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In this article, we examine whether organ procurement of the heart and transplantation contravenes the dead donor rule and Australian legislative definitions of death as an irreversible cessation of the circulation. We contend that this practice upholds a long-held belief that donors of any organs after cessation of the circulation are not actually dead at the time of procurement – principally because of insufficient time lapse between cessation of the circulation and procurement of organs. Moreover, the fact that the transplanted heart functions in a recipient proves the donor’s circulation had never actually ceased irreversibly. Nonetheless, we suggest that this practice may be legitimised by amending legislation to redefine death as an irreversible cessation of brain function preceded by cessation of the circulation and requiring medical proof that the donor’s cortical brain function has ceased function before organ procurement.

We studied rates of cadaveric organ donation on transition from apnoeic-oxygenation to radioisotope brain perfusion scanning to diagnose brain death. We studied records of children who were organ donors and/or had Technetium Tc99m Exametazine brain scans over 1989-2018. Donation after Brain Death (DBD) commenced in 1989, Donation after Circulatory Death (DCD) in 2011. Brain scanning was adopted in 2002 and apnoeic-oxygenation abandoned in 2007. In total, 95 of 1930 children (4.9%) donated organs (81 DBD, 14 DCD). During 1989-2001, with brain death diagnosed by clinical tests including apnoeic-oxygenation, 40 of 1059 children (3.8%) donated organs at average 3.1/annum. During 2002-2007 when either apnoeic-oxygenation or scanning was used, 18 of 351 children (5.1%) donated organs at average 3.0/year. During 2008-2018 with scanning in lieu of apnoeic-oxygenation, 23 of 520 children (4.4%) donated organs at average 2.1/annum. The difference in DBD rate between eras was not significant (P=0.52). Of 77 children scanned, 65(84%) were diagnosed brain dead after 1 or 2 scans, and 29 (45%) of these donated organs. Of 12 children with limited brain perfusion (not brain dead), DCD proceeded in 8 (67%). DCD or DBD (death diagnosed by scanning) was performed during 2011-2018 in 35 of 370 children (9.5%) which is significantly more (P

The apneic-oxygenation test is an integral part of clinical testing to determine brain death. The medical and legal criticisms of the test are presented together which make a strong argument that it should be abandoned.

Because the median dose of one vial ‘clears the blood of circulating venom’, the authors of the Australian Snakebite Project recommend restriction of antivenom to one vial for all envenomated victims. This is neither scientific nor safe. Methodological flaws in the case series include limited detection of venom toxins and misinterpretation of data. The recommendation fails to consider larger doses of venom than that neutralised by one vial of antivenom. Although one vial may be adequate for minor envenomation, the initial dose should be two vials with more on a clinical basis.

Legal definitions of death and its medical determination have been challenged in high-profile cases in several jurisdictions which define death as either cessation of all functions of the brain or only of the brain stem. Several patients diagnosed brain dead have recovered some vestigial brain activity. Plaintiffs, seeking to prevent withdrawal of life-sustaining treatment, have sought to prevent performance of the key test, the apnoeic-oxygenation test, because it can cause harm and as a medical procedure requires informed consent. Reform of the American Uniform Determination of Death Act, which resembles Australian legislation, has been proposed to include specification of the medical determination of death and lack of requirement of consent to conduct testing. In this article we consider cases and proposals for law reform, concluding that the Australian definition of brain death ought to be retained but that the apnoeic-oxygenation test should be abandoned in lieu of testing brain blood flow and that religious accommodation should be considered.

The World Brain Death Project clarified many aspects of the diagnosis of brain death/death by neurologic criteria. Clearer descriptions than previously published were presented concerning the etiology, prerequisites, minimum clinical criteria, apnea testing targets, and indications for ancillary testing. Nevertheless, there remained many epistemic and metaphysical assertions that were either false, ad hoc, or confused. Epistemically, the project was not successful in explaining away remaining brain functions, complex reflexes as "spinal," the risk and lack of utility of the apnea test, the ignored and often present confounders of central endocrine dysfunction and high-cervical-spinal-cord injury, the limitations of ancillary tests, or the cases of reversibility of some findings of brain death/death by neurologic criteria. Metaphysically, the World Brain Death Project variously suggested different concepts of death that were not supported with argument. Concepts offered included simply restating the criterion of brain death/death by neurologic criteria; personhood, without recognizing it is a higher-brain concept; and emergent functions of the organism as a whole, without specifying what these might be, if not biologic anti-entropic integration that actually remains after brain death/death by neurologic criteria. The World Brain Death Project only offered confused metaphysical discussion, and gave no reason why the state they described as brain death/death by neurologic criteria should be considered death itself. The main epistemic and metaphysical problems with brain death/death by neurologic criteria remain untouched by the World Brain Death Project.

An adolescent victim of an urban snakebite developed respiratory failure, rhabdomyolysis and consumption procoagulopathy but recovered with two vials of tiger snake antivenom administered after a delay of 48 hours. The clinical significance of a post-bite collapse was not initially appreciated. Tiger snake (Notechis spp.) venom antigen was measurable in blood before antivenom but not after whereas antivenom was measurable in blood for nine ensuing days. This case adds to growing evidence that further pharmacokinetic research of venom-antivenom interaction is required to establish the correct dose and timing of tiger snake antivenom. Antivenom therapy, even when delayed, facilitates recovery from snake envenomation.

Objective: To determine the frequency, nature and consequence of adverse events sustained by children admitted to a combined general and cardiac paediatric intensive care unit (PICU). Design: Retrospective analysis of data collected between January 1st 2008 and December 31st 2017 from PICU. Setting: The Royal Children’s Hospital, a paediatric tertiary referral centre in Melbourne, Victoria, Australia. The PICU has thirty beds. Results: During the study period, PICU received 15208 admissions, of which 73% sustained at least one adverse event with a frequency of 67 adverse events per 100 PICU-days and 3 per admission. One adverse event was sustained for every 35 hours of care. The risk of an adverse event was highest in children less than a month of age, or if mechanically ventilated, a high Pediatric Index of Mortality (PIM2) score, longer PICU length of stay, had a pre-existing disability or a high risk adjustment for congenital heart surgery (RACHS) score. Those patients who sustained an adverse event, as compared to those who did not, were mechanically ventilated for longer (80 hrs Vs. 7 hrs, p=

Reprint: The American Heart Association requests that this document be cited as follows: de Caen AR, Maconochie IK, Aickin R, Atkins DL, Biarent D, Guerguerian AM, Kleinman ME, Kloeck DA, Meaney PA, Nadkarni VM, Ng KC, Nuthall G, Reis AG, Shimizu N, Tibballs J, Veliz Pintos R; on behalf of the Pediatric Basic Life Support and Pediatric Advanced Life Support Chapter Collaborators. Part 6: pediatric basic life support and pediatric advanced life support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation . 2015;132(suppl 1):S177–S203. Reprinted with permission of the American Heart Association, Inc., European Resuscitation Council, and International Liaison Committee on Resuscitation. This article has been published in Circulation and Resuscitation . ( Circulation. 2015;132[suppl 1]:S177–S203. DOI: 10.1161/CIR.0000000000000275.) The Pediatric Task Force reviewed all questions submitted by the International Liaison Committee on Resuscitation (ILCOR) member councils in 2010, reviewed all council training materials and resuscitation guidelines and algorithms, and conferred on recent areas of interest and controversy. We identified a few areas where there were key differences in council-specific guidelines based on historical recommendations, such as the A-B-C (Airway, Breathing, Circulation) versus C-A-B (Circulation, Airway, Breathing) sequence of provision of cardiopulmonary resuscitation (CPR), initial back blows versus abdominal thrusts for foreign-body airway obstruction, an upper limit for recommended chest compression rate, and initial defibrillation dose for shockable rhythms (2 versus 4 J/kg). We produced a working list of prioritized questions and topics, which was adjusted with the advent of new research evidence. This led to a prioritized palate of 21 PICO (population, intervention, comparator, outcome) questions for ILCOR task force focus. The 2015 process was supported by information specialists who performed in-depth systematic searches, liaising with pediatric content experts so that the most appropriate terms and outcomes and the most relevant publications were identified. …

Objective: Outcomes for children with chronic critical illness are not defined. We examined the long-term survival of these children in Australia and New Zealand.

Objective:To evaluate the psychosocial status of mothers and fathers in response to their infant’s diagnosis of hypoplastic left heart syndrome.Design:A study on interviews with parents whose children had survived staged surgery.Setting:Tertiary hospital paediatric ICU.Subjects:A total of 29 parents (16 mothers and 13 fathers) of surviving children.Intervention: A semi-structured face-to-face interview was conducted to explore experiences of parents in response to their infant’s diagnosis, their interaction with the doctor delivering the diagnosis, their deliberation about staged surgery, and their reasons for this choice.Measurement and Main Results: All parents were devastated about their infant’s diagnosis, and most (83%) of them said that the time of the diagnosis and the aftermath was the worst time of their lives. Parents reported helpful and unhelpful communication at this time. Although all parents in this study chose surgery for their infant, when faced with the choice, 17 of them made an immediate decision “to protect their infant’s life”, 8 were initially unsure when their infant was diagnosed in utero, and 4 were unsure when the infant was diagnosed after birth. Parents also experienced loss and other stressors.Conclusions:All parents of the infants diagnosed with hypoplastic left heart syndrome experienced intense loss and stressors. Physicians need to be sensitive to the needs and thinking of the parents when discussing treatment options before surgery. The nature of the relationship with the doctor at this time can support parents or be a further source of stress.

This paper examines the few, but important legal and coronial cases concerning withdrawing or withholding life-sustaining treatment from severely disabled or critically impaired infants in Australia. Although sparse in number, the judgements should influence common clinical practices based on assessment of "best interests" but these have not yet been adopted. In particular, although courts have discounted assessment of "quality of life" as a legitimate component of determination of "best interests," this remains a prominent component of clinical guidelines. In addition, this paper highlights the lack of uniform clinical guidelines available to medical professionals and parents in Australia when making end-of-life decisions for severely ill infants. Thus, it is argued here that there is a need for an overarching prescriptive uniform framework or set of guidelines in end-of-life decision-making for impaired infants. This would encourage greater transparency, consistency, and some degree of objectivity in an area that often appears subjective.

Reduction of adverse events depends on accurate detection. The utility of a Trigger Tool to detect and classify severity of adverse events in an intensive care unit of a paediatric university hospital was compared to voluntary reporting. Sixty patient records were randomly selected from 314 admissions over three months. Events detected by the Trigger Tool were classified by two independent investigators as insignificant, minor, moderate, major or catastrophic. Examination of each record required, on average, 40 minutes. Ninety-eight adverse events (1.66/patient) were detected in 59 available records. Mean admission was 2.77 days. The incidence of adverse events was 59.9 per 100 patient days or 0.60 events per patient per day. The number of events detected by the Trigger Tool was related to duration of admission (r=0.70, P < 0.0001) and risk of mortality on admission (r=0.50, P=0.0001) but not to age. The inter-rater agreement on detection of adverse events was good. Investigator One detected 66 adverse events while Investigator Two detected 93 events (kappa 0.63). Of the 61 events detected by both investigators, the agreement of classification of severity was very good (kappa 0.89). Of the 56 events rated similarly by both investigators, 13 (23%) were insignificant, 19 (34%) were minor, 17 (30%) were moderate, 4 (7%) were major and 3 (6%) were catastrophic. Only four adverse events had been reported voluntarily, of which two were detected using the Trigger Tool. Whereas the Trigger Tool is a simple, efficient and robust method, voluntary reporting is inadequate and captures very few adverse events in the intensive care unit environment.

To evaluate the psychosocial status of mothers and fathers of infants with hypoplastic left heart syndrome while in the PICU.A retrospective study combining interviews and psychometric testing of parents.Tertiary hospital PICU.Twenty-nine parents (16 mothers and 13 fathers) of surviving children.A semistructured face-to-face interview was conducted to explore parental experiences, and a Structured Clinical Interview for Diagnosis-Clinical Version (posttraumatic stress disorder module) was conducted to determine the possibility of an acute stress disorder or a posttraumatic stress disorder.All parents reported multiple stresses which commenced with their infant's diagnosis and endured throughout their infant's time in PICU. The Structured Clinical Interview for Diagnosis revealed that acute stress disorder or posttraumatic stress disorder developed in 24 parents (83%). Of 18 parents whose infants were diagnosed with hypoplastic left heart syndrome in utero, eight of nine mothers (88%) and six of nine fathers (66%) had posttraumatic stress disorder. Of 11 parents whose infants were diagnosed with hypoplastic left heart syndrome postbirth, six of seven mothers had acute stress disorder and one mother had posttraumatic stress disorder, and of four fathers, two fathers had acute stress disorder and one father had posttraumatic stress disorder. The prevalence of parental stress-related disorder was not different between mothers and fathers (p = 0.85). Only five parents were free of traumatic stress-related illness. Parents also experienced losses. Many parents were marginalized from their infant's care by the environment of PICU. Fifty percent of mothers experienced difficulties with parental-infant bonding. Ten parents (34%) began the process of adaptation to their infant's hypoplastic left heart syndrome and were assisted by the support and sensitivity of staff or had discovered other resources.All parents of surviving infants with hypoplastic left heart syndrome in PICU, irrespective of timing of diagnosis, experienced numerous stresses and losses, and the majority exhibited clinical levels of traumatic stress. Receiving the diagnosis itself is very traumatic and is compounded by the environment of the PICU which alienates parents from their infants and interferes with parent-infant bonding. Parental adaptation to this situation can be assisted by staff.

Guidelines for basic and advanced paediatric cardiopulmonary resuscitation (CPR) have been revised by Australian and New Zealand Resuscitation Councils. Changes encourage CPR out-of-hospital and aim to improve the quality of CPR in-hospital. Features of basic CPR include: omission of abdominal thrusts for foreign body airway obstruction; commencement with chest compression followed by ventilation in a ratio of 30:2 or compression-only CPR if the rescuer is unwilling/unable to give expired-air breathing when the victim is ‘unresponsive and not breathing normally’. Use of automated external defibrillators is encouraged. Features of advanced CPR include: prevention of cardiac arrest by rapid response systems; restriction of pulse palpation to 10 s to diagnosis cardiac arrest; affirmation of 15:2 compression–ventilation ratio for children and for infants other than newly born; initial bag-mask ventilation before tracheal intubation; a single direct current shock of 4 J/kg for ventricular fibrillation (VF) and pulseless ventricular tachycardia followed by immediate resumption of CPR for 2 min without analysis of cardiac rhythm and avoidance of unnecessary interruption of continuous external cardiac compressions. Monitoring of exhaled carbon dioxide is recommended to detect non-tracheal intubation, assess quality of CPR, and to help match ventilation to reduced cardiac output. The intraosseous route is recommended if immediate intravenous access is impossible. Amiodarone is strongly favoured over lignocaine for refractory VF and adrenaline over atropine for severe bradycardia, asystole and pulseless electrical activity. Family presence at resuscitation is encouraged. Therapeutic hypothermia is acceptable after resuscitation to improve neurological outcome. Extracorporeal circulatory support for in-hospital cardiac arrest may be used in equipped centres.

Just over a century ago, animal responses to injections of jellyfish extracts unveiled the phenomenon of anaphylaxis. Yet, until very recently, understanding of jellyfish sting toxicity has remained limited. Upon contact, jellyfish stinging cells discharge complex venoms, through thousands of barbed tubules, into the skin resulting in painful and, potentially, lethal envenomations. This review examines the immunological and toxinological responses to stings by prominent species of jellyfish including Physalia sp. (Portuguese Man-o-War, Blue-bottle), Cubozoan jellyfish including Chironex fleckeri, several Carybdeids including Carybdea arborifera and Alatina moseri, Linuche unguiculta (Thimble jellyfish), a jellyfish responsible for Irukandji syndrome (Carukia barnesi) and Pelagia noctiluca. Jellyfish venoms are composed of potent proteinaceous porins (cellular membrane pore-forming toxins), neurotoxic peptides, bioactive lipids and other small molecules whilst the tubules contain ancient collagens and chitins. We postulate that immunologically, both tubular structural and functional biopolymers as well as venom components can initiate innate, adaptive, as well as immediate and delayed hypersensitivity reactions that may be amenable to topical anti-inflammatory-immunomodifier therapy. The current challenge for immunotoxinologists is to deconstruct the actions of venom components to target therapeutic modalities for sting treatment.

The outcome of cardiac arrest in hospitalized infants and children is poor. However, cardiac arrest is often predictable based on many hours of hypoxaemia, hypotension and associated symptoms and signs (heart rate, respiratory rate, respiratory effort, neurological change) and staff concern. If intensive expert medical and nursing interventions are provided quickly before cardiac arrest, some deaths on wards outside the intensive care environment are preventable. Over the past decade, the introduction of rapid response and early warning systems in some large paediatric hospitals has reduced the incidence of unexpected cardiac arrest by some 40% and death by 20%. These systems enable any staff member (or parent) to summon urgent expert assistance to the patient's bedside without the need to consult senior staff members. Introduction of a system is a culture change necessitating institutional adoption, extensive education in recognition of the seriously-ill patient, and abolition of hierarchical barriers to obtain rapid assistance.

Aim To determine the attitudes and barriers to an established paediatric Medical Emergency Team (MET) system among nurses and doctors. Methods Invitation to all clinical staff in a paediatric hospital to complete an electronic 41-item branched survey. Responses were graded on a Likert scale. Results 407 staff completed the survey (280 nurses, 127 doctors). The MET system was highly valued for obtaining urgent assistance for the seriously ill patients by 85% of nurses and 83% of doctors. However, barriers to MET activation included; preference to contact the covering (attending) doctors by 80% of nurses and 45% of doctors, active discouragement to activating a MET by 41% of nurses and 12% of doctors, and fear of criticism by 17% of nurses and 9% of doctors if the patient was not deemed seriously ill by the MET attendees. Less experienced staff were significantly more likely to report barriers to calling a MET. Negative attitudes from MET attendees were reported by nurses (24%) and doctors (6.5%). Failure to recognize serious illness was revealed by unwillingness of 47% of doctors and 32% of nurses to activate MET when activation criteria were attained and by retrospective realization by 30% of doctors and 15% of nurses that they had failed to activate MET when needed. Conclusions Cultural and behavioral barriers to MET activation and inability to recognize serious illness may explain in part the failure of a MET system to completely eliminate unexpected cardiac arrest and death. Unless these issues are addressed, the full benefits of a MET system may not be realised.

Aim: To determine differentiating symptoms and signs of epiglottitis and laryngotracheobronchitis (croup). Methods: Contemporaneous interview of parents and clinical examination of children with acute upper airway obstruction presenting to the intensive care unit of a paediatric hospital. Results: Two hundred and three children were examined over a 40-month period. One hundred and two had croup, of whom 49 had the diagnosis confirmed at intubation and another six by direct laryngeal inspection without intubation. One hundred and one had epiglottitis of whom 95 were diagnosed by direct inspection of the larynx at intubation, five by a lateral X-ray of the neck and one on direct inspection without intubation. One child with epiglottitis died. Although both illnesses presented with stridor, the additional presence of drooling had a high sensitivity (0.79, 95% CI 0.70–0.86) and specificity (0.94, 95% CI 0.88–0.97) for epiglottitis while coughing had a high sensitivity (1.00, 95% CI 0.96–1.00) and high specificity (0.98, 95% CI 0.93–0.99) for croup. Coughing predicted croup but drooling predicted epiglottitis. Additional reliable signs of epiglottitis were a preference to sit, refusal to swallow and dysphagia. Thirty-seven percent of children with epiglottitis and 16% with croup were treated as having another respiratory illness at least once before definitive diagnosis. Conclusions: Epiglottitis and croup are often confused because they share symptoms and signs including stridor. However, differentiation in early illness is possible by additional observation of coughing and absence of drooling in croup and by the additional observation of drooling with absence of coughing in epiglottitis.

To determine cardioversion doses of biphasic DC shock for paediatric atrial dysrhythmias.Prospective recording of energy, pre-shock and post-shock rhythms.Paediatric hospital.Shockable atrial dysrhythmias.Forty episodes of atrial dysrhythmias among 25 children (mean age 6.8+/-7.1 years, mean weight 28.2+/-28.5 kg) were treated with external shock. The first shock converted the dysrhythmia to sinus rhythm in 25 episodes. Cardioversion occurred in 2 of 8 (25%) episodes with a dose of0.5 J/kg, 14 of 16 (88%) with a dose of 0.5-1.0 J/kg and 9 of 16 (56%) with a dose of1.0 J/kg (p=0.01, Fisher's exact test). Ten of 15 initially non-responsive episodes were cardioverted with additional shocks at 1.1+/-0.6 J/kg (range 0.5-2.1 J/kg). Of the remaining 5 unresponsive episodes, 2 of ventricular fibrillation (induced by unsynchronized shock) were successfully defibrillated, and 3 were managed with cardiopulmonary bypass. Among 11 additional children (mean age 4.3+/-6.8 years, mean weight 18.1+/-22.0 kg), 18 episodes of atrial dysrhythmias were treated with internal shock which successfully cardioverted all episodes with one or more shocks at 0.4+/-0.2 J/kg.In rounded doses, recommended initial external cardioversion doses are 0.5-1.0 J/kg and subsequently up to 2 J/kg, internal cardioversion doses are 0.5 J/kg.

Background: Previous studies of paediatric cardiac arrest have reported a low survival rate but there is limited data from Australia. We sought to determine the characteristics and outcomes of paediatric out-of-hospital cardiac arrest in Melbourne, Australia. Methods: Between October 1999 and June 2007, all cases of out-of-hospital cardiac arrest attended by emergency medical services in Melbourne, Australia were entered into a database (the Victorian Ambulance Cardiac Arrest Registry). Data on patients aged less than 16 years in cardiac arrest on arrival of ambulance paramedics was analysed. Results: There were 209 children in cardiac arrest on arrival of paramedics during the study period. Of these, resuscitation was not attempted in 16 children due to signs of definite death. Of the 193 children who had attempted resuscitation, 143 (74%) had an initial cardiac rhythm of asystole, 36 (18%) were in pulseless electrical activity and 14 (7%) were in ventricular fibrillation. There were 49 patients (25%) with return of spontaneous circulation at arrival to hospital of whom 14 (7%) survived to hospital discharge. Of 138 patients without return of a circulation, 120 were transported to hospital with continuing resuscitation and one survived (0.9%). Survival was higher in patients with an initial cardiac rhythm of ventricular fibrillation (5/14; 35%) compared with other rhythms (10/179; 4%), OR 9.38, 95% CI 2.64-33.2. Conclusions: Overall, 7.7% of paediatric patients with out-of-hospital cardiac arrest survive to leave hospital. Increased survival was seen if the initial cardiac rhythm was ventricular fibrillation. Survival was very rare (

Little is known of the incidence of adverse events in the paediatric intensive care unit (PICU). Perceived incidence may be dependent on data-collection methods.To determine the incidence of adverse events by voluntary reporting and systematic enquiry.Adverse events in PICU were recorded contemporaneously by systematic enquiry with bedside nurses and attending doctors, and compared with data submitted voluntarily to the hospital's quality and safety unit. Events were classified as insignificant, minor, moderate, major and catastrophic or lethal, and assigned origins as medical/surgical diagnosis or management, medical/surgical procedures, medication or miscellaneous.Among 740 patients, 524 adverse events (mean 0.71 per patient) occurred in 193 patients (26.1%). Systematic enquiry detected 405 (80%) among 165 patients and were classified by one investigator as insignificant 30 (7%); minor 100 (25%); moderate 160 (37%); major 103(25%) and catastrophic 12 (3%). The coefficient of agreement (kappa) of severity between the two investigators was 0.82 (95% CI 0.78-0.87). Voluntary reporting detected 166 (32%) adverse events among 100 patients, of which 119 were undetected by systematic reporting. Forty-nine events (9%) were detected by both methods. The number and severity of events reported by the two methods were significantly different (p0.0001). Voluntary reporting, mainly by nurses, did not capture major, severe or catastrophic events related to medical/surgical diagnosis or management.Neither voluntary reporting nor systematic enquiry captures all adverse events. While the two methods both capture some events, systematic reporting captures serious events, while voluntary reporting captures mainly insignificant and minor events.

A review of outcomes of hypoplastic left heart syndrome at a pediatric hospital 1983–2004 identified 154 deaths among 206 children (75%). Of 134 surgically treated, 82 (62%) died: 68 (83%) in intensive care, six (7%) in the operating theatre, three (4%) during transport from home, two (2%) on the cardiac ward, one (1 %) at home, one (1 %) in the emergency department, and one (1 %) elsewhere. Seventy died after stage one Norwood surgery (median age: 13 days), three died after second stage surgery (ages: 3, 4, and 20 months), two died after third stage surgery (ages: 1.2 and 3.5 years), two died after heart transplantation (ages: 4.6 and 15 years), and five died after non-Norwood surgery. All 72 infants treated without surgery died: 68 died at a median age 3 days; 57 (79%) in intensive care, three (4%) on the ward, and 12 (17%) elsewhere. Discussion involves strategies to support parents and staff at diagnosis, and before and after a child's death.

Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: An Utstein-style scientific statement A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiopulmonary, Perioperative, and Critical Care; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research Mary Ann Peberdy ∗, Michelle Cretikos, Benjamin S. Abella, Michael DeVita, David Goldhill, Walter Kloeck, Steven L. Kronick, Laurie J. Morrison, Vinay M. Nadkarni, Graham Nichol, Jerry P. Nolan, Michael Parr, James Tibballs, Elise W. van der Jagt, Lis Young

Aim: To determine outcomes of surgical treatment of infants with hypoplastic left heart syndrome (HLHS). Methods: Retrospective analysis of medical records of infants with HLHS. Results: 129 of 206 (63%) infants with HLHS were managed surgically over the period 1983–2004. Survival from all stages of surgical repair was 52 (40%) patients with significantly different (P

Withholding and withdrawing life-sustaining medical treatment is common in hospitals, particularly in intensive care unit environments. Usually, decisions regarding limitation of therapy are based on ethical considerations and derived by discussion and mutual agreement between parents and clinicians. However, disputes sometimes arise. When such disputes are settled in court, the judgements constitute common law and may serve as the basis for ethical decisions. All cases have been decided in the 'best interests' of the unfortunate child. Although each case has its own circumstances, a composite view reveals three legal criteria for withholding or withdrawing treatment. These are based on the present and future 'quality of life', 'futility' of present treatment and a comparison of 'burdens versus benefits' of present and future treatment and its discontinuance. These legal principles may facilitate difficult ethical decisions. This article identifies a number of common law cases which establishes these principles.

The Pediatric Task Force reviewed all questions submitted by the International Liaison Committee on Resuscitation (ILCOR) member councils in 2010, reviewed all council training materials and resuscitation guidelines and algorithms, and conferred on recent areas of interest and controversy. We identified a few areas where there were key differences in council-specific guidelines based on historical recommendations, such as the A-B-C (Airway, Breathing, Circulation) versus C-A-B (Circulation, Airway, Breathing) sequence of provision of cardiopulmonary resuscitation (CPR), initial back blows versus abdominal thrusts for foreign-body airway obstruction, an upper limit for recommended chest compression rate, and initial defibrillation dose for shockable rhythms (2 versus 4 J/kg). We produced a working list of prioritized questions and topics, which was adjusted with the advent of new research evidence. This led to a prioritized palate of 21 PICO (population, intervention, comparator, outcome) questions for ILCOR task force focus. The 2015 process was supported by information specialists who performed in-depth systematic searches, liaising with pediatric content experts so that the most appropriate terms and outcomes and the most relevant publications were identified. Relevant adult literature was considered (extrapolated) in those PICO questions that overlapped with other task forces, or when there were insufficient pediatric data. In rare circumstances (in the absence of sufficient human data), appropriate animal studies were incorporated into reviews of the literature. However, these data were considered only when higher levels of evidence were not available and the topic was deemed critical. When formulating the PICO questions, the task force felt it important to evaluate patient outcomes that extend beyond return of spontaneous circulation (ROSC) or discharge from the pediatric intensive care unit (PICU). In recognition that the measures must have meaning, not only to clinicians but also to parents and caregivers, longer-term outcomes at 30 …

This publication presents the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of the pediatric patient and the 2005 American Academy of Pediatrics/AHA guidelines for CPR and ECC of the neonate. The guidelines are based on the evidence evaluation from the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, hosted by the American Heart Association in Dallas, Texas, January 23–30, 2005.The “2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care” contain recommendations designed to improve survival from sudden cardiac arrest and acute life-threatening cardiopulmonary problems. The evidence evaluation process that was the basis for these guidelines was accomplished in collaboration with the International Liaison Committee on Resuscitation (ILCOR). The ILCOR process is described in more detail in the “International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.”The recommendations in the “2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care” confirm the safety and effectiveness of many approaches, acknowledge that other approaches may not be optimal, and recommend new treatments that have undergone evidence evaluation. These new recommendations do not imply that care involving the use of earlier guidelines is unsafe. In addition, it is important to note that these guidelines will not apply to all rescuers and all victims in all situations. The leader of a resuscitation attempt may need to adapt application of the guidelines to unique circumstances.The following are the major pediatric advanced life support changes in the 2005 guidelines: There is further caution about the use of endotracheal tubes. Laryngeal mask airways are acceptable when used by experienced providers.Cuffed endotracheal tubes may be used in infants (except newborns) and children in in-hospital settings provided that cuff inflation pressure is kept 20 kg who have a perfusing rhythm. Correct placement must be verified when the tube is inserted, during transport, and whenever the patient is moved.During CPR with an advanced airway in place, rescuers will no longer perform “cycles” of CPR. Instead, the rescuer performing chest compressions will perform them continuously at a rate of 100/minute without pauses for ventilation. The rescuer providing ventilation will deliver 8 to 10 breaths per minute (1 breath approximately every 6–8 seconds).Timing of 1 shock, CPR, and drug administration during pulseless arrest has changed and now is identical to that for advanced cardiac life support.Routine use of high-dose epinephrine is not recommended.Lidocaine is de-emphasized, but it can be used for treatment of ventricular fibrillation/pulseless ventricular tachycardia if amiodarone is not available.Induced hypothermia (32–34°C for 12–24 hours) may be considered if the child remains comatose after resuscitation.Indications for the use of inodilators are mentioned in the postresuscitation section.Termination of resuscitative efforts is discussed. It is noted that intact survival has been reported following prolonged resuscitation and absence of spontaneous circulation despite 2 doses of epinephrine.The following are the major neonatal resuscitation changes in the 2005 guidelines: Supplementary oxygen is recommended whenever positive-pressure ventilation is indicated for resuscitation; free-flow oxygen should be administered to infants who are breathing but have central cyanosis. Although the standard approach to resuscitation is to use 100% oxygen, it is reasonable to begin resuscitation with an oxygen concentration of less than 100% or to start with no supplementary oxygen (ie, start with room air). If the clinician begins resuscitation with room air, it is recommended that supplementary oxygen be available to use if there is no appreciable improvement within 90 seconds after birth. In situations where supplementary oxygen is not readily available, positive-pressure ventilation should be administered with room air.Current recommendations no longer advise routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid. Endotracheal suctioning for infants who are not vigorous should be performed immediately after birth.A self-inflating bag, a flow-inflating bag, or a T-piece (a valved mechanical device designed to regulate pressure and limit flow) can be used to ventilate a newborn.An increase in heart rate is the primary sign of improved ventilation during resuscitation. Exhaled CO2 detection is the recommended primary technique to confirm correct endotracheal tube placement when a prompt increase in heart rate does not occur after intubation.The recommended intravenous (IV) epinephrine dose is 0.01 to 0.03 mg/kg per dose. Higher IV doses are not recommended, and IV administration is the preferred route. Although access is being obtained, administration of a higher dose (up to 0.1 mg/kg) through the endotracheal tube may be considered.It is possible to identify conditions associated with high mortality and poor outcome in which withholding resuscitative efforts may be considered reasonable, particularly when there has been the opportunity for parental agreement. The following guidelines must be interpreted according to current regional outcomes: When gestation, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated. Examples are provided in the guidelines.In conditions associated with a high rate of survival and acceptable morbidity, resuscitation is nearly always indicated.In conditions associated with uncertain prognosis in which survival is borderline, the morbidity rate is relatively high, and the anticipated burden to the child is high, parental desires concerning initiation of resuscitation should be supported.Infants without signs of life (no heartbeat and no respiratory effort) after 10 minutes of resuscitation show either a high mortality rate or severe neurodevelopmental disability. After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life.

Four children with congenital central hypoventilation syndrome (CCHS) treated with noninvasive techniques of ventilation are presented. Two infants (one in the newborn period) were treated with nasal mask bilevel positive airway pressure (BiPAP), and then both were transitioned to negative pressure chamber ventilation at several years of age because of possible midface hypoplasia. Tracheostomies were not performed. Two older children were transitioned from mechanical ventilation via tracheostomy to nasal mask BiPAP, and then in one case to negative pressure chamber ventilation, and in the other to phrenic nerve pacing. Their tracheostomies were removed.

If snake antivenoms are considered orphan drugs, then jellyfish antivenoms are the poorest of the orphans. Despite the diversity, ubiquity and toxicity of the venomous cnidarians, only a single antivenom is available for jellyfish stings worldwide. That antivenom, an ovine whole IgG product, is directed against the ‘box’ jellyfish, Chironex fleckeri, and is manufactured by CSL Limited (Melbourne, Australia). It also neutralises the venom of closely related cubozoans such as Chiropsalmus quadrigatus. The recognition of the life‐threatening effects of various other jellyfish demonstrates the need for broadening the specificity of the existing product and/or developing additional specific jellyfish antivenoms. These emerging threats include the irukandji syndrome, due to Carukia barnesi and other carybdeids, as well as those from scyphozoans such as Stomolophus spp. The role of ancillary drug therapy, in addition to, or instead of, antivenoms remains controversial. This review will consider the development o...

Australia has a shortfall in donated hearts for transplantation. Hearts are usually procured from brain dead donors, but procurement from circulatory dead donors is a potential additional source. However, heart transplantation after circulatory death of the donor may not conform to the dead donor rule. An amendment in law is required to permit heart procurement for transplantation after circulatory death.

The absorbance of NO (5–90 ppm) and NO2 (0.5–4 ppm) by a number of absorbers and filters was assessed via bench testing. All absorbers (Sodasorb, Purafil CP, Purafil Select, Sofnolime, Sofnofil and 50/50 mix of Sofnolime/Sofnofil) except Sodasorb absorbed NO almost completely. Only Sofnolime absorbed NO 2 completely while Sodasorb and the Sofnolime/Sofnofil 50/50 mix had absorbances between 47% and 90%. The absorbance of four filters (ILF100, ILF150, ILF200 and HgCONO) as well as Sofnolime and the Sofnolime/Sofnofil 50/50 mix was tested in the expiratory port of a Servo 900C ventilator. All absorbers and filters produced a change in ventilator pressures. The HgCONO filter, Sofnolime and the Sofnolime/Sofnofil 50/50 mix all absorbed NO. At 80 ppm NO, the HgCONO filter had 100% absorbance for four hours while Sofnolime's absorbance was significantly reduced after one hour. All filters and absorbers tested on the ventilator except the Sofnolime/Sofnofil 50/50 mix and the ILF150 filter absorbed NO 2 completely for a period ranging from 90 minutes to four hours. We recommend the HgCONO filter and Sofnolime to absorb both NO and NO 2. If absorption of NO 2 only is required we recommend the HgCONO, ILF100 or ILF200 filters or the Sofnolime absorber.

OBJECTIVES: To investigate the circumstances and means of access to six poisoning agents by children under 5 years of age and to make recommendations for countermeasures and strategies for implementation. METHODOLOGY: A case series study of access to six poisoning agents was conducted. Cases were identified prospectively through a poisons information centre and hospital emergency departments. Interviews were conducted with 523 parents and caregivers using a structured questionnaire. RESULTS: The majority of children (94.1%) accessed the agent in their own home or another home and, in 38% of cases (excluding mistakes in administration), the parent or caregiver was present in the immediate area at the time of the incident. In cases in which the child was alone in the room, caregivers were frequently involved in household duties (51%), with only 10% undertaking leisure activities and 8% on the telephone. The span of unsupervised time reported was 5 min or less in 79.5% of these cases. The means of access was generally during periods of use of the agent (75.3%), including just purchased, rather than when agents were in their usual storage place. CONCLUSIONS: There is little scope for improved supervision as a major intervention. Design and regulatory changes such as local safe storage for bench tops and while travelling, improved labelling and packaging, improved child-resistant packaging and its more general application are required. These and agent-specific interventions, including child-resistant bait stations for rodenticides and well covers for vaporizers, are more likely to prevent poisoning. The recent identification of childhood poisoning prevention as a national priority may lead to coordinated action to implement these and other preventive measures. Language: en

We present the clinical course and management of two infants with idiopathic infantile arterial calcification. Both had coronary artery involvement and presented with ischaemic cardiac failure. Neither responded well to conventional therapy with inotropic agents, glyceryl trinitrate, diuretic and mechanical ventilation, nor to short-term biphosphonates. One was treated with levosimendan and extracorporeal membrane oxygenation to no avail.

Commotio cordis or ventricular fibrillation caused by a blow to the chest is a rare cause of cardiac arrest in a well child. We report a case of a young child falling from a low height landing chest first with rapid onset of unconsciousness, apnoea and cyanosis. Cardiopulmonary resuscitation was given by parents under telephone instruction from an ambulance dispatch centre. On arrival of officers, 7 min after the fall, ventricular fibrillation was present but responded to defibrillation (biphasic 3 J/kg). No clinical or CT evidence of chest or brain trauma was present and investigations (ECGs, cardiac MRI, echocardiography, viral tests, metabolic tests, drug tests, serum electrolytes) did not reveal any cardiac illness or abnormal cardiac anatomy. Specifically, a long QT was absent and a Flecainide challenge for Brugada syndrome was negative. There was no family history of sudden death. No further dysrrhythmia occurred and the child recovered neurologically well after 3 days of therapeutic hypothermia (for cerebral ischaemia) and 7 days of mechanical ventilation.

Objectives—To describe the epidemiology of unintentional childhood poisoning hospitalisation in Victoria, Australia, in order to monitor trends and identify areas for research and prevention. Methods—For children under 5 years, all Victorian public hospital admissions, July 1987 to June 1995, due to unintentional poisoning by drugs, medicines, and other substances were analysed. Similar cases were also extracted from the database of the Royal Children’s Hospital intensive care unit, Melbourne for the years 1979‐ 91. Log linear regression modelling was used for trend analyses. Results—The annual average childhood unintentional poisoning rate was 210.7 per 100 000. Annual rates for males consistently exceeded those for females. The most common agents were those acting on the respiratory system and on smooth and skeletal muscles (muscle relaxants, cough and cold medicines, antiasthmatics), aromatic analgesics (paracetamol), and systemic agents (including antihistamines). Further investigation is justified for cardiac agents, some respiratory agents, and asthma medications. Conclusions—Childhood poisoning hospitalisation rates have not decreased in Victoria over recent years. A focused, agent specific approach, as well as a series of generic measures for the prevention of poisoning to children under 5 is advocated. The ongoing surveillance, collection and analysis of data, in addition to research on specific poisoning agents are essential components of any prevention strategy. (Injury Prevention 1999;5:31‐35)

The concept of "loss of chance" as an alternative cause of action in cases of medical negligence has succeeded in recent cases where actions based on causation have failed. The plaintiff must prove negligence and loss of a chance of a better outcome. The quantity of loss of chance must be more than "speculative" (1%). Damages are awarded as a proportion of the total injury commensurate with the loss of chance. More claims may be expected, although damages will generally be less than those awarded under causation. Doctors' insurance premiums may rise.

The cardiovascular, coagulation and haematological effects of Tiger Snake (Notechis scutatus) venom were investigated in anaesthetized, mechanically ventilated dogs. Intravenous infusion of venom caused dose-related systemic hypotension, low cardiac output, pulmonary hypertension and raised pulmonary artery occlusion pressure. These effects occurred within several minutes of venom administration but recovered over 30 to 40 minutes. They were accompanied by prolongation of prothrombin and activated partial thromboplastin times and by depletion of serum fibrinogen. Fibrin degradation products were not detected. Thrombocytopenia and leucopenia were observed within minutes of venom administration but recovered over 30 to 40 minutes. The mechanism of systemic hypotension is probably pulmonary vascular obstruction and coronary ischaemia caused by disseminated intravascular coagulation, although the existence of a myocardial depressant in venom or release of vasoactive substances by venom cannot be excluded.

To evaluate the performance of two pulse oximeters in the measurement of arterial hemoglobin saturation in hypoxemic children.Prospective, repeated-measures observational study.A 16-bed pediatric intensive care unit in a children's tertiary hospital.Sixty-six patients with arterial saturation of90%.Three arterial blood samples were taken from each subject during a 48-hr period. Pulse oximeter measurements of arterial saturation were compared with arterial saturation determined by cooximetry.Arterial saturation was measured using one or both pulse oximeters (SpO2) and compared with the arterial hemoglobin saturation determined by cooximetry (SaO2). Sixty-two subjects were studied, using the Ohmeda pulse oximeter giving 185 data points (78 with saturations75% [defined by the average of pulse oximeter and cooximeter]); 53 subjects were studied, using the Hewlett-Packard pulse oximeter yielding 155 data points (60 with saturations75%). SpO2 ranged from 24% to 94%. Bias and precision of the Ohmeda pulse oximeter were -2.8% and 4.8%75% and -0.8% and 8.0%75%. Bias and precision of the Hewlett-Packard pulse oximeter were -0.5% and 5.1%75% and 0.4% and 4.6%75%. Intrapatient regression coefficient (r) for the differences between pulse oximeter and cooximeter was 0.58 for the Ohmeda and 0.59 for the Hewlett-Packard. Regression coefficients for predicting change in cooximeter value given a change in the Ohmeda pulse oximeter were 0.59 and 0.7175% and75%, respectively. Similar coefficients for the Hewlett-Packard pulse oximeter were 0.50 and 0.70, respectively.The performance of the Ohmeda pulse oximeter deteriorated below an SpO2 of 75%. The Hewlett-Packard pulse oximeter performed consistently above and below an SpO2 of 75%. The ability of both pulse oximeters to reliably predict change in SaO2 based on change in pulse oximetry was limited. We recommend measurement of PaO2 or SaO2 for important clinical decisions.

The efficacy of antivenom and verapamil against Chironex fleckeri (box jellyfish) venom was investigated in monitored mechanically ventilated piglets. Chironex fleckeri tentacle extract alone, a mixture of tentacle extract with antivenom, and verapamil before tentacle extract were administered intravenously to groups of animals. Tentacle extract caused severe systemic hypotension, cardiac dysrrhythmias, pulmonary hypertension, haemolysis and hyper-kalaemia. These effects were prevented by pre-incubation of tentacle extract with antivenom. Verapamil did not prevent any effect of venom, exacerbated cardiovascular collapse and increased mortality. We conclude that antivenom neutralizes the cardiovascular, haemolytic and hyperkalaemic effects of box jellyfish venom. Verapamil does not prevent any of these effects and is contra-indicated for treatment of envenomation.