Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.

P-COSCA (Pediatric Core Outcome Set for Cardiac Arrest) in Children: An Advisory Statement From the International Liaison Committee on Resuscitation.

Studies of pediatric cardiac arrest use inconsistent outcomes, including return of spontaneous circulation and short-term survival, and basic assessments of functional and neurological status. In 2018, the International Liaison Committee on Resuscitation sponsored the COSCA initiative (Core Outcome Set After Cardiac Arrest) to improve consistency in reported outcomes of clinical trials of adult cardiac arrest survivors and supported this P-COSCA initiative (Pediatric COSCA). The P-COSCA Steering Committee generated a list of potential survival, life impact, and economic impact outcomes and assessment time points that were prioritized by a multidisciplinary group of healthcare providers, researchers, and parents/caregivers of children who survived cardiac arrest. Then expert panel discussions achieved consensus on the core outcomes, the methods to measure those core outcomes, and the timing of the measurements. The P-COSCA includes assessment of survival, brain function, cognitive function, physical function, and basic daily life skills. Survival and brain function are assessed at discharge or 30 days (or both if possible) and between 6 and 12 months after arrest. Cognitive function, physical function, and basic daily life skills are assessed between 6 and 12 months after cardiac arrest. Because many children have prearrest comorbidities, the P-COSCA also includes documentation of baseline (ie, prearrest) brain function and calculation of changes after cardiac arrest. Supplementary outcomes of survival, brain function, cognitive function, physical function, and basic daily life skills are assessed at 3 months and beyond 1 year after cardiac arrest if resources are available.

[Ethics of resuscitation and end of life decisions]. / Ethik der Reanimation und Entscheidungen am Lebensende: Leitlinien des European Resuscitation Council 2021.

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

[Paediatric Life Support]. / Lebensrettende Maßnahmen bei Kindern (Paediatric Life Support, PLS): Leitlinien des European Resuscitation Council 2021.

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

[Executive summary]. / Kurzfassung: Leitlinien des European Resuscitation Council 2021.

Informed by a series of systematic reviews, scoping reviews and evidence updates from the International Liaison Committee on Resuscitation, the 2021 European Resuscitation Council Guidelines present the most up to date evidence-based guidelines for the practice of resuscitation across Europe. The guidelines cover the epidemiology of cardiac arrest; the role that systems play in saving lives, adult basic life support, adult advanced life support, resuscitation in special circumstances, post resuscitation care, first aid, neonatal life support, paediatric life support, ethics and education.

2018 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the second annual summary of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations that includes the most recent cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation. This summary addresses the role of antiarrhythmic drugs in adults and children and includes the Advanced Life Support Task Force and Pediatric Task Force consensus statements, which summarize the most recent published evidence and an assessment of the quality of the evidence based on Grading of Recommendations, Assessment, Development, and Evaluation criteria. The statements include consensus treatment recommendations approved by members of the relevant task forces. Insights into the deliberations of each task force are provided in the Values and Preferences and Task Force Insights sections. Finally, the task force members have listed the top knowledge gaps for further research.

2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary.

The International Liaison Committee on Resuscitation has initiated a near-continuous review of cardiopulmonary resuscitation science that replaces the previous 5-year cyclic batch-and-queue approach process. This is the first of an annual series of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations summary articles that will include the cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation in the previous year. The review this year includes 5 basic life support and 1 pediatric Consensuses on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Each of these includes a summary of the science and its quality based on Grading of Recommendations, Assessment, Development, and Evaluation criteria and treatment recommendations. Insights into the deliberations of the International Liaison Committee on Resuscitation task force members are provided in Values and Preferences sections. Finally, the task force members have prioritized and listed the top 3 knowledge gaps for each population, intervention, comparator, and outcome question.

Streptococcal pharyngitis in children: to treat or not to treat?

UNLABELLED: Controversy remains about the need for antibiotic therapy of group A streptococcal (GAS) pharyngitis in high-resource settings. Guidelines on the management of GAS pharyngitis differ considerably, especially in children. We performed a literature search on the diagnosis and treatment of GAS pharyngitis in children and compared different guidelines with current epidemiology and the available evidence on management. Some European guidelines only recommend antibiotic treatment in certain high-risk patients, while many other, including all American, still advise antimicrobial treatment for all children with GAS pharyngitis, given the severity and re-emerging incidence of complications. Empirical antimicrobial treatment in children with sore throat and a high clinical suspicion of GAS pharyngitis will still result in significant overtreatment of nonstreptococcal pharyngitis. This is costly and leads to emerging antibiotic resistance. Early differential diagnosis between viral and GAS pharyngitis, by means of a 'rapid antigen detection test' (RADT) and/or a throat culture, is therefore needed if 'pro treatment' guidelines are used. CONCLUSION: Large scale randomized controlled trials are necessary to assess the value of antibiotics for GAS pharyngitis in high-resource countries, in order to achieve uniform and evidence-based guidelines. The severity and the possibly increasing incidence of complications in school-aged children suggests that testing and treating proven GAS pharyngitis can still be beneficial.

Dispatcher-assistance in lay rescuer infant CPR: Promoting the enhancement of the guiding protocol.

In the 2021 guidelines of the European Resuscitation Council (ERC) on infant CPR, a two-thumb encircling technique (TTET) is advised instead of the former two-finger technique (TFT), even for single rescuers. It is however unclear if this is also feasible and effective in case of dispatcher-assisted CPR by untrained bystanders and was explored in a cross-over infant manikin study including CPR-trained students and lay people. Both groups performed the TTET and the TFT, with dispatcher-assistance (according to Belgian protocol) only being provided to the CPR-untrained group. Results suggest it is feasible to advice single lay rescuers to perform TTET as part of a dispatcher-assisted CPR protocol, although we identified an ongoing risk, regardless of the technique advised, of suboptimal compression depth. Further research should be performed to confirm these preliminary data and explore optimal protocols for dispatcher-assisted infant CPR.

Assessing Chest Tube Insertion Skills Using a Porcine Rib Model-A Validity Study.

INTRODUCTION: Assessments require sufficient validity evidence before their use. The Assessment for Competence in Chest Tube Insertion (ACTION) tool evaluates proficiency in chest tube insertion (CTI), combining a rating scale and an error checklist. The aim of this study was to collect validity evidence for the ACTION tool on a porcine rib model according to the Messick framework. METHODS: A rib model, consisting of a porcine hemithorax that was placed in a wooden frame, was used as simulator. Participants were recruited from the departments of surgery, pulmonology, and emergency medicine. After familiarization with the rib model and the equipment, standardized instructions and clinical context were provided. They performed 2 CTIs while being scored with the ACTION tool. All performances were assessed live by 1 rater and by 3 blinded raters using video recordings. Generalizability-analysis was performed and mean scores and errors of both groups on the first performance were compared. A pass/fail score was established using the contrasting groups' method. RESULTS: Nine novice and 8 experienced participants completed the study. Generalizability coefficients where high for the rating scale (0.92) and the error checklist (0.87). In the first CTI, novices scored lower than the experienced group (38.1/68 vs. 47.1/68, P = 0.042), but no difference was observed on the error checklist. A pass/fail score of 44/68 was established. CONCLUSION: A solid validity argument for the ACTION tool's rating scale on a porcine rib model is presented, allowing formative and summative assessment of procedural skills during training before patient contact.

The traumatic impact of motor vehicle accidents in high school students.

OBJECTIVES: To obtain the year prevalence of nonfatal motor vehicle accidents (MVAs) in adolescents, to describe trauma symptoms (posttraumatic stress, depression, anxiety, dissociation), and to test a theoretical model of traumatic events. METHODS: A community-based sample of 3,007 adolescents (mean age: 14.6 years) completed questionnaires regarding MVAs, appraisals, coping, support, and trauma symptoms. RESULTS: Three percent of the adolescents reported being injured in a MVA during the past year. Of the adolescents who reported a MVA in their life (22.4%), 11.0% reported significant posttraumatic stress or other trauma symptoms. Structural equation modeling revealed that negative appraisals mediated the relation between trauma symptoms and MVA severity. Avoidant coping partially mediated the relation between appraisal and trauma symptoms. Social support was associated with less negative appraisals and with more avoidant coping. CONCLUSIONS: Results suggest the need for a better registration of young traffic victims to optimize screening for psychological problems.

Germs, Guns, and Fear in Disaster Response: A Rapid Qualitative Assessment to Understand Fear-Based Responses in the Population at Large: Lessons From Sierra Leone 2014-2015.

We set out to assess the feasibility of community-focused randomized qualitative assessment at the start of an emergency to identify the root causes of fear-based responses driving the pandemic. We used key informant interviews, focus group discussions, reviewing of government and non-government organization documents, combined with direct field observation. Data were recorded and analyzed for key-themes: (1) lack of evidence-based information about Ebola; (2) lack of support to quarantined families; (3) culturally imbedded practices of caring for ill family members; (4) strong feeling that the government would not help them, and the communities needed to help themselves: (5) distrust of nongovernmental organizations and Ebola treatment centers that the communities viewed as opportunistic. On-the-ground real-time engagement with stakeholders provided deep insight into fear-based-responses during the Ebola epidemic, formed a coherent understanding of how they drove the epidemic, presenting an alternative to the standard disaster-response United Nations-strategy, producing community-driven solutions with local ownership.

Lay rescuer use of automated external defibrillators in infants, children and adolescents: A systematic review.

Importance: Automated external defibrillator (AED) use is increasing, but use in children is uncommon. A growing literature of use in children by lay rescuers warrants review. Objective: A systematic review of AED effectiveness in children experiencing out-of-hospital cardiac arrest (OHCA). Data Sources: PubMed, EMBASE, Cochrane Register of Controlled Trials. Study Selection: Children, ages 0-18, experiencing OHCA with an AED applied by a lay rescuer. Control population: children with no AED application. Data Extraction and Synthesis: Results are reported according to PRISMA guidelines. Two authors independently reviewed all titles and abstracts of references identified by the search strategy, then generated a subset which all authors reviewed. Main Outcomes and Measures: Critical outcomes were survival with Cerebral Performance Category (CPC) 1-2 at hospital discharge or 30 days and survival to hospital discharge. Results: Population: age categories: <1 year, 1-12 years, 13-18 years. Lay rescuer AED application resulted in improved survival with CPC 1-2 at hospital discharge or 30 days to hospital discharge in age groups 1-12 and 13-18 years (RR 3.84 [95 % CI 2.69-5.5], RR 3.75 [95 %CI 2.97-4.72]), respectively and hospital discharge in both groups(RR 3.04 [95 % CI 2.18-4.25], RR 3.38 [95 % CI 2.17-4.16]), respectively. AED use with CPR improved CPC 1-2 at hospital discharge and hospital discharge (RR 1.49 [95 % CI 1.11-1.97], RR 1.55[1.12-2.12]). Conclusions: AED application by lay rescuers is associated with improved survival with a CPC of 1-2 at 30 days, and improved survival to hospital discharge for children 1-18 years. There are limited data for children < 1 year.

Assessing competence in Chest Tube Insertion with the ACTION-tool: A Delphi study.

INTRO: Chest Tube Insertion (CTI) should be trained in simulated settings prior to patient contact. Feedback and certification is based on valid assessments, especially in simulation-based training. This study aimed to develop a novel assessment tool for CTI and to ensure content validity based on expert opinion collected through a structured Delphi study. METHODS: A diverse European expert panel was invited to participate. In round 1, the experts provided at least five procedural steps and three errors involved in CTI. Round 2 evaluated the level of agreement with the inclusion of each item in the assessment tool on a five-point Likert scale. In round 3, experts rated their agreement on inclusion of the procedural step with its descriptive anchors. Consensus was reached when ≥80% of participants agreed on an item's inclusion. RESULTS: Thirty-six of 105 (34%) invited surgeons (26/75, 35%), pulmonologists (8/23, 35%) and emergency physicians (2/7, 29%) participated. The overall response rate was 81% (29/36): 100% (36/36) in round 1, 83% (30/36) in round 2, and 97% (29/30) in round 3. Round 1 resulted in 23 steps and 44 errors after condensation and removal of duplicates. In round 2 consensus was achieved for 15 steps (65%) and 14 errors (32%). Nineteen steps were adapted into a rating scale with descriptive anchors and a list of 16 errors was presented to the panel. In round 3, experts reached consensus on the inclusion of 17 procedural steps (89%) with descriptive anchors and on all 16 errors. CONCLUSION: A multidisciplinary expert panel achieved consensus in the development of the ACTION (Assessment of Competence in Chest Tube Insertion) tool. This procedure-specific rating scale of 17 steps, supplemented with a checklist of 16 errors, requires further research to collect validity evidence.

Five vs. two initial rescue breaths during infant basic life support: A manikin study using bag-mask-ventilation.

Background and objectives: Children are more likely to suffer a hypoxic-ischaemic cause for cardiac arrest. Early ventilation may provide an advantage in outcome during paediatric cardiopulmonary resuscitation [CPR]. European Resuscitation Council guidelines recommend five initial rescue breaths [IRB] in infants, stemming from the hypothesis that rescuers might need 5 attempts in order to deliver 2 effective ventilations. This study aimed to verify this hypothesis. Methods: Participants (n = 112, convenience sample) were medical students from the Faculty of Medicine and Health Sciences Ghent University, Belgium. Students were divided into duos and received a 15 min just-in-time training regarding the full CPR-cycle using BMV. Participants then performed five cycles of 2-person CPR. The IRB were given by 1-person BMV, as opposed to a 2-persons technique during the further CPR-cycle. Correct ventilations for the infant were defined as tidal volumes measured (Laerdal® Q-CPR) between 20 and 60 ml, with n = 94 participants included in the analysis. The primary outcome consisted of the difference in the % of medical student duos providing at least 2 effective IRB between 2 and 5 attempts. Results: Off all duos, 55,3% provided correct volumes during their first 2 initial ventilations. An increase up to 72,4% was noticed when allowing 5 ventilations. The proportional difference between 2 and 5 IRB allowed was thus significant [17,0%, 95% confidence interval (5.4; 28.0)]. Conclusion: In this manikin study, 5 IRB attempts during infant CPR with BMV increased the success rate in delivering 2 effective ventilations. Besides, students received training emphasizing the need for 5 initial rescue breaths. This study provides evidence supporting European Resuscitation Council guidelines.

The Incident Management Response of the Emergency Departments in Belgium During the First Wave of the COVID-19 Pandemic.

The COVID-19 pandemic has demonstrated that emergency departments (EDs) need to reorganize their operations rapidly. This study investigated the impact of the pandemic on structural and logistical issues at EDs and the measures taken. Belgian EDs were surveyed on the implemented changes at the start of the pandemic in relation to the 4 S's in disaster medicine: Structure, Staff, Supplies, and System. The study demonstrated that Belgian EDs felt largely unprepared for this pandemic, but nevertheless dynamically restructured their organization. A 46% increase in ED beds was created in different types of structures and more than 50% of all ED beds were reserved for COVID-19 care, but overall the number of patient presentations dropped by 29%. EDs deployed extra personnel, additional training, and psychological support. More than 50% reported an acute shortage of personal protective equipment, and several reported a shortage of ventilatory equipment and medications.

Update on the Coordinated Efforts of Looking After the Health Care Needs of Children and Young People Fleeing the Conflict Zone of Ukraine Presenting to European Emergency Departments-A Joint Statement of the European Society for Emergency Paediatrics and the European Academy of Paediatrics.

This joint statement by the European Society for Emergency Paediatrics and European Academy of Paediatrics aims to highlight recommendations for dealing with refugee children and young people fleeing the Ukrainian war when presenting to emergency departments (EDs) across Europe. Children and young people might present, sometimes unaccompanied, with either ongoing complex health needs or illnesses, mental health issues, and injuries related to the war itself and the flight from it. Obstacles to providing urgent and emergency care include lack of clinical guidelines, language barriers, and lack of insight in previous medical history. Children with complex health needs are at high risk for complications and their continued access to specialist healthcare should be prioritized in resettlements programs. Ukraine has one of the lowest vaccination coverages in the Europe, and outbreaks of cholera, measles, diphtheria, poliomyelitis, and COVID-19 should be anticipated. In Ukraine, rates of multidrug resistant tuberculosis are high, making screening for this important. Urgent and emergency care facilities should also prepare for dealing with children with war-related injuries and mental health issues. Ukrainian refugee children and young people should be included in local educational systems and social activities at the earliest opportunity.

The long-term outcome after severe trauma of children in Flanders (Belgium): a population-based cohort study using the International Classification of Functioning--related outcome score.

Important long-term health problems have been described after severe paediatric trauma. The International Classification of Functioning (ICF) was developed as a universal framework to describe that health. We evaluated outcome in children after 'severe' trauma (defined as: hospitalised >48 h) by means of a questionnaire based on this ICF construct (IROS). Questionnaires were sent to children; one year after this trauma and to 'control' children without any previous 'severe' trauma. We created propensity score-matched pairs (n = 133) and evaluated differences in health perception. IROS characteristics were investigated by means of Item Response Theory models. We then estimated the health state of each individual based on his/her response pattern (factor score z01) and investigated the effect of selected covariates with simple linear regression. Significant odds ratios for differences between matched groups (p < 0.05) were observed for among others emotional problems, mobility, societal life and family burden, but not for chronic pain. Children in the trauma group showed, e.g. significant more physician (estimated relative risk R' 1.7) and psychologist (R' 3.5) visits. IROS primarily provides information from medium to high health burden levels and factor scores ranged from 0.41 (lowest) to 0.967 (highest burden). A significant impact on health burden could only be proven for the 'state at discharge' (p = 0.015), although there was a tendency towards worse factor scores for children that were older, had a higher Injury Severity Score or after traffic injury. In conclusion, we showed that the burden of health problems for children and families after severe trauma is still high and physical, as well as psychosocial in nature. The health state at discharge seems to predict long-term outcome, which might be of importance in view of, e.g. trajectory assistance. IROS may provide an improved scoring system to evaluate outcome after (paediatric) injury or critical illness.

Focused echocardiography, end-tidal carbon dioxide, arterial blood pressure or near-infrared spectroscopy monitoring during paediatric cardiopulmonary resuscitation: A scoping review.

AIM: To evaluate the individual use and predictive value of focused echocardiography, end-tidal carbon dioxide (EtCO2), invasive arterial blood pressure (BP) and near-infrared spectroscopy (NIRS) during cardiopulmonary resuscitation (CPR) in children. METHODS: This scoping review was undertaken as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR) and based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) extension for scoping reviews. PubMed, MEDLINE, CINAHL and EMBASE were searched from the last ILCOR reviews until September 2020. We included all published studies evaluating the effect of echocardiography, EtCO2, BP or NIRS guided CPR on clinical outcomes and quality of CPR. RESULTS: We identified eight observational studies, including 288 children. Two case series reported the use of echocardiography, one in detecting pulmonary emboli, the second in cardiac standstill, where contractility was regained with the use of extracorporeal membrane oxygenation. The two studies describing EtCO2 were ambivalent regarding the association between mean values and any outcomes. Mean diastolic BP was associated with increased survival and favourable neurological outcome, but not with new substantive morbidity in two studies describing an overlapping population. NIRS values reflected changes in EtCO2 and cerebral blood volume index in two studies, with lower values in patients who did not achieve return of circulation. CONCLUSION: Although there seems some beneficial effect of these intra-arrest variables, higher quality paediatric studies are needed to evaluate whether echocardiography, EtCO2, BP or NIRS guided CPR could improve outcomes.