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Introduction: The American Heart Association (AHA) CPR guidelines states that effective chest compression depth, rate and recoil are essential factors for establishment of return of spontaneous circulation. A recent survey from an international pediatric resuscitation collaborative showed that healthcare providers failed to meet the metrics of the AHA guidelines, with the greatest difficulty in achieving targeted chest compression depth in infants. The recommended techniques for infant compression include two finger (TFT) or two-thumb technique (TTT). We hypothesized using the heel of one palm (open palm technique, OPT) in infants will result in improved chest compression depth with decreased provider fatigue. Methods: Each participant performed three techniques including TFT, TTT, and novel open-palm technique (OPT) with randomization for sequence of techniques for each participant. Each technique was performed for 2 minutes followed by a 5-minute rest period on an infant manikin. Data were collected through Zoll R series defibrillators on chest compression depth, rate, and fraction. At the end of the study, each participant filled out a survey for difficulty level, finger fatigue, and rescuer fatigue. Results: Thirty pediatric critical care providers participated in the study consisting of 16 nurses, 9 respiratory therapists, 3 fellows, 2 nurse practitioners. The mean chest compression depth for OPT was significantly deeper (2.61 ± 0.63 cm) in comparison to TFT (2.25 ± 0.54 cm, p= 0.0004) but not significantly deeper in comparison to TTT (2.43 ± 0.46 cm, p= 0.0820). There were no significant differences between the three techniques in chest compression rate or chest compression fraction. The finger fatigue and rescuer fatigue surveys were graded from 0-10 with 10 being the most fatigue. OPT showed significantly less finger and rescuer fatigue in comparison to TTT and TFT (p Conclusion: This study demonstrated that OPT generated improved chest compression depth with considerably less rescuer and finger fatigue. However, chest compression depth with all three techniques failed to meet the AHA infant goal of 4 cm. Further research is needed to optimize CPR performance to achieve the targeted chest compression depth in infants.

Introduction: Amplitude spectral area (AMSA) predicts termination of fibrillation (TOF) with return of spontaneous circulation (ROSC) and hospital survival in adults, but has not been studied during pediatric cardiac arrest (pCA). Hypothesis: We characterized AMSA during pCA from a pediatric resuscitation quality (pediRES-Q) collaborative and hypothesized that AMSA would be associated with TOF and ROSC. Methods: Children 20 mins without chest compressions. Univariate and multivariable logistic regression analyses controlling for weight, current, and illness category (cardiac vs non-cardiac) were performed. Primary endpoints were TOF and ROSC without ECMO. Secondary endpoints were 24-hr survival and survival to hospital discharge. Results: Between 2015-2019, 50 children from 14 hospitals (median age 3.7 years [IQR 0.6, 13.1]; median weight 16.3 kgs [IQR 6.9, 37.2]; 46% male; 73% cardiac illness category) were identified. IHCA occurred in 47 children and OHCA in 3 children. We analyzed 111 shocks with median number of DFs 1.0 [IQR 1.0, 3.0], median DF energy dose 3.27 J/kg [IQR 2.65,5.01], median DF current 0.64 A/kg [IQR 0.38,0.96], median AMSA 12.21 [IQR 7.17,17.03], and median AMSA-avg 14.6 [IQR 8.6,19.2]. TOF was achieved in 72 DFs (65%), ROSC without ECMO in 31 (62%), ROC with ECMO in 11 (22%), 24-hr survival in 40 (80%), and survival to hospital discharge in 26 (52%). Weight (OR 0.91 [0.84, 0.99] P=0.025) and DF current (OR 1.44 [0.97, 2.2] P=0.07), but not AMSA, were significantly associated with TOF for the first shock. Controlling for DF current and illness category, there was a significant association between AMSA-avg (OR 1.11 [1.0, 1.24] P=0.044) and ROSC without ECMO. There was no significant association between AMSA-avg and 24-hr survival or survival to hospital discharge. Conclusions: In pediatric patients, TOF was associated with weight and DF current, but not AMSA, whereas AMSA-avg was associated with ROSC without ECMO, but not 24-hr survival or survival to hospital discharge.

This 2019 focused update to the American Heart Association pediatric basic life support guidelines follows the 2019 systematic review of the effects of dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) on survival of infants and children with out-of-hospital cardiac arrest. This systematic review and the primary studies identified were analyzed by the Pediatric Task Force of the International Liaison Committee on Resuscitation. It aligns with the International Liaison Committee on Resuscitation’s continuous evidence review process, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update summarizes the available pediatric evidence supporting DA-CPR and provides treatment recommendations for DA-CPR for pediatric out-of-hospital cardiac arrest. Four new pediatric studies were reviewed. A systematic review of this data identified the association of a significant improvement in the rates of bystander CPR and in survival 1 month after cardiac arrest with DA-CPR. The writing group recommends that emergency medical dispatch centers offer DA-CPR for presumed pediatric cardiac arrest, especially when no bystander CPR is in progress. No recommendation could be made for or against DA-CPR instructions when bystander CPR is already in progress.

OBJECTIVES Pediatric in-hospital cardiac arrest cardiopulmonary resuscitation quality metrics have been reported in few children less than 8 years. Our objective was to characterize chest compression fraction, rate, depth, and compliance with 2015 American Heart Association guidelines across multiple pediatric hospitals. DESIGN Retrospective observational study of data from a multicenter resuscitation quality collaborative from October 2015 to April 2017. SETTING Twelve pediatric hospitals across United States, Canada, and Europe. PATIENTS In-hospital cardiac arrest patients (age < 18 yr) with quantitative cardiopulmonary resuscitation data recordings. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 112 events yielding 2,046 evaluable 60-second epochs of cardiopulmonary resuscitation (196,669 chest compression). Event cardiopulmonary resuscitation metric summaries (median [interquartile range]) by age: less than 1 year (38/112): chest compression fraction 0.88 (0.61-0.98), chest compression rate 119/min (110-129), and chest compression depth 2.3 cm (1.9-3.0 cm); for 1 to less than 8 years (42/112): chest compression fraction 0.94 (0.79-1.00), chest compression rate 117/min (110-124), and chest compression depth 3.8 cm (2.9-4.6 cm); for 8 to less than 18 years (32/112): chest compression fraction 0.94 (0.85-1.00), chest compression rate 117/min (110-123), chest compression depth 5.5 cm (4.0-6.5 cm). "Compliance" with guideline targets for 60-second chest compression "epochs" was predefined: chest compression fraction greater than 0.80, chest compression rate 100-120/min, and chest compression depth: greater than or equal to 3.4 cm in less than 1 year, greater than or equal to 4.4 cm in 1 to less than 8 years, and 4.5 to less than 6.6 cm in 8 to less than 18 years. Proportion of less than 1 year, 1 to less than 8 years, and 8 to less than 18 years events with greater than or equal to 60% of 60-second epochs meeting compliance (respectively): chest compression fraction was 53%, 81%, and 78%; chest compression rate was 32%, 50%, and 63%; chest compression depth was 13%, 19%, and 44%. For all events combined, total compliance (meeting all three guideline targets) was 10% (11/112). CONCLUSIONS Across an international pediatric resuscitation collaborative, we characterized the landscape of pediatric in-hospital cardiac arrest chest compression quality metrics and found that they often do not meet 2015 American Heart Association guidelines. Guideline compliance for rate and depth in children less than 18 years is poor, with the greatest difficulty in achieving chest compression depth targets in younger children.

Objective: We performed a systematic review as part of the International Liaison Committee on Resuscitation process to create a consensus on science statement regarding amiodarone or lidocaine during pediatric cardiac arrest for the 2015 International Liaison Committee on Resuscitation's Consensus on Science and Treatment Recommendations. Data Sources: Studies were identified from comprehensive searches in PubMed, Embase, and the Cochrane Library. Study Selection: Studies eligible for inclusion were randomized controlled and observational studies on the relative clinical effect of amiodarone or lidocaine in cardiac arrest. Data Extraction: Studies addressing the clinical effect of amiodarone versus lidocaine were extracted and reviewed for inclusion and exclusion criteria by the reviewers. Studies were rigorously analyzed thereafter. Data Synthesis: We identified three articles addressing lidocaine versus amiodarone in cardiac arrest: 1) a prospective study assessing lidocaine versus amiodarone for refractory ventricular fibrillation in out-of-hospital adults; 2) an observational retrospective cohort study of inpatient pediatric patients with ventricular fibrillation or pulseless ventricular tachycardia who received lidocaine, amiodarone, neither or both; and 3) a prospective study of ventricular tachycardia with a pulse in adults. The first study showed a statistically significant improvement in survival to hospital admission with amiodarone (22.8% vs 12.0%; p = 0.009) and a lack of statistical difference for survival at discharge (p = 0.34). The second article demonstrated 44% return of spontaneous circulation for amiodarone and 64% for lidocaine (odds ratio, 2.02; 1.36-3.03) with no statistical difference for survival at hospital discharge. The third article demonstrated 48.3% arrhythmia termination for amiodarone versus 10.3% for lidocaine (p < 0.05). All were classified as lower quality studies without preference for one agent. Conclusions: The confidence in effect estimates is so low that International Liaison Committee on Resuscitation felt that a recommendation to use of amiodarone over lidocaine is too speculative; we suggest that amiodarone or lidocaine can be used in the setting of pulseless ventricular tachycardia/ventricular fibrillation in infants and children.

Introduction: Among adults with in-hospital cardiac arrest (IHCA), overall survival is lower in black patients compared to white patients. Data regarding racial differences in survival for pediatric IHCA remain unknown. Methods: Using data from the American Heart Association Get With the Guidelines-Resuscitation registry, we identified children >24 hours and < 18 years of age with IHCA due to an initial pulseless rhythm. We used generalized estimation equation to examine the association of black race with survival to hospital discharge and return of spontaneous circulation (ROSC). Results: Overall, 2940 pediatric patients (898 black, 2042 white) with IHCA were included. The mean age was 6 years, 57% were male and 16% had an initial shockable rhythm. Baseline demographics, cardiac arrest characteristics including initial rhythm did not differ significantly by race. Although black race was associated with lower rates of ROSC compared to white patients (69.5% in blacks vs. 74.6% in whites; adjusted OR 0.8012, 95% CI 0.6749 - 0.9512, P= 0.0113), it was not associated with survival to discharge (34.7% in blacks vs. 37.8% in whites; adjusted OR 0.9705, 95% CI 0.8086 – 1.1648, P=0.7476). A lower rate of ROSC in black patients was not explained by longer delays in epinephrine administration for patients with a non-shockable rhythm, or defibrillation in patients with a shockable rhythm. Conclusion: In contrast to adults, no statistically significant racial differences in survival were present in pediatric IHCA.

Although the occurrence of sudden cardiac death (SCD) in a young person is a rare event, it is traumatic and often widely publicized. In recent years, SCD in this population has been increasingly seen as a public health and safety issue. This review presents current knowledge relevant to the epidemiology of SCD and to strategies for prevention, resuscitation, and identification of those at greatest risk. Areas of active research and controversy include the development of best practices in screening, risk stratification approaches and postmortem evaluation, and identification of modifiable barriers to providing better outcomes after resuscitation of young SCD patients. Institution of a national registry of SCD in the young will provide data that will help to answer these questions.

Background— Guidelines for cardiopulmonary resuscitation recommend a chest compression rate of at least 100 compressions per minute. Animal and human studies have reported that blood flow is greatest with chest compression rates near 120/min, but few have reported rates used during out-of-hospital (OOH) cardiopulmonary resuscitation or the relationship between rate and outcome. The purpose of this study was to describe chest compression rates used by emergency medical services providers to resuscitate patients with OOH cardiac arrest and to determine the relationship between chest compression rate and outcome. Methods and Results— Included were patients aged ≥20 years with OOH cardiac arrest treated by emergency medical services providers participating in the Resuscitation Outcomes Consortium. Data were abstracted from monitor-defibrillator recordings during cardiopulmonary resuscitation. Multiple logistic regression analysis assessed the association between chest compression rate and outcome. From December 2005 to May 2007, 3098 patients with OOH cardiac arrest were included in this study. Mean age was 67±16 years, and 8.6% survived to hospital discharge. Mean compression rate was 112±19/min. A curvilinear association between chest compression rate and return of spontaneous circulation was found in cubic spline models after multivariable adjustment ( P =0.012). Return of spontaneous circulation rates peaked at a compression rate of ≈125/min and then declined. Chest compression rate was not significantly associated with survival to hospital discharge in multivariable categorical or cubic spline models. Conclusions— Chest compression rate was associated with return of spontaneous circulation but not with survival to hospital discharge in OOH cardiac arrest.

PURPOSE OF REVIEW Public access defibrillation programs have increased dramatically over the past 15 years. This review will focus on their effectiveness and operational characteristics and discuss the characteristics of successful programs, which can improve outcomes. RECENT FINDINGS Automated external defibrillators increase survival from cardiac arrest when used by a bystander. Recent studies show that the best outcomes are achieved when devices are placed in areas with a high frequency of cardiac arrest and there is ongoing supervision with emergency plans and cardiopulmonary resuscitation training. Programs are cost-effective under these circumstances, but become very inefficient when placed in areas of low risk. There are few adverse events related to the public access defibrillation programs and volunteers are not harmed. Unguided placement results in devices not being used and a decline in organizational structure of the program. As most cardiac arrests occur in the home, the impact on overall survival remains low. SUMMARY Automated external defibrillators are highly effective at reducing death from ventricular fibrillation and easy access in public areas is most effective. Placement must be prioritized based on public health impact and characteristics of the community.

The fundamentals of modern-day CPR, compressions and ventilations, were first described in the 1950s and 1960s.1–3 The American Heart Association endorsed CPR in 1963 followed by the first publication of the Advanced Cardiac Life Support Guidelines in 1974.4 Since then, there have been modest changes in the delivery of CPR, primarily recommendations for compression/ventilation ratios, compression depth, advanced life support measures with early defibrillation, airway management, and pharmacologic therapies and improved organization of emergency response systems. Despite these changes, survival from out-of-hospital cardiac arrest remains poor, usually

Background— Population-based data for pediatric cardiac arrest are scant and largely from urban areas. The Resuscitation Outcomes Consortium (ROC) Epistry–Cardiac Arrest is a population-based emergency medical services registry of out-of-hospital nontraumatic cardiac arrest (OHCA). This study examined age-stratified incidence and outcomes of pediatric OHCA. We hypothesized that survival to hospital discharge is less frequent from pediatric OHCA than adult OHCA. Methods and Results— This prospective population-based cohort study in 11 US and Canadian ROC sites included persons P =0.03). Unadjusted odds ratio for pediatric survival to discharge compared with adults was 0.71 (95% confidence interval, 0.37 to 1.39) for infants, 2.11 (95% confidence interval, 1.21 to 3.66) for children, and 2.04 (95% confidence interval, 1.24 to 3.38) for adolescents. Conclusions— This study demonstrates that the incidence of OHCA in infants approaches that observed in adults but is lower among children and adolescents. Survival to discharge was more common among children and adolescents than infants or adults.

Background: American Heart Association (AHA) guidelines recommend administration of epinephrine (epi) every 3 to 5 minutes during CPR to improve systemic blood pressure and coronary perfusion pressure. In adults with in-hospital cardiac arrest (IHCA), longer dosing intervals are associated with improved survival to hospital discharge. The purpose of this study is to investigate whether longer epi dosing intervals are associated with improved survival to hospital discharge after pediatric IHCA. Methods: A retrospective review of the AHA Get With The Guidelines-Resuscitation registry identified 1,260 pediatric IHCAs that met our inclusion criteria: index IHCA event; no vasoactive infusion in place or alternate vasoactive medication boluses; > 1 dose of epi administered; not located in delivery room, nursery, NICU or obstetrical units. For each arrest, an epi dosing interval was defined by dividing the duration of resuscitation after the first dose of epi by the total doses given. This was necessary as the database does not provide time of individual epi doses. For analysis, epi dosing intervals were categorized as 1 to Results: Table 1 displays the descriptive characteristics of the patients and subsequent events. Adjusted odds ratio for survival to hospital discharge for dosing interval of 5 to Conclusions: Longer dosing intervals than those currently recommended by the AHA guidelines for epinephrine administration during pediatric IHCA are associated with improved survival to hospital discharge.

Publication of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) marks 49 years since the first CPR guidelines were published in 1966 by an Ad Hoc Committee on Cardiopulmonary Resuscitation established by the National Academy of Sciences of the National Research Council.1 Since that time, periodic revisions to the Guidelines have been published by the AHA in 1974,2 1980,3 1986,4 1992,5 2000,6 2005,7 2010,8 and now 2015. The 2010 AHA Guidelines for CPR and ECC provided a comprehensive review of evidence-based recommendations for resuscitation, ECC, and first aid. The 2015 AHA Guidelines Update for CPR and ECC focuses on topics with significant new science or ongoing controversy, and so serves as an update to the 2010 AHA Guidelines for CPR and ECC rather than a complete revision of the Guidelines. The purpose of this Executive Summary is to provide an overview of the new or revised recommendations contained in the 2015 Guidelines Update. This document does not contain extensive reference citations; the reader is referred to Parts 3 through 9 for more detailed review of the scientific evidence and the recommendations on which they are based. There have been several changes to the organization of the 2015 Guidelines Update compared with 2010. “Part 4: Systems of Care and Continuous Quality Improvement” is an important new Part that focuses on the integrated structures and processes that are necessary to create systems of care for both in-hospital and out-of-hospital resuscitation capable of measuring and improving quality and patient outcomes. This Part replaces the “CPR Overview” Part of the 2010 Guidelines. Another new Part of the 2015 Guidelines Update is “Part 14: Education,” which focuses on evidence-based recommendations to facilitate widespread, consistent, efficient and effective implementation …

Lay rescuer automated external defibrillator (AED) programs may increase the number of people experiencing sudden cardiac arrest who receive bystander cardiopulmonary resuscitation (CPR), can reduce time to defibrillation, and may improve survival from sudden cardiac arrest. These programs require an organized and practiced response, with rescuers trained and equipped to recognize emergencies, activate the emergency medical services system, provide CPR, and provide defibrillation. To determine the effect of public access defibrillation (PAD) programs on survival and other outcomes after SCA, the National Heart, Lung, and Blood Institute, the American Heart Association (AHA), and others funded a large prospective randomized trial. The results of this study were recently published in The New England Journal of Medicine and support current AHA recommendations for lay rescuer AED programs and emphasis on planning, training, and practice of CPR and use of AEDs. The purpose of this statement is to highlight important findings of the Public Access Defibrillation Trial and summarize implications of these findings for healthcare providers, healthcare policy advocates, and the AHA training network.

Sudden cardiac arrest (SCA) is recognized as a serious public health problem, accounting for 250 000 to 300 000 deaths per year; it is now the third-leading cause of death behind cancer and nonsudden cardiovascular deaths.1,2 Immediate, well-performed cardiopulmonary resuscitation (CPR) and early defibrillation are the only out-of-hospital interventions that improve outcomes.3 The chain of survival relies on lay responders and emergency medical services (EMS) to initiate the potentially life-saving procedures of CPR and defibrillation. Articles see pp 510 and 518 In 1994, the American Heart Association (AHA) convened the first conference on public access defibrillation (PAD) to introduce the strategy of placing easy-to-use defibrillators in public places to decrease the death rate from SCA.4 Specific recommendations encouraged the stakeholders (the AHA, the US Food and Drug Administration, the National Institutes of Health, industry, and communities) to facilitate PAD by developing user-friendly, less-expensive automated external defibrillators (AEDs); testing the concept within large clinical trials; and organizing communities to promote and support effective PAD programs. Widespread CPR and AED training of the public was emphasized. In the ensuing 15 years, many of these recommendations have been heeded, and PAD programs are now commonplace. The National Institutes of Health–sponsored PAD trial demonstrated that survival doubled when events occurred in communities equipped and trained with CPR and AEDs compared with CPR alone.5 Within the Resuscitations Outcomes Consortium (ROC), out-of-hospital cardiac arrest victims had a markedly increased chance of survival if the first shock was delivered by a bystander using an AED rather than by EMS.6 PAD programs in airports, airlines, and casinos have also validated the effectiveness of the concept. Out-of hospital cardiac arrest is treatable, and outcomes can be improved with currently available approaches. Multiple locations have been recognized as having a higher incidence of cardiac arrest …

The sudden death of a competitive athlete is a personal tragedy with great impact on the lay and medical communities.1 Sudden deaths in athletes are usually caused by previously unsuspected cardiovascular disease.2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Such an event often assumes a high public profile because of the generally held perception that trained athletes constitute the healthiest segment of our society. The death of a well-known elite athlete often emphasizes this visibility.1 21 Athletic field catastrophes strike to the core of our sensibilities and often galvanize us. They also inevitably raise a number of practical and ethical issues. This statement is a response to these considerations and represents the consensus of a panel appointed by the American Heart Association Science Advisory and Coordinating Committee. The panel comprised cardiovascular specialists, other physicians with extensive clinical experience with athletes of all ages, and a legal expert. The panel (1) assessed the benefits and limitations of preparticipation screening for early detection of cardiovascular abnormalities in competitive athletes; (2) addressed cost-efficiency and feasibility issues as well as the medical and legal implications of screening; and (3) developed consensus recommendations and guidelines for the most prudent, practical, and effective screening procedures and strategies (the recommendations are listed at the end of this statement). This endeavor seems particularly relevant and timely, given the large number of competitive athletes in this country, recent public health initiatives on physical activity and exercise, and the staging of the 1996 Olympic Games in the United States. The competitive athlete has been described as one who participates in an organized team or individual sport requiring systematic training and regular competition against others while placing a high premium on athletic excellence and achievement.20 The …

In summary, the evidence review process has attempted to provide a systematic review of the scientific literature using a priori defined methods. The details and steps of the literature review are transparent and replicable. External opinions and community critique are highly valued, and the final products represent the combined labor of hundreds of participants.

The recommendations for electrical therapies described in this section are designed to improve survival from SCA and life-threatening arrhythmias. Whenever defibrillation is attempted, rescuers must coordinate high-quality CPR with defibrillation to minimize interruptions in chest compressions and to ensure immediate resumption of chest compressions after shock delivery. The high first-shock efficacy of newer biphasic defibrillators led to the recommendation of single shocks plus immediate CPR instead of 3-shock sequences that were recommended prior to 2005 to treat VF. Further data are needed to refine recommendations for energy levels for defibrillation and cardioversion using biphasic waveforms.

The 2010 ILCOR Pediatric Task Force experts developed 55 questions related to pediatric resuscitation. Topics were selected based on the 2005 Consensus on Science and Treatment Recommendations (CoSTR) document,1,2 emerging science, and newly identified issues. Not every topic reviewed for the 2005 International Consensus on Science was reviewed in the 2010 evidence evaluation process. In general, evidence-based worksheets were assigned to at least 2 authors for each topic. The literature search strategy was first reviewed by a “worksheet expert” for completeness. The expert also approved the final worksheet to ensure that the levels of evidence were correctly assigned according to the established criteria. Worksheet authors were requested to draft CoSTR statements (see Part 3: Evidence Evaluation Process). Each worksheet author or pair of authors presented their topic to the Task Force in person or via a webinar conference, and Task Force members discussed the available science and revised the CoSTR draft accordingly. These draft CoSTR summaries were recirculated to the International Liaison Committee on Resuscitation (ILCOR) Pediatric Task Force for further refinement until consensus was reached. Selected controversial and critical topics were presented at the 2010 ILCOR International Evidence Evaluation conference in Dallas, Texas, for further discussion to obtain additional input and feedback. This document presents the 2010 international consensus on the science, treatment, and knowledge gaps for each pediatric question. The most important changes or points of emphasis in the recommendations for pediatric resuscitation since the publication of the 2005 ILCOR International Consensus on CPR and ECC Science With Treatment Recommendations1,2 are summarized in the following list. The scientific evidence supporting these changes is detailed in this document. Additional evidence shows that healthcare providers do not reliably determine the presence or absence of a pulse in infants or children. New evidence documents the important role of ventilations in CPR for infants and children. However, rescuers who are unable or unwilling to provide ventilations should be encouraged to perform compression-only CPR. To achieve effective chest compressions, rescuers should compress at least one third the anterior-posterior dimension of the chest. This corresponds to approximately 1½ inches (4 cm) in most infants and 2 inches (5 cm) in most children. When shocks are indicated for ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in infants and children, an initial energy dose of 2 to 4 J/kg is reasonable; doses higher than 4 J/kg, especially if delivered with a biphasic defibrillator, may be safe and effective. More data support the safety and effectiveness of cuffed tracheal tubes in infants and young children, and the formula for selecting the appropriately sized cuffed tube was updated. The safety and value of using cricoid pressure during emergency intubation are not clear. Therefore, the application of cricoid pressure should be modified or discontinued if it impedes ventilation or the speed or ease of intubation. Monitoring capnography/capnometry is recommended to confirm proper endotracheal tube position. Monitoring capnography/capnometry may be helpful during CPR to help assess and optimize quality of chest compressions. On the basis of increasing evidence of potential harm from exposure to high-concentration oxygen after cardiac arrest, once spontaneous circulation is restored, inspired oxygen concentration should be titrated to limit the risk of hyperoxemia. Use of a rapid response system in a pediatric inpatient setting may be beneficial to reduce rates of cardiac and respiratory arrest and in-hospital mortality. Use of a bundled approach to management of pediatric septic shock is recommended. The young victim of a sudden, unexpected cardiac arrest should have an unrestricted, complete autopsy, if possible, with special attention to the possibility of an underlying condition that predisposes to a fatal arrhythmia. Appropriate preservation and genetic analysis of tissue should be considered; detailed testing may reveal an inherited “channelopathy” that may also be present in surviving family members.

BACKGROUND . Ventricular fibrillation occurs in 10 –20% of pediatric cardiac arrests. Survival rates in children with ventricular fibrillation can be as high as 30% when the rhythm is identified and treated promptly. In the last five years, recommendations have been made for the use of automated external defibrillators(AED) in children 1– 8 years of age. OBJECTIVE . The goal of this study was to determine the awareness of American Heart Association (AHA) guidelines and statewide protocols concerning AED use in children ages 1– 8 among emergency medical providers after new guideline release. Availability of pediatric capable AED equipment was also assessed. METHODS . Surveys were distributed to EMS providers in Iowa and Montana within one year of the AHA advisory statement in 2003 recommending use of AEDs in children ages 1– 8, and again approximately one year after the 2005 AHA guidelines on cardiopulmonary resuscitation were published. In Iowa, there were concentrated efforts to disseminate information about AED use in children, while there were minimal efforts in Montana. RESULTS . Awareness of AHA guidelines for use of AEDs in children was low in both states in 2003 (29% in Iowa vs 9% in Montana, p< 0.001). After release of the 2005 guidelines, awareness improved significantly in both states but was still significantly greater in Iowa (83% vs. 60 %, p < 0.002). In 2003, less than 20% of respondents in both states reported access to pediatric capable AEDs. Availability of pediatric pads and cables increased significantly in 2006 but remained low in Montana (74% in Iowa vs 37% in Montana, p < 0.001). CONCLUSIONS . At the present time, publication of new or interim guidelines in the scientific literature alone is insufficient to ensure that awareness among providers and that new protocols are implemented. An effective and efficient method to disseminate new pediatric out-of-hospital protocols emergency care to become standard of care in a timely matter should be developed.

Objectives Population-based data for pediatric cardiac arrest are scant and concentrated from large urban areas. The Resuscitation Outcomes Consortium (ROC) Epistry-Cardiac Arrest is a prospective population-based EMS registry of out-of-hospital non-traumatic cardiac arrest (OHCA). The purpose of this study is to examine the characteristics of OHCA in patients Methods Design : Prospective population based cohort study with uniform data definitions. Setting : 11 US and Canadian urban and rural sites participating in the ROC. Population : Persons receive CPR by EMTs and/or receive a bystander AED shock or are pulseless but receive no EMS resuscitation between 12/2005 thru 11/2006. Hypothesis : Survival from pediatric OHCA is less than adult survival. Survival is discharge from hospital. Patients were divided in 3 groups: Results Data from 389 OHCAs in children were submitted: 315 (81%) patients received EMS treatment. Table 1 shows data from all children with OHCA. Table 2 shows EMS-treated OHCAs. Survival of pediatric patients was statistically better than adults for all OHCAs (7.5% vs. 3.9%, p < 0.009) and for EMS-treated OHCAs (9.2% vs 6.9% p = 0.001). EMS scene time was Conclusions Survival from OHCA is better among children than adults, and this current survival rate is better than most previous studies. Bystander CPR is provided for Table 1 Baseline Characteristics for all OHCA Patients Table 2 EMS-Treated OHCA Patients

Introduction The Public Access Defibrillation (PAD) Trial demonstrated improved survival of cardiac arrest victims when automated external defibrillators (AEDs) were combined with CPR by lay responders. These PAD sites incorporated American Heart Association (AHA) recommended elements of a PAD site and the volunteer responders received refresher CPR/AED training. It is unknown if typical community PAD sites maintain these elements after initial program development. The Johnson County Early Defibrillation Task Force (JCEDTF) in Johnson County, IA distributed AEDs throughout the county in 2002. CPR training was provided at program initiation. The purpose of this study was to evaluate the PAD sites 5 years later to assess compliance with AHA recommendations. Methods A 25 point scoring system was developed to assign numerical values to the components of a PAD site: planned and practiced response, links with local EMS, and training of rescuers. Surveys were mailed to all 39 PAD sites. Site visits with tours were conducted at each the site to confirm the survey. Sites were grouped into educational, community, or business sites. Results Thirty two surveys were returned (response rate 82%): 5 educational sites, 13 business and industrial sites and 14 community sites. The Table shows the percentage of points that each group achieved for the components of an AED program. No site had incorporated all the recommended elements: the best sites included only 2/3 of the recommendations. There was a statistical difference in CPR training, with business and industrial sites performing best. Community sites were particularly weak with CPR training. Conclusions PAD sites incorporate approximately half of the elements of an effective PAD program. Business and industrial sites perform slightly better than educational or community sites. CPR training and EMS links are the poorest areas of compliance. These results may indicate that the effectiveness of a PAD site may diminish with time. Table: Percentage of Achieved Points

Background— Prosthesis survival, growth, and functional status after initial mechanical mitral valve replacement (MVR) in children Methods and Results— The experience of the Pediatric Cardiac Care Consortium (45 centers, 1982 to 1999), which included 102 survivors after initial MVR, was analyzed. Median follow-up: 6.0 years (interquartile range: 3.0 to 10.6 years; 96% complete). Twenty-nine survivors had undergone a second MVR at an interval of 4.8±3.8 years after initial MVR. Reasons for second MVR were prosthetic valve stenosis 24 (83%), thrombosis 4 (14%), and endocarditis 1 (3%). For those who had second MVR, prosthesis sizes were: first MVR 19±2 mm and second MVR 22±3 mm, and their body weight increased from 7.4±2.8 kg to 16.8±10.5 kg. To identify risk factors for having a second MVR, the 29 second MVR survivors were compared with the 73 who did not have a second MVR on first-MVR demographic and perioperative variables. By univariate analysis, patients with shorter prosthesis survival were younger, weighed less, had smaller prostheses, greater ratio of prosthesis size:body weight, were less likely to have a St. Jude prosthesis and more likely to have Shone’s syndrome. By multivariate analysis prosthesis survival was predicted only by first MVR age: odds ratio (OR) 7.7 (95% confidence interval [CI] 2.6–22.7) and prosthesis size: OR 6.8 (95% CI 2.6–18.2). High risk patients (age P =0.017). An estimate of current New York Heart Association (NYHA) functional status was class 1 in 76%, class 2 in 22%, and classes 3 or 4 in 2%. Conclusion— Prosthesis survival can be predicted based on first MVR age and prosthesis size. Somatic growth is comparable regardless of the need for second MVR. There is an increment in prosthesis size at second MVR, suggesting continued annular growth. Significant limitation of function after MVR is uncommon. MVR may be an appropriate strategy for children

Background Short- and long-term outcomes after prosthetic mitral valve replacement (MVR) in children aged Methods and Results MVR was performed 176 times on 139 patients. Median follow-up was 6.2 years (range 0 to 20 years, 96% complete). Age at initial MVR was 1.9±1.4 years. Complications after initial MVR included heart block requiring pacemaker (16%), endocarditis (6%), thrombosis (3%), and stroke (2%). Patient survival was as follows: 1 year, 79%; 5 years, 75%; and 10 years, 74%. The majority of deaths occurred early after initial MVR, with little late attrition despite repeat MVR and chronic anticoagulation. Among survivors, the 5-year freedom from reoperation was 81%. Age-adjusted multivariable predictors of death include the presence of complete atrioventricular canal (hazard ratio 4.76, 95% CI 1.59 to 14.30), Shone’s syndrome (hazard ratio 3.68, 95% CI 1.14 to 11.89), and increased ratio of prosthetic valve size to patient weight (relative risk 1.77 per mm/kg increment, 95% CI 1.06 to 2.97). Age- and diagnosis-adjusted prosthetic size/weight ratios predicted a 1-year survival of 91% for size/weight ratio 2, 79% for size/weight ratio 3, 61% for size/weight ratio 4, and 37% for size/weight ratio 5. Conclusions Early mortality after MVR can be predicted on the basis of diagnosis and the size/weight ratio. Late mortality is low. These data can assist in choosing between MVR and alternative palliative strategies.