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AIM: To examine the relationship between survival and diastolic blood pressure (DBP) throughout resuscitation from paediatric asphyxial cardiac arrest. METHODS: Retrospective, secondary analysis of 200 swine resuscitations. Swine underwent asphyxial cardiac arrest and were resuscitated with predefined periods of basic and advanced life support (BLS and ALS, respectively). DBP was recorded every 30 s. Survival was defined as 20-min sustained return of spontaneous circulation (ROSC). RESULTS: During BLS, DBP peaked between 1–3 min and was greater in survivors (20.0 [11.3, 33.3] mmHg) than in non-survivors (5.0 [1.0, 10.0] mmHg; p

AIM To examine the associations between ETCO2, ROSC, and chest compression quality markers in paediatric patients during active resuscitation. METHODS This was a single-centre cohort study of data collected as part of an institutional prospective quality initiative improvement program that included all paediatric patients who received chest compressions of any duration from January 1, 2013, through July 10, 2018, in the Johns Hopkins Children's Center. Data was collected from Zoll R Series® defibrillators. Events were included if Zoll data files contained both chest compression and ETCO2 data. 2,746 minutes corresponding to 143 events were included in the analyses. RESULTS The median event ETCO2 for all 143 events was 16.8 [9.3-26.3] mmHg. There was a significant difference in median event ETCO2 between events that achieved ROSC and those that did not (ROSC: 19.3 [14.4-26.6] vs. NO ROSC: 13.9 [6.6-25.5] mmHg; p

To determine if integrating a trained CPR Coach into resuscitation teams can improve CPR quality during simulated pediatric cardiopulmonary arrest (CPA).We conducted a multicenter, prospective, randomized trial. An 18-minute simulated CPA scenario was run for resuscitation teams comprised of CPR-certified professionals from four International Network for Simulation-based Pediatric Innovation, ResearchEducation (INSPIRE) institutions. Forty teams (200 participants) were randomized to having a trained CPR Coach vs. no CPR Coach. CPR Coaches were responsible for providing real-time verbal feedback of CPR performance to compressors. All teams utilized CPR feedback technology. We report the proportion of overall excellent CPR, proportion of chest compressions (CC) with depth 50-60 mm, the proportion of CC with rate 100-120 per minute, CC fraction, and pre-, post-, and peri-shock pause duration.CPR coached teams compared with teams without a CPR Coach resulted in an absolute improvements in overall excellent CPR by 31.8% (95% CI, 17.7, 35.9; p 0.001), mean CC depth compliance by 31.5% (15.7, 47.4; p 0.001), mean CC depth by 4.6 mm (1.6, 7.5; p 0.001), mean CC fraction by 5.4% (0.2, 10.6; p = 0.04), and mean pre-, post- and peri-shock pause duration by -2.7 s (-5.1, -0.4; p = 0.02), -1.0 s (-1.8, -0.2; p = 0.01); and -3.8 (-6.6, -1.0; p = 0.008), respectively. Changes in mean CC rate compliance and mean CC rate were not statistically significant.In the presence of CPR feedback technology, the integration of a trained CPR coach into resuscitation teams enhances CPRquality metrics associated with improved survival outcomes from pediatric cardiac arrest.

The variability in quality of CPR provided during cardiac arrest across pediatric institutions is unknown. We aimed to describe the degree of variability in the quality of CPR across 9 pediatric institutions, and determine if variability across sites would be affected by Just-in-Time CPR training and/or visual feedback during simulated cardiac arrest.We conducted secondary analyses of data collected from a prospective, multi-center trial. Participants were equally randomized to either: (1) No intervention; (2) Real-time CPR visual feedback during cardiac arrest or (3) Just-in-Time CPR training. We report the variability in median chest compression depth and rate across institutions, and the variability in the proportion of 30-s epochs of CPR meeting 2010 American Heart Association guidelines for depth and rate.We analyzed data from 528 epochs in the no intervention group, 552 epochs in the visual feedback group, and 525 epochs in the JIT training group. In the no intervention group, compression depth (median range 22.2-39.2mm) and rate (median range 116.0-147.6 min(-1)) demonstrated significant variability between study sites (p0.001). The proportion of compressions with adequate depth (0-11.5%) and rate (0-60.5%) also varied significantly across sites (p0.001). The variability in compression depth and rate persisted despite use of real-time visual feedback or JIT training (p0.001).The quality of CPR across multiple pediatric institutions is variable. Variability in CPR quality across institutions persists even with the implementation of a Just-in-Time training session and visual feedback for CPR quality during simulated cardiac arrest.

Many healthcare providers rely on visual perception to guide cardiopulmonary resuscitation (CPR), but little is known about the accuracy of provider perceptions of CPR quality. We aimed to describe the difference between perceived versus measured CPR quality, and to determine the impact of provider role, real-time visual CPR feedback and Just-in-Time (JIT) CPR training on provider perceptions.We conducted secondary analyses of data collected from a prospective, multicenter, randomized trial of 324 healthcare providers who participated in a simulated cardiac arrest scenario between July 2012 and April 2014. Participants were randomized to one of four permutations of: JIT CPR training and real-time visual CPR feedback. We calculated the difference between perceived and measured quality of CPR and reported the proportion of subjects accurately estimating the quality of CPR within each study arm.Participants overestimated achieving adequate chest compression depth (mean difference range: 16.1-60.6%) and rate (range: 0.2-51%), and underestimated chest compression fraction (0.2-2.9%) across all arms. Compared to no intervention, the use of real-time feedback and JIT CPR training (alone or in combination) improved perception of depth (p0.001). Accurate estimation of CPR quality was poor for chest compression depth (0-13%), rate (5-46%) and chest compression fraction (60-63%). Perception of depth is more accurate in CPR providers versus team leaders (27.8% vs. 7.4%; p=0.043) when using real-time feedback.Healthcare providers' visual perception of CPR quality is poor. Perceptions of CPR depth are improved by using real-time visual feedback and with prior JIT CPR training.

Traditional American Heart Association (AHA) cardiopulmonary resuscitation (CPR) curriculum focuses on teams of two performing quality chest compressions with rescuers on their knees but does not include training specific to In-Hospital Cardiac Arrests (IHCA), i.e. patient in hospital bed with large resuscitation teams and sophisticated technology available.A randomized controlled trial was conducted with the primary goal of evaluating the effectiveness and ideal frequency of in-situ training on time elapsed from call for help to; (1) initiation of chest compressions and (2) successful defibrillation in IHCA.Non-intensive care unit nurses were randomized into four groups: standard AHA training (C) and three groups that participated in 15 min in-situ IHCA training sessions every two (2M), three (3M) or six months (6M). Curriculum included specific choreography for teams to achieve immediate chest compressions, high chest compression fractions and rapid defibrillation while incorporating use of a backboard, stepstool.More frequent training was associated with decreased median (IQR) seconds to: starting compressions: [C: 33(25-40) vs. 6M: 21(15-26) vs. 3M: 14(10-20) vs. 2M: 13(9-20); p0.001]; and defibrillation: [C: 157(140-254) vs. 6M: 138(107-158) vs. 3M: 115(101-119) vs. 2M: 109(98-129); p0.001]. A composite outcome of key priorities, compressions within 20s, defibrillation within 180 s and use of a backboard, revealed improvement with more frequent training sessions: [C:5%(1/18) vs. 6M: 23%(4/17) vs. 3M: 56%(9/16) vs. 2M: 73%(11/15); p0.001].Results revealed short in-situ training sessions conducted every 3 months are effective in improving timely initiation of chest compressions and defibrillation in IHCA.

Background Observations of cardiopulmonary arrests (CPAs) reveal concerning patterns when clinicians identify a problem, (e.g. loss of pulse) but do not immediately initiate appropriate therapy (e.g. compressions) resulting in delays in life saving therapy. Methods We hypothesized that when individuals utilized specific, short, easy-to-state action phrases stating an observation followed by an associated intervention, there would be a higher likelihood that appropriate action would immediately occur. Phase I: A retrospective analysis of residents in simulated CPAs measured what proportion verbalized “There's no pulse”, statements and/or actions that followed and whether “Action-Linked Phrases” were associated with faster initiation of compressions. Phase II: Two prospective, quasi-experimental studies evaluated if teaching three Action-Linked Phrases for Basic Life Support (BLS) courses or six Action-Linked Phrases for Advanced Cardiovascular Life Support (ACLS) courses was associated with increased use of these phrases. Results Phase I: 62% (42/68) of residents verbalized “there's no pulse” during initial assessment of a pulseless patient, and only 16/42 (38%) followed that by stating “start compressions”. Residents verbalizing this Action-Linked Phrase started compressions sooner than others: (30 s [IQR:19–42] vs. 150 [IQR:51-242], p

Improved survival after cardiac arrest has placed greater emphasis on neurologic resuscitation. The purpose of this pilot study was to evaluate the relationship between cerebrovascular autoregulation and neurologic outcomes after pediatric cardiac arrest.Children resuscitated from cardiac arrest had autoregulation monitoring during the first 72h after return of circulation with an index derived from near-infrared spectroscopy in a pilot study. The range of mean arterial blood pressure (MAP) with optimal vasoreactivity (MAPOPT) was identified. The area under the curve (AUC) of the time spent with MAP below MAPOPT and MAP deviation below MAPOPT was calculated. Neurologic outcome measures included placement of a new tracheostomy or gastrostomy, death from a primary neurologic etiology (brain death or withdrawal of support for neurologic futility), and change in the Pediatric Cerebral Performance Category score (ΔPCPC).Thirty-six children were monitored. Among children who did not require extracorporeal membrane oxygenation (ECMO), children who received a tracheostomy/gastrostomy had greater AUC during the second 24h after resuscitation than those who did not (P=0.04; n=19). Children without ECMO who died from a neurologic etiology had greater AUC during the first 48h than did those who lived or died from cardiovascular failure (P=0.04; n=19). AUC below MAPOPT was not associated with ΔPCPC when children with or without ECMO were analyzed separately.Deviation from the blood pressure with optimal autoregulatory vasoreactivity may predict poor neurologic outcomes after pediatric cardiac arrest. This experimental autoregulation monitoring technique may help individualize blood pressure management goals after resuscitation.

Previous studies reveal pediatric resident resuscitation skills are inadequate, with little improvement during residency. The Accreditation Council for Graduate Medical Education highlights the need for documenting incremental acquisition of skills, i.e., "Milestones". We developed a simulation-based teaching approach "Rapid Cycle Deliberate Practice" (RCDP) focused on rapid acquisition of procedural and teamwork skills (i.e., "first-five minutes" (FFM) resuscitation skills). This novel method utilizes direct feedback and prioritizes opportunities for learners to "try again" over lengthy debriefing.Pediatric residents from an academic medical center.Prospective pre-post interventional study of residents managing a simulated cardiopulmonary arrest. Main outcome measures include: (1) interval between onset of pulseless ventricular tachycardia to initiation of compressions and (2) defibrillation.Seventy pediatric residents participated in the pre-intervention and fifty-one in the post-intervention period. Baseline characteristics were similar. The RCDP-FFM intervention was associated with a decrease in: no-flow fraction: [pre: 74% (5-100%) vs. post: 34% (26-53%); p0.001)], no-blow fraction: [pre: 39% (22-64%) median (IQR) vs. post: 30% (22-41%); p=0.01], and pre-shock pause: [pre: 84 s (26-162) vs. post: 8s (4-18); p0.001]. Survival analysis revealed RCDP-FFM was associated with starting compressions within 1 min of loss of pulse: [Adjusted Hazard Ratio (HR): 3.8 (95% CI: 2.0-7.2)] and defibrillating within 2 min: [HR: 1.7 (95% CI: 1.03-2.65)]. Third year residents were significantly more likely than first years to defibrillate within 2 min: [HR: 2.8 (95% CI: 1.5-5.1)].Implementation of the RCDP-FFM was associated with improvement in performance of key measures of quality life support and progressive acquisition of resuscitation skills during pediatric residency.

Introduction Assessing the knowledge of Pediatric Advanced Life Support (PALS) based learning objectives of medical trainees is an important evaluation component for both residency programs and for research studies. In this study, a multiple-choice question (MCQ) examination was developed and validated for use in a larger pediatric simulation resuscitation study (EXPRESS study). Methods Experts in pediatric resuscitation developed two MCQ exams using a set of pre-determined learning objectives. After a single center pilot, the exam was used as an assessment of cognitive skills in the EXPRESS study, a multicenter trial examining the use of scripted debriefing and high-fidelity simulation in pediatric resuscitation education. Results from the MCQ in the pre-intervention phase of the EXPRESS study were used to assess the reliability and validity of the MCQ examination. In addition, an Exploratory Factor Analysis (EFA) was carried to assess the underlying structure of the PALS-based learning objectives. Results 435 health care professionals completed the MCQ examination with an average score of 69.3%. Significantly higher examination results were seen in physicians vs. non-physicians, senior vs. junior physicians and participants with up-to-date PALS certification. The EFA results indicated four distinct categories of items were assessed. Conclusion This short MCQ examination demonstrated reasonable reliability and construct validity. It may be useful to assess pediatric resuscitation knowledge in future studies or courses.

The objective was to compare resuscitation performance on simulated in-hospital cardiac arrests after traditional American Heart Association (AHA) Healthcare Provider Basic Life Support course (TradBLS) versus revised course including in-hospital skills (HospBLS).This study is a prospective, randomized, controlled curriculum evaluation.Johns Hopkins Medicine Simulation Center.One hundred twenty-two first year medical students were divided into fifty-nine teams.HospBLS course of identical length, containing additional content contextual to hospital environments, taught utilizing Rapid Cycle Deliberate Practice (RCDP).The primary outcome measure during simulated cardiac arrest scenarios was chest compression fraction (CCF) and secondary outcome measures included metrics of high quality resuscitation.Out-of-hospital cardiac arrest HospBLS teams had larger CCF: [69% (65-74) vs. 58% (53-62), p0.001] and were faster than TradBLS at initiating compressions: [median (IQR): 9s (7-12) vs. 22s (17.5-30.5), p0.001]. In-hospital cardiac arrest HospBLS teams had larger CCF: [73% (68-75) vs. 50% (43-54), p0.001] and were faster to initiate compressions: [10s (6-11) vs. 36s (27-63), p0.001]. All teams utilized the hospital AED to defibrillate within 180s per AHA guidelines [HospBLS: 122s (103-149) vs. TradBLS: 139s (117-172), p=0.09]. HospBLS teams performed more hospital-specific maneuvers to optimize compressions, i.e. utilized: CPR button to flatten bed: [7/30 (23%) vs. 0/29 (0%), p=0.006], backboard: [21/30 (70%) vs. 5/29 (17%), p0.001], stepstool: [28/30 (93%) vs. 8/29 (28%), p0.001], lowered bedrails: [28/30 (93%) vs. 10/29 (34%), p0.001], connected oxygen appropriately: [26/30 (87%) vs. 1/29 (3%), p0.001] and used oral airway and/or two-person bagging when traditional bag-mask-ventilation unsuccessful: [30/30 (100%) vs. 0/29 (0%), p0.001].A hospital focused BLS course utilizing RCDP was associated with improved performance on hospital-specific quality measures compared with the traditional AHA course.

Background: Most reports of Rapid Response Systems (RRS) focus on the efferent, response component of the system, although evidence suggests that improved vital sign monitoring and recognition of a clinical crisis may have outcome benefits. There is no consensus regarding how best to detect patient deterioration or a clear description of what constitutes patient monitoring. Methods: A consensus conference of international experts in safety, RRS, healthcare technology, education, and risk prediction was convened to review current knowledge and opinion on clinical monitoring. Using established consensus procedures, four topic areas were addressed: (1) To what extent do physiologic abnormalities predict risk for patient deterioration? (2) Do workload changes and their potential stresses on the healthcare environment increase patient risk in a predictable manner? (3) What are the characteristics of an "ideal" monitoring system, and to what extent does currently available technology meet this need? and (4) How can monitoring be categorized to facilitate comparing systems? The major findings include: (1) vital sign aberrations predict risk, (2) monitoring patients more effectively may improve outcome, although some risk is random, (3) the workload implications of monitoring on the clinical workforce have not been explored, but are amenable to study and should be investigated, (4) the characteristics of an ideal monitoring system are identifiable, and it is possible to categorize monitoring modalities. It may also be possible to describe monitoring levels, and a system is proposed. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

Summary This is a report of an 11-year-old boy who had sudden cardiac death after a lightning strike while playing lacrosse at summer camp. The camp staff had performed weekly drills to prepare for various medical emergencies and quickly activated their "Emergency Activation System". The child received immediate cardiopulmonary resuscitation (CPR) and was defibrillated with an automated defibrillator (AED) within 3min of becoming pulseless and was ultimately resuscitated after being defibrillated three times. A community ambulance with a defibrillator on board did not arrive until several minutes after the on-site team had achieved return of spontaneous circulation. In this report, we describe the clinical course of this patient; briefly review lightning injuries, other causes of sudden cardiac death in children and use of AEDs. Finally, we review how simulation has been used in this case and others as a mechanism to ensure preparedness for medical emergencies. This child is alive and well today because of these well-trained camp counselors. Their system of using simulation to maintain emergency readiness serves as an example for lay and professional medical providers alike.

Background The quality of life support delivered during cardiopulmonary resuscitation affects outcomes. However, little data exist regarding the quality of resuscitation delivered to children and factors associated with adherence to American Heart Association (AHA) resuscitation guidelines. Participants Pediatric residents from an academic, tertiary care hospital. Design Prospective, observational cohort study of residents trained in the AHA PALS 2000 guidelines managing a high-fidelity mannequin simulator programmed to develop pulseless ventricular tachycardia (PVT). Main outcome measures Proportion of residents who: (1) started compressions in ≤1min from onset of PVT, (2) defibrillated in ≤3min and (3) factors associated with time to defibrillation. Results Seventy of eighty (88%) residents participated. Forty-six of seventy (66%) failed to start compressions within 1min of pulselessness and 23/70 (33%) never started compressions. Only 38/70 (54%) residents defibrillated the mannequin in ≤3min of onset of PVT. There was no significant difference in time elapsed between onset of PVT and defibrillation by level of post-graduate training. However, residents who had previously discharged a defibrillator on either a patient or a simulator compared to those who had not were 87% more likely to successfully defibrillate the mannequin at any point in time (hazard ratio 1.87, 95% CI: 1.08–3.21, p =0.02). Conclusions Pediatric residents do not meet performance standards set by the AHA. Future curricula should focus training on identified defects including: (1) equal emphasis on "airway and breathing" and "circulation" and (2) hands-on training with using and discharging a defibrillator in order to improve safety and outcomes.

Determine anesthesiologists' knowledge of the 2005 American Heart Association (AHA) Pediatric Advanced Life Support (PALS) recommendations.After obtaining institutional review board approval, a survey was sent in February 2007 to members of the Society for Pediatric Anesthesia via a web-based survey tool, and re-sent to nonresponders five times over the following 7 months.Overall response rate was 51% (389/768 members). Eighty-five percent of respondents had pediatric anesthesia fellowships, 71% provided anesthesia primarily to children, 71% had been in practice10 years, 29% had PALS or APLS training during the previous year, and 37% had a patient requiring chest compressions in the previous year. Overall, 89% of respondents knew the correct initial dose of epinephrine (adrenaline) for asystole, 44% knew subsequent management for asystole if initial epinephrine dose was ineffective, 49% knew defibrillation sequence to treat pulseless ventricular tachycardia (VT), and 73% knew the medication sequence to treat pulseless VT. Only those respondents who reported to be in practice for10 years scored significantly (p0.0001) better on all resuscitation treatment questions. Respondents who had PALS or APLS training in the previous year or previous 2 years scored significantly better on the defibrillation sequence for pulseless VT (p=0.001 and p=0.045, respectively), and the medication sequence for pulseless VT (p=0.0005 and p=0.011, respectively) when compared with those who had no previous training.Deficiencies exist in the knowledge of current AHA PALS guidelines among anesthesiologists. Formal resuscitation training programs should be considered in ongoing continuing medical education.