- Email: [email protected]
Pediatric Resuscitation and Emergency Medical Services
EDITORIALS
Pediatric Resuscitation and Emergency Medical Services Linda Quan, MD Emergency Services Children’s Hospital Regional Medical Center Seattle, WA Address for reprints: Linda Quan, MD, Childrens Hospital Regional Medical Center, CH-04, 4800 Sandpoint Way NE, Box C5371, Seattle, WA 98105-3901. 47/1/96618 Copyright © 1999 by the American College of Emergency Physicians. 0196-0644/99/$8.00 + 0
2 1 4
Pediatric Resuscitation and Emergency Medical Services See related articles, p. 174, 195, and 206. [Quan L: Pediatric resuscitation and emergency medical services. Ann Emerg Med February 1999;33:214-217.] In this issue of Annals, the study by Sirbaugh et al 1 on an EMS system’s pediatric resuscitation experience, flanked by Young and Seidel’s 2 literature review of pediatric resuscitation, and the research agenda by Seidel et al3 on EMS for children present a sobering triptych of the state of the art of pediatric resuscitation and EMS.The grim message from Sirbaugh et al1 is that pediatric out-of-hospital cardiac arrest (OHCA) patients rarely survive. The comprehensive review of past OHCA studies by Young and Seidel 2 elucidates their key findings, gaps, and methodologic flaws, and suggests standards for future research. Seidel et al3 identify the road to better outcomes through research. Together they raise awareness of how tenuous is the pediatric chain of survival. In their study, Sirbaugh et al1 report one of the worst pediatric OHCA outcomes in an EMS system. What can we learn from yet another pediatric resuscitation study with terrible outcomes? With only 5 survivors of 300 OHCA, the survival rate was 1.7% and only 1 was a good survivor. Such dismal outcomes prompted 1 EMS system to disavow any commitment to pediatric OHCA, thereby throwing the proverbial baby out with the bathwater.4 In comparison, Sirbaugh et al assessed the care given and found that the weak link was the lack of bystander, and especially, parental CPR. This study is important because it should prompt systems changes designed to improve the effectiveness of community-wide emergency cardiac care.5,6 Despite the dismal findings, the article by Sirbaugh et al1 is a superb example of how to do pediatric OHCA research. The study, with 1 exception, meets all the research recommendations suggested by Young and Seidel.2 Sirbaugh et al conducted a prospective study, worked with the medical examiner to define arrest causes, used the pediatric Utstein templates for evaluation,7 defined carefully the criteria for cardiac arrest, evaluated time intervals, included enough data to make the lumpers and the splitters happy, and maintained a follow-up database. Although Sirbaugh et al collected 1 of the largest single-site pediatric cardiac arrest samples, their study was not large enough for multivariate analyses to identify variables associated with good outcomes.
ANNALS OF EMERGENCY MEDICINE
33:2 FEBRUARY 1999
EDITORIALS
The article by Young and Seidel2 summarizes current knowledge on the outcome of pediatric OHCA and evaluates how well these studies reported data that the pediatric Utstein report recommended. The result is a report card for pediatric resuscitation research that one might not want to bring home. It seems ironic that the definition of “pediatric” occurred in only 45% of studies, and that neurologic outcome was reported in only 41% of survivors.2 Young and Seidel’s contribution is identifying key resuscitation issues that should be addressed in pediatric studies as they are in studies of adults with OHCA. These include distinguishing the very dead (those with rigor) from those without rigor so that survival rates can be meaningful. Also, because ventricular fibrillation and witnessed arrest were the only factors associated with better outcomes in the pediatric studies, they deserve more careful study in the future. However, Young and Seidel2 should have faulted the pediatric studies for their lack of attention to time intervals. Almost 2 decades of adult OHCA research has clarified that time is of the essence for adult survival. Using logistic regression, Valenzuela et al 6 recently demonstrated that the key predictors of adult survival are the time intervals from arrest to CPR and arrest to defibrillation. These predictors continue to drive all EMS system changes for adult emergency cardiac care. Their role and that of other time intervals, perhaps time to intubation, in the pediatric patient must be evaluated. Young and Seidel recommended expanding beyond one’s hospital walls to conduct community-based cardiac arrest studies. Even more important is the collaboration between the pediatric and EMS communities exemplified in the Houston study by Sirbaugh et al. Seidel et al3 led a group of Emergency Medical Services for Children (EMS-C) researchers through the daunting task of prioritizing topics to set a research agenda in EMS-C. The group used 7 research categories to impose order. At first glance, pediatric resuscitation appears once. However, the majority of topic headings are broad enough that each could include research in pediatric resuscitation. Conversely, almost all the topics listed need to be addressed for pediatric resuscitation. For example, outcome and follow-up studies of pediatric cardiac arrest patients are needed, as are “determination of the direct and indirect costs” and the long-term effect on families who have a child who has had cardiac arrest or is at risk for a cardiac arrest. Young and Seidel ask “what changes can be made in EMS systems to benefit the pediatric patient?”2 Seidel et al point the way by prioritizing a need for “practical and effective ways to
FEBRUARY 1999
33:2
ANNALS OF EMERGENCY MEDICINE
upgrade EMS system components.”For example, research aimed at developing safe, economical, automatic external defibrillators for children with ventricular fibrillation could save some lives and make current controversies concerning the prevalence of ventricular fibrillation in children less relevant.8 “Quality of care,” and sometimes, equality of care with adults, for the pediatric patient in an EMS system has long been an issue. For instance, most EMS systems report low successful vascular access rates in the pediatric OHCA patient. 1,9 By giving priority to studying “effective ways to improve the quality of EMS care,” the agenda proposed by Seidel et al encourages EMS systems to improve emergency vascular access in children. The final draft of the Paramedic and EMT-Intermediate National Standard Curricula Revision requires annual neonatal and pediatric paramedic education for a minimum of 9 hours of didactic and laboratory with 16 clinical hours in an emergency department and 4 hours in an operating room.10 How shall those few precious hours be spent? Seidel et al prioritize research to develop “effective ways to provide professional education, training, and retraining.” This wisely developed agenda could work well to improve knowledge, systems, and all aspects of care of the pediatric cardiac arrest patient. Modeled after the adult “chain of survival,”11 the pediatric “chain of survival” concept is that each link in the chain must be functional in order for survival from cardiac arrest to occur. The links in the pediatric chain of survival are: prevention, early CPR, access, and Advanced Life Support.12 The chain begins with prevention, reflecting the major role of injury in the etiology of pediatric OHCA.1,13 Additionally, prevention should include early recognition and treatment of respiratory distress, potential respiratory failure, and respiratory arrest. Respiratory conditions are the underlying cause for most pediatric CA, and patient outcome is better when cardiopulmonary arrest is prevented by early treatment of significant respiratory disease. 7 Early CPR is the second link in the pediatric chain, and as Sirbaugh et al1 demonstrated, would most likely involve parents or child care providers. The guidelines recommend that the single rescuer should provide CPR for 1 minute to the unresponsive, nonbreathing pediatric patient. Access is calling EMS providers for help, a significant link in the chain that ideally involves having available an enhanced 911 system. The call is to set in motion the EMS system to provide the fourth link, Advanced Life Support, to the patient. The pediatric chain of survival differs from the adult chain of survival by including prevention as a link and in delaying access until after a
2 1 5
EDITORIALS
trial of early CPR. The latter difference is based on the higher likelihood of respiratory conditions and the lower likelihood of ventricular fibrillation in the pediatric patient compared with the adult. However, each link in the chain represents a very complex intervention. Multiple steps are involved in forging each link. Generally, these steps include developing an intervention, developing a training program to teach the intervention to providers, and implementation. The efficacy, effectiveness, and outcome associated with each recommended intervention should be evaluated. Does the intervention produce the desired physiologic result under ideal conditions? What happens when the intervention is applied in the field? Is it still effective? Even if effective, does the intervention actually improve patient outcome? When the guidelines for pediatric CPR were developed in 1973, a scientific basis for them did not exist. Subsequently, they have undergone only minor modifications. Are the present guidelines for pediatric CPR the right set of guidelines? Are the recommended compression to ventilation ratios efficacious, that is, if performed ideally, do they result in the best oxygenation, ventilation, or perfusion in a child? A physiologic evaluation is still pending for both the pediatric and adult guidelines.14 How effective are the recommendations, that is, can the bystander actually perform them? Studies are needed to determine how well for how long a single rescuer can sustain the fast-paced 5:1 compression/ventilation ratio in the pediatric patient without fatigue and ineffective performance. Sirbaugh et al identify the more pressing question: Will the bystander provide CPR? We know the guidelines are so complex that even trained parents are hesitant to provide CPR to their infant. The urge to simplify the guidelines and to create a universal set of Basic Life Support guidelines for the pediatric and adult victim tantalize and torment.15 Do the present training programs succeed in teaching? For CPR training, the answer is not favorable. Only recently, Braslow et al16 demonstrated poor CPR trainee performance immediately after completion of a CPR course. The failure of so many parents to initiate CPR in Houston raises other questions. Are CPR courses widely available to nonwhite populations and given in Spanish in Houston? What program modifications need to be made to approach different ethnic groups? Creative community efforts to attract the higher-risk, older age groups for CPR training have been unsuccessful.17 Is it time to dedicate resources to focus on other citizen groups who might be more amenable and more trainable, such as school-aged children?
2 1 6
Finally, when provided, does bystander CPR improve outcome in the pediatric OHCA? One study has demonstrated improved outcomes in near-drowning patients.18 Bystander CPR in adults with ventricular fibrillation extends the window of opportunity for defibrillation and results in improved survival. 19 Because bystander CPR was not provided to most children in the Houston study, the low prevalence of ventricular fibrillation in Houston is not surprising. It is likely that opportunities to reverse airway problems or to sustain ventricular fibrillation were missed. The victims’ fates were possibly determined before the arrival of EMS and Advanced Life Support. In conclusion, the sobering results of the studies by Sirbaugh et al1 and Young and Seidel2 emphasize the need for fresh, aggressive approaches to pediatric resuscitation. Early recognition and treatment of ventricular fibrillation were identified as opportunities for improvement by Young and Seidel. Inserting effective bystanders into the chain of survival may be the key to successful intervention for an impending or actual cardiac arrest. Multiple different open-minded approaches with rigorous evaluation are needed to improve outcomes. Ultimately, however, prevention of the conditions that lead to cardiac arrest in children will undoubtedly yield the best outcomes. Ironically, in countries where injury prevention has lowered pediatric trauma rates, even large regional studies of pediatric OHCA are hampered by small numbers of patients.20 Only when this is the last remaining research dilemma will we know that we have strengthened the pediatric chain of survival. 1. Sirbaugh PE, Pepe PE, Shook JE, et al: A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest. Ann Emerg Med 1999;33:174-184. 2. Young KD, Seidel JS: Pediatric cardiopulmonary resuscitation: A collective review. Ann Emerg Med 1999;33:195-205. 3. Seidel JS, Henderson D, Tittle S, et al: Priorities for research in emergency medical services for children: Results of a consensus conference. Ann Emerg Med 1999;33:206-210. 4. Applebaum D, Slater PE: Should the mobile intensive care unit respond to pediatric emergencies? Clin Pediatr (Phila) 1986;25:620-623. 5. Becker LB, Pepe PE: Ensuring the effectiveness of community-wide emergency cardiac care. Ann Emerg Med 1993;22:354-365. 6. Valenzuela TD, Roe DJ, Cretin S, et al: Estimating effectiveness of cardiac arrest interventions: A logistic regression survival model. Circulation 1997:96;3308-3313. 7. Zaritsky A, Nadkarni V, Hazinski MF, et al: Recommended guidelines for uniform reporting of pediatric advanced life support: The pediatric Utstein style. Ann Emerg Med 1995;26:487-503. 8. Hazinski MF: Is pediatric resuscitation unique? Relative merits of early CPR and ventilation versus early defibrillation for young victims of cardiac arrest [editorial]. Ann Emerg Med 1995;25:540-543. 9. Losek JD, Bonadio WA, Walsh-Kelly C, et al: Prehospital pediatric endotracheal intubation performance review. Pediatr Emerg Care 1989;5:1-4.
ANNALS OF EMERGENCY MEDICINE
33:2 FEBRUARY 1999
EDITORIALS
10. Paramedic and EMT-Intermediate: National Standard Curriculum. Available at: www.pitt.edu/paramedic/CE. 11. Cummins RO, Ornato JP, Thies WH, et al: Improving survival from sudden cardiac arrest: The “chain of survival concept.” A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation 1991;83:1832-1847. 12. Chameides L: CPR challenges in pediatrics. Ann Emerg Med 1993;22:388-392. 13. Mogayzel C, Quan L, Graves JR, et al: Out-of-hospital ventricular fibrillation in children and adolescents: Causes and outcomes. Ann Emerg Med 1995;25:484-491. 14. Becker LB, Berg RA, Pepe PE, et al: A reappraisal of mouth-to-mouth ventilation during bystander-initiated cardiopulmonary resuscitation. A statement for healthcare professionals from the Ventilation Working Group of the Basic Life Support and Pediatric Life Support Subcommittees, American Heart Association. Circulation 1997;96:2102-2112. 15. Nadkarni V, Hazinski MF, Zideman D, et al: Pediatric resuscitation: An advisory statement from the Pediatric Working Group of the International Liaison Committee on Resuscitation. Circulation 1997;95:2185-2195. 16. Braslow A, Brennan RT, Newman MM, et al: CPR training without an instructor: Development and evaluation of a video self-instructional system for effective performance of cardiopulmonary resuscitation. Resuscitation 1997:34:207-220. 17. Eisenberg M, Damon S, Mandel L, et al: CPR instruction by videotape: Results of a community project. Ann Emerg Med 1995;25:198-202. 18. Kyriacou DN, Arcinue EL, Peek C, et al: Effect of immediate resuscitation on children with submersion injury. Pediatrics 1994;94:137-142. 19. Larsen MP, Eisenberg MS, Cummins RO, et al: Predicting survival from out-of-hospital cardiac arrest: A graphic model. Ann Emerg Med 1993;22:1652-1658. 20. Suominen P, Räsänen J, Kivioja A: Efficacy of cardiopulmonary resuscitation in pulseless paediatric trauma patients. Resuscitation 1998;36:9-13.
FEBRUARY 1999
33:2
ANNALS OF EMERGENCY MEDICINE
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Pediatric Resuscitation and Emergency Medical Services Linda Quan, MD Emergency Services Children’s Hospital Regional Medical Center Seattle, WA Address for reprints: Linda Quan, MD, Childrens Hospital Regional Medical Center, CH-04, 4800 Sandpoint Way NE, Box C5371, Seattle, WA 98105-3901. 47/1/96618 Copyright © 1999 by the American College of Emergency Physicians. 0196-0644/99/$8.00 + 0
2 1 4
Pediatric Resuscitation and Emergency Medical Services See related articles, p. 174, 195, and 206. [Quan L: Pediatric resuscitation and emergency medical services. Ann Emerg Med February 1999;33:214-217.] In this issue of Annals, the study by Sirbaugh et al 1 on an EMS system’s pediatric resuscitation experience, flanked by Young and Seidel’s 2 literature review of pediatric resuscitation, and the research agenda by Seidel et al3 on EMS for children present a sobering triptych of the state of the art of pediatric resuscitation and EMS.The grim message from Sirbaugh et al1 is that pediatric out-of-hospital cardiac arrest (OHCA) patients rarely survive. The comprehensive review of past OHCA studies by Young and Seidel 2 elucidates their key findings, gaps, and methodologic flaws, and suggests standards for future research. Seidel et al3 identify the road to better outcomes through research. Together they raise awareness of how tenuous is the pediatric chain of survival. In their study, Sirbaugh et al1 report one of the worst pediatric OHCA outcomes in an EMS system. What can we learn from yet another pediatric resuscitation study with terrible outcomes? With only 5 survivors of 300 OHCA, the survival rate was 1.7% and only 1 was a good survivor. Such dismal outcomes prompted 1 EMS system to disavow any commitment to pediatric OHCA, thereby throwing the proverbial baby out with the bathwater.4 In comparison, Sirbaugh et al assessed the care given and found that the weak link was the lack of bystander, and especially, parental CPR. This study is important because it should prompt systems changes designed to improve the effectiveness of community-wide emergency cardiac care.5,6 Despite the dismal findings, the article by Sirbaugh et al1 is a superb example of how to do pediatric OHCA research. The study, with 1 exception, meets all the research recommendations suggested by Young and Seidel.2 Sirbaugh et al conducted a prospective study, worked with the medical examiner to define arrest causes, used the pediatric Utstein templates for evaluation,7 defined carefully the criteria for cardiac arrest, evaluated time intervals, included enough data to make the lumpers and the splitters happy, and maintained a follow-up database. Although Sirbaugh et al collected 1 of the largest single-site pediatric cardiac arrest samples, their study was not large enough for multivariate analyses to identify variables associated with good outcomes.
ANNALS OF EMERGENCY MEDICINE
33:2 FEBRUARY 1999
EDITORIALS
The article by Young and Seidel2 summarizes current knowledge on the outcome of pediatric OHCA and evaluates how well these studies reported data that the pediatric Utstein report recommended. The result is a report card for pediatric resuscitation research that one might not want to bring home. It seems ironic that the definition of “pediatric” occurred in only 45% of studies, and that neurologic outcome was reported in only 41% of survivors.2 Young and Seidel’s contribution is identifying key resuscitation issues that should be addressed in pediatric studies as they are in studies of adults with OHCA. These include distinguishing the very dead (those with rigor) from those without rigor so that survival rates can be meaningful. Also, because ventricular fibrillation and witnessed arrest were the only factors associated with better outcomes in the pediatric studies, they deserve more careful study in the future. However, Young and Seidel2 should have faulted the pediatric studies for their lack of attention to time intervals. Almost 2 decades of adult OHCA research has clarified that time is of the essence for adult survival. Using logistic regression, Valenzuela et al 6 recently demonstrated that the key predictors of adult survival are the time intervals from arrest to CPR and arrest to defibrillation. These predictors continue to drive all EMS system changes for adult emergency cardiac care. Their role and that of other time intervals, perhaps time to intubation, in the pediatric patient must be evaluated. Young and Seidel recommended expanding beyond one’s hospital walls to conduct community-based cardiac arrest studies. Even more important is the collaboration between the pediatric and EMS communities exemplified in the Houston study by Sirbaugh et al. Seidel et al3 led a group of Emergency Medical Services for Children (EMS-C) researchers through the daunting task of prioritizing topics to set a research agenda in EMS-C. The group used 7 research categories to impose order. At first glance, pediatric resuscitation appears once. However, the majority of topic headings are broad enough that each could include research in pediatric resuscitation. Conversely, almost all the topics listed need to be addressed for pediatric resuscitation. For example, outcome and follow-up studies of pediatric cardiac arrest patients are needed, as are “determination of the direct and indirect costs” and the long-term effect on families who have a child who has had cardiac arrest or is at risk for a cardiac arrest. Young and Seidel ask “what changes can be made in EMS systems to benefit the pediatric patient?”2 Seidel et al point the way by prioritizing a need for “practical and effective ways to
FEBRUARY 1999
33:2
ANNALS OF EMERGENCY MEDICINE
upgrade EMS system components.”For example, research aimed at developing safe, economical, automatic external defibrillators for children with ventricular fibrillation could save some lives and make current controversies concerning the prevalence of ventricular fibrillation in children less relevant.8 “Quality of care,” and sometimes, equality of care with adults, for the pediatric patient in an EMS system has long been an issue. For instance, most EMS systems report low successful vascular access rates in the pediatric OHCA patient. 1,9 By giving priority to studying “effective ways to improve the quality of EMS care,” the agenda proposed by Seidel et al encourages EMS systems to improve emergency vascular access in children. The final draft of the Paramedic and EMT-Intermediate National Standard Curricula Revision requires annual neonatal and pediatric paramedic education for a minimum of 9 hours of didactic and laboratory with 16 clinical hours in an emergency department and 4 hours in an operating room.10 How shall those few precious hours be spent? Seidel et al prioritize research to develop “effective ways to provide professional education, training, and retraining.” This wisely developed agenda could work well to improve knowledge, systems, and all aspects of care of the pediatric cardiac arrest patient. Modeled after the adult “chain of survival,”11 the pediatric “chain of survival” concept is that each link in the chain must be functional in order for survival from cardiac arrest to occur. The links in the pediatric chain of survival are: prevention, early CPR, access, and Advanced Life Support.12 The chain begins with prevention, reflecting the major role of injury in the etiology of pediatric OHCA.1,13 Additionally, prevention should include early recognition and treatment of respiratory distress, potential respiratory failure, and respiratory arrest. Respiratory conditions are the underlying cause for most pediatric CA, and patient outcome is better when cardiopulmonary arrest is prevented by early treatment of significant respiratory disease. 7 Early CPR is the second link in the pediatric chain, and as Sirbaugh et al1 demonstrated, would most likely involve parents or child care providers. The guidelines recommend that the single rescuer should provide CPR for 1 minute to the unresponsive, nonbreathing pediatric patient. Access is calling EMS providers for help, a significant link in the chain that ideally involves having available an enhanced 911 system. The call is to set in motion the EMS system to provide the fourth link, Advanced Life Support, to the patient. The pediatric chain of survival differs from the adult chain of survival by including prevention as a link and in delaying access until after a
2 1 5
EDITORIALS
trial of early CPR. The latter difference is based on the higher likelihood of respiratory conditions and the lower likelihood of ventricular fibrillation in the pediatric patient compared with the adult. However, each link in the chain represents a very complex intervention. Multiple steps are involved in forging each link. Generally, these steps include developing an intervention, developing a training program to teach the intervention to providers, and implementation. The efficacy, effectiveness, and outcome associated with each recommended intervention should be evaluated. Does the intervention produce the desired physiologic result under ideal conditions? What happens when the intervention is applied in the field? Is it still effective? Even if effective, does the intervention actually improve patient outcome? When the guidelines for pediatric CPR were developed in 1973, a scientific basis for them did not exist. Subsequently, they have undergone only minor modifications. Are the present guidelines for pediatric CPR the right set of guidelines? Are the recommended compression to ventilation ratios efficacious, that is, if performed ideally, do they result in the best oxygenation, ventilation, or perfusion in a child? A physiologic evaluation is still pending for both the pediatric and adult guidelines.14 How effective are the recommendations, that is, can the bystander actually perform them? Studies are needed to determine how well for how long a single rescuer can sustain the fast-paced 5:1 compression/ventilation ratio in the pediatric patient without fatigue and ineffective performance. Sirbaugh et al identify the more pressing question: Will the bystander provide CPR? We know the guidelines are so complex that even trained parents are hesitant to provide CPR to their infant. The urge to simplify the guidelines and to create a universal set of Basic Life Support guidelines for the pediatric and adult victim tantalize and torment.15 Do the present training programs succeed in teaching? For CPR training, the answer is not favorable. Only recently, Braslow et al16 demonstrated poor CPR trainee performance immediately after completion of a CPR course. The failure of so many parents to initiate CPR in Houston raises other questions. Are CPR courses widely available to nonwhite populations and given in Spanish in Houston? What program modifications need to be made to approach different ethnic groups? Creative community efforts to attract the higher-risk, older age groups for CPR training have been unsuccessful.17 Is it time to dedicate resources to focus on other citizen groups who might be more amenable and more trainable, such as school-aged children?
2 1 6
Finally, when provided, does bystander CPR improve outcome in the pediatric OHCA? One study has demonstrated improved outcomes in near-drowning patients.18 Bystander CPR in adults with ventricular fibrillation extends the window of opportunity for defibrillation and results in improved survival. 19 Because bystander CPR was not provided to most children in the Houston study, the low prevalence of ventricular fibrillation in Houston is not surprising. It is likely that opportunities to reverse airway problems or to sustain ventricular fibrillation were missed. The victims’ fates were possibly determined before the arrival of EMS and Advanced Life Support. In conclusion, the sobering results of the studies by Sirbaugh et al1 and Young and Seidel2 emphasize the need for fresh, aggressive approaches to pediatric resuscitation. Early recognition and treatment of ventricular fibrillation were identified as opportunities for improvement by Young and Seidel. Inserting effective bystanders into the chain of survival may be the key to successful intervention for an impending or actual cardiac arrest. Multiple different open-minded approaches with rigorous evaluation are needed to improve outcomes. Ultimately, however, prevention of the conditions that lead to cardiac arrest in children will undoubtedly yield the best outcomes. Ironically, in countries where injury prevention has lowered pediatric trauma rates, even large regional studies of pediatric OHCA are hampered by small numbers of patients.20 Only when this is the last remaining research dilemma will we know that we have strengthened the pediatric chain of survival. 1. Sirbaugh PE, Pepe PE, Shook JE, et al: A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest. Ann Emerg Med 1999;33:174-184. 2. Young KD, Seidel JS: Pediatric cardiopulmonary resuscitation: A collective review. Ann Emerg Med 1999;33:195-205. 3. Seidel JS, Henderson D, Tittle S, et al: Priorities for research in emergency medical services for children: Results of a consensus conference. Ann Emerg Med 1999;33:206-210. 4. Applebaum D, Slater PE: Should the mobile intensive care unit respond to pediatric emergencies? Clin Pediatr (Phila) 1986;25:620-623. 5. Becker LB, Pepe PE: Ensuring the effectiveness of community-wide emergency cardiac care. Ann Emerg Med 1993;22:354-365. 6. Valenzuela TD, Roe DJ, Cretin S, et al: Estimating effectiveness of cardiac arrest interventions: A logistic regression survival model. Circulation 1997:96;3308-3313. 7. Zaritsky A, Nadkarni V, Hazinski MF, et al: Recommended guidelines for uniform reporting of pediatric advanced life support: The pediatric Utstein style. Ann Emerg Med 1995;26:487-503. 8. Hazinski MF: Is pediatric resuscitation unique? Relative merits of early CPR and ventilation versus early defibrillation for young victims of cardiac arrest [editorial]. Ann Emerg Med 1995;25:540-543. 9. Losek JD, Bonadio WA, Walsh-Kelly C, et al: Prehospital pediatric endotracheal intubation performance review. Pediatr Emerg Care 1989;5:1-4.
ANNALS OF EMERGENCY MEDICINE
33:2 FEBRUARY 1999
EDITORIALS
10. Paramedic and EMT-Intermediate: National Standard Curriculum. Available at: www.pitt.edu/paramedic/CE. 11. Cummins RO, Ornato JP, Thies WH, et al: Improving survival from sudden cardiac arrest: The “chain of survival concept.” A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation 1991;83:1832-1847. 12. Chameides L: CPR challenges in pediatrics. Ann Emerg Med 1993;22:388-392. 13. Mogayzel C, Quan L, Graves JR, et al: Out-of-hospital ventricular fibrillation in children and adolescents: Causes and outcomes. Ann Emerg Med 1995;25:484-491. 14. Becker LB, Berg RA, Pepe PE, et al: A reappraisal of mouth-to-mouth ventilation during bystander-initiated cardiopulmonary resuscitation. A statement for healthcare professionals from the Ventilation Working Group of the Basic Life Support and Pediatric Life Support Subcommittees, American Heart Association. Circulation 1997;96:2102-2112. 15. Nadkarni V, Hazinski MF, Zideman D, et al: Pediatric resuscitation: An advisory statement from the Pediatric Working Group of the International Liaison Committee on Resuscitation. Circulation 1997;95:2185-2195. 16. Braslow A, Brennan RT, Newman MM, et al: CPR training without an instructor: Development and evaluation of a video self-instructional system for effective performance of cardiopulmonary resuscitation. Resuscitation 1997:34:207-220. 17. Eisenberg M, Damon S, Mandel L, et al: CPR instruction by videotape: Results of a community project. Ann Emerg Med 1995;25:198-202. 18. Kyriacou DN, Arcinue EL, Peek C, et al: Effect of immediate resuscitation on children with submersion injury. Pediatrics 1994;94:137-142. 19. Larsen MP, Eisenberg MS, Cummins RO, et al: Predicting survival from out-of-hospital cardiac arrest: A graphic model. Ann Emerg Med 1993;22:1652-1658. 20. Suominen P, Räsänen J, Kivioja A: Efficacy of cardiopulmonary resuscitation in pulseless paediatric trauma patients. Resuscitation 1998;36:9-13.
FEBRUARY 1999
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2 1 7