODS

In accordance with the curriculum guidelines, the instructors produced panoramic videos demonstrating procedures such as spinal injury management, humeral fracture with abdominal wall intestinal tube prolapse, head and chest composite injuries, cardiopulmonary resuscitation, and tracheal intubation. Using Unity software, a virtual training application for bronchoscopy was developed and integrated into the PICO4 VR all-in-one device to create a metaverse teaching environment. Fourth-year medical undergraduate students were allocated into either an experimental group (n = 26) or a control group (n = 30) based on student IDs. The experimental group received instruction through the metaverse immersive teaching method, while the control group followed the traditional simulation-based medical teaching approach. Both groups participated in theoretical and practical lessons as usual. Subsequently, all students underwent a four-station Objective Structured Clinical Examination (OSCE) to assess the effectiveness of the teaching methods based on their performance. Additionally, students in the experimental group provided subjective evaluations to assess their acceptance of the new teaching approach.

RESULTS

Before the training commenced, there were no significant statistical differences in the first aid test scores between the experimental and control groups. Following the training, the experimental group outperformed the control group in the four-station OSCE examination, with all P-values being less than 0.05. The satisfaction rate among the experimental group regarding the new teaching method reached 88.46%, reflecting levels of satisfaction and extreme satisfaction.

CONCLUSION

The open-source metaverse immersive teaching method has demonstrated a positive impact on enhancing the emergency skills of medical undergraduate students, with a high level of acceptance among students. In comparison to traditional simulated medical teaching methods, this approach requires less time and space, incurring lower costs, and is deemed worthy of wider adoption.

Comparative Analysis of Out-of-Hospital Cardiac Arrest Outcomes in Health Clinics, Nursing Homes, and Public Places: Implications for Optimizing Automated External Defibrillator Strategies

Purpose

Various factors, such as event location and response time, influence the outcomes of out-of-hospital cardiac arrest (OHCA). Very few studies have explored the delivery of basic life support (BLS) to patients having OHCA at health clinics or nursing homes-settings with professional BLS providers. Thus, in this study, we compared prognostic and survival outcomes between health clinics, nursing homes, and other public places (eg, workplaces and sports facilities/recreational areas) to offer insights for optimizing OHCA outcomes.

Patients

This study included adults who had nontraumatic OHCA in Taoyuan City between January 2017 and December 2022.

Methods

We collected data on patient characteristics, emergency medical service parameters, onsite patient management, automated external defibrillator (AED) locations, OHCA prognosis, and survival outcomes. Multivariate analyses were performed to predict survival to discharge (primary outcome) and neurological outcomes at discharge (secondary outcome).

Results

During the study period, the numbers of OHCA events at health clinics, nursing homes, and other public places were 158, 208, and 1986, respectively. The mean age of OHCA in health medical clinics, nursing home and other public places were 63.4, 81.5 and 64.7, respectively (P value<0.001). The proportion of witnessed events, rate of bystander resuscitation, and frequency of AED utilization were the highest for health clinics (53.2% (84/158), 83.4% (132/158), and 13.3% (21/158), respectively, P value<0.001). The average AED-scene distances and response times were the lowest for health clinics (388.8 m and 5.4 min, respectively). In initial shockable rhythm group, the probabilities of survival to discharge at discharge were the highest for health clinics (aOR=1.41, 95% CI=1.04-1.81, P value=0.041)) and lowest for nursing homes (aOR=0.84, 95% CI=0.76-0.93, P value=0.024).

Conclusion

Our research shows that OHCA patients at medical health clinics have higher rates of witnessing and bystander CPR and AED usage than other public places. However, while survival rates for patients with shockable rhythms are slightly better at health clinics, the neurological outcomes are not significantly different. The AED-scene distances are too far to be used effectively.

Effective ventilation and chest compressions during neonatal resuscitation - the role of the respiratory device

BACKGROUND

The success of cardiopulmonary resuscitation (CPR) in newborns largely depends on effective lung ventilation; however, a direct randomized comparison using different available devices has not yet been performed.

METHODS

Thirty-six professionals were exposed to a realistic newborn CPR scenario. Ventilation with either a bag-valve mask (BVM), T-piece, or ventilator was applied in a randomized manner during CPR using a Laerdal manikin. The primary outcome was the number of unimpaired inflations, defined as the peak of the inflation occurring after chest compression and lasting at least 0.35 s before the following chest compression takes place. The secondary outcomes were tidal volume delivered and heart compression rate. To simulate potential distractions, the entire scenario was performed with or without a quiz. Statistically, a mixed model assessing fixed effects for experience, profession, device, and distraction was used to analyze the data. For direct comparison, one-way ANOVA with Bonferroni's correction was applied.

RESULTS

The number of unimpaired inflations was highest in health care professionals using the BVM with a mean ± standard deviation of 12.8 ± 2.8 (target: 15 within 30 s). However, the tidal volumes were too large in this group with a tidal volume of 42.5 ± 10.9 ml (target: 25-30 ml). The number of unimpaired breaths with the mechanical ventilator and the T-piece system were 11.6 (±3.6) and 10.1 (±3.7), respectively. Distraction did not change these outcomes, except for the significantly lower tidal volumes with the T-piece during the quiz.

CONCLUSIONS

In summary, for our health care professionals, ventilation using the mechanical ventilator seemed to provide the best approach during CPR, especially in a population of preterm infants prone to volutrauma.

Pediatric Cardiac Arrest and Resuscitation

Pediatric cardiac arrest in the emergency department is rare. We emphasize the importance of preparedness for pediatric cardiac arrest and offer strategies for the optimal recognition and care of patients in cardiac arrest and peri-arrest. This article focuses on both prevention of arrest and the key elements of pediatric resuscitation that have been shown to improve outcomes for children in cardiac arrest. Finally, we review changes to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care that were published in 2020.

2022 Systematic Review of Evidence-Based Guidelines for Prehospital Care

INTRODUCTION

Multiple national organizations and federal agencies have promoted the development, implementation, and evaluation of evidence-based guidelines (EBGs) for prehospital care. Previous efforts have identified opportunities to improve the quality of prehospital guidelines and highlighted the value of high-quality EBGs to inform initial certification and continued competency activities for EMS personnel.

OBJECTIVES

We aimed to perform a systematic review of prehospital guidelines published from January 2018 to April 2021, evaluate guideline quality, and identify top-scoring guidelines to facilitate dissemination and educational activities for EMS personnel.

METHODS

We searched the literature in Ovid Medline and EMBASE from January 2018 to April 2021, excluding guidelines identified in a prior systematic review. Publications were retained if they were relevant to prehospital care, based on organized reviews of the literature, and focused on providing recommendations for clinical care or operations. Included guidelines were appraised to identify if they met the National Academy of Medicine (NAM) criteria for high-quality guidelines and scored across the six domains of the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool.

RESULTS

We identified 75 guidelines addressing a variety of clinical and operational aspects of EMS medicine. About half (n = 39, 52%) addressed time/life-critical conditions and 33 (44%) contained recommendations relevant to non-clinical/operational topics. Fewer than half (n = 35, 47%) were based on systematic reviews of the literature. Nearly one-third (n = 24, 32%) met all NAM criteria for clinical practice guidelines. Only 27 (38%) guidelines scored an average of >75% across AGREE II domains, with content relevant to guideline implementation most commonly missing.

CONCLUSIONS

This interval systematic review of prehospital EBGs identified many new guidelines relevant to prehospital care; more than all guidelines reported in a prior systematic review. Our review reveals important gaps in the quality of guideline development and the content in their publications, evidenced by the low proportion of guidelines meeting NAM criteria and the scores across AGREE II domains. Efforts to increase guideline dissemination, implementation, and related education may be best focused around the highest quality guidelines identified in this review.

Optimizing an Emergency Medical Dispatch System to Improve Prehospital Diagnosis and Treatment of Acute Coronary Syndrome: Nationwide Retrospective Study in China

Background

Acute coronary syndrome (ACS) is the most time-sensitive acute cardiac event that requires rapid dispatching and response. The medical priority dispatch system (MPDS), one of the most extensively used types of emergency dispatch systems, is hypothesized to provide better-quality prehospital emergency treatment. However, few studies have revealed the impact of MPDS use on the process of ACS care.

Objective

This study aimed to investigate whether the use of MPDS was associated with higher prehospital diagnosis accuracy and shorter prehospital delay for patients with ACS transferred by an emergency medical service (EMS), using a national database in China.

Methods

This retrospective analysis was based on an integrated database of China’s MPDS and hospital registry. From January 1, 2016, to December 31, 2020, EMS-treated ACS cases were divided into before MPDS and after MPDS groups in accordance with the MPDS launch time at each EMS center. The primary outcomes included diagnosis consistency between hospital admission and discharge, and prehospital delay. Multivariable logistic regression and propensity score–matching analysis were performed to compare outcomes between the 2 groups for total ACS and subtypes.

Results

A total of 9806 ACS cases (3561 before MPDS and 6245 after MPDS) treated by 43 EMS centers were included. The overall diagnosis consistency of the after MPDS group (Cohen κ=0.918, P<.001) was higher than that of the before MPDS group (Cohen κ=0.889, P<.001). After the use of the MPDS, the call-to-EMS arrival time was shortened in the matched ACS cases (20.0 vs 16.0 min, P<.001; adjusted difference: –1.67, 95% CI –2.33 to –1.02; P<.001) and in the subtype of ST-elevation myocardial infarction (adjusted difference: –3.81, 95% CI –4.63 to –2.98, P<.001), while the EMS arrival-to-door time (20.0 vs 20.0 min, P=.31) was not significantly different in all ACS cases and subtypes.

Conclusions

The optimized use of MPDS in China was associated with increased diagnosis consistency and a reduced call-to-EMS arrival time among EMS-treated patients with ACS. An emergency medical dispatch system should be designed specifically to fit into different prehospital modes in the EMS system on a regional basis.

Expert consensus on the prevention and first-aid management of burns in children

Burns are the second leading cause of unintentional injuries in children and are one of the major causes of disability in children. Timely and effective first-aid management of burns can have a major impact on the prognosis, but there is still a lack of the knowledge on burn management in the general public. With reference to expert opinions and related literature, this consensus summarizes the causes of burns, preventive measures, first-aid methods for common types of burns, and the prevention and treatment of serious complications of burns. It also provides recommendations on the most appropriate pre-hospital treatment. This consensus aims to emphasize the importance of burn prevention, improve the ability of first-aid treatment among witnesses and rescuers, avoid further injury caused by inappropriate treatment, and reduce the mortality and disability rates of burns and the harm to family and society. It can be used as guidance for pre-hospital treatment of childhood burns by first responders, parents, and passers-by.

Dispatcher-assisted conventional cardiopulmonary resuscitation and outcomes for paediatric out-of-hospital cardiac arrests

AIM

As asphyxial cardiac arrest is more common than cardiac arrest from a primary cardiac event in paediatric cardiac arrest, effective ventilation is important during paediatric cardiopulmonary resuscitation (CPR). We aimed to determine optimal dispatcher-assisted CPR instructions for bystanders after paediatric out-of-hospital cardiac arrest (OHCA).

METHODS

We analysed the records of 8172 children who received bystander dispatcher-assisted CPR. Data were obtained from an All-Japan Utstein-style registry from 2005 to 2017. Patients were divided into conventional CPR and compression-only CPR groups. The primary study endpoint was 1-month neurologically intact survival, defined as a Cerebral Performance Category score of 1 or 2 (CPC 1-2).

RESULTS

The 1-month CPC 1-2 rate was significantly higher in the dispatcher-assisted conventional CPR group than in the dispatcher-assisted compression-only CPR group (before propensity score matching, 5.7% [175/3077] vs. 3.1% [160/5095], p < 0.0001, adjusted odds ratio 2.48, 95% confidence interval 1.19-3.22; after propensity score matching, 6.0% [156/2618] vs. 2.6% [69/2618], p < 0.0001, adjusted odds ratio 2.42, 95% confidence interval 1.76-3.32). In most subgroup analyses after matching, dispatcher-assisted conventional CPR had a higher CPC 1-2 rate than dispatcher-assisted compression-only CPR; however, CPC 1-2 rates were similar between the two groups for patients with an initial shockable rhythm, those with total prehospital CPR time ≥ 20 min, those receiving public access defibrillation, advanced airway management, or adrenaline administration.

CONCLUSION

Within the limitations of this retrospective observational study, dispatcher-assisted conventional CPR was preferable to dispatcher-assisted compression-only CPR as optimal CPR instructions for coaching callers to perform bystander CPR.

Impact of puberty as threshold to differentiate outcome of out-of-hospital cardiac arrest care groups: a nationwide observational study in France

BACKGROUND

Since 2005, the international guidelines for out-of-hospital cardiac arrest (OHCA) use puberty to differentiate paediatric and adult care. This threshold is mainly relied on the more frequent respiratory aetiologies in children. Hitherto, to the best of our knowledge, no study has compared the characteristics and outcomes of non-pubescent children, adolescents and adult patients with OHCA. In this study, we intended to describe the characteristics, outcome and factors associated with survival of patients who experienced OHCA in the three groups: children, adolescents (pubescent<18 years) and adults (<65 years), to assess the pertinence of the guidelines.

METHODS

Data from the French national cardiac arrest registry (2012-2017) were used in this nationwide observational study. Victims of OHCA who were <65 years old were included. The characteristics and outcomes of children and adolescents, and adolescents and adults were compared. Logistic regression was performed in each group to identify factors associated with survival at day 30.

RESULTS

We included 934 children, 433 adolescents and 26 952 adults. Respiratory aetiology was more frequent and shockable rhythm less frequent in children compared with adolescents (25.5% vs 17.2%, p=0.025 and 2.4% vs 6.8%, p<0.001, respectively). However, these differences were not observed between adolescents and adults (17.2% vs 14.1%, p=0.266 and 6.8% vs 10%, p=0.055, respectively). Between children and adolescents, and adolescents and adults, there was no significant difference in survival at day 30 (8.6%vs 9.8% and 9.8% vs 8.5%, respectively). For all groups, shockable initial rhythm was a factor of survival.

CONCLUSION

Frequency of respiratory aetiologies and shockable rhythm were common in adolescents and adults and different between children and adolescents. These results indicate that puberty as a threshold in international guidelines seems to be relevant.

Effects of regional differences on the outcome of cardiopulmonary resuscitation in children: How much different is Gaziantep from Izmir?

OBJECTIVES:

We aimed to compare the demographic and clinical characteristics between pediatric cardiac arrest patients treated in Gaziantep at South-eastern Anatolian region and Izmir at Aegean Shore.

MATERIALS And METHODS:

We retrospectively reviewed sociodemographic characteristics, laboratory parameters, and clinical outcomes of pediatric patients that underwent cardiopulmonary resuscitation due to prehospital cardiac arrest at two pediatric emergency departments in Izmir Hospital of Health Sciences University and Gaziantep Cengiz Gökçek Kadın Doğum ve Çocuk Hospital of Health Ministry between August 2017 and August 2018.

RESULTS:

The present study included 188 patients (112 patients from Gaziantep and 76 patients from Izmir). All patients arrived at the hospital through emergency medical services. The median age was lower (14 days vs. 15 months; P < 0.001), and the proportion of Syrian refugees was higher in patients from Gaziantep (78.6% vs. 7.9%; P < 0,001). In both centers, respiratory failure was the most common etiology. In patients from Gaziantep, pH levels were lower (median: 7.10 vs. 7.24), and lactate levels were higher (median: 6 mmol/L vs. 3.6 mmol/L; P < 0.001). The mortality rate was higher among patients from Gaziantep (27.7% vs. 7.9%; P = 0.001).

CONCLUSIONS:

The rate of Syrian refugees among children who were brought to emergency department due to pre-hospital cardiac arrest was much higher in Gaziantep compared to Izmir. Syrian children were significantly younger and had more severe tissue hypoxia, resulting in a higher mortality rate.

Sudden Death in the Young: Information for the Primary Care Provider

There are multiple conditions that can make children prone to having a sudden cardiac arrest (SCA) or sudden cardiac death (SCD). Efforts have been made by multiple organizations to screen children for cardiac conditions, but the emphasis has been on screening before athletic competition. This article is an update of the previous American Academy of Pediatrics policy statement of 2012 that addresses prevention of SCA and SCD. This update includes a comprehensive review of conditions that should prompt more attention and cardiology evaluation. The role of the primary care provider is of paramount importance in the evaluation of children, particularly as they enter middle school or junior high. There is discussion about whether screening should find any cardiac condition or just those that are associated with SCA and SCD. This update reviews the 4 main screening questions that are recommended, not just for athletes, but for all children. There is also discussion about how to handle post-SCA and SCD situations as well as discussion about genetic testing. It is the goal of this policy statement update to provide the primary care provider more assistance in how to screen for life-threatening conditions, regardless of athletic status.

Professional Assessment Tool for Team Improvement: An assessment tool for paediatric intensive care unit nurses' technical and nontechnical skills

BACKGROUND

Cardiorespiratory arrests are rare in paediatric intensive care units, yet intensive care nurses must be able to initiate resuscitation before medical assistance is available. For resuscitation to be successful, instant decision-making, team communication, and the coordinating role of the first responsible nurse are crucial. In-house resuscitation training for nurses includes technical and nontechnical skills.

OBJECTIVES

The aim of this study was to develop a valid, reliable, and feasible assessment instrument, called the Professional Assessment Tool for Team Improvement, for the first responsible nurse's technical and nontechnical skills.

METHODS

Instrument development followed the COnsensus-based Standards for the selection of health Measurement Instruments guidelines and professionals' expertise. To establish content validity, experts reached consensus via group discussions about the content and the operationalisation of this team role. The instrument was tested using two resuscitation assessment scenarios. Inter-rater reliability was established by assessing 71 nurses in live scenario sessions and videotaped sessions, using intraclass correlation coefficients and Cohen's kappa. Internal consistency for the total instrument was established using Cronbach's alpha. Construct validity was assessed by examining the associations between raters' assessments and nurses' self-assessment scores.

RESULTS

The final instrument included 12 items, divided into four categories: Team role, Teamwork and communication, Technical skills, and Reporting. Intraclass correlation coefficients were good in both live and videotaped sessions (0.78-0.87). Cronbach's alpha was stable around 0.84. Feasibility was approved (assessment time reduced by >30%).

CONCLUSIONS

The Professional Assessment Tool for Team Improvement appears to be a promising valid and reliable instrument to assess both technical and nontechnical skills of the first responsible paediatric intensive care unit nurse. The ability of the instrument to detect change over time (i.e., improvement of skills after training) needs to be established.

Influence of Cardiopulmonary Resuscitation Coaching on Interruptions in Chest Compressions During Simulated Pediatric Cardiac Arrest

OBJECTIVES

To determine the impact of a cardiopulmonary resuscitation coach on the frequency and duration of pauses during simulated pediatric cardiac arrest.

DESIGN

This is a secondary analysis of video data collected from a prospective multicenter trial. Forty simulated pediatric cardiac arrest scenarios (20 noncoach and 20 coach teams), each lasting 18 minutes in duration, were reviewed by three clinical experts to document events surrounding each pause in chest compressions.

SETTING

Four pediatric academic medical centers from Canada and the United States.

SUBJECTS

Two-hundred healthcare providers in five-member interprofessional resuscitation teams that included either a cardiopulmonary resuscitation coach or a noncoach clinical provider.

INTERVENTIONS

Teams were randomized to include either a trained cardiopulmonary resuscitation coach or an additional noncoach clinical provider.

MEASUREMENTS AND MAIN RESULTS

The frequency, duration, and associated factors with each interruption in chest compressions were recorded and compared between the groups with and without a cardiopulmonary resuscitation coach, using t tests, Wilcoxon rank-sum tests, or chi-squared tests, depending on the distribution and types of outcome variables. Mixed-effect linear models were used to explore the effect of cardiopulmonary resuscitation coaching on pause durations, accounting for multiple measures of pause duration within teams. A total of 655 pauses were identified (noncoach n = 304 and coach n = 351). Cardiopulmonary resuscitation-coached teams had decreased total mean pause duration (98.6 vs 120.85 s, p = 0.04), decreased intubation pause duration (median 4.0 vs 15.5 s, p = 0.002), and similar mean frequency of pauses (17.6 vs 15.2, p = 0.33) when compared with noncoach teams. Teams with cardiopulmonary resuscitation coaches are more likely to verbalize the need for pause (86.5% vs 73.7%, p < 0.001) and coordinate change of the compressors, rhythm check, and pulse check (31.7% vs 23.2%, p = 0.05). Teams with cardiopulmonary resuscitation coach have a shorter pause duration than non-coach teams, adjusting for number and types of tasks performed during the pause.

CONCLUSIONS

When compared with teams without a cardiopulmonary resuscitation coach, the inclusion of a trained cardiopulmonary resuscitation coach leads to improved verbalization before pauses, decreased pause duration, shorter pauses during intubation, and better coordination of key tasks during chest compression pauses.

An approach to define newborns´ sniffing position using an angle based on reproducible facial landmarks

BACKGROUND

The neutral or sniffing position is advised for mask ventilation in neonates to avoid airway obstruction. As definitions are manifold and often unspecific, we wanted to investigate the reliability and reproducibility of angle measurements based on facial landmarks that may be used in future clinical trials to determine a hypothetical head position with minimal airway obstruction during mask ventilation.

METHODS

In a prospective single-center observational study, 2D sagittal photographs of 24 near-term and term infants were taken, with five raters marking facial landmarks to assess interobserver agreement of those landmarks and angle δ, defined as the angle between the line parallel to the lying surface and the line crossing Subnasale (Sn) and Porion' (P'). Angle δ was assessed in sniffing (δ^sniff ) and physiologic (δ^phys ) head position, the former based on a published, yet poorly defined head position where the tip of the nose aligns to the ceiling with the head in a supine, relaxed mid-position.

RESULTS

Infants had a mean (SD) gestational age of 37.3 (2.3) weeks. Angle δ could be determined in all 48 images taken in either the sniffing or the physiological head position. Interobserver correlation coefficient was 98.6 for all measurements independent of head position. Angle δ^sniff was 90.5° (5.7) in the sniffing position.

CONCLUSIONS

This study provides a new measuring technique using an angle that is reproducible and reliable and may be used in future studies to correlate head position with airway obstruction.

Part 2: Evidence Evaluation and Guidelines Development: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

The 2020 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care is based on the extensive evidence evaluation performed in conjunction with the International Liaison Committee on Resuscitation. The Adult Basic and Advanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal Life Support, Resuscitation Education Science, and Systems of Care Writing Groups drafted, reviewed, and approved recommendations, assigning to each recommendation a Class of Recommendation (ie, strength) and Level of Evidence (ie, quality). The 2020 Guidelines are organized in knowledge chunks that are grouped into discrete modules of information on specific topics or management issues. The 2020 Guidelines underwent blinded peer review by subject matter experts and were also reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. The AHA has rigorous conflict-of-interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines. Anyone involved in any part of the guideline development process disclosed all commercial relationships and other potential conflicts of interest.

Evaluating practioners' preferences regarding vascular emergency access in newborn infants in the delivery room: a national survey

Background

Venous access during neonatal emergencies in the delivery room (DR) can be accomplished through an umbilical venous catheter (UVC) or an intraosseous (IO) access. Preference of one over the other is unclear. We wanted to evaluate practioners’ views.

Methods

An anonymous online questionnaire was circulated to healthcare professionals with different background and experience, all working in neonatal intensive care units in Germany. The web-based survey consisted of 13 questions and data collection was performed using an online tool.

Results

We received 502 completed questionnaires, 152 (30%) were from neonatologists, the remainder from residents, fellows and neonatal nurses. For resuscitation of term newborns in the DR 61% of neonatologists vs. 53% of non-neonatologists were in favour of UVC instead of an IO as an emergency access. UVC placement was rated (very) difficult to impossible by 60% of neonatologists and 90% of non-neonatologists (p < 0.05). All respondents cited lack of experience as the main reason for feeling reluctant to place an UVC or IO access, the latter only being taken into consideration in term infants.

Conclusions

UVC placement in the DR is rated more often difficult to use by non-neonatologists than by neonatologists, apparently related to lack of experience. IO access was only considered for resuscitating term infants due to lacking practice and missing approval for birth weights < 3000 g. Frequent training might improve these clinical skills.

Development a clinical prediction model of the neurological outcome for patients with coma and survived 24 hours after cardiopulmonary resuscitation

Background

Cardiac arrest is still a global public health problem at present. The neurological outcome is the core indicator of the prognosis of cardiac arrest. However, there is no effective means or tools to predict the neurological outcome of patients with coma and survived 24 hours after successful cardiopulmonary resuscitation (CPR).

Hypothesis

Therefore, we expect to construct a prediction model to predict the neurological outcome for patients with coma and survived 24 hours after successful CPR.

Methods

A retrospective cohort study was used to construct a prediction model of the neurological function for patients with coma and survived 24 hours after successful CPR. From January 2007 to December 2015, a total of 262 patients met the inclusion and exclusion criteria.

Results

The predictive model was developed using preselected variables by a systematic review of the literature. Finally, we get five sets of models (three sets of construction models and two sets of internal verification models) which with similar predictive value. The stepwise model, which including seven variables (age, noncardiac etiology, nonshockable rhythm, bystander CPR, total epinephrine dose, APTT, and SOFA score), was the simplest model, so we choose it as our final predictive model. The area under the ROC curve (AUC), specificity, and sensitivity of the stepwise model were respectively 0.82 (0.77, 0.87), 0.72and 0.82. The AUC, specificity, and sensitivity of the bootstrap stepwise (BS stepwise) model were respectively 0.82 (0.77, 0.87), 0.71, and 0.82.

Conclusion

This new and validated predictive model may provide individualized estimates of neurological function for patients with coma and survived 24 hours after successful CPR using readily obtained clinical risk factors. External validation studies are required further to demonstrate the model's accuracy in diverse patient populations.

Quality of chest compressions during pediatric resuscitation with 15:2 and 30:2 compressions-to-ventilation ratio in a simulated scenario

The main objetive was to compare 30:2 and 15:2 compression-to-ventilation ratio in two simulated pediatric cardiopulmonary resuscitation (CPR) models with single rescuer. The secondary aim was to analyze the errors or omissions made during resuscitation. A prospective randomized parallel controlled study comparing 15:2 and 30:2 ratio in two manikins (child and infant) was developed. The CPR was performed by volunteers who completed an basic CPR course. Each subject did 4 CPR sessions of 3 minutes each one. Depth and rate of chest compressions (CC) during resuscitation were measured using a Zoll Z series defibrillator. Visual assessment of resuscitation was performed by an external researcher. A total of 26 volunteers performed 104 CPR sessions. Between 54–62% and 44–53% of CC were performed with an optimal rate and depth, respectively, with no significant differences. No differences were found in depth or rate of CC between 15:2 and 30:2 compression-to-ventilation ratio with both manikins. In the assessment of compliance with the ERC CPR algorithm, 69.2–80.8% of the subjects made some errors or omissions during resuscitation, the most frequent was not asking for help and not giving rescue breaths. The conclusions were that a high percentage of CC were not performed with optimal depth and rate. Errors or omissions were frequently made by rescuers during resuscitation.

2019 American Heart Association Focused Update on Pediatric Basic Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

This 2019 focused update to the American Heart Association pediatric basic life support guidelines follows the 2019 systematic review of the effects of dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) on survival of infants and children with out-of-hospital cardiac arrest. This systematic review and the primary studies identified were analyzed by the Pediatric Task Force of the International Liaison Committee on Resuscitation. It aligns with the International Liaison Committee on Resuscitation's continuous evidence review process, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update summarizes the available pediatric evidence supporting DA-CPR and provides treatment recommendations for DA-CPR for pediatric out-of-hospital cardiac arrest. Four new pediatric studies were reviewed. A systematic review of this data identified the association of a significant improvement in the rates of bystander CPR and in survival 1 month after cardiac arrest with DA-CPR. The writing group recommends that emergency medical dispatch centers offer DA-CPR for presumed pediatric cardiac arrest, especially when no bystander CPR is in progress. No recommendation could be made for or against DA-CPR instructions when bystander CPR is already in progress.

Nursery Assistants' Performance and Knowledge on Cardiopulmonary Resuscitation: Impact of Simulation-Based Training

Background: Child cardiac arrest is rare, but more frequent among infants, requiring immediate cardiopulmonary resuscitation (CPR). Many studies have reported that simulation-based training (SBT) increased CPR performance of healthcare providers. However, the CPR performance of laypeople using basic life support remains poorly known. The aim of this study was to assess nursery assistants' (non-healthcare providers) CPR performance and knowledge, before and after SBT. Methods: The study was carried out from January to June 2018 in the city of Poitiers, France. Two teaching sessions (T1 and T2) and two evaluation sessions (E1 and E2) were performed. Performance in infant CPR on a manikin at E1 and E2 were videotaped and assessed automatically with Resusci Baby QCPR® and a SimPad PLUS SkillReporter (QCPR Global Score and skills) and by an observer using an original CPR performance checklist (MCPR Global-Score and skills). Nursery assistant's CPR knowledge was assessed by a questionnaire at the beginning and the end of the session T1, E1, and E2. Results: Twenty-Seven nursery assistants over 30 contacted were included. There was an improvement between E1 and E2 in QCPR Global-Score (E1: 42.4 ± 23.6 vs. E2: 55.1 ± 23.7%, p = 0.032), MCPR Global-Score (E1: 50.0+11.9 vs. E2: 72.3+8.5%; p < 0.001) and theoretical knowledge with score (over 45) of 16.9+5.4 before T1 and 35.2+2.7 after E2, respectively (p < 0.001). The improvement mainly concerned QCPR and MCPR compression steps scores. MCPR Global-Score was strongly correlated to QCPR Global-Score (r = 0.61; p < 0.01) and predictive to CPR quality determined by QCPR Global-Score (AUC = 0.77; p < 0.01) with a high sensitivity and negative predictive values. Moreover, these improvements were maintained 2 months after training with no difference between scores obtained by the three groups 15, 30, or 60 days after simulation-based training session T2. Conclusion: SBT could significantly improve knowledge and skills in infant CPR management by nursery assistants especially for chest compression. CPR performance checklist appeared as an interesting tool to assess CPR performance quality.

2019 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

This 2019 focused update to the American Heart Association pediatric advanced life support guidelines follows the 2018 and 2019 systematic reviews performed by the Pediatric Life Support Task Force of the International Liaison Committee on Resuscitation. It aligns with the continuous evidence review process of the International Liaison Committee on Resuscitation, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update provides the evidence review and treatment recommendations for advanced airway management in pediatric cardiac arrest, extracorporeal cardiopulmonary resuscitation in pediatric cardiac arrest, and pediatric targeted temperature management during post-cardiac arrest care. The writing group analyzed the systematic reviews and the original research published for each of these topics. For airway management, the writing group concluded that it is reasonable to continue bag-mask ventilation (versus attempting an advanced airway such as endotracheal intubation) in patients with out-of-hospital cardiac arrest. When extracorporeal membrane oxygenation protocols and teams are readily available, extracorporeal cardiopulmonary resuscitation should be considered for patients with cardiac diagnoses and in-hospital cardiac arrest. Finally, it is reasonable to use targeted temperature management of 32°C to 34°C followed by 36°C to 37.5°C, or to use targeted temperature management of 36°C to 37.5°C, for pediatric patients who remain comatose after resuscitation from out-of-hospital cardiac arrest or in-hospital cardiac arrest.

2019 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

This 2019 focused update to the American Heart Association pediatric advanced life support guidelines follows the 2018 and 2019 systematic reviews performed by the Pediatric Life Support Task Force of the International Liaison Committee on Resuscitation. It aligns with the continuous evidence review process of the International Liaison Committee on Resuscitation, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update provides the evidence review and treatment recommendations for advanced airway management in pediatric cardiac arrest, extracorporeal cardiopulmonary resuscitation in pediatric cardiac arrest, and pediatric targeted temperature management during post-cardiac arrest care. The writing group analyzed the systematic reviews and the original research published for each of these topics. For airway management, the writing group concluded that it is reasonable to continue bag-mask ventilation (versus attempting an advanced airway such as endotracheal intubation) in patients with out-of-hospital cardiac arrest. When extracorporeal membrane oxygenation protocols and teams are readily available, extracorporeal cardiopulmonary resuscitation should be considered for patients with cardiac diagnoses and in-hospital cardiac arrest. Finally, it is reasonable to use targeted temperature management of 32°C to 34°C followed by 36°C to 37.5°C, or to use targeted temperature management of 36°C to 37.5°C, for pediatric patients who remain comatose after resuscitation from out-of-hospital cardiac arrest or in-hospital cardiac arrest.

Comparison between synchronized and non-synchronized ventilation and between guided and non-guided chest compressions during resuscitation in a pediatric animal model after asphyxial cardiac arrest

Introduction

There are no studies comparing synchronized and non-synchronized ventilation with bag-valve mask ventilation (BVMV) during cardiopulmonary resuscitation (CPR) in pediatric patients. The main aim is to compare between synchronized and non-synchronized BVMV with chest compressions (CC), and between guided and non-guided CC with a real-time feedback-device in a pediatric animal model of asphyxial cardiac arrest (CA). The secondary aim is to analyze the quality of CC during resuscitation.

Methods

60 piglets were randomized for CPR into four groups: Group A: guided-CC and synchronized ventilation; Group B: guided-CC and non-synchronized ventilation; Group C: non-guided CC and synchronized ventilation; Group D: non-guided CC and non-synchronized ventilation. Return of spontaneous circulation (ROSC), hemodynamic and respiratory parameters, and quality of CC were compared between all groups.

Results

60 piglets were included. Twenty-six (46.5%) achieved ROSC: A (46.7%), B (66.7%), C (26.7%) and D (33.3%). Survival rates were higher in group B than in groups A+C+D (66.7% vs 35.6%, p = 0.035). ROSC was higher with guided-CC (A+B 56.7% vs C+D 30%, p = 0.037). Piglets receiving non-synchronized ventilation did not show different rates of ROSC than synchronized ventilation (B+D 50% vs A+C 36.7%, p = 0.297). Non-synchronized groups showed lower arterial pCO₂ after 3 minutes of CPR than synchronized groups: 57 vs 71 mmHg, p = 0.019. No differences were found in arterial pH and pO₂, mean arterial pressure (MAP) or cerebral blood flow between groups. Chest compressions were shallower in surviving than in non-surviving piglets (4.7 vs 5.1 cm, p = 0.047). There was a negative correlation between time without CC and MAP (r = -0.35, p = 0.038).

Conclusions

The group receiving non-synchronized ventilation and guided-CC obtained significantly higher ROSC rates than the other modalities of resuscitation. Guided-CC achieved higher ROSC rates than non-guided CC. Non-synchronized ventilation was associated with better ventilation parameters, with no differences in hemodynamics or cerebral flow.

The Process of Integrating an Evidence-Based Intervention into a Public Health Department to Improve Nutrition and Physical Activity Behaviors in Parents and Children

The purpose of this manuscript is to describe a mutually beneficial collaboration with a Public Health Department and a University to implement an evidence-based program to teach nutrition and physical activity to improve adult and child outcomes. We first assessed the needs of the Public Health Department to build sustainable capacity. Next, all collaborators were invited to work together to focus on success. We invested in the leadership structure and strategically planned together. Finally, all of the collaborators worked together to practice cultural awareness. The process of implementing evidence-based programs allows all collaborators to emerge from the interaction stronger as a result of respectful dialogue and team building.

Clinical Efficacy of Extracorporeal Cardiopulmonary Resuscitation for Adults with Cardiac Arrest: Meta-Analysis with Trial Sequential Analysis

Objective

This meta-analysis with trial sequential analysis (TSA) compared the clinical efficacy of extracorporeal cardiopulmonary resuscitation (ECPR) with conventional CPR (CCPR) for adult patients who experienced in-hospital cardiac arrest (IHCA) or out-of-hospital CA (OHCA).

Methods

A literature search was used to identify eligible publications (up to 30 July 2018) from PubMed, the Cochrane Library, the ISI Web of Knowledge, and Embase. Two investigators independently conducted the literature search, study selection, data extraction, and quality evaluation. Meta-analysis and TSA were used to analyze each outcome, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the level of evidence. The primary outcome was 30-day survival, and the secondary outcomes were 30-day neurologic outcome, 3-6 months' survival, 3-6 months' neurological outcome, 1-year survival, and 1-year neurological outcome.

Results

We identified 13 eligible observational studies for the final analysis. Pooled analyses showed that ECPR was associated with a significantly better 30-day survival (RR = 1.60, 95% CI = 1.25-2.06) and 30-day neurologic outcome (RR = 2.69, 95% CI = 1.63-4.46), and TSA confirmed these results. However, subgroup analysis of patients with OHCA indicated that ECPR and CCPR had similar effects on 30-day survival (RR = 1.18, 95% CI = 0.71-1.97), which was not confirmed by TSA. Analysis of OHCA patients indicated that ECPR provided a better 30-day neurological outcome (RR = 3.93, 95% CI = 1.00-15.50), but TSA did not support these results. Analysis of IHCA patients indicated that ECPR was associated with a better 30-day survival (RR 1.90, 95% CI 1.43-2.52) and 30-day neurologic outcome (RR 2.02, 95% CI 1.21-3.39), and TSA supported these results. Other subgroup analyses showed that the results were generally consistent, regardless of nation, propensity score matching, presumed etiology, whether the CA was witnessed or not, and study quality.

Conclusions

Relative to CCPR, ECPR improved the survival and neurological outcome of patients who had IHCA. Compared to IHCA patients, TSA could not confirm better survival and neurologic outcome of ECPR in OHCA patients, suggesting that further studies are needed.

Trial Registration

This trial was registered with PROSPERO (CRD42018100513) on 17 July 2018.

2018 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

This 2018 American Heart Association focused update on pediatric advanced life support guidelines for cardiopulmonary resuscitation and emergency cardiovascular care follows the 2018 evidence review performed by the Pediatric Task Force of the International Liaison Committee on Resuscitation. It aligns with the International Liaison Committee on Resuscitation’s continuous evidence review process, and updates are published when the group completes a literature review based on new published evidence. This update provides the evidence review and treatment recommendation for antiarrhythmic drug therapy in pediatric shock-refractory ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. As was the case in the pediatric advanced life support section of the “2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care,” only 1 pediatric study was identified. This study reported a statistically significant improvement in return of spontaneous circulation when lidocaine administration was compared with amiodarone for pediatric ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. However, no difference in survival to hospital discharge was observed among patients who received amiodarone, lidocaine, or no antiarrhythmic medication. The writing group reaffirmed the 2015 pediatric advanced life support guideline recommendation that either lidocaine or amiodarone may be used to treat pediatric patients with shock-refractory ventricular fibrillation or pulseless ventricular tachycardia.