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Critical lessons from prehospital pediatric cardiac arrest
Pennsylvania, Philadelphia
This study compared serum catecholamine levels and blood pressure response to intraosseous and intravenous (IV) epinephrine in a cardiac arrest model. Fifteen swine (10 to 15 kg) were anesthetized with ketamine intramuscularly and alpha-ehloralose IV and ventilated with room air. The right femoral artery, carotid artery, and external jugular vein were eannulated for blood sampling and blood pressure measurement. Cardiac arrest was induced with 50 to 60 Hz current delivered to the right ventricle by venous pacemaker. Blood pressure and lead II ECG were monitored continuously. Blood samples for epinephrine were drawn before arrest and every two minutes thereafter; at five minutes, cardiac compressions were initiated with a mechanical resuscitator and the animal was ventilated with 100% oxygen. Five animals received no further therapy and served as controls; five received IV epinephrine 0.01 mg/kg at ten and 20 minutes after arrest, and five received intraosseous epinephrine 0.01 mg/kg. Blood samples were assayed for epinephrine using a Beckman high-pressure liquid chromatograph.Epinephrine and mean arterial pressure (MAP) are listed for control, IV, and intraosseous infusion at baseline and at six, 12, 22, and 30 minutes after arrest. Controls Epinephrine MAP
Baseline 6
12
22
30
.6 _+.4 116_+15
38 _+18 31_+17
36 _+14 18_+5
38 _+21 12+3
76 _+43 42_+14
IV Epinephrine at 10 and 20 Min Epinephrine MAP
1.1-+1.8 116_+12
51-+18 42+_13
235-+ 118 292_+217 38_+23 65+17 56+8 24_+12
Intraosseous Epinephrine at 10 and 20 Min Epinephrine MAP
1.5_+1 120_+38
95_+100 53-+ 11
291 +_124 297_+96 41 _+24 34+21
96+_40 25-+ 14
An ANOVA demonstrated a significant increase in epinephrine levels at ~12 and 22 minutes for the IV and intraosseous groups compared with controls. There was no difference between the IV and intraosseous groups. These data suggest epinephrine is transported to the central circulation as effectively as from the bone during cardiac arrest. 67 Comparison of Intravenous, Intraosseous, and Intramuscular Administration of Succinylcholine in Sheep
GP Moore, SA Pace, W Busby/Emergency Medicine Residency, Fort Hood, Texas; Emergency Medicine Residency, Madigan Army Medical Center, Tacoma, Washington
The intraosseous route of vascular access has been popularized recently for resuscitation in children. Succinylcholine has been anecdotally reported for airway management intraosseously. This drug could be used for control of the airway in pediatric burns, status epiiepticus, head injury, or combative patients. No series quantifying the efficacy of the intraosseous route has been reported for succiny!choline. To accomplish this goal, six sheep serving as their own controls were anesthetized with halothane and intubated. Succinylcholine (1 mg/kg) was given, and the time to respiratory arrest as well as the loss of the "train-of-four" stimulation of the anterior tibial nerve was noted. Each sheep was studied successively using the IV, intraosseous, and intramuscular routes of administration with a m i n i m u m of seven days separating trials. Results were as follows: Route of Administration
Average Time to RespiratoryArrest (sec)
AverageTime to Loss of "Train-of-Four" (sec)
IV Intraosseous Intramuscular
30.8 _+7.3 57.5 _+10.3 230.0 + 106.0
93.3 + 34.0 100.8 _+24.2 291.0 + 109.0
All groups were statistically significantly diffferent using the t test for the difference of means (P < .0015). We conclude that the intraosseous route of administration of succinylcholine in this series of sheep is comparable to the IV route and is superior to the intramuscular route. 68 Comparison of Intraosseous Versus Intravenous Loading of Phenytoin in Pigs and Effect on Bone Marrow
PJ Vinsel, GP Moore, KC O'Hair/Department of Emergency Medicine, Darnall Army Community Hospital, Fort Hood, T e x a s 18:4 April 1989
There has been much recent literature supporting the resurgence of use of the intraosseous route of access in pediatrics. Intraosseous lines provide a timely noncollapsible route to the circulation in medical or traumatic emergencies when IV access is unobtainable. There has been no controlled study comparing IV and intraosseous loading of phenytoin. A 15 mg/kg dose of phenytoin was administered over 15 minutes to pigs using either the IV (six) or tibial intraosseous route (six)i Femoral artery blood samples were drawn every five minutes for 35 minutes after initiation of the infusion to determine phenytoin levels. There was no statistical difference between the two groups using analysis of variance repeated measures (P = .106). It has been suggested that alkaline substances or those with high osmolarity may damage the marrow; however, microscopic examination of the cortex and marrow at the intraosseous site in these pigs was normal five weeks after infusion. We conclude that the intraosseous route is an effective alternative to IV loading of phenytoin without permanent damage to the marrow. 69 Critical Lessons From Prehospital Pediatric Cardiac Arrest
RF Lavery, BJ Tortella, CC Griffin/New Jersey T r a u m a Center, University Emergency Medical Services, New Jersey Medical School; University of Medicine and Dentistry of New Jersey, Newark This report examined pediatric (_<18years old) cardiac arrest patients over a two-year period. History, mechanism of injury, on-scene times, and procedure attempts and successes were obtained from mobile intensive care unit ambulance run sheets. Forty-seven patients were reviewed, representing 3% of all pediatric advanced life support responses, and were divided into medical (61%) and surgical (39%) cases. Mean on-scene time for all arrests was 13.0 minutes. Medical arrest mean on-scene time was 15.2 minutes, which was significantly longer than that for traumatic arrests, 9.9 minutes (P < .05). Mean on-scene time for unsuccessful IV line placement was 10.4 minutes, which was significantly shorter than that for successful cases, 15.0 minutes (P < .05). Further data analysis revealed the following: Endotracheal On-scene IV Line Intubation time (min) ETI No ETI Age < 1 yr > 1 yr
On-scene time (min) IV No IV
Attempt SuccessAttempt Attempt Attempt SuccessAttempt Attempt 88% 86% 11.7 5.0 58% 30% 11.7 9.5 96% 82% 13.2 3.0 93% 78% 13.4 6.5
This is the first report of on-scene times and success rates for pediatric cardiac arrest patients. The data show that paramedics spend significantly longer at the scene with medical than with traumatic arrests, yet do not delay on the scene when unable to establish an IV line or intubate. When examining those patients less than 1 year old, paramedics have a tendency to "scoop and transport" and forgo intubation and forgo intubation and IV line placement. The reasons for this are presently under investigation, but these data do support expansion of the pediatric segments of paramedics' curriculum to provide greater clinical confidence and technical security. These data also raise the question as to whether this "scoop and transport" tendency may be prompted by paramedic discomfort with pediatric IV and airway management. 70 Caretaker Neglect and Injury Prevention Instruction for Preschool Child Injuries: 475 Consective Cases DM Cline, T Grant, J King, C Snow, E Katz, A Stewart, E Carrol, TW Whitley/Departments of Emergency Medicine, Home Economics, Psychiatry, and Pediatrics, East Carolina University, Greenville, North Carolina
Preschool injury reduction through instruction has been documented, but not in the emergency department. A panel from the emergency medicine, child development, psychiatry, and pediatrics departments retrospectively reviewed 475 consecutive injuries in 366 children, ages 1 to 60 months. Group consensus was reached concerning"perceived caretaker neglect leading to injury, child abuse, preventable injuries, and documented instruction. Caretaker neglect was perceived in 40% of injuries: poor supervision, 18.3%; poor childproofing, 7.2%; more than 24 hours delay, 2.3%; and multiple types, 12.7%. No significant differences were found in neglect frequencies for children with one (282), two (61), three (21), or four (two) emergency visits during the 30-month study period. Chi-square revealed that burns and poisonings had significantly higher neglect frequencies, while injuries from falls, lacerations, and sprains had signficantly lower neglect frequencies. Based on the chart, the panel recommended Social Service investigation for 43 children: physical abuse, five, all reported; repeated neglect,
Annals of Emergency Medicine
449/169
This study compared serum catecholamine levels and blood pressure response to intraosseous and intravenous (IV) epinephrine in a cardiac arrest model. Fifteen swine (10 to 15 kg) were anesthetized with ketamine intramuscularly and alpha-ehloralose IV and ventilated with room air. The right femoral artery, carotid artery, and external jugular vein were eannulated for blood sampling and blood pressure measurement. Cardiac arrest was induced with 50 to 60 Hz current delivered to the right ventricle by venous pacemaker. Blood pressure and lead II ECG were monitored continuously. Blood samples for epinephrine were drawn before arrest and every two minutes thereafter; at five minutes, cardiac compressions were initiated with a mechanical resuscitator and the animal was ventilated with 100% oxygen. Five animals received no further therapy and served as controls; five received IV epinephrine 0.01 mg/kg at ten and 20 minutes after arrest, and five received intraosseous epinephrine 0.01 mg/kg. Blood samples were assayed for epinephrine using a Beckman high-pressure liquid chromatograph.Epinephrine and mean arterial pressure (MAP) are listed for control, IV, and intraosseous infusion at baseline and at six, 12, 22, and 30 minutes after arrest. Controls Epinephrine MAP
Baseline 6
12
22
30
.6 _+.4 116_+15
38 _+18 31_+17
36 _+14 18_+5
38 _+21 12+3
76 _+43 42_+14
IV Epinephrine at 10 and 20 Min Epinephrine MAP
1.1-+1.8 116_+12
51-+18 42+_13
235-+ 118 292_+217 38_+23 65+17 56+8 24_+12
Intraosseous Epinephrine at 10 and 20 Min Epinephrine MAP
1.5_+1 120_+38
95_+100 53-+ 11
291 +_124 297_+96 41 _+24 34+21
96+_40 25-+ 14
An ANOVA demonstrated a significant increase in epinephrine levels at ~12 and 22 minutes for the IV and intraosseous groups compared with controls. There was no difference between the IV and intraosseous groups. These data suggest epinephrine is transported to the central circulation as effectively as from the bone during cardiac arrest. 67 Comparison of Intravenous, Intraosseous, and Intramuscular Administration of Succinylcholine in Sheep
GP Moore, SA Pace, W Busby/Emergency Medicine Residency, Fort Hood, Texas; Emergency Medicine Residency, Madigan Army Medical Center, Tacoma, Washington
The intraosseous route of vascular access has been popularized recently for resuscitation in children. Succinylcholine has been anecdotally reported for airway management intraosseously. This drug could be used for control of the airway in pediatric burns, status epiiepticus, head injury, or combative patients. No series quantifying the efficacy of the intraosseous route has been reported for succiny!choline. To accomplish this goal, six sheep serving as their own controls were anesthetized with halothane and intubated. Succinylcholine (1 mg/kg) was given, and the time to respiratory arrest as well as the loss of the "train-of-four" stimulation of the anterior tibial nerve was noted. Each sheep was studied successively using the IV, intraosseous, and intramuscular routes of administration with a m i n i m u m of seven days separating trials. Results were as follows: Route of Administration
Average Time to RespiratoryArrest (sec)
AverageTime to Loss of "Train-of-Four" (sec)
IV Intraosseous Intramuscular
30.8 _+7.3 57.5 _+10.3 230.0 + 106.0
93.3 + 34.0 100.8 _+24.2 291.0 + 109.0
All groups were statistically significantly diffferent using the t test for the difference of means (P < .0015). We conclude that the intraosseous route of administration of succinylcholine in this series of sheep is comparable to the IV route and is superior to the intramuscular route. 68 Comparison of Intraosseous Versus Intravenous Loading of Phenytoin in Pigs and Effect on Bone Marrow
PJ Vinsel, GP Moore, KC O'Hair/Department of Emergency Medicine, Darnall Army Community Hospital, Fort Hood, T e x a s 18:4 April 1989
There has been much recent literature supporting the resurgence of use of the intraosseous route of access in pediatrics. Intraosseous lines provide a timely noncollapsible route to the circulation in medical or traumatic emergencies when IV access is unobtainable. There has been no controlled study comparing IV and intraosseous loading of phenytoin. A 15 mg/kg dose of phenytoin was administered over 15 minutes to pigs using either the IV (six) or tibial intraosseous route (six)i Femoral artery blood samples were drawn every five minutes for 35 minutes after initiation of the infusion to determine phenytoin levels. There was no statistical difference between the two groups using analysis of variance repeated measures (P = .106). It has been suggested that alkaline substances or those with high osmolarity may damage the marrow; however, microscopic examination of the cortex and marrow at the intraosseous site in these pigs was normal five weeks after infusion. We conclude that the intraosseous route is an effective alternative to IV loading of phenytoin without permanent damage to the marrow. 69 Critical Lessons From Prehospital Pediatric Cardiac Arrest
RF Lavery, BJ Tortella, CC Griffin/New Jersey T r a u m a Center, University Emergency Medical Services, New Jersey Medical School; University of Medicine and Dentistry of New Jersey, Newark This report examined pediatric (_<18years old) cardiac arrest patients over a two-year period. History, mechanism of injury, on-scene times, and procedure attempts and successes were obtained from mobile intensive care unit ambulance run sheets. Forty-seven patients were reviewed, representing 3% of all pediatric advanced life support responses, and were divided into medical (61%) and surgical (39%) cases. Mean on-scene time for all arrests was 13.0 minutes. Medical arrest mean on-scene time was 15.2 minutes, which was significantly longer than that for traumatic arrests, 9.9 minutes (P < .05). Mean on-scene time for unsuccessful IV line placement was 10.4 minutes, which was significantly shorter than that for successful cases, 15.0 minutes (P < .05). Further data analysis revealed the following: Endotracheal On-scene IV Line Intubation time (min) ETI No ETI Age < 1 yr > 1 yr
On-scene time (min) IV No IV
Attempt SuccessAttempt Attempt Attempt SuccessAttempt Attempt 88% 86% 11.7 5.0 58% 30% 11.7 9.5 96% 82% 13.2 3.0 93% 78% 13.4 6.5
This is the first report of on-scene times and success rates for pediatric cardiac arrest patients. The data show that paramedics spend significantly longer at the scene with medical than with traumatic arrests, yet do not delay on the scene when unable to establish an IV line or intubate. When examining those patients less than 1 year old, paramedics have a tendency to "scoop and transport" and forgo intubation and forgo intubation and IV line placement. The reasons for this are presently under investigation, but these data do support expansion of the pediatric segments of paramedics' curriculum to provide greater clinical confidence and technical security. These data also raise the question as to whether this "scoop and transport" tendency may be prompted by paramedic discomfort with pediatric IV and airway management. 70 Caretaker Neglect and Injury Prevention Instruction for Preschool Child Injuries: 475 Consective Cases DM Cline, T Grant, J King, C Snow, E Katz, A Stewart, E Carrol, TW Whitley/Departments of Emergency Medicine, Home Economics, Psychiatry, and Pediatrics, East Carolina University, Greenville, North Carolina
Preschool injury reduction through instruction has been documented, but not in the emergency department. A panel from the emergency medicine, child development, psychiatry, and pediatrics departments retrospectively reviewed 475 consecutive injuries in 366 children, ages 1 to 60 months. Group consensus was reached concerning"perceived caretaker neglect leading to injury, child abuse, preventable injuries, and documented instruction. Caretaker neglect was perceived in 40% of injuries: poor supervision, 18.3%; poor childproofing, 7.2%; more than 24 hours delay, 2.3%; and multiple types, 12.7%. No significant differences were found in neglect frequencies for children with one (282), two (61), three (21), or four (two) emergency visits during the 30-month study period. Chi-square revealed that burns and poisonings had significantly higher neglect frequencies, while injuries from falls, lacerations, and sprains had signficantly lower neglect frequencies. Based on the chart, the panel recommended Social Service investigation for 43 children: physical abuse, five, all reported; repeated neglect,
Annals of Emergency Medicine
449/169