Update in pediatric resuscitation

PEDIATRIC EMERGENCY MEDICINE: CURRENT CONCEPTS AND CONTROVERSIES

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UPDATE IN PEDIATRIC RESUSCITATION Kathleen Brown, MD, and Jennifer Bocock, MD

THE STATE OF PEDIATRIC ADVANCED LIFE SUPPORT Current State of Evidence about Pediatric Resuscitation Fortunately, cardiopulmonary arrest (CPA) and the need for advanced life support (ALS) in the pediatric patients are relatively rare events. Unfortunately, this fact, coupled with the fact that outcome from CPA in children is dismal, makes for a small number of subjects on which to collect data to gain knowledge about the nature of CPA and the effectiveness of ALS interventions. Adding to this problem of small sample sizes and inadequate power is the fact that much of the previous research on pediatric resuscitation used varying definitions of terms such as CPA and resuscitation and different outcome measures. This heterogeneity makes combining these studies in a systematic review or meta-analysis difficult, if not impossible. Thus, physicians are left with individual small studies that often have conflicting results. The need for standardization of terms and outcome measures in resuscitation research was first addressed in 1991 for the adult cardiac arrest patient. Criteria for conducting resuscitation research and reporting data were developed. These criteria were called the Utstein style for reporting of data from out-of-hospital cardiac arrest.42 They did not,

From the Department of Emergency Medicine, State University of New York, Upstate Medical University, Syracuse, New York

EMERGENCY MEDICINE CLINICS OF NORTH AMERICA VOLUME 20 • NUMBER 1 • FEBRUARY 2002

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however, specifically address the pediatric patient. In 1994, the first international conference on pediatric resuscitation was held, and a task force was assigned to this topic. In 1995, the guidelines for pediatric Utstein style criteria were published.154 These guidelines encompass data for not only cardiopulmonary arrest but also respiratory arrest or the need for any ALS interventions. This recognizes the fact that many children require respiratory support as the primary intervention. The guidelines define many terms that are used in the acute care of children, such as resuscitation, cardiac arrest, respiratory arrest, cardiopulmonary resuscitation (CPR), and return of spontaneous circulation or ventilation (ROSC/ROSV). This allows interventions and outcomes to be grouped specifically for data analysis. Time intervals in the resuscitation are also defined as core or supplemental, for emergency medical services (EMS), emergency department (ED), and in-hospital patient care. For review of outcome data in resuscitation survivors, the task force has recommended two measurement systems: pediatric overall performance category (POPC), and the pediatric cerebral performance category (PCPC). These data sets allow for comparison and analysis of the results of individual small studies and set a standard for larger multicenter studies. Utilization of these criteria by researchers allows better descriptions of pediatric arrest and the impact of resuscitative intervention. Incidence and Etiology of Pediatric CPA In the United States, an estimated 16,000 children per year die of unexpected CPA. CPA in children represents 5% to 10% of all cases of out-of-hospital resuscitation.7, 50, 74 A recent collective review of the literature on pediatric CPA was plagued with many of the problems discussed above.152 Young and Seidel identified 44 studies with survival data on pediatric patients who received CPR. Different definitions were used for many terms, including what constituted a child or CPA. Fourteen different outcome measures were used. These methodologic problems made comparisons difficult and meta-analysis of the data impossible. Some information about the demographics and etiologies of CPA in children the can be gleaned from these studies, however. Approximately one half of pediatric patients who suffered cardiopulmonary arrest were younger than 1 year of age. Sixty-two percent of the victims were male. Out-ofhospital arrest was witnessed in 31% of the cases, and bystander CPR was given in 30% of the cases in which this was reported. When recorded, the initial rhythm was bradysystole in 73% of patients and ventricular fibrillation or ventricular tachycardia (VF/VT) in 10%. Similar demographic information was obtained in a recent prospective population-based study that did use the pediatric Utstein style criteria for reporting some of their data.131 They looked at 300 children (ages 0–17) with CPA over a 3 1/2-year period. They found an overall annual incidence of 19.7/100,00 population at risk. Fifty-four percent were younger than 1 year, and 76% were younger than 4 years of age. Sixty

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percent were male, and sixty percent of arrests occurred at home. Of those cases, only 22% received bystander CPR. Etiology of CPA was also looked at in these studies. In the collective review by Young and Seidel, the most common etiologies in order of incidence (when reported) were: Sudden infant death syndrome (SIDS), trauma, submersion, cardiac diagnosis, and sepsis.152 Individual studies that have looked at the causes of CPA in patients have shown similar results. (8–14) In the population-based study by Sirbaugh et al, trauma, SIDS, submersion, pulmonary disease, asphyxia aspiration, and cardiac disease were the most commonly reported causes of CPA. In 68% of the nontrauma cases, the patients were younger than 12 months of age. Most of those patients suffered from SIDS.131 SIDS affects 1.5-2 in 1000 infants in this country and has a peak incidence at 5 months. Its etiology is still not well defined. It has been consistently found to be the most common cause of CPA in infants. In children older than 1 year, trauma has been consistently the most common cause of CPA and death. Toxic ingestion and drug overdose are other causes that should be considered, especially in the adolescent and young adult populations. Thus, unlike in adults, in whom the most common cause of CPA is a sudden cardiac event, cardiovascular disease and primary cardiac failure are rare in pediatric patients. The cause of pediatric CPA is much more heterogeneous and varies with the victim’s age. The significance of this information is manifold. Because the causes of CPA in pediatric patients are so different from those of adult CPA patients, it is probably not valid to extrapolate results on the effectiveness of resuscitative measures in the adult population to the pediatric population. The heterogeneity of causes of pediatric arrest makes pediatric resuscitation interventions more difficult to study. Different interventions are probably more helpful to patients in one cause of arrest than in those with another. If one were to study an intervention in patients with only one cause of arrest, however, it further compounds the problems of sample size discussed earlier. It is possible that with further study, demographic factors and the patient’s medical history could predict the most likely etiology of arrest in pediatric patients and thus dictate the most effective resuscitative sequence of interventions. Survival from Pediatric CPA Previous studies that have looked at survival from pediatric arrest have been difficult to interpret because of differences in the definitions of arrest and outcome measures discussed earlier. In these studies, survival rates varying from 0% to 17% have been reported. The collective review by Young and Seidel looked at survival to hospital discharge rates, as this was the most common outcome measure reported. They were unable to comment on the neurologic outcome of the patients who survived, because many of the studies did not include this as an outcome measures and those that did used different definitions and measures of

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neurologic outcome. The overall survival-to-discharge rate from CPA was 13%. Survival from out-of-hospital CPA was 8%. Patients with inhospital CPA had a higher (24%) survival rate. Sirbaugh’s prospective study demonstrated a 2% overall survival rate. Of the six surviving patients, only one was considered neurologically intact. Survival rates for patients who present to the ED still in CPA are even more dismal. In Sirbaugh’s study, no patient without ROSC in the field survived. Three previous studies looked specifically at patients who were pulseless on presentation to the ED.46, 66, 117 Of the 177 patients who were pulseless in the ED in these three studies, 4 (2%) survived to hospital discharge; all were neurologically devastated. Thus it appears that the current survival rates from CPA in children are alarmingly low and much lower than in the adult population. These data on actual survival rates from pediatric arrests are in contrast to the beliefs of some healthcare professionals about pediatric survival from CPA. In a survey by Roberts et al, 401 people recruited from physician’s waiting rooms and resuscitation courses were asked to estimate the rate of survival from CPA in adults and in children.114 The estimates of survival rates for adults by lay rescuers, physicians, and nurses were 52%, 30%, and 24% respectively. The estimates of survival rates for children by lay rescuers, physicians, and nurses were 63%, 45%, and 41% respectively. These beliefs about what resuscitation measures can accomplish in CPA, especially in children, are in stark contrast to the evidence regarding actual survival from CPA in children. Pediatric patients who experience a respiratory arrest (as opposed to CPA) have a much better prognosis. Children with respiratory arrest alone have been reported to have much higher survival rates.54, 68, 77, 125, 141, 153 The collective review demonstrated a 75% survival-to-discharge rate for apneic patients with a pulse.152 Eighty-eight percent of these surviving patients who had a neurologic outcome reported had a good outcome. These data underscore the importance of early intervention in the management of ill or injured pediatric patients to prevent CPA. Factors Associated with Survival In Young and Seidel’s collective review, patients younger than 1 year of age, representing one half of the total patients, had a lower survival rate (6%).152 Sirbaugh et al were not able to correlate age with survival because of the small number of survivors in their population.131 There are some data to suggest that particular causes are associated with improved survival rates. In the collective review by Young and Seidel, 26% of near drowning patients, 4% of trauma patients, and 0.2% of SIDS patients survived to hospital discharge.152 Previous studies on neardrowning patients also have suggested that this group of patients has a better prognosis.110, 111 Sirbaugh did not report the relationship between cause of arrest and survival. Because there were only 6 survivors in the study, few conclusions could be drawn even if these data had been

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reported.31 This same problem of small sample size and low survival rates plagues other individual studies on CPA that have attempted to look at the relationship of cause to survival.6, 50, 100, 117, 125, 143, 153 In addition, these factors are probably interrelated. For example, given the poor survival of patients with SIDS, the fact that most of the patients younger than 1 year of age had SIDS as the etiology of their CPA could account for the poorer prognosis among this age group. Thus, factors such as age and cause could be useful in making resuscitation decisions, but further research is needed to help separate the individual effects of age and cause on survival. Presenting rhythm was also looked at as a prognostic factor in the collective review. Approximately 10% of the patients had (VF/VT) ventricular fibrillation/ventricular tachycardia as a presenting rhythm.52 This is consistent with previous reports of the incidence of VF/VT in pediatric CPA. These patients had a much higher survival rate than did those who presented with bradysystole (30% vs 5%). This difference also has been reported in individual studies that have looked at this issue.50, 96, 143, 153 Because virtually all patients with SIDS have asystole as their presenting rhythm, and in most patients younger than 1 year of age, SIDS is the etiology of CPA, presenting rhythm or etiology of arrest rather than age itself may be the most important prognostic factor. The fact that most adults with CPA have VF/VT as their presenting rhythm most likely accounts for the much higher overall survival rate from CPA in adults than in children. Thus, the relatively low prevalence of VF/VT must be weighed against the fact that it is the most treatable cause of CPA in making decisions about the priority and timing of interventions in pediatric resuscitation. A study that excluded patients with SIDS showed a 19% rate of VF/VT in pediatric patients.92 In adult CPA patients, particular ALS interventions, such as early defibrillation and bystander CPR, have been associated with improved outcome. Investigators also have attempted to correlate ALS interventions with improved outcome in pediatric patients, with mixed results. In the collective review by Young and Seidel, bystander CPR (when reported) was associated with an improved outcome (20% survival rate).152 In Sirbaugh’s study, all of the six survivors had a return of spontaneous circulation in the field (prior to arrival in the ED), and none of them required any medications other than oxygen. The one neurologically intact patient was successfully defibrillated prior to arrival in the ED. The only intervention that they could correlate with ROSC was successful prehospital endotracheal (ET) intubation. All 33 patients with ROSC were intubated in the field. They could not correlate this or any other intervention with survival to discharge or good neurologic outcome, however, because of the small number of patients and dismal survival rate.131 Other studies that have attempted to correlate prehospital CPR with improved outcome have had similar problems and have not been able to demonstrate such an association.68, 119, 125, 129 This again underscores the need for larger multicenter studies using uniform data collection sets.

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DEVELOPMENT OF THE CURRENT PEDIATRIC ALS GUIDELINES Despite the current paucity of data on the effectiveness of ALS interventions in pediatric CPA victims, medical professionals and even lay rescuers must make decisions about the resuscitation of the pediatric patients in need of ALS when they are faced with such a situation. The American Heart Association (AHA) began publishing standardized resuscitation guidelines in 1974, based on consensus of expert opinion. These guidelines have been updated regularly and have come to represent a standard of care for resuscitation, especially in the prehospital arena in the United States. Initially, these guidelines were developed to address the problem of sudden cardiac death in adults. They did not recognize the differences in origin and physiology between adult and pediatric CPA victims. Prior to the First National Conference on Pediatric Resuscitation in 1983, pediatric patients in need of ALS were treated by the guidelines that were designed for the adult resuscitation victims. The first AHA guidelines for pediatric resuscitation were published in 1986.136 Since that time, AHA has published revised separate guidelines for adult and pediatric patients. The pediatric guidelines were revised in 1992.4 Similar guidelines were published by the European Resuscitation Council.60 In 2000, the AHA collaborated with resuscitation scientists from other countries to form the first international conference on CPR and emergency cardiovascular care (ECC) to produce international resuscitation guidelines. This conference brought together resuscitation experts from all over the world to collaborate and review the available evidence to support or refute existing and new recommendations. The resulting consensus guidelines included an overall class of recommendation (Class I, IIa, IIb, indeterminate, and III).61 Class I, the highest level of recommendation, indicates that there is at least one randomized controlled trial with an excellent critical assessment, and the results are homogeneous and consistently positive. Class I recommendations are considered excellent and are definitely recommended. Class IIa indicates that there are multiple studies with good to very good critical assessment and mostly positive results. Class IIa recommendations are considered good to very good and are acceptable and useful. Class IIb recommendations indicate that there are few studies with fair or poor critical assessment and generally positive results. Class IIb recommendations are considered acceptable and useful. Class indeterminate indicates that there is promising but low-level evidence or high-level but inconsistent evidence; Class indeterminate recommendations are not recommended until further evidence is available. Class III, the lowest level of recommendation, indicates that positive evidence is completely absent or confirms harm. Class III recommendations are not acceptable, not useful, and can be harmful. The guidelines also report a measure of the level of the available evidence based on study methodology. Level 1, the highest level, indicates a positive, prospective, randomized controlled trial. Level 2 indicates a neutral, randomized, controlled trial. Level 3 indicates a

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prospective, non randomized study. Level 4 indicates a retrospective human study. Level 5 indicates case series. Level 6 indicates animal studies. Level 7 indicates extrapolations from existing data or data gathered for other purposes. Level 8 indicates common sense or rational conjecture.61 Unfortunately, because of the problems noted earlier in conducting and analyzing research on pediatric resuscitation, the guidelines for pediatric ALS rarely reach a high class of recommendation or level of evidence. Most pediatric ALS recommendations are class indeterminate, and none are class I. In the remainder of this update, the authors will review changes from previous guidelines, discuss the evidence to support these changes, and identify areas for which information is still lacking and discuss challenges for future research. CURRENT PALS GUIDELINES: WHAT HAS CHANGED? Chain of Survival: ‘‘Phone Fast’’ Versus ‘‘Phone First’’ Previous resuscitation guidelines have differentiated the initial sequence of interventions when one encounters a patient in CPA based on the patient’s age. For patients older than age 8, rescuers are advised to ‘phone first’ (ie, activate the EMS system prior to performing CPR). The rational for this is that defibrillation is known to be the most effective resuscitative intervention currently available, and ensuring early access to defibrillation is most likely to result in a good outcome. In children, reported rates of VF in CPA are much lower and most instances of CPA are a result of progression from respiratory arrest and hypoxia. Therefore, access to defibrillation is less important, and early CPR can be more important. Recommendations were to provide CPR and then activate EMS (‘‘phone fast’’) in children less than 8 years old. This age based differentiation in the recommended sequence has been questioned by some. As discussed previously, cause of arrest could be a better predictor of presenting rhythm than age. This evidence, in combination with the dismal outcome of patients in CPA who do not receive defibrillation, has led some to suggest that probable cause of arrest rather than age alone should be the determining factor in whether one ‘‘phone first’’ rather than ‘‘phones fast.’’ An example of this is submersion victims. In these victims, regardless of age, immediate CPR is associated with improved outcome, regardless of the victim’s age.75, 118 Other instances were victims older than 8 years old may benefit from immediate CPR versus immediate EMS activation are victims of trauma, respiratory arrests, or drug overdoses. In children with a sudden witnessed arrest or history of cardiac disease, however, VF/VT is more likely, and it could be more effective to phone first, even if the victim is less than 8 years old. Despite acknowledging the merits of an etiologically based differentiation, the international committee decided to recommend a modified age-based sequence for initial resuscitation and EMS activation. The decision was based on the belief that simplification was of utmost

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importance, especially when designing principles to be taught, especially for lay rescuers. For single-rescuer scenarios in children younger than 8 years, initial rescue breathing and initiation of CPR for up to 1 minute is recommended, followed by a call to activate the EMS system (‘‘phone fast’’). For children older than 8 years, ‘‘phone first’’, to activate the EMS system immediately is recommended (Class indeterminate). In all scenarios, if more than one rescuer is present, one remains with the patient and one should begin the activation of the EMS system. Etiologically based exceptions to this should be taught to professional rescuers and selected lay rescuers (ie, parents of children with heart disease) and described in ALS and BLS texts. For example, in a submersion/neardrowning scenario, regardless of the victim’s age a ‘‘phone fast’’ approach should be taught to professional rescuers. In a child with known cardiac disease who has a sudden collapse, the lone professional rescuer should be taught to ‘‘phone first.’’ Bystander (Lay-Rescuer) Resuscitation Data in adults clearly demonstrate worse outcome in victims when bystander CPR is not provided.23, 144 In children, it has also been suggested that bystander CPR improves survival, although the evidence is less clear.6, 74 In the prospective review of pediatric cardiopulmonary arrest by Sirbaugh et al, 60% of the cases occurred at home, but only 17% of the victims received bystander CPR.152 In the collective review by Young and Seidel, bystander CPR was performed in fewer than 30% of the victims.7 The distressingly low rate of bystander CPR in pediatric arrests has led to speculation as to what the barriers are to providing CPR. Some evidence in adult victims suggests that providing mouthto-mouth breathing is one such barrier for both professional and lay rescuers.65, 83 There is also evidence that compression-only CPR is efficacious in the first 6 to 12 minutes of an acute VF arrest in animal models and in adult humans with VF.13, 97 Partial CPR has also been shown to be superior to no CPR in animal models; however, it is unclear if this evidence applies to pediatric arrest patients. Most arrests in pediatric patients are respiratory in origin, and evidence suggests that both chest compressions and active rescue breathing are necessary for optimal resuscitation of asphyxial arrests.14, 17 For these reasons, the AHA has recommended in the 2000 guidelines that for pediatric cardiac arrest, both chest compressions and rescue breathing be provided as soon as possible. If a lay rescuer is unable or unwilling to provide rescue breathing, however, it s better to provide compression-only CPR than no CPR. This is a Class IIb recommendation. It has been found that rescuers have difficulty assessing the presence of a pulse in both adults and children. Studies have demonstrated the inability of parents (lay rescuers) to find and count a pulse in healthy infants, and that even professional rescuers take much longer than the recommended 10 seconds to assess the presence of a carotid pulse in

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adult victims.36, 44 The sensitivity of the pulse check in adults by all rescuers was found to be 90% and the specificity 60% in the largest study on this subject.49 This means that in 10% of cases, pulseless victims would not receive CPR, and in 40% of victims, CPR would be given when it might not have been necessary. It has also been shown that the application of CPR in infants and children has few complications.32, 72, 134 Therefore, reducing the number of patients who erroneously do not receive CPR is more important than reducing the number who erroneously do not receive CPR. In the interest of both simplification of the teaching of BLS and increasing the application of appropriate CPR, the assessment of circulation, for the lay rescuer has been changed in the 2000 guidelines. The pulse check is no longer taught or required for this group of rescuers. This is a Class IIa recommendation. Lay rescuers are to be taught to rely on signs of circulation. These include spontaneous breathing, coughing, or response to rescue breathing efforts. If these are not present, compressions should be started. Healthcare workers are to continue to use the pulse check to assess circulation, although this has been shown to be challenging, even in healthy children and infants. The final change in lay-rescuer resuscitation is the elimination of the teaching of complex maneuvers for relief of foreign body airway obstruction in unresponsive victims. This eliminates the old sequence: jaw lift, look for the foreign body, finger sweep (if an object is visible), head-tilt chin lift, attempt rescue breath, reposition reattempt breaths, and then perform back blows or chest thrusts in the infant and abdominal thrusts in the child or adolescent, repeating until the object is retrieved or breaths are effective. This sequence was thought to be too complex to teach to lay rescuers. Lay rescuers now are to be taught simply to provide CPR with the addition of looking in the mouth for a foreign body each time the airway is opened. If a foreign body is found, it should be removed. The rationale for this change is again simplification and that it has been shown in adult cadavers that CPR is just as effective as back blows for removal of a foreign body airway obstruction.32 This is a Class IIb recommendation. Professional rescuers will continue to be taught the sequence of actions recommended in the 1992 guidelines for both responsive and unresponsive foreign body obstruction patients. Family Member Presence Several studies have assessed whether parents want to be present when procedures are performed on their children.10–12, 24, 47, 108, 122, 150 All of these studies have revealed that most parents want to be present and believe it is helpful both to themselves and their children.10, 24, 47, 108, 122, 150 Some of these studies have demonstrated a decrease in the anxiety of the patient and/or family member, however.47, 150 Many these studies have asked specifically about resuscitative procedures such as intubation and CPR.24, 122 One study found that 83% of parents wanted to be present

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for resuscitation efforts on their child if that child were ‘‘likely to die.’’24 Another study documented lower depression, anxiety and grief scores in family members who were present for resuscitation attempts on their loved one than in those who were not.116 Successful programs of family member presence for resuscitation of both adult and pediatric patients have been described in the literature. Advice on how to set up such a program has also been published.51 The 2000 international guidelines support family member presence for both adult and pediatric victims. Whenever possible, family members should be given this option. If at all possible, a member of the resuscitation team should remain with the family members to answer their questions, provide support, and recognize when they might need to leave. Breathing and Airway Management Previous guidelines have recommended mouth-to-mouth breathing for children older than 1 year old and mouth-to-nose-and-mouth for infants. There is some evidence that mouth-to-nose ventilation may be as effective for infants.45, 142 The 2000 recommendations allow for this technique as an alternative technique for rescuers who have difficulty with mouth to mouth and nose ventilations. (Class IIb) A recent prospective randomized trial compared the effectiveness of out-of-hospital ventilations by a tracheal tube versus bag valve mask ventilation (BVM) for pediatric respiratory failure.53 The study was conducted in Los Angeles in a system with short transport times. The prehospital providers were given a standardized, well-described training program in both bagvalve-mask (BVM) ventilation and tracheal intubation. Individual EMS providers had few opportunities to perform tracheal intubation on actual pediatric patients, however. Outcome measures in the patients in each group were not significantly different. In a subgroup of patients with respiratory failure and not CPA, BVM ventilation was superior to tracheal intubation. This information challenged the concept that ventilatory support by a tracheal tube was the gold standard in pediatric resuscitation. This led the international guidelines conference to recommend that proficiency in BVM be mandatory for all prehospital providers and is higher in priority than training in tracheal intubation (Class IIa, LOE 1,2). They also recommend that the choice of method of ventilation be based on several factors, including level of training and skill of the provider. Previous studies have demonstrated that paramedic success rates at pediatric intubation improve with increased training.29, 86 Other factors that should be considered in deciding how best to manage the airway of a pediatric patient include the clinical condition of the patient and distance to the ED. When endotracheal intubation is used to provide ventilation during a resuscitation, there is a risk of undetected esophageal intubation and associated morbidity and mortality. Traditionally, clinical signs have been advocated as the best method for confirmation of correct tube

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placement; however, evidence suggests that auscultation is often unreliable as a means of confirming proper tube placement.5 In addition, animal data show that detection of a displaced or obstructed tube by changes in oximetry or heart rate can be delayed up to 3 minutes.106 Measurement of exhaled CO2 has been shown to be an effective method of confirming tube placement in both adults and children with a perfusing rhythm.21, 22 A positive waveform or color change after 6 ventilations (to wash out any CO2 in the stomach) accurately confirms proper tube placement. In patients in CPA (nonperfusing rhythms), however, absence of detectable exhaled CO2 can represent a false-negative result (ie, the tube could be properly placed).20, 22, 99 Secondary confirmation of tracheal tube placement by end-tidal CO2 detection is strongly recommended in the international guidelines. This is a Class IIa (LOE 3, 5, 7) recommendation for patients with perfusing rhythms and a Class IIb (LOE 5, 7) recommendation in patients without a perfusing rhythm. The committee states that with further evidence in children outside of the operating suite, this could be a Class I recommendation. Use of an exhaled CO2 monitor or capnography is required immediately after intubation and during transport. Use during transport is especially important, because it has been shown that tube displacement often occurs when the patient is being moved.19 In adult patients, the use of an esophageal detector device (EDD) is an alternative means of confirming tracheal tube placement. The device consists of a self-inflating bulb that is placed on the end of the endotracheal tube. The utility of this device is based on the fact that air can easily be drawn by negative pressure from the lungs through the trachea. If the endotracheal tube is in the trachea, the bulb refills, because the trachea does not collapse, being it is supported by cartilage. Conversely, the esophagus collapses against negative pressure, and the bulb does not refill. It has been found to be reliable in detecting esophageal intubations in adults and may be especially useful in confirming endotracheal tube placement in cases of CPA were the end-tidal CO2 monitor can yield a false-negative result.26 In adults, it is a Class IIa recommendation in patients with a perfusing rhythm and a Class IIb recommendation in patients with a nonperfusing rhythm. It has also been reported to also be useful in children148 but appears to be unreliable in infants.63 Its use in children is therefore classified as a class indeterminate (LOE 5, 6, 7) recommendation in the international guidelines. Because of the recognition that endotracheal intubation is a skill that requires specific training and maintenance to be effective and in some settings is associated with a high complication rate, the use of alternative airway devices has been advocated by some experts. The laryngeal mask airway (LMA) consists of a tube with a cuffed masklike projection at the distal end. It is placed into the pharynx and advanced until resistance is felt as it enters the hypopharynx. The cuff is then inflated, sealing off the hypopharynx. The distal opening of the tube then sits just above the glottic opening. The LMA has been used successfully in the operating suite to secure an airway in unconscious children.84, 85 They have also been shown to be

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effective means of controlling the airway of unconscious adults in the prehospital setting.89, 120 Adult data also suggest that LMA insertion is a skill that is easier to master than tracheal intubation.9, 27, 103 In addition, their use in adults has been shown to be associated with aspiration infrequently and less often than in BVM ventilation.28, 137 Unfortunately, the LMA has not been studied in pediatric patients outside of the surgical suite. The international guidelines classified their use in pediatric resuscitation as class indeterminate (LOE 5, 7). Routine use of the LMA for pediatric patients requires the availability of a number of sizes of the device and is therefore relatively expensive in the prehospital setting. MANAGEMENT OF CIRCULATION CPR Methods Previous recommendations for performing CPR in infants offered a choice between the two-finger technique and the two-thumb/encircling hand technique. Recently, studies in infant mechanical and animal models suggested that the two-thumb/encircling hand technique provides better blood flow and is preferred by rescuers.67, 149 The 2000 recommendations advocate the use of the two-hand technique when there are two professional rescuers present. It is difficult to perform when there is only one rescuer and therefore is not recommended for the lone rescuer. In the interest of simplification, this technique is not to be taught to lay rescuers. This is a Class IIb recommendation. Studies in animal models and in some cases adult patients have suggested that there may be benefit to using alternative methods of CPR in patients with CPA. These techniques include active compression-decompression CPR (ACD CPR), interposed abdominal compression CPR (IAC-CPR) and open-chest cardiac compression for nontraumatic CPA. None of these techniques has been studied in clinical trials in pediatric patients. In adults, active compression-decompression CPR has been recommended as an optional technique for patients requiring CPR. This is a Class IIb recommendation (LOE 2,5,7). This technique has not been studied in children and thus is not recommended as alternative technique in pediatric resuscitation (Class indeterminate, LOE7). IAC-CPR has also been recommended as an optional technique for adults requiring CPR (Class IIb recommendation). It has been poorly studied in children and can be associated with increased risk.146 Limited data suggest that open-chest cardiac compression for nontraumatic arrest patients could have a benefit in such adult patients.140 This technique has not been evaluated in pediatric patients and is therefore a class indeterminate recommendation. Intraosseous Access Numerous animal studies and case series and nonrandomized trials in human patients have demonstrated that intraosseous (IO) access is a

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safe and effective route for delivering drugs and medications to pediatric patients requiring resuscitation. Previous AHA guidelines for use of IO access recommended waiting for three attempts at peripheral access or 90 seconds prior to attempting intraosseous access. These recommendations also limited the use of IO access to children 6 years of age or younger. In the 2000 guidelines, it is recommended that IO access be established if peripheral access cannot be achieved rapidly. Immediate IO access, without waiting for attempts at a peripheral access, is recommended in CPA victims in both the ED and prehospital setting. The use of IO access is also extended to include victims younger than 6 years old. The use of IO access in these settings is a Class IIa recommendation (LOE 3, 5). Automated External Defibrillator The automated external defibrillator (AED) has been introduced into prehospital care and into in public settings, where lay rescuers can provide the electrical therapy that has been shown to be lifesaving. In clinical trials in adults, the use of an AED has been shown to decrease the time to delivery of shock and increases survival rates.43, 138 The AED has not been well tested in the pediatric population, but there are limited data on its use in older children and adolescents.8 Despite the lack of evidence for its use in children, it remains an attractive potential intervention because of the same factors discussed previously (i.e., in the ‘‘phone first vs phone fast’’ debate). These include the effectiveness of appropriate defibrillation compared with other ALS interventions and the fact that VF or pulseless VT is the presenting rhythm in at least 10% of pediatric arrests and is probably present in a higher percentage of arrests in children younger than 1 year old.7, 92 AEDs have been shown to detect rhythms in children and adolescents accurately.8, 37, 64 These studies did not include a significant percentage of young infants. It has been suggested that the AED may be less accurate at higher heart rates and therefore in a young infant may misdiagnose sinus tachycardia as a rhythm that should be defibrillated.64 Therefore the committee recommended that AED use may be considered to detect ‘‘shockable’’ rhythms only in children greater than or equal to 8 years old. This is a Class IIb recommendation (LOE 3,5). In infants and children younger than 8 years old, it is a Class indeterminate recommendation. Currently, available AED devices are programmed to emit an electrical charge that does not require or allow for calculation or setting by the operator, of 150 to 200 joules. This is a standard initial adult dose. The average 8-year-old child weighs approximately 25 kg. If the equipment is used on them, they receive 6 to 8 joules/kg. This threshold has been evaluated in animal studies and is thought to be safe, but there is no published experience in humans. Based on their concerns for avoiding harm to children who might be misdiagnosed as having VT when they are actually in rapid sinus tachycardia, the committee could not

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recommend the use of AEDS to deliver shocks in children younger than 8 years old. Based on the lack of clinical experience with AEDs in children in general the committee classified the use of an AED to deliver shocks in children greater than or equal to 8 years of age (or 25 kg) as a class indeterminate (LOE 6) recommendation.

Vagal Maneuvers for Supraventricular Tachycardia Although long recommended by many experts, the use of vagal maneuvers for treatment of supraventricular tachycardia (SVT) were not included in previous guidelines. In the 2000 guidelines, they have been introduced. Their use in hemodynamically stable patients with SVT or while preparing for cardioversion or drug therapy in patients with SVT and poor perfusion, is suggested as a Class IIa (LOE 4, 5, 7, 8) recommendation. There is less agreement on the merits of individual methods of producing a vagal response. The induction of a diving reflex with icewater to the face is thought to be the most effective method in infants and young children.135 In older children and adolescents, other methods, such as the Vasalva maneuver or carotid sinus massage, can be effective.78, 147 These are suggested as Class IIb (LOE 5, 7) recommendations. The technique of having a child blow through a straw to produce a vagal response has been advocated as an effective way of producing a Vasalva response in a younger child.78 Application of external ocular pressure to produce a vagal response can cause retinal detachment and is not recommended. When any vagal maneuver is attempted, the patient’s rhythm should be monitored continuously.

MEDICATIONS High-dose Epinephrine Therapy In the late 1980s and early 1990s the results of animal studies and a small study in the pediatric population led to the belief that high-dose epinephrine therapy (0.1–0.2 mg/kg) can be beneficial to the pulseless pediatric patient.31, 56, 57 The 1992 AHA Guidelines, recommended for pediatric patients that high-dose epinephrine be given as the second dose of epinephrine if the patient remained pulseless after a standard dose (0.01 mg/kg). Unfortunately, clinical trials have failed to reproduce the results of these earlier studies. Several large multicenter adult studies failed to show any benefit of high-dose epinephrine in the adult CPA patient.30, 34, 79, 82 Two retrospective studies in pediatric patients also failed to show any benefit.35, 46 Initial results of a multicenter trial in pediatric patients also failed to demonstrate an improvement in long-term outcome.102 Subsequent animal studies have failed to show any benefit, and some even suggest harm as the result of using high-dose epinephrine.15, 16

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In the 2000 guidelines, the same (standard) dose is recommended for second and subsequent doses in pediatric CPA patients, but higher doses of epinephrine (0.1–0.2 mg/kg) may be considered. High-dose epinephrine use in this setting is categorized as a class IIb (LOE 6) recommendation. Vasopressin Vasopressin (argenine) is an endogenous hormone. Its primary role is to maintain a normal serum osmolality; this is achieved by binding to receptors in the kidney, increasing reabsorption of water at the tubules. Vasopressin also binds receptors in vasculature, causing contraction of smooth muscle. This has been noted in capillaries and small arterioles, with decreased flow to splanchnic, gastric, and muscle regions, with less constriction in renal, coronary, and possibly cerebral vasculature.38 Vasopressin has a plasma half-life of approximately 10 to 20 minutes. Hepatic and renal metabolism occur, with very small amounts being excreted intact, in urine.1 The vasoconstrictive effects of vasopressin are thought to benefit patients in arrest, increasing the vascular resistance and shunting blood to the cardiac and cerebral vascular beds. In an eight-patient case report in 1996, Linder et al noted the return of spontaneous circulation in all 8 after IV vasopressin (40 u). These patients were in VF and refractory to ACLS standard therapies. Three of these 8 patients survived to hospital discharge with minimal or no neurologic deficit.81 In subsequent human studies, there was a trend to increased ROSC and 24-hour survival.80 Based on these studies and supporting animal data, vasopressin is listed as an alternative to epinephrine for the treatment of adult shock refractory VF. This is a Class IIb recommendation. In 1999, Rosenzweig et al found potential benefit for vasopressin in pediatric patients with vasodilatory shock after cardiac surgery.119 Voelckel et al used a porcine model for pediatric arrest to compare the use of epinephrine, vasopressin, and the combination of the two drugs. Their findings showed ROSC to be more likely in the animals treated with epinephrine, alone or in combination, than those treated with vasopressin alone.145 There are no studies at this time on the use of vasopressin in pediatric cardiac arrest. Without adequate data to support its use in the pediatric population, vasopressin is not recommended (class indeterminate) for use in infants and children in cardiac arrest in the 2000 guidelines. Amiodarone The algorithm for pulseless arrest is modified in the 2000 guidelines to include the antiarrhythmic drug amiodarone for refractory VF/VT. Amiodarone is an antiarrhythmic agent with complex effects. Effects include changes at sodium, potassium, and calcium channels, as well as alpha- and beta-receptor blockades. It has primarily class III properties, with prolonged action potential and increased cardiac myocyte refrac-

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tory period, while also exhibiting properties from classes I, II, and IV.90, 130 The most notable side effect seen in the acute patient is a profound hypotension, with a 10% to 20% occurrence rate.104, 124 In the new guidelines, amiodarone is included in the VF/VT arm of the pulseless arrest algorithm. After initial defibrillation, epinephrine should be given, and defibrillation should be repeated. If the patient remains in VF/VT, amiodarone, or lidocaine (or magnesium for torsades de pointes VT), can be given as an antiarrhythmic prior to the third attempt at defibrillation. The dose of amiodarone in this situation is 5 mg/kg rapidly delivered by IV or IO route. The use of amiodarone in this clinical situation has been listed as class indeterminate (LOE 7) recommendation. As the level of evidence rating of 7 indicates, the data to support this recommendation is based on extrapolation from data collected in other clinical uses. There is one randomized controlled trial of amiodarone in refractory VF/VT in adult patients.73 This study demonstrated an improved rate of early survival in patients who received amiodarone versus those who received lidocaine. It did not demonstrate an improvement in survivalto-discharge rates. In fact, no pharmacologic intervention has been shown to increase survival to discharge rates in adult or pediatric CPA patients. Based primarily on this study, amiodarone has been placed in the adult pulseless arrest algorithm as a class IIb recommendation. Amiodarone has also been studied in pediatric intensive care patients with refractory arrhythmias primarily after cardiac surgery.52, 104, 105, 107, 112, 133 There is, however, no reported information on the use of amiodarone in pediatric patients with out-of-hospital pulseless arrest. It is considered a class indeterminate recommendation in pediatric patients with refractory VF or VT. The pediatric tachycardia algorithm has also been modified to include the drug amiodarone. If the QRS is greater than 0.08 sec and the patient is unstable (i.e., poor perfusion), then cardioversion is indicated. If the patient is alert with palpable distal pulses, however, it is recommended that a cardiologist be consulted and medications (e.g., amiodarone, procainamide, or lidocaine) be considered as an alternative to cardioversion. The dose of amiodarone in this circumstance is 5 mg/kg IV over 20 to 60 minutes. The dose can be repeated, in doses of 5 mg/ kg, up to a total maximum of 15 mg/kg. In this context, the use of amiodarone is considered a class IIb recommendation (LOE 7). The evidence to support its use is extrapolated from the data on pediatric intensive care patients with arrhythmias after cardiac surgery discussed previously.52, 104, 105, 107, 112, 133 Procainamide is also listed as a class IIb recommendation (LOE 5, 6, 7) in this circumstance. Because both drugs can prolong the QT interval, they should not be used together. POSTARREST STABILIZATION The 1997 edition of the PALS textbook states that hyperventilation is necessary during initial stabilization of the pediatric trauma patient to

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eliminate excess CO2 and maintain moderate hypocarbia (PaCO222–29 mmHg).95 This recommendation was questioned because of more recent knowledge about the pathophysiology of the postarrest or injured brain. In animal studies, it appears that hyperventilation can lead to increased cerebral vasoconstriction, ischemia and worsening injury.93, 121, 123 There is now evidence in both adults and children that routine hyperventilation of head-injured or postarrest patients results in additional brain ischemia.33, 115, 121, 132 One study of head-injured children with a Glasgow Coma Scale score of 6 or less demonstrated worse outcomes in patients who received routine hyperventilation.94 Based on the available data, routine hyperventilation is considered a Class III (LOE 3, 5, 6) recommendation. The committee thought that the goal of ventilation in postarrest or head-injured patients should be physiologic oxygenation and ventilation. This is a class IIa (LOE 5,6) recommendation. Although routine hyperventilation is not recommended, the international panel agreed that in the setting of posthermiation syndrome, hyperventilation is a therapeutic option. This is also a Class IIa recommendation. There is some evidence to suggest that postarrest or postischemic hypothermia can improve neurologic outcome.18, 88 The international committee thought that there were not enough data to support a recommendation of routine hypothermia (class indeterminate recommendation). It is suggested, however, that active rewarming not be undertaken in patients with core temperatures greater than 33C and if the core temperature falls below 33 then rewarming should be undertaken only until a temperature of 34C is achieved (Class IIb recommendation). It has also been shown that in the brain-injured patient, hyperthermia is associated with a worse neurologic outcome. It is therefore recommended that in the brain-injured or postarrest patient hyperthermia should be corrected with active cooling to achieve a normal core temperature (Class IIa, LOE 5, 6, 7).

COPING WITH DEATH Ceasing Resuscitative Efforts In a survey by Roberts et al physicians and nurses were asked how long they thought resuscitative efforts should be continued in pediatric and adult victims. Both the physicians and nurses thought that the code should be continued longer in the child victim than in the adult.114 Other surveys have confirmed that ED physicians often prolong a code in a child much longer than they would in an adult and often beyond all hope.2, 69, 128 Because adult cases of CPA occur much more frequently than pediatric cases and because there is the more widespread use of the standardized Utstein criteria in adult resuscitation studies, consensus recommendations have been developed and published regarding the length of time that adult resuscitations should be carried out before

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efforts are ceased.25, 71 Similar statements have not been published for pediatric patients. However, there are data that suggest a similar or even shorter time limit on resuscitative efforts can be appropriate for children in CPA. There are also data that suggest that the number of epinephrine doses received by a patient in CPA is predictive of survival. In the prospective study by Sirbaugh et al, of 300 pediatric patients in CPA, no survivor received any epinephrine. Schindler et al. looked at the outcome of 101 children who suffered CPA or respiratory arrest. No survivors required resuscitative efforts for more than 20 minutes or two doses of epinephrine.125 Gillis et al found no survivors if resuscitative efforts lasted greater than 15 minutes, or required any epinephrine.20 Nichols et al found no survivors of CPR lasted longer than 15 minutes or longer than 2 doses of epinephrine were required.96 Zaritsky et al found no survivors if efforts lasted longer than 10 minutes or more than two doses of epinephrine were required. In a study by Hickey et al, no patient who received more than one dose of epinephrine survived.66 Innes et al found that there were no survivors after 30 minutes of resuscitative efforts.68 Quan et al found similar results in submersion victims.110, 111 Unfortunately, because these studies are afflicted with many of the of the problems associated with doing research on survival from pediatric CPA discussed previously, such as small sample size, heterogenous populations and retrospective design, the international committee was reluctant to make firm guidelines. The 2000 guidelines state that ‘‘if a child fails to respond to two doses of epinephrine with a ROSC the child is unlikely to survive’’.61 The guidelines also suggest that resuscitative efforts may be ceased in pediatric CPA victims after 30 minutes if there are no exceptional circumstances, such as primary hypothermic insult, toxic drug exposure, or recurrent or refractory VF/VT. Caring for the Family of a Deceased Child Unfortunately, as discussed before, the result of almost all pediatric resuscitations for CPA is death. Fear of breaking the news of the child’s death to the family is postulated as a common reason for prolonging resuscitation efforts in hopeless situations. In a survey by Ahrens et al, of 122 ED physicians, 40% admitted to prolonging a resuscitation beyond all hope. The reasons given for why they prolonged the resuscitation included guilt in 64% and reluctance to talk to the family in 40%.2 Other surveys have confirmed that this is a difficult and stressful task for physicians,87, 139 and unfortunately, physicians receive little training on this topic.2, 139 Several authors have described methods for teaching this skill to students and residents.3, 59, 126 One author published a proposed addition to the current AHA PALS course on handling the death of a patient.151 The newest version of the PALS course has such a module. Information on how to handle breaking the news of a child’s death to the family comes from two sources: expert opinion and surveys of families. Three surveys of families’ opinions about the experience of

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receiving the news of the death of a loved on in the ED have been published. Ahrens et al described responses from 37 of 60 families that were mailed questionnaires an average of 6.4 years after the death of their children in the ED.62 The average age of the deceased was 3.5 years, and 34 of 37 had died of SIDS. They were asked several questions about the actual experience and what they felt should have been different. The parents in this survey felt that the attending physician should deliver the news. Eighty-eight percent found viewing the child’s body to be helpful. Ninety-three percent wanted a memento of the child, including a print of the child’s hand, lock of hair, or a photo. Returning the child’s clothes was also thought to be important. Most parents stated they were not offended and were not or would not be offended by being asked for an autopsy or organ donation. Sixty-five percent thought also that follow-up ‘‘would have been helpful’’ but only 16% received follow-up. Parish et al conducted telephone interviews of 66 families of 166 patients who had died in the ED in the last 6 years.101 The deceased included both children and adults. The family members were asked about attitudes of the ED staff and any complaints about their experience. One quarter felt the staff was cold, unsympathetic and not reassuring. The top three complaints were (1) they were not kept informed or waited too long for information; (2) they had no method for having questions answered, and (3) they did not talk to the physician. A survey by Jurkovich et al of 54 family members (including 17 parents) of trauma victims dying in ED or SICU ranked the importance of items associated with giving bad news.70 The items that over 50% of the respondents ranked ‘‘highly important’’ were the attitude of the deliverer of the news, clarity, privacy, and ability of the deliverer to answer questions. Expert opinion on breaking the news of the death of a loved one has been summarized in several journal articles.48, 55, 91, 98, 104 Recommendations include breaking the news in a private room (if the family were not present for the resuscitation), briefly preparing oneself prior to entering the room (know the child’s name and what happened), and do not keep the family waiting. Once one enters the room, identify oneself, address both parents, use the patient’s name, and give a brief chronology of what has happened. Let them know everything was done, and if possible that the child felt no pain. Many experts advise issuing a ‘‘warning shot,’’ such as ‘‘I’m afraid I have bad news,’’ prior to stating that the child has died. It is important to use the word dead and not a euphemism. Reassure the family that it is not their fault and that they acted correctly. One must remember that although occult child abuse does exist, more than 95% of children who appear to have died of SIDS are later confirmed actually to have been cases of SIDS.39, 40 After telling the parents that their child has died, one should allow for an initial grief response. Things not to do include standing when delivering the news, refer to ‘‘the baby’’ or ‘‘it,’’ using euphemisms or jargon, implying blame, sealing off the grief response, or forgeting other family members. Parents remember how the news was delivered better than any details of the treatment. They want to know that their child was cared for by someone both competent and

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tender. After one has broken the news of the child’s death, giving the family the opportunity to view the child’s body (if they were not present for the resuscitation) is suggested by all experts. Follow-up contact should include giving the family the name and number of a staff member to contact with questions, contacting the patient’s primary care doctor and providing information on support groups. A follow-up phone call or letter from an ED staff member also can be helpful. The formation of a team in the ED to assist in handling these difficult events has been advocated by experts and found to be helpful to families.41, 113 Stress debriefing for staff is also important and desired by but not available to most physicians surveyed.3, 58 References 1. AHFS drug information (2000). 68:28, 2000 2. Ahrens WR, Hart RG: Emergency physicians’ experience with pediatric death. Am J Emerg Med 15:642–643, 1997 3. Ahrens W, Hart R, Maryuma N: Pediatric death: Managing the aftermath in the emergency department. J Emerg Med 15:600–603, 1997 4. American Heart Association: Guidelines for cardiopulmonary resuscitation Emergency Cardiac Care VI: Pediatric advanced life support. JAMA 268:2262–2275, 1992 5. Anderson KH, Schultz-Leban T: Oesophageal intubation can be undetected by auscultation of the chest. Acta Anaesthesiol Scand 38:580–582, 1994 6. Applebaum D: Advanced prehospital care for pediatric emergencies. Ann Emerg Med 14:656–659, 1985 7. Appleton GO, Cummins RO, Larson MP, et al: CPR and the single rescuer: At what age should you ‘‘call first’’ rather than ‘‘call fast.’’ Ann Emerg Med 25:492–494, 1995 8. Atkins DL, Hartley LL, York DK: Accurate recognition and effective treatment of ventricular fibrillation by automated external defibrillators in adolescents. Pediatrics 101:393–397, 1998 9. Basket PJF: The use of the laryngeal mask airway by nurses during cardiopulmonary resuscitation: results of a multicenter trial. Anaesthesia 49:3–7, 1994 10. Bauchner H, Vinci R, Bak S, Pearson C, et al: Parents and procedures: A randomized controlled trial. Pediatrics 98:861–867, 1996 11. Bauchner H, Vinci R, Waring C: Pediatric procedures: Do parents want to watch? 84:907–909, 1989 12. Bauchner H, Waring C, Vinci R: Parental presence during procedures in an emergency room: Results from 50 observations. Pediatrics 87:544–548, 1991 13. Berg RA, Kern KB, Hilwig RW, et al: Assisted ventilation does not improve outcome in a porcine model of single-rescuer bystander cardiopulmonary resuscitation. Circulation 95:1635–1641, 1997 14. Berg RA, Kern KB, Hilwig RW, et al: Bystander chest compression and assisted ventilation independently improve outcome from piglet asphyxiation pulseless cardiac arrest. Circulation 101:1743–1748, 2000 15. Berg RA, Otto CW, Kern KB, et al: High-dose epinephrine results in greater early mortality after resuscitation from prolonged cardiac arrest in pigs: A prospective randomized study. Crit Care Med 22:282–290, 1994 16. Berg RA, Otto CW, Kern KB, et al: A randomized blinded trial of high-dose epinephrine versus standard-dose epinephrine in a swine model of pediatric asphyxial arrest. Crit Care Med 42:1695–1670, 1996 17. Berg RA, Kern KB, Hilwig RW, et al: Simulated mouth-to-mouth ventilation and chest compressions (bystander cardiopulmonary resuscitation) improves outcome in a swine model of prehospital pediatric asphyxial cardiac arrest. Crit Care Med 27:1893–1899, 1999

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18. Bernard SA, Jones BM, Horne MK: Clinical trial of induced hypothermia in comatose survivors of out-of-hospital arrest. Ann Emerg Med 30:146–153, 1997 19. Beyer AJ III, Land G, Zaritsky A: Nonphysician transport of intubated pediatric patients: A system evaluation. Crit Care Med 20:961–966, 1992 20. Bhende MS, Thompson AE: Evaluation of an end-tidal CO2 detector during pediatric cardiopulmonary resuscitation. Pediatrics 95:395–399, 1995 21. Bhende MS, Thompson AE, Cook DR, et al: Validity of a disposable end-tidal CO2 detector in verifying endotracheal tube placement in infants and children. Ann Emerg Med 21:142–145, 1992 22. Bhende MS, Thompson AE, Orr RA: Utility of an end-tidal carbon dioxide detector during stabilization and transport of critically ill children. Pediatrics 89:1042–1044, 1992 23. Boessert L, Van Hoeyweghan RJ: Bystander CPR in out-of-hospital cardiac arrest. Resuscitation 7(suppl):55–69, 1989 24. Boie ET, Moore GP, Brummett C, et al: Do parents want to be present during invasive procedures performed on their children in the emergency department? A survey of 400 parents. Ann Emerg Med 34:70–74, 1999 25. Bonin MJ, Pepe PE, Kimball KT, et al: Distinct criteria for termination of resuscitation in the out-of-hospital setting. JAMA 270:1457–1462, 1993 26. Bozeman WP, Hexter D, Liang HK, et al: Esophageal detector device versus detection of end tidal carbon dioxide level in emergency intubation. Ann Emerg Med 27:595– 599, 1996 27. Brimacombe J: The advantages of the LMA over the tracheal tube or facemask: A meta-analysis. Can J Anaesth 42:1017–1023, 1995 28. Brimacombe JR, Berry A: The incidence of aspiration associated with the laryngeal mask airway: A meta-analysis of published literature. J Clin Anesth 7:297–305, 1995 29. Browenstein DR, Quan L, Orr R, et al: Paramedic intubation training in a pediatric operating room. Am J Emerg Med 10:418–420, 1992 30. Brown CG, Martin DR, Pepe PE, et al: A comparison of standard dose and high-dose epinephrine in cardiac arrest outside the hospital. N Engl J Med 327:1051–1055, 1992 31. Brown C, Werman H: Adrenergic agonists during cardiopulmonary resuscitation. Resuscitation 19:1–16, 1990 32. Bush CM, Jones JS, Cohle SD, et al: Pediatric injuries from cardiopulmonary resuscitation. Ann Emerg Med 28:40–44, 1996 33. Buunk G, van der Hoeven JG, Meinders AE: Cerebrovascular reactivity in comatose patients resuscitated from cardiac arrest. Stroke 28:1569–1573, 1997 34. Callaham M, Madsen CD, Barton CW, et al: A randomized trial of high-dose epinephrine and norepinephrine versus standard dose epinephrine in prehospital cardiac arrest. JAMA 268:2667–2762, 1992 35. Carpenter TC, Stenmark KR: High-dose epinephrine is not superior to standard-dose epinephrine in in-hospital cardiopulmonary arrest. Pediatrics 99:403–408, 1997 36. Cavallaro DL, Melker RI: Comparison of two techniques for detecting cardiac activity in infants. Crit Care Med 11:189–190, 1983 37. Cecchin F, Perry JC, Berul CI et al: Accuracy of automatic external defibrillator analysis algorithm in young children. Circulation 100(suppl):1–63 (abstract), 1999 38. Chugh SS, Lurie KG, Linder KH: Pressor with promise: Using vasopressin in cardiopulmonary arrest. Circulation 96:2453–2454, 1997 39. Committee on child abuse and neglect: Distinguishing sudden infant death syndrome from child abuse fatalities. Pediatrics 94:124–126, 1994 40. Committee on child abuse and neglect: Investigation and review of unexpected infant and child deaths. Pediatrics 104:1158–1160, 1999 41. Committee Pediatric Emergency Medicine: Death of a child in the emergency department. Pediatrics 93:861, 1994 42. Cummins RO, Chamberlin DA, Abramson NS, et al: Recommended guidelines for uniform reporting of data from out of hospital cardiac arrest: The Utstein Style. Ann Emerg Med 20:861–874, 1991 43. Cummins RO, Eisenberg MS, Litwin PE, et al: Automatic external defibrillators used

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44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68.

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by emergency medical technicians: A controlled clinical trial. JAMA 257:1605–1610, 1987 Cummins RO, Hazinski MF: Cardiopulmonary resuscitation techniques and instruction: When does evidence justify revision? Ann Emerg Med 34:780–784, 1999 Dembofsky CA, Gibson E, Nadkarni V, et al: Assessment of infant cardiopulmonary resuscitation rescue breathing technique: Relationship of infant and caregiver facial measurements. Pediatrics 103:17, 1999 Diekman RA, Vardis R: High-dose epinephrine in the pediatric out-of-hospital cardiopulmonary arrest. Pediatrics 95:901–913, 1995 Doyle CJ, Post H, Burney RE, et al: Family member participation during resuscitation: An option. Ann Emerg Med 16:673–675, 1987 Dubin WR, Sarnoff JR: Sudden unexpected death: Intervention with the survivors. Ann Emerg Med 15:54–57, 1986 Eberle B, Dick WF, Schneider T, et al: Checking the carotid pulse check: Diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation 33:107–116, 1996 Eisenberg MS, Bergner L, Hallstrom A: Epidemiology of cardiac arrest and resuscitation in children. Ann Emerg Med 12:672–667, 1983 Emergency Nurses Association position statements: Family presence at the bedside during invasive procedures and/or resuscitation. J Emerg Nurs 21:26A, 1995 Figa FH, Gow RM, Hamilton RM, et al: Clinical efficacy and safety of intravenous amiodarone in infants and children. Am J Cardiol 74:573–577, 1994 Gausche M, Lewis RJ, Stratton SJ, et al: A prospective randomized study of the effect of out-of-hospital pediatric endotracheal intubation on survival and neurologic outcome. JAMA 283:783–790, 2000 Gillis J, Dickson D, Rieder M, et al: Results of inpatient pediatric resuscitation. Crit Care Med 14:69–471, 1986 Girgis A, Sanson-Fisher RW: Breaking bad news: Consensus guidelines for medical practitioners. J Clin Oncol 13:2449–2456, 1995 Goetting MG, Paradis NA: High-dose epinephrine improves outcome from pediatric cardiac arrest. Ann Emerg Med 20:22–26, 1991 Gonzalez E, Ornato J, Garnett A, et al: Dosage-dependent vasopressor responses to epinephrine during CPR in human beings. Ann Emerg Med 18:920–926, 1989 Greenberg LW, Ochsenschlager D, Cohen GJ, et al: Counseling parents of a child dead on arrival: A survey of emergency departments. Am J Emerg Med 11:225–229, 1993 Greenberg LW, Ochsenschlager D, O’Donnell R, et al: Communicating bad news: A pediatric department’s evaluation of a simulated intervention. Pediatrics 103:1210– 1217, 1999 Guidelines for Advanced Life Support: A statement by the advanced life support working party of the European resuscitation council 1992. Resuscitation 24:111–112, 1992 Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Circulation 102, 2000 Hart RG, Ahrens WR: Coping with pediatric death in the ED by learning from parental experience. Am J Emerg Med 16:I-1–I-384, 1998 Haynes SR, Morton NS: Use of the oesophageal detector device in children under one year of age. Anaesthesia 45:1067–1069, 1990 Hazinski MF, Walker C, Smith H, et al: Specificity of automatic external defibrillator rhythm analysis in pediatric tachyarrhythmias. Circulation 96(suppl):1–561, 1997 Hew P, Brenner B, Kaufman J: Reluctance of paramedics and emergency medical technicians to perform mouth-to-mouth resuscitation. J Emerg Med 15:279–284, 1997 Hickey RW, Cohen DM, Strausbaugh S, et al: Pediatric patients requiring CPR in the prehospital setting. Ann Emerg Med 25:495–501, 1995 Houri PK, Frank LR, Menegazzi JJ, et al: A randomized controlled trial of two-thumb vs two-finger chest compression in a swine infant model of cardiac arrest. Prehosp Emerg Care 1:65–67, 1997 Innes PA, Summers CA, Boyd IM, et al: Audit of paediatric cardiopulmonary resuscitation. Arch Dis Child 68:487–491, 1993

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69. Iserson KV, Stocking C: Standards and limits: Emergency physicians attitude toward prehospital resuscitation. Am J Emerg Med 11:592–594, 1993 70. Jurkovich GJ, Pierce B, Pananen L, et al: Giving bad news: The family perspective. J Trauma 48:865–873, 2000 71. Kellerman AL, Hackman BB, Somes G: Predicting the outcome of unsuccessful prehospital advanced cardiac life support. JAMA 270:1433–1436, 1993 72. Kramer K, Goldstein B: Retinal hemorrhages following cardiopulmonary resuscitation. Clin Pediatr 32:366–368, 1993 73. Kudenchuk PJ, Cobb LA, Copass MK, et al: Amiodarone for resuscitation after out-ofhospital cardiac arrest due to ventricular fibrillation. N Engl J Med 341:871–878, 1999 74. Kuisma M, Suominen P, Korpela R: Pediatric out-of-hospital cardiac arrests— epidemiology and outcome. Resuscitation 30:141–150, 1995 75. Kyriacou DN, Arcinue EL, Peek C, et al: Effect of immediate resuscitation on children with submersion injury. Pediatrics 94:137–142, 1994 76. Langhelle A, Sunde K, Wik L, et al: Airway pressure with chest compressions versus Heimlich manoevre in recently dead adults with complete airway obstruction. Resuscitation 44:105–108, 2000 77. Lewis JK, Mintr MG, Eshelman SJ, et al: Outcome of pediatric resuscitation. Ann Emerg Med 12297–299, 1983 78. Lim SH, Anantharaman V, Teo WS, et al: Comparison of treatment of supraventricular tachycardia by Vasalva maneuver and carotid sinus massage. Ann Emerg Med 31:30– 35, 1998 79. Lindner KH, Ahnefeld FW, Prengel AW: Comparison of standard and high dose adrenaline in the resuscitation of asystole and electromechanical dissociation. Acta Anaesthesiol Scand 35:253–256, 1991 80. Linder KH, Dirks B, Strohmenger HU, et al: A randomized comparison of epinephrine and vasopressin in patients with out-of-hospital ventricular fibrillation. Lancet 349:535–537, 1997 81. Linder KH, Prengal AW, Keller A, et al: Vasopressin administration in refractory cardiac arrest. Ann Intern Med 124:1061–1064, 1996 82. Lipman J, Wilson W, Kobiliski S, et al: High-dose adrenaline in adult in-hospital asystolic cardiopulmonary resuscitation: A double-blind randomized trial. Anaesth Intensive Care 21:192–196, 1993 83. Locke CJ, Berg RA, Sanders AB, et al: Bystander cardiopulmonary resuscitation: Concerns about mouth-to-mouth contact. Arch Intern Med 155:938–943, 1995 84. Lopez-Gil M, Brimacombe J, Alvarez M: Safety and efficacy of the laryngeal mask airway: A prospective survey of 1400 children. Anaesthesia 51:969–972, 1996 85. Lopez-Gil M, Brimacombe J, Cebrian J, et al: Laryngeal mask airway in pediatric practice: aprospective study of skill acquisition by anesthesia residents. Anesthesiology 84:807–811, 1996 86. Losek JD, Del Szewczuga, Glaaeser PW: Improved prehospital pediatric ALS care after an EMT-Paramedic clinical training course. Am J Emerg Med 12:429–432, 1994 87. Makoul G: Medical student and resident perspectives on delivering bad news. Acad Med 73(suppl):35–37, 1998 88. Marion DW, Leonov Y, Ginsberg M, et al: Resuscitative hypothermia. Crit Care Med 24(suppl):81–89, 1996 89. Martin SE, Ochsner MG, Jarman RH, et al: Use of the laryngeal mask airway in air transport when intubation fails. J Trauma 47:352–357, 1999 90. Mason JW: Amiodarone: N Engl J Med 316:455–466, 1987 91. McLaughlin CAJ: Handling distressed relatives and breaking bad news. Br Med J 301:1145–1149, 1990 92. Mogayzel C, Quan L, Graves JR, et al: Out-of-hospital ventricular fibrillation in children and adolescents: Causes and outcomes. Ann Emerg Med 149:210–214, 1995 93. Muizelaar JP, van der Poel HG, Li ZC, et al: Pial arteriolar vessel diameter and CO2 reactivity during prolonged hyperventilation in the rabbit. J Neurosur 69:923–927, 1988 94. Muizelaar JP, Marmarou A, Ward J, et al: Adverse effects of prolonged hyperventila-

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95. 96. 97. 98. 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110. 111. 112. 113. 114. 115. 116. 117. 118. 119.

BROWN & BOCOCK

tion in patients with severe head injury: A randomized clinical trial. J Neurosurg 75:731–739, 1991 Nadkarni V (ed): Pediatric Advanced Life Support. Dallas, TX, American Heart Association, 8–4, 1997 Nichols DG, Ketterick RG, Swedlow DB, et al: Factors influencing outcome of cardiopulmonary resuscitation in children. Pediatr Emerg Care 2:1–5, 1986 Noc M, Weil MH, Tang W, et al: Mechanical ventilation may not be essential for initial cardiopulmonary resuscitation. Chest 108:821–827, 1995 Olsen JC, Buenefe ML, Falco WD: Death in the emergency department. Ann Emerg Med 31:758–765, 1998 Ornato JP, Shipley JB, Racht EM, et al: Multicenter study of a portable hand-size, colorimetric end-tidal carbon dioxide detection device. Ann Emerg Med 21:518–523, 1992 O Rourke PP: Outcome of children who are apneic and pulseless in the emergency room. Crit Care Med 14:466–468, 1986 Parish GA, Holdren KS, Skiendzielewski JJ, et al: Emergency department experience with sudden death: A survey of survivors. Ann Emerg Med 16:792–796, 1987 Patterson M, Boenning D, Klein B: High dose epinephrine in pediatric cardiopulmonary arrest [abstr]. Pediatr Emerg Care 10:310, 1994 Pennant JH, Walker MB: Comparison of the endotracheal tube and the laryngeal mask in airway management by paramedical personnel. Anesth Analg 74:531–534, 1992 Perry JC, Fenrich AL, Hulse JE, et al: Pediatric use of intravenous amiodarone: efficacy and safety in critically ill patients from a multicenter protocol. J Am Coll Cardiol 27:1246–1250, 1996 Perry JC, Knilans TK, Marlow D, et al: Intravenous amiodarone for life threatening tachyarrhythmias in children and young adults. J Am Coll Cardiol 22:95–98, 1993 Poirere MP, Gonzalez Del-Rey JA, McAneney CM, et al: Utility of monitoring capnography, pulse oximetry and vital signs in the detection of airway mishaps: A hyperoxemic animal model. Am J Emerg Med 16:350–352, 1998 Pongiglione G, Strasburger JF, Deal BJ, et al: Use of amiodarone for short-term and adjuvant therapy in young patients. Am J Cardiol 68:603–608, 1991 Powers KS, Rubinstein JS: Family presence during invasive procedures in the pediatric intensive care unit. Arch Pediatr Adolesc Med 153:955–958, 1999 Ptacek JT, Eberhardt TL: Breaking bad news: A review of the literature. JAMA 276:496–502, 1996 Quan L, Kinder D: Pediatric submersion victims: Prehospital predictors of outcome. Pediatrics 90:909–913, 1992 Quan L, Wentz KR, Gore EJ, et al: Outcome and predictors of outcome in pediatric submersion victims receiving prehospital care in King County, Washington. Pediatrics 86:586–593, 1990 Raja P, Hawker RE, Chaikitpinyo A, et al: Amiodarone management of junctional ectopic tachycardia after cardiac surgery in children. Br Heart J 72:261–265, 1994 Reilly ME, Cohen GJ: Follow-up study on the effectiveness of an emergency room DOA protocol. Clin Proc 83:92–99, 1983 Roberts D, Hirscmann D, Scheltema K: Adult and pediatric CPR: Attitudes and expectations of health professionals and laypersons. Am J Emerg Med 18:465–468, 2000 Robertson CS, Valadka AB, Hannay HJ, et al: Porevention of secondary ischemic insults after severe head injury. Crit Care Med 27:2086–2095, 1999 Robinson SM, Mackenzie-Ross S, Campbell Hewson GI, et al: Psychological effects of witnessed resuscitation on bereaved relatives. Lancet 352:614–617, 1998 Ronco R, King W, Donley D, et al: Outcome and cost at a children’s hospital following resuscitation for out-of-hospital cardiopulmonary arrest. Arch Pediatr Adolesc Med 149:210–214, 1995 Rosen P, Stoto M, Harley J: The use of the Heimlich maneuver in near drowning: Institute of Medicine report. J Emerg Med 13:397–405, 1995 Rosenzweig EB, Starc TJ, Chen JM, et al: Intravenous argenine, vasopressin in children with vasodilatory shock after cardiac surgery. Circulation 100:182–186, 1999

UPDATE IN PEDIATRIC RESUSCITATION

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120. Rumball CJ, Macdonald D: The PTL, combitube, laryngeal mask, and oral airway: A randomized prehospital comparative study of ventilatory device effectiveness and cost-effectiveness in 470 cases of cardiorespiratory arrest. Prehosp Emerg Care 1:1– 10, 1997 121. Ruta TS, Drummond JC, Cole DJ: The effect of acute hypocapnia on local cerebral blood flow during middle cerebral artery occlusion in isoflourane-anesthetized rats. Anesthesiology 78:134–140, 1993 122. Sachetti A, Lichenstein R, Carraccio CA, et al: Family member presence during pediatric emergency department procedures. Pediatr Emerg Care 12:268–271, 1996 123. Safar P, Xiao F, Radovsky A, et al: Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion. Stroke 27:105–113, 1996 124. Scheinman MM, Levine JH, Cannon DS, et al: Dose ranging study of intravenous amiodarone in patients with life threatening ventricular tachyarrhythmias. Circulation 92:3264–3272, 1995 125. Schindler MB, Bohn D, Cox PN, et al: Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 335:1473–1479, 1996 126. Schmidt TA, Tolle SW: Sudden death in the ED: Educating residents to compassionately inform families. J Emerg Med 10:643–647, 1992 127. Schneider GH, Sarrafzadeh AS, Kiening KL, et al: Influence of hyperventilation on brain tissue PO2, PCO2 and pH in patients with intracranial hypertension. Acta Neurochir Suppl 71:62–65, 1998 128. Scribano PV, Baker D, Ludwig S: Factors influencing termination of resuscitative efforts in children: A comparison of pediatric emergency physicians and adult emergency physicians. Pediatr Emerg Care 320–324, 1997 129. Sheikh A, Brogan T: Outcome and cost of open and closed chest cardiopulmonary resuscitation in pediatric cardiac arrests. Pediatrics 93:392–398, 1994 130. Singh BN: Amiodarone: Historical development and pharmacologic profile. Am Heart J 106:788–797, 1983 131. 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 33:174, 1999 132. Skippen P, Seear M, Poskitt K, et al: Effect of hyperventilation on regional cerebral blood flow in head-injured children. Crit Care Med 25:1402–1409, 1997 133. Soult JA, Munoz M, Lopez JD, et al: Efficacy and safety of intravenous amiodaronefor short-term treatment of paroxysmal supraventricular tachycardia in children. Pediatr Cardiol 16:16–19, 1995 134. Spevak MR, Kleinman PK, Belanger PL, et al: Cardiopulmonary resuscitation and rib fractures in infants: A postmortem radiologic-pathologic study. JAMA 272:617–618, 1994 135. Sreeram N, Wren C: Supraventricular tachycardia in infants: Response to initial treatment. Arch Dis Child 65:127–129, 1990 136. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 255:2905–2984, 1986 137. Stone BJ, Chantler PJ, Baskett PJ: The incidence of regurgitation during cardiopulmonary resuscitation: A comparison between the bag valve mask and the laryngeal mask airway. Resuscitation 38:3–6, 1998 138. Stults KR, Brown DD, Kerber RE: Use of the automated external defibrillator in the management of out-of-hospital cardiac arrest. N Engl J Med 319:661–666, 1988 139. Swisher LA, Nieman LZ, Nilsen G, et al: Death notification in the emergency department: A survey of residents and attending physicians. Ann Emerg Med 22:1319– 1323, 1993 140. Takino M, Okada Y: The optimum timing of resuscitative thoracotomy for nontraumatic out-of-hospital cardiac arrest. Resuscitation 26:69–74, 1993 141. Thompson JE, Bonner B, Lower GM: Pediatric cardiopulmonary arrests in rural populations. Pediatrics 86:302–306, 1990 142. Tonkin SL, Davis SL, Gunn TR: Nasal route for infant resuscitation by mothers. Lancet 345:1353–1354, 1995

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BROWN & BOCOCK

143. Torphy DE, Mintner MG, Thompson BM: Cardiopulmonary arrest and resuscitation of children. Am J Dis Child 138:1099–1102, 1984 144. Van Hoeyweghan RJ, Boessert LL, Mullie A, et al: Quality and efficacy of bystander CPR. Resuscitation 26:47–52, 1993 145. Voelckel WG, Lurie KG, Zielenski T, et al: Comparison of epinephrine and vasopressin in a pediatric porcine model of asphyxial cardiac arrest [abstr]. Crit Care Med 28:3777–3783, 2000 146. Waldman PJ, Walters BL, Grunau CFV: Pancreatic injury associated with interposed abdominal compressions in pediatric cardiopulmonary resuscitation. Am J Emerg Med 2:510–512, 1984 147. Waxman WB, Wald RW, Sharma AD, et al: Vagal techniques for termination of paroxysmal supraventricular tachycardia. Am J Cardiol 46:655–654, 1980 148. Wee MY, Walker AK: The oesophageal detector device: An assessment with uncuffed tubes in children. Anaesthesia 46:869–871, 1991 149. Whitelaw CC, Slywka B, Goldsmith LJ: Comparison of a two-finger vs two-thumb method for chest compressions by healthcare providers in an infant mechanical model. Resuscitation 43:213–216, 2000 150. Wolfram WR, Turner ED, Philput C: Effects of parental presence during young childreni´s venipuncture. Pediatr Emerg Care 13:325–328, 1997 151. Wolfram RW, Timmel DJ, Doyle CR, et al: Incorporation of a coping with the death of a childiˆ module into the PALS curriculum. Acad Emerg Med 5:242–246, 1998 152. Young KD, Siedel JS: Pediatric cardiopulmonary resuscitation: A collective review. Ann Emerg Med 1999;33:195–205. 153. Zaritsky A, Nadkarni V, Getson P, et al: CPR in children. Ann Emerg Med 16:1107– 1111, 1987 154. 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 26:487–503, 1995 Address reprint requests to Kathleen Brown, MD Department of Emergency Medicine State University of New York Upstate Medical University 750 East Adams Street Syracuse, NY 13210 e-mail: [email protected]