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Cardiac arrest and resuscitation in children
Opinions expressed in the Correspondence section are those of the authors and not necessarily of the editors,f..ACEP, or UAEM. The ediiors reserve the right to edit and publish letters as space permits.
CORRESPONDENCE Cardiac Arrest and Resuscitation in Children To the Editor." In their discussion of success rates amongi~pediatric and adult p a t i e n t s r e s u s c i t a t e d from c a r d i a c ; a r r e s t ("Epidemiology of Cardiac Arrest and Resuscitation in Children," November 1983; 12:672-674), Eisenberg et al concluded that "high incidence of asystole" and individual "cardiac etiologies" were the reasons for lower survivability among the pediatric population. I think an important factor requires clarification. Unclear is the degree of intervention initiated prior to arrival at the hospital. As stated in their research, 17 patients received EMT services (basic life support) and another 102 patients had paramedic intervention. The report fails to state whether advanced life support was performed by the paramedics and, if so, in how many cases. The fact that paramedics assumed care in these cases does not guarantee that ACLS was given. Noting that 87 patients (72%)were 5 years of age or younger, I question an important exclusion: were intravenous lines, endotracheal tubes, and dru~ intervention initiated in these patients, as they were in the adults with whom they were compared? The authors point out that 17 patients received only basic life support, with one patient discharged from the hospital. Paramedics saw 102 patients, of w h o m seven were discharged. According to these figures the availability of paramedic services did not significantly increase the survivability of patients over the regular EMT units, for both averaged a 7% survival rate. This might suggest difficulty in initiating advanced cardiac life support or a "scoop and run" action. A pediatric cardiac arrest can be a frustrating trial for a paramedic. Not only is the size of the patient a factor, but one may not have sufficient contact with these patients to develop an adequate level of expertise. Such is the scenario in the "scoop and run" actions or prolonged "on scene" times trying to initiate procedures. Either of these actions would be deleterious at a time when the patients may be most susceptible to intervention. I think survivability from cardiac arrest in the pediatric patient is also related to the skills and training the technicians receive, and the ability to implement the same treatment and protocols that are afforded the adult patient.
Patrick B Moore Nationally Registered EMT-Paramedic
Department of Emergency Medical Services East Baton Rouge Parish Baton Rouge, Louisiana To the Editor: Eisenberg et al report the incidence of pediatric cardiac arrest in their study to be 13% the incidence of cardiac arrest in adults. This figure seems high to me, and I wonder if a similar incidence is found throughout the country.
David A De Vere, MD Fairfield, Pennsylvania
Author's Reply: All 102 pediatric patients treated by paramedics received ACLS at the scene. Invariably this included medications, endotracheal intubation and, with rare exception, intravenous lines. The reason paramedic-treated cases did not fare better than EMT-treated cases is not because of difficulty in initiating ACLS at the scene, but rather because of the etiology and nature of cardiac arrest in a pediatric population. The high proportion of asystole (77%} precluded the opportunity for paramedic services to have much of an impact on overall survival rates. I agree completely with Mr Moore that a pediatric cardiac arrest can be a trying experience for a paramedic or EMT. I think, however, it would be even more of a trial for a well-trained paramedic not to do everything possible directly at the scene. Our study did not include pediatric trauma cases, and thus the case for a "scoop and run" approach in traumatic cardiac arrest may be an entirely different matter. Our annual incidence of pediatric resuscitation of i2.7/ 100,000 in individuals less than 18 years of age compares to an incidence of 97 resuscitations per 100,000 among individuals over the age of 18. These figures are populationbased. In terms of actual events, resuscitations among individuals younger than 18 represent 4.4% of the total number of resuscitations.
Mickey Eisenberg, MD, PhD, Director Emergency Medicine Service University of Washington Seattle
Manual Detorsion of Testis Using Xylocaine Block To the Editor: I was interested in the article by Perry et al on testicular torsion in the older patient (May 1983;12:319-320). As the authors correctly state, time is of the e s s ~ c e in treatment if testicular function is to be saved. By th~ time the patient presents, two hours have usually passed since the onset of symptoms. As the authors also state, clinical examination 118/482
is unsatisfactory because "pain frequently discourages acute palpation." I have used a method of diagnosing and treating this condition several times with success. Suspicion of the diagnosis is aroused by the sudden onset of severe pain in thetestis in the absence of preceding urethral discharge and fever. The
Annals of Emergency Medicine
136 June !984
CORRESPONDENCE Cardiac Arrest and Resuscitation in Children To the Editor." In their discussion of success rates amongi~pediatric and adult p a t i e n t s r e s u s c i t a t e d from c a r d i a c ; a r r e s t ("Epidemiology of Cardiac Arrest and Resuscitation in Children," November 1983; 12:672-674), Eisenberg et al concluded that "high incidence of asystole" and individual "cardiac etiologies" were the reasons for lower survivability among the pediatric population. I think an important factor requires clarification. Unclear is the degree of intervention initiated prior to arrival at the hospital. As stated in their research, 17 patients received EMT services (basic life support) and another 102 patients had paramedic intervention. The report fails to state whether advanced life support was performed by the paramedics and, if so, in how many cases. The fact that paramedics assumed care in these cases does not guarantee that ACLS was given. Noting that 87 patients (72%)were 5 years of age or younger, I question an important exclusion: were intravenous lines, endotracheal tubes, and dru~ intervention initiated in these patients, as they were in the adults with whom they were compared? The authors point out that 17 patients received only basic life support, with one patient discharged from the hospital. Paramedics saw 102 patients, of w h o m seven were discharged. According to these figures the availability of paramedic services did not significantly increase the survivability of patients over the regular EMT units, for both averaged a 7% survival rate. This might suggest difficulty in initiating advanced cardiac life support or a "scoop and run" action. A pediatric cardiac arrest can be a frustrating trial for a paramedic. Not only is the size of the patient a factor, but one may not have sufficient contact with these patients to develop an adequate level of expertise. Such is the scenario in the "scoop and run" actions or prolonged "on scene" times trying to initiate procedures. Either of these actions would be deleterious at a time when the patients may be most susceptible to intervention. I think survivability from cardiac arrest in the pediatric patient is also related to the skills and training the technicians receive, and the ability to implement the same treatment and protocols that are afforded the adult patient.
Patrick B Moore Nationally Registered EMT-Paramedic
Department of Emergency Medical Services East Baton Rouge Parish Baton Rouge, Louisiana To the Editor: Eisenberg et al report the incidence of pediatric cardiac arrest in their study to be 13% the incidence of cardiac arrest in adults. This figure seems high to me, and I wonder if a similar incidence is found throughout the country.
David A De Vere, MD Fairfield, Pennsylvania
Author's Reply: All 102 pediatric patients treated by paramedics received ACLS at the scene. Invariably this included medications, endotracheal intubation and, with rare exception, intravenous lines. The reason paramedic-treated cases did not fare better than EMT-treated cases is not because of difficulty in initiating ACLS at the scene, but rather because of the etiology and nature of cardiac arrest in a pediatric population. The high proportion of asystole (77%} precluded the opportunity for paramedic services to have much of an impact on overall survival rates. I agree completely with Mr Moore that a pediatric cardiac arrest can be a trying experience for a paramedic or EMT. I think, however, it would be even more of a trial for a well-trained paramedic not to do everything possible directly at the scene. Our study did not include pediatric trauma cases, and thus the case for a "scoop and run" approach in traumatic cardiac arrest may be an entirely different matter. Our annual incidence of pediatric resuscitation of i2.7/ 100,000 in individuals less than 18 years of age compares to an incidence of 97 resuscitations per 100,000 among individuals over the age of 18. These figures are populationbased. In terms of actual events, resuscitations among individuals younger than 18 represent 4.4% of the total number of resuscitations.
Mickey Eisenberg, MD, PhD, Director Emergency Medicine Service University of Washington Seattle
Manual Detorsion of Testis Using Xylocaine Block To the Editor: I was interested in the article by Perry et al on testicular torsion in the older patient (May 1983;12:319-320). As the authors correctly state, time is of the e s s ~ c e in treatment if testicular function is to be saved. By th~ time the patient presents, two hours have usually passed since the onset of symptoms. As the authors also state, clinical examination 118/482
is unsatisfactory because "pain frequently discourages acute palpation." I have used a method of diagnosing and treating this condition several times with success. Suspicion of the diagnosis is aroused by the sudden onset of severe pain in thetestis in the absence of preceding urethral discharge and fever. The
Annals of Emergency Medicine
136 June !984