Virginia Apgar (1909-1974): The Mother of Neonatal Resuscitation.

Dr. Virginia Apgar was an American anesthesiologist and researcher who heavily influenced the development of neonatal resuscitation in the immediate postpartum period with her simple five-point scoring system. Today, the APGAR scoring system is used around the world in delivery rooms to guide clinicians in the evaluation of newborns and to distinguish which might need urgent resuscitation. With a simple scoring system, timer, and clipboard, Dr. Virginia Apgar shifted focus from the parturient to the neonate, improving infant mortality as a result.

Virtual Reality Simulation in Pediatric Resuscitation for Pre-hospital Providers.

This technical report explored the feasibility and utility of virtual reality (VR) pediatric resuscitation simulations for pre-hospital providers during their scheduled shifts. To our knowledge, neither the pediatric resuscitation VR simulation nor the feasibility of in situ, on-shift training with VR had been previously evaluated in pre-hospital providers. VR headset was available at an urban city fire station for 10 days where a total of 60 pre-hospital providers were scheduled to work. Providers were made aware of the VR module but no formal demonstration was done. There were no facilitators. Participants filled out an anonymous retrospective pre- and post-survey using a five-point Likert scale, rating their confidence from "not confident" to "very confident" in recognizing and managing pediatric emergencies. We found that VR simulation for pediatric resuscitation was a feasible training tool to use in situ as 63% of the providers were able to use it on shift. Furthermore, self-reported confidence increased after the training where responses of "very confident" increased from 20% to 30% for emergency medical technicians and 55% to 63% for paramedics.

Advances in pediatric emergency from 2023.

Most children receive emergency care by general emergency physicians and not in designated children's hospitals. There are unique considerations in the care of children that differ from the care of adults. Many management principles can be extrapolated from adult studies, but the unique pathophysiology of pediatric disease requires specialized attention and management updates. This article highlights ten impactful articles from the year 2023 whose findings can improve the care of children in the Emergency Department (ED). These studies address pediatric resuscitation, traumatic arrest, septic shock, airway management, nailbed injuries, bronchiolitis, infant fever, cervical spine injuries, and cancer risk from radiation (Table 1). The findings in these articles have the potential to impact the evaluation and management of children (Table 2).

Ventricular Assist Device Training and Emergency Management Among Pediatric Cardiac Intensive Care Physicians - Multicenter Cross-Sectional Survey.

Background/Aim: Pediatric cardiac intensive care physicians practicing at centers that implant ventricular assist devices (VAD's) are exposed to increasing numbers of VAD patients, with a significant number of VAD-days. We aimed to delineate pediatric cardiac critical care practices surrounding routine and emergency management of VADs. Methodology: We administered a multicenter cross-sectional survey of pediatric cardiac intensive care unit (CICU) physicians in the United States and Canada. Survey distribution occurred between August 31st and October 26th 2021. Results: A total of 254 CICU physicians received a formal invitation to participate, with 108 returning completed surveys (42.5% response rate). Responses came from CICU attending physicians at 26 separate institutions. Respondents' level of experience was well distributed across junior, mid-level, and senior staff: less than 5 years (38%), 5-9 years (25%), and >/= 10 years (37%). Most respondents had received formal training in the management of VAD patients (n = 93, 86.1%), with training format including fellowship (61%), simulation (36%), and national/international conferences (26.5%). Dedicated advanced cardiac therapies teams were available at the institutions of 97.2% of respondents. A total of 78/108 (72.2%) described themselves as "comfortable" or "very comfortable" in pediatric VAD management. While 63% (68/108) of respondents reported that they had never performed (or overseen the performance of) chest compressions in a pediatric patient with a VAD, 37% (40/108) reported performing CPR at least once in a VAD patient. Conclusion: With no existing international guidelines for emergency cardiovascular care in the pediatric VAD population, our survey identifies an important gap in resuscitation recommendations.

Interdisciplinary training program for pediatric cardiorespiratory arrest using rapid cycle deliberate practice: A descriptive cross-sectional study

ABSTRACT BACKGROUND: cardiorespiratory arrest (CRA) is a severe public health concern, and clinical simulation has proven to be a beneficial educational strategy for training on this topic. OBJECTIVE: To describe the implementation of a program for pediatric cardiac arrest care using rapid-cycle deliberate practice (RCDP), the quality of the technique employed, and participants' opinions on the methodology. DESIGN AND SETTING: This descriptive cross-sectional study of pre- and post-performance training in cardiopul monary resuscitation (CPR) techniques and reaction evaluation was conducted in a hospital in São Paulo. METHODS: Multidisciplinary groups performed pediatric resuscitation in a simulated scenario with RCDP mediated by a facilitator. The study sample included professionals working in patient care. During the simulation, the participants were evaluated for their compliance with the CRA care algorithm. Further, their execution of chest compressions was assessed pre- and post-intervention. RESULTS: In total, 302 professionals were trained in this study. The overall quality of CPR measured pre-intervention was inadequate, and only 26% had adequate technique proficiency, whereas it was 91% (P < 0.01) post-intervention. Of the participants, 95.7% responded to the final evaluation and provided positive comments on the method and their satisfaction with the novel simulation. Of these, 88% considered that repetition of the technique used was more effective than traditional simulation. CONCLUSIONS: The RCDP is effective for training multidisciplinary teams in pediatric CPR, with an emphasis on the quality of chest compressions. However, further studies are necessary to explore whether this trend translates to differential performances in practical settings.

[How I treat pediatric burn management in emergency department]. / Comment je traite la brûlure de l'enfant aux urgences.

Acute management in emergency department of pediatric burns is challenging for clinicians. Many of these burns are minor and can be treated on an outpatient basis. However, moderate and severe burns require hospitalization. Although management principles are similar between children and adults polytrauma, children have differences in their pathophysiological response to burn injury. Understanding these differences is essential to optimize the patient care. Particularities of acute management of pediatric burns are discussed in this article.

La prise en charge aux urgences d'un enfant brûlé est un défi pour les cliniciens. Souvent superficielles, la plupart des brûlures peuvent être traitées en ambulatoire. Cependant, les brûlures modérées et sévères nécessitent une hospitalisation. Bien que la prise en charge repose sur des principes similaires à ceux des patients polytraumatisés, les enfants présentent des différences dans la réponse physiopathologique à la brûlure. Tenir compte de ces différences est essentiel pour une prise en charge optimale. Les spécificités des modalités thérapeutiques urgentes lors de brûlures chez l'enfant sont discutées dans cet article.

Pediatric Cardiac Arrest and Resuscitation.

Pediatric cardiac arrest in the emergency department is rare. We emphasize the importance of preparedness for pediatric cardiac arrest and offer strategies for the optimal recognition and care of patients in cardiac arrest and peri-arrest. This article focuses on both prevention of arrest and the key elements of pediatric resuscitation that have been shown to improve outcomes for children in cardiac arrest. Finally, we review changes to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care that were published in 2020.

Economic evaluation of tele-resuscitation intervention on emergency department pediatric visits in the Niagara Region, Canada a pilot study.

Introduction: The use of telemedicine in critical care is emerging, however, there is a paucity of information surrounding the costs relative to health gains in the pediatric population. This study aimed to estimate the cost-effectiveness of a pediatric tele-resuscitation (Peds-TECH) intervention compared to the usual care in five community hospital emergency departments (EDs). Using a decision tree analysis approach with secondary retrospective data from a 3-year time period, this cost-effectiveness analysis was completed. Methods: A mixed methods quasi-experimental design was embedded in the economic evaluation of Peds-TECH intervention. Patients aged <18 years triaged as Canadian Triage and Acuity Scale 1 or 2 at EDs were eligible to receive the intervention. Qualitative interviews were conducted with parents/caregivers to explore the out-of-pocket (OOP) expenses. Patient-level health resource utilization was extracted from Niagara Health databases. The Peds-TECH budget calculated one-time technology and operational costs per patient. Base-case analyses determined the incremental cost per year of life lost (YLL) averted, and additional sensitivity analysis confirmed the robustness of the results. Results: Odds ratio for mortality among cases was 0.498 (95% CI: 0.173, 1.43). The average cost of a patient receiving the Peds-TECH intervention was $2,032.73 compared to $317.45 in usual care. In total, 54 patients received the Peds-TECH intervention. Fewer children died in the intervention group resulting in 4.71 YLL. The probabilistic analysis revealed an incremental cost-effectiveness ratio of $64.61 per YLL averted. Conclusion: Peds-TECH appears to be a cost-effective intervention for resuscitating infants/children in hospital emergency departments.

Gamification educational intervention improves pediatric nurses' comfort and speed drawing up code-dose epinephrine.

PURPOSE: Drawing up weight-based doses of epinephrine is a vital skill for pediatric nurses; however, non-intensive care unit (ICU) nurses may not routinely perform this skill and may not be as efficient or comfortable doing so during pediatric resuscitations. This study aimed to evaluate the impact of a gamification program on non-ICU pediatric nurses' knowledge and skills regarding epinephrine for pediatric cardiac arrest. DESIGN AND METHODS: Comfort and time to draw up three doses of epinephrine during out-of-ICU in-hospital pediatric cardiac arrest were measured pre- and post- a gamification-centered educational intervention. RESULTS: Nursing comfort improved from 2.93 ± 1.90 to 6.68 ± 1.46 out of 10 (mean difference 3.6 +/- 2.1, p < 0.001). Overall time to draw up three doses of epinephrine decreased after the intervention by an average of 27.1 s (p = 0.019). The number of nurses who could complete the task in under 2 min improved from 23% to 59% (p = 0.031). CONCLUSIONS: At baseline few non-ICU nurses could draw up multiple weight-based doses of epinephrine in under two minutes. A gamification simulation-based educational intervention improved pediatric non-ICU nurses' comfort and speed drawing up epinephrine. PRACTICE IMPLICATIONS: Wide-spread implementation of gamification-centered educational initiatives could result in faster epinephrine administration and improved mortality rates from in-hospital pediatric cardiac arrest.

The Reliability of the Resuscitation Assessment Tool (RAT) in Assessing Emergency Medicine Resident Competence in Pediatric Resuscitation Scenarios: A Prospective Observational Pilot Study.

Introduction Emergency medicine (EM) postgraduate medical education in Canada has transitioned from traditional time-based training to competency-based medical education (CBME). In order to promote residents through stages of training, simulated assessments are needed to evaluate residents in high-stakes but low-frequency medical emergencies. There remains a gap in the literature pertaining to the use of evaluative tools in simulation, such as the Resuscitation Assessment Tool (RAT) in the new CBME curriculum design. Methods We completed a pilot study of resident physicians in one Canadian EM training program to evaluate the effectiveness and reliability of a simulation-based RAT for pediatric resuscitation. We recorded 10 EM trainees completing simulated scenarios and had nine EM physicians use the RAT tool to evaluate their performances. Generalizability theory was used to evaluate the reliability of the RAT tool. Results The mean RAT score for the management of pediatric myocarditis, cardiac arrest, and septic shock (appendicitis) across raters was 3.70, 3.73, and 4.50, respectively. The overall generalizability coefficient for testing simulated pediatric performance competency was 0.77 for internal consistency and 0.75 for absolute agreement. The performance of senior participants was superior to that of junior participants in the management of pediatric myocarditis (p = 0.01) but not statistically significant in the management of pediatric septic shock (p=0.77) or cardiac arrest (p =0.61). Conclusion Overall, our findings suggest that with an appropriately chosen simulated scenario, the RAT tool can be used effectively for the simulation of high-stakes and low-frequency scenarios for practice to enhance the new CBME curriculum in emergency medicine training programs.

[When pediatric resuscitation and anesthesia teams simulate together]. / Quand des équipes de réanimation et d'anesthésie pédiatrique simulent ensemble.

At the Grenoble-Alpes University Hospital Center, a high-fidelity simulation training project was born from the collaboration of the intensive care and pediatric anesthesia teams. The objective of these sessions was to improve practices by developing the technical and non-technical skills of the teams. Fifteen days were organized from 2018 to 2022, training 170 healthcare professionals. The results highlighted excellent satisfaction and helped improve professional practices.

Fat embolism after intraosseous catheters in pediatric forensic autopsies.

In our center, we performed the autopsy of a child who died from drowning and presented, at autopsy, a major pulmonary fat embolism (PFE). A cardiopulmonary resuscitation (CPR) was performed, including infusion by intraosseous catheter (IIC). No other traumatic lesions and diseases classically related to a risk of PFE were detected. According to some animal studies, we considered the IIC as the only possible cause for PFE. However, we could not find literature to confirm this hypothesis in humans, especially in a pediatric population. To verify the occurrence of PFE after IIC in a pediatric population, we retrospectively selected 20 cases of pediatric deaths autopsied in our center, in which a CPR was performed, without bone fractures or other possible causes of PFE: 13 cases with IIC (group A) and 7 cases without IIC (group B). Several exclusion criteria were considered. The histology slides of the pulmonary tissue were stained by Oil Red O. PFE was classified according to the Falzi scoring system. In group A, 8 cases showed PFE: 4 cases with a score 1 of Falzi and 4 cases with a score 2 of Falzi. In group B, no case showed PFE. The difference between the two groups was statistically significant. The results of our study seem to confirm that IIC can lead to PFE in a pediatric population and show that the PFE after IIC can be important (up to score 2 of Falzi). To the best of our knowledge, our study is the first specifically focused on the occurrence of PFE after IIC in a pediatric population by using autoptic data.

Chest Pain and Electrocardiographic Changes in a Child With Duchenne Muscular Dystrophy.

A 12-year-old boy known to have Duchenne muscular dystrophy presented to our Emergency Department with acute onset central chest pain. A 12-lead electrocardiogram (ECG) was performed showing ST-segment elevation with reciprocal changes. An echocardiogram showed reduced left ventricular systolic function with an ejection fraction of 45%. Initial cardiac biomarkers were significantly elevated, with troponin-T result recorded at 7,065 ng/L (reference range: 0-14 ng/L). The patient was admitted to the pediatric intensive care unit with a differential diagnosis of acute myocardial infarction or acute myocardial injury related to cardiomyopathy and commenced on an ACE (angiotensin-converting enzyme) inhibitor. Computed tomography (CT) of the coronary arteries was performed, which showed normal coronary arteries and cardiac anatomy. The patient was discharged on day 5 and continues to follow up in the pediatric cardiology clinic. He was commenced on a beta blocker at one-month follow-up when he was asymptomatic.

The impact of clinical result acquisition and interpretation on task performance during a simulated pediatric cardiac arrest: a multicentre observational study.

PURPOSE: The acquisition and interpretation of clinical results during resuscitations is common; however, this can delay critical clinical tasks, resulting in increased morbidity and mortality. This study aims to determine the impact of clinical result acquisition and interpretation by the team leader on critical task completion during simulated pediatric cardiac arrest before and after team training. METHODS: This is a secondary data analysis of video-recorded simulated resuscitation scenarios conducted during Teams4Kids (T4K) study (June 2011-January 2015); scenarios included cardiac arrest before and after team training. The scenario included either a scripted paper or a phone call delivery of results concurrently with a clinical transition to pulseless ventricular tachycardia. Descriptive statistics and non-parametric tests were used to compare team performance before and after training. RESULTS: Performance from 40 teams was analyzed. Although the time taken to initiate CPR and defibrillation varied depending on the type of interruption and whether the scenario was before or after team training, these findings were not significantly associated with the leader's behaviour [Kruskal-Wallis test (p > 0.05)]. An exact McNemar's test determined no statistically significant difference in the proportion of leaders involved or not in interpreting results between and after the training (exact p value = 0.096). CONCLUSIONS: Team training was successful in reducing time to perform key clinical tasks. Although team training modified the way leaders behaved toward the results, this behaviour change did not impact the time taken to start CPR or defibrillate. Further understanding the elements that influence time to critical clinical tasks provides guidance in designing future simulated educational activities, subsequently improving clinical team performance and patient outcomes.

RéSUMé: BUT: L'acquisition et l'interprétation des résultats cliniques pendant les réanimations sont courantes; toutefois, cela peut retarder les tâches cliniques critiques, ce qui entraîne une augmentation de la morbidité et de la mortalité. Cette étude vise à déterminer l'impact de l'acquisition et de l'interprétation des résultats cliniques par le chef d'équipe sur la réalisation des tâches critiques lors d'un arrêt cardiaque pédiatrique simulé, avant et après la formation de l'équipe. MéTHODES: Il s'agit d'une analyse de données secondaires de scénarios de réanimation simulés enregistrés sur vidéo, réalisés au cours de l'étude Teams4Kids (T4K) (juin 2011-janvier 2015); les scénarios comprenaient un arrêt cardiaque avant et après la formation de l'équipe. Le scénario comprenait un document écrit ou un appel téléphonique donnant les résultats en même temps qu'une transition clinique vers la tachycardie ventriculaire sans pouls. Des statistiques descriptives et des tests non paramétriques ont été utilisés pour comparer le rendement de l'équipe avant et après la formation. RéSULTATS: Les performances de 40 équipes ont été analysées. Bien que le temps nécessaire au déclenchement de la RCP et de la défibrillation ait varié selon le type d'interruption et selon que le scénario se déroulait avant ou après la formation de l'équipe, ces résultats n'étaient pas significativement associés au comportement du leader [test de Kruskal-Wallis (p > 0,05)]. Un test exact de McNemar n'a déterminé aucune différence statistiquement significative dans la proportion de dirigeants impliqués ou non dans l'interprétation des résultats entre et après la formation (valeur p exacte = 0,096). CONCLUSIONS: La formation en équipe a permis de réduire le temps nécessaire pour effectuer les tâches cliniques clés. Bien que la formation de l'équipe ait modifié le comportement des dirigeants vis-à-vis des résultats, ce changement de comportement n'a pas eu d'incidence sur le temps nécessaire pour commencer la RCP ou la défibrillation. Une meilleure compréhension des éléments qui influencent le temps consacré aux tâches cliniques critiques fournit une orientation pour la conception des futures activités éducatives simulées, améliorant par la suite le rendement des équipes cliniques et les résultats pour les patients.

Focused assessment with sonography for trauma in predicting early surgical intervention in hemodynamically unstable children with blunt abdominal trauma.

OBJECTIVES: The predictive accuracy and clinical role of the focused assessment with sonography for trauma (FAST) exam in pediatric blunt abdominal trauma are uncertain. This study investigates the performance of the emergency department (ED) FAST exam to predict early surgical intervention and subsequent free fluid (FF) in pediatric trauma patients. METHODS: Pediatric level 1 trauma patients ages 0 to 15 years with blunt torso trauma at a single trauma center were retrospectively reviewed. After stratification by initial hemodynamic (HD) instability, the association of a positive FAST with (1) early surgical intervention, defined as operative management (laparotomy or open pericardial window) or angiography within 4 hours of ED arrival and (2) presence of FF during early surgical intervention was determined. RESULTS: Among 508 salvageable pediatric trauma patients with an interpreted FAST exam, 35 (6.9%) had HD instability and 98 (19.3%) were FAST positive. A total of 42 of 508 (8.3%) patients required early surgical intervention, and the sensitivity and specificity of FAST predicting early surgical intervention were 59.5% and 84.3%, respectively. The specificity and positive predictive value of FF during early surgical intervention in FAST-positive HD unstable patients increased from 50% and 90.9% at 4 hours after ED arrival to 100% and 100% at 2 hours after ED arrival, respectively. CONCLUSIONS: In this large series of injured children, a positive FAST exam improves the ability to predict the need for early surgical intervention, and accuracy is greater for FF in HD unstable patients 2 hours after arrival to the ED.

Pediatric Resuscitation.

This article describes evidence-based nursing practices for detecting pediatric decompensation and prevention of cardiopulmonary arrest and outlines the process for effective and high-quality pediatric resuscitation and postresuscitation care. Primary concepts include pediatric decompensation signs and symptoms, pediatric resuscitation essential practices, and postresuscitation care, monitoring, and outcomes. Pediatric-specific considerations for family presence during resuscitation, ensuring good outcomes for medically complex children in community settings, and the role of targeted temperature management, continuous electroencephalography, and the use of extracorporeal membrane oxygenation in pediatric resuscitation are also discussed.

Simulation of an Atypical Presentation of Necrotizing Enterocolitis in the Emergency Department.

Necrotizing enterocolitis (NEC) is a gastrointestinal emergency most commonly seen in premature infants, but equally important to recognize in term infants. Early diagnosis and management is critical to achieving optimal patient outcomes. This report outlines a simulation of the challenging scenario of a term infant presenting to the emergency center with NEC as a result of bacteremia and sepsis due to a urinary tract infection (UTI). This simulation can be used for teaching different levels of learners including novice, intermediate, and advanced. It focuses on the presentation, diagnosis, and emergent management of NEC, and additionally incorporates Pediatric Advanced Life Support (PALS) for more advanced learners.

Family presence during resuscitation in paediatric and neonatal cardiac arrest: A systematic review.

CONTEXT: Parent/family presence at pediatric resuscitations has been slow to become consistent practice in hospital settings and has not been universally implemented. A systematic review of the literature on family presence during pediatric and neonatal resuscitation has not been previously conducted. OBJECTIVE: To conduct a systematic review of the published evidence related to family presence during pediatric and neonatal resuscitation. DATA SOURCES: Six major bibliographic databases was undertaken with defined search terms and including literature up to June 14, 2020. STUDY SELECTION: 3200 titles were retrieved in the initial search; 36 ultimately included for review. DATA EXTRACTION: Data was double extracted independently by two reviewers and confirmed with the review team. All eligible studies were either survey or interview-based and as such we turned to narrative systematic review methodology. RESULTS: The authors identified two key sets of findings: first, parents/family members want to be offered the option to be present for their child's resuscitation. Secondly, health care provider attitudes varied widely (ranging from 15% to >85%), however, support for family presence increased with previous experience and level of seniority. LIMITATIONS: English language only; lack of randomized control trials; quality of the publications. CONCLUSIONS: Parents wish to be offered the opportunity to be present but opinions and perspectives on the family presence vary greatly among health care providers. This topic urgently needs high quality, comparative research to measure the actual impact of family presence on patient, family and staff outcomes. PROSPERO REGISTRATION NUMBER: CRD42020140363.

Pediatric Hospitalist Resuscitation Skills Refresher Training With Pauses for Deliberate Practice.

Introduction Pediatric hospitalists are expected to lead resuscitative efforts for cardiopulmonary arrests, but the infrequency of these events and pediatric advanced life support (PALS) re-certifications are insufficient to maintain skill proficiency.We created a novel resuscitation refresher curriculum for pediatric hospitalists with strategic pauses during simulations for expert and peer coaching of procedural skills. Methods In a tertiary care academic pediatric hospital between September 2018 to June 2019, pediatric hospitalists and fellows voluntarily participated in a series of three quarterly two-hour training sessions taught by expert peer facilitators. Sessions focused on the thirty-second rapid cardiopulmonary assessment and each of the pediatric advanced life support (PALS) algorithms. Scenarios were strategically paused to practice critical hands-on skills. Cases centered on the themes of shock, respiratory, and cardiac emergencies and took place in a high-fidelity simulation lab requiring a technician and expert peer facilitator. Participants anonymously completed Likert scale-based evaluations after each session and again at the end of the year that focused on participants' own perceived change in their comfort levels in performing various resuscitation skills and in knowing basic resuscitation steps. As part of our institutional and personal assessment of the curriculum, an end-of-year survey additionally asked participants to reflect on the overall simulation curriculum and resultant changes in their clinical practice. Results Comfort in all skills practiced across the three sessions increased. The end-of-year survey showed a significant rise in comfort above baseline but some decrements when compared to that immediately post-training. Ninety-six percent of pediatric hospitalists rated the overall quality of the training "better" or "much better" than other resuscitation training (including PALS classes and traditional simulations with skills training after the scenario). The overall effect of the curriculum on perceived knowledge, skills, and confidence levels was significant (p <0.0001). Conclusion Serial resuscitation skills refreshers with expert peer coaching and strategic pauses for hands-on skills practice can result in significant improvements in perceived knowledge and comfort with skill performance as well as the leadership role among pediatric hospitalists.