Table of Contents
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Abstract
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Abbreviations Used In This Article
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Critical Appraisal Of The Literature
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Pediatric Out-of-Hospital Cardiopulmonary Arrest
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The Use of AEDs by Minimally Trained or Untrained Individuals
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The Development of AEDs for Children
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Emergency Plans for Elementary and Secondary Schools
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Children
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College Athletes
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Unrealistic Expectations
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Epidemiology, Etiology, Pathophysiology
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Epidemiology
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Etiology
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Pathophysiology
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Differential Diagnosis
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Prehospital Care
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ED Evaluation
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History
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Physical Examination
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Diagnostic Studies Laboratory Studies
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Radiographs and Ultrasound
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Electrocardiogram
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Echocardiogram
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Treatment
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Special Circumstances
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Defibrillating in a Wet Environment
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Controversies/Cutting Edge
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Disposition
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Summary
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Key Points For Out-Of-Hospital Cardiopulmonary Arrest
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Cost-Effective Strategies: Cardiopulmonary Arrest
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Risk Management
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Clinical Pathway: Determining The Need For An AED In A Specific Location
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Tables and Figures
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Locations Of Pediatric Out-Of-Hospital Cardiopulmonary Arrest
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Frequency Of Selected Causes Of Pediatric Out-Of-Hospital Cardiopulmonary Arrest
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Initial Cardiac Rhythm Identified In Children With Out-Of-Hospital Cardiopulmonary Arrest
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Problems To Anticipate After A Child Has A Return Of Spontaneous Circulation
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Age Distribution Out-Of-Hospital Cardiopulmonary Arrest In Children 0-12 Years Of Age
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References
Abstract
PUBLIC health initiatives for children have been tremendously successful in the last few decades. One of the earliest initiatives identified child abuse (nonaccidental trauma) as a public health problem. Legal changes to how children are viewed changed child labor laws and made the physical abuse of children a crime.3-6 In addition, vaccination programs have nearly eliminated conditions that were previously very common in children. Although now mentioned as a possible biological weapon,7 smallpox has been eradicated as a natural disease.8 Polio, measles, mumps, rubella, diphtheria, and tetanus are now very rare in pediatric practice.9-12 The more recent introduction of vaccinations against Haemophilus influenzae type b in the early 1990s and invasive strains of Streptococcus pneumoniae about 10 years later have greatly reduced the number of cases of bacterial meningitis, epiglottitis, septic arthritis, and clinically important bacteremia.13-15 Injury prevention has led to advances in protecting children through the enactment of laws requiring car seats and booster seats,16 as well as bicycle helmets.17 The development of the National Electronic Injury Surveillance System has facilitated the identification and withdrawal of consumer projects that hurt children.18 The development of poison control centers has allowed for detailed data collection and prompt expert advice for managing pediatric ingestions.19,20
More recently, public health measures that are designed to provide prompt defibrillation to adults who have collapsed from a sudden cardiac arrest have shown some benefit.21-28 It is clear that prolonged, basic cardiopulmonary
resuscitation (CPR) without early defibrillation is unlikely to be successful in resuscitating adults who experience cardiopulmonary arrest.29 This concept has been reinforced by the current Advanced Cardiac Life Support (ACLS) recommendation, which states that solo rescuers should "call first" when a pulseless, apneic adult is found.30 Early defibrillation seems to be a key component to increasing the likelihood of a meaningful clinical outcome in cases of cardiac arrest in adults.31 Because of this, efforts have been made to provide early defibrillation to adults who collapse presumably due to cardiac causes.32 Since the first clinical use of automated external defibrillators (AEDs) in 1979,33 refinements in the technology have made it possible for minimally trained individuals to provide prompt defibrillation to adults who collapse in public.23,26-28,34 These efforts have included placing AEDs in high-traffic locations, such as businesses,31,35 airports,34 and casinos.27 These efforts have also included techniques to place AEDs in mobile units likely to be called to the scene of an unconscious individual, such as in police cars,26 with security personnel,27 and with basic emergency medical technicians.28 When AEDs are placed in strategic locations throughout high-traffic public locations, this process is typically referred to as a "public access defibrillation" (PAD).36 PAD programs aimed at adults are intuitively appealing, due to the relatively high percentage of "sudden death" cases from primary cardiac disorders that lead to ventricular fibrillation.37 The results of studies evaluating adult PAD programs suggest that these programs will not be uniformly successful in saving lives.35,38
More recently, AEDs specifically designed for children have been developed, and state laws have been passed mandating that all schools have AEDs in place and ready to use.39,40 Since children don't tend to die from the same conditions as adults, it is not immediately clear whether these pediatric PAD programs will be effective. In this issue of Pediatric Emergency Medicine PRACTICE, I will review pediatric out-of-hospital cardiopulmonary arrest and discuss the utility of pediatric PAD programs based on the available evidence.
Abbreviations Used In This Article
ABCDE — Airway, breathing, circulation, disability, exposure
ACLS — Advanced cardiac life support
ADAM — Automated defibrillation in Adam's memory
AED — Automated external defibrillator
CPR — Cardiopulmonary resuscitation
CT — Computerized tomography or computerized tomographic
DNR — Do not resuscitate
ECG — Electrocardiogram
EMS — Emergency medical services
PAD — Public access defibrillation
SIDS — Sudden infant death syndrome
Critical Appraisal Of The Literature
I have been unable to identify any data directly addressing the effectiveness, human and financial costs, demonstrable benefits, or risks associated with PAD programs for children. As far as I can determine, to date no one has implemented a PAD program aimed specifically at children and reported on the outcome of such a public health initiative. Such a study would, of course, be the most helpful in understanding the issues associated with implementing PAD programs for children. Instead, available studies provide information that indirectly addresses the potential risks, costs, and benefits of implementing pediatric PAD programs. These articles focus on 5 main areas: the epidemiology of pediatric out-of-hospital cardiopulmonary arrest, the use of AEDs by minimally trained or untrained individuals, the development of AEDs for children, emergency plans for schools, and PAD programs.
Risk Management
1. "The child didn't have any ST elevations or depressions, so I figured the ECG was OK."
The main purpose of the ECG in evaluating children who have had the return of spontaneous circulation following an episode of out-of-hospital cardiopulmonary arrest is to check for a long QT interval. Children with long QT intervals are at risk for future episodes of "sudden death." ECG patterns consistent with acute coronary syndromes are exceedingly rare in children.
2. "Fontanelle? No, I didn't check her fontanelle."
If a child has return of spontaneous circulation, identifying a bulging fontanelle suggests increased intracranial pressure.One cause of this is nonaccidental head trauma. A CT scan of the head may identify acute and chronic bleeds supporting the diagnosis of nonaccidental trauma. Although the patient may die from this event, identifying nonaccidental trauma may save her siblings.
3. "Sure, I'd love to be the medical director for the AEDs at the local school!"
Physicians unfamiliar with medical direction are probably wise to take a cautious approach to accepting responsibility for PAD programs. It is unlikely that the malpractice insurance that covers a physician at the hospital will cover other activities like these. State laws seem to vary with regard to legal protections for physicians who provide this service. Investigating the legal implications before accepting such a position is prudent.
4. "I gave lots of high-dose epi, because I really wanted this child to make it."
Intravenous high-dose epinephrine has been shown to offer no advantages compared to standard-dose epinephrine and is no longer recommended.
5. "I had no reason to suspect the child was hypoglycemic."
Critically ill and injured children are unable to feed, have small glycogen stores, and have very large metabolic demands. Hypoglycemia is relatively common in these children. A simple glucose check early in the ED course is typically useful.
6. "He just kept getting harder to ventilate with each attempt to intubate. I figured he had orrible lung disease or something."
Episodes of prolonged bagging can lead to dramatic gastric distension which can, in turn, impair efforts to ventilate the child. A nasogastric or orogastric tube can solve this problem quickly and easily.
7. "I wanted to know more about what was going on before I called for the transport team."
If your hospital does not have a pediatric intensive care unit and does not typically care for mechanically ventilated children, once you decide to intubate a child, put the call out for the transport team. There is no need to delay initiating the process to get the team together and have them startheading your way. You can provide updated information while the team is en route or once they arrive. If you discover that the child needs care that your hospital doesn't provide (eg, pediatric neurosurgery), you will be that much further along in getting the child to the care they need.
8. "I called for fresh frozen plasma, but there was a lab delay."
Fresh frozen plasma is frozen. The lab needs to thaw fresh frozen plasma before it can be administered to a patient. This takes time. Anticipate the need for fresh frozen plasma(particularly in cases of head injuries or liver injuries) forchildren at risk for developing coagulopathies.
9. "The family just flipped out when I told them their child had died. I couldn't believe it. Most kids like this die."
After watching medical dramas on television, families may have unrealistically high expectations (and hopes) of survival. This should be taken into account when talking to the family.
10. "There wasn't a history of trauma. I had no reason to think the child would have an intraabdominal injury and be so anemic."
Unfortunately, the history in cases of nonaccidental trauma might be false. When the story doesn't match the severity of the injuries identified, or if there are bruises on a young infant, nonaccidental trauma is likely. Pursue life-threatening diagnoses known to be associated with nonaccidental trauma.
Tables and Figures
References
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in the paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.
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Pewaukee Schools. Save-A-Life Saturday. Available at: http:// www.pewaukee.k12.wi.us/do/save_a_life.htm. Accessed September 30, 2005. (Web-based newsletter article)
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Children's Hospital and Health System. Community Outreach Programs: Project ADAM. Available at: http://www.chw.org/display/PPF/DocID/6050/router.asp. Accessed September 30,2005. (Web-based, hospital-based review)
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Caffey J. Multiple fractures in the long bones of infants suffering from chronic subdural hematomas. Am J Roentgenol 1946;56:163- 173. (Case report)
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Roche AJ, Fortin G, Labbe J, et al. The work of Ambroise Tardieu:The first definitive description of child abuse. Child Abuse Negl 2005;29:325-334. (Review)
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Kempe CH, Silverman FN, Steele BF, et al. The battered-child syndrome. JAMA 1962;181:17-24. (Case series; 2 cases)
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Lynch MA. Child abuse before Kempe: An historical literature review. Child Abuse Negl 1985;9:7-15. (Review)
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Qutaishat SS, Olson JL. Bioterrorism preparedness: The smallpox vaccine debate. Clin Med Res 2003;1:85-86. (Review)
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Breman JG, Arita I. The confirmation and maintenance of smallpox eradication. N Engl J Med 1980;303:1263-1273. (Review)
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Morgan OW. Following the footsteps of smallpox: Can we achieve the global eradication of measles? BMC Int Health Hum Rights 2004;4:1. (Review)
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Taranger J. Vaccination programme for eradication of measles, mumps, and rubella. Lancet 1982;1(8277):915-916. (Letter)
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Goergens ED, McEvoy A, Watson M, et al. Acute osteoarthritis and septic arthritis in children. J Paediatr Child Health 2005;41:5962. (Retrospective medical record review; 149 cases)
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Scheifele D, Halperin S, Law B, et al. Invasive Haemophilus influenzae type b infections in vaccinated and unvaccinated children in Canada, 2001-2003. CMAJ 2005;172:53-56. (Retrospective database review; 29 cases)
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Kaplan SL, Mason EO Jr, Wald ER, et al. Decrease of invasive pneumococcal infections in children among 8 children's hospitals in the United States after the introduction of the 7-valent pneumococcal conjugate vaccine. Pediatrics 2004;113: 443-449. (Prospective surveillance study; 8 pediatric hospitals)
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Durbin DR, Elliott MR, Winston FK. Belt-positioning booster seats and reduction in risk of injury among children in vehicle crashes. JAMA 2003;289:2835-2840. (Cross-sectional study utilizinginsurance claims and a telephone survey; 4243 children)
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Thompson RS, Rivara FP, Thompson DC. A case-control study of the effectiveness of bicycle safety helmets. N Engl J Med 1989;320:1361-1367. (Case control study; 235 cases and 991 controls)
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Consumer Product Safety Commission. National Electronic Injury Surveillance System. CPSC Document #3002. Available at: http://www.cpsc.gov/cpscpub/pubs/3002.html. Accessed September 30, 2005. (Web-based governmental information site)
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Burda AM, Burda NM. The nation's first poison control center: taking a stand against accidental childhood poisonings in Chicago. Vet Hum Toxicol 1997;39:115-119. (Review)
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Lovejoy FH Jr, Robertson WO, Woolf AD. Poison centers, poison prevention, and the pediatrician. Pediatrics 1994;94:220-224.(Editorial/commentary)
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Caffrey SL, Willoughby PJ, Pepe PE, et al. Public use of automated external defibrillators. N Engl J Med 2002;347:1242-1247. (Prospective observational study; 21 subjects who had nontraumatic cardiac arrest in airports)
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Callans DJ. Out-of-hospital cardiac arrest -- The solution is shocking. N Engl J Med 2004;351:632-634. (Editorial)
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Forrer CS, Swor RA, Jackson RE, et al. Estimated cost effectiveness of a police automated external defibrillator program in a suburban community: 7 years experience. Resuscitation2002;52:23-29. (Case control study; 209 subjects)
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* Hallstrom AP, Ornato JP, Weisfelt M, et al. Public-access defibrillationand survival after out-of-hospital cardiac arrest. N Engl J Med 2004;351:637-646. (Prospective, community-based, multicenter study; 526 out-of-hospital cardiac arrests)
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Marenco JP, Wang PJ, Link MS, et al. Improving survival from sudden cardiac arrest: The role of the automated external defibrillator. JAMA 2001;285:1193-1200. (Structured literature review and meta-analysis; 101 peer-reviewed journal articles)
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Myerburg RJ, Fenster J, Velez M, et al. Impact of communitywide police car deployment of automated external defibrillators on survival from out-of-hospital cardiac arrest. Circulation2002;106:1058-1064. (Case control study; 738 cardiac arrests)
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Valenzuela TD, Roe DJ, Nichol G, et al. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med 2000;343;1206-1209. (Prospective, observational study; 105 subjects)
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van Alem AP, Vrenken RH, de Vos R,et al. Use of automated external defibrillator by first responders in out of hospital cardiac arrest: Prospective controlled trial. BMJ 2003;327: 312. (Prospective, comparative, controlled trial; 469 subjects)
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* Stiell IG, Wells GA, Field B, et al. Advanced cardiac life supportin out-of-hospital cardiac arrest. N Engl J Med 2004;351:647-656.(Prospective, multicenter, controlled trial; 5638 subjects)
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Revisions to CPR-Related Courses. American Red Cross of Central Maryland. Available at: http://www.redcross-cmd.org/Chapter/CPRevisd.html. Accessed September 30, 2005.(Review)
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Jorgenson DB, Skarr T, Russell JK, et al. AED use in businesses, public facilities and homes by minimally trained first responders. Resuscitation 2003;59:225-233. (Telephone survey; 2683 businesses and public facilities and 145 homes)
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Cummins RO, Ornato JP, Thies WH, et al. Improving survival from sudden cardiac arrest: "The chain of survival" concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation1991;83:1832-1847. (Review)
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Diack AW, Welborn WS, Rullman RG, et al. An automatic cardiacresuscitator for emergency treatment of cardiac arrest. Med Instrum 1979;13:78-83. (Prospective pilot study; 21 subjects inventricular fibrillation)
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Page RL, Joglar JA, Kowal RC, et al. Use of automated external defibrillators by a U.S. Airline. N Engl J Med 2000;343:1210-1216.(Prospective, observational study; 200 subjects)
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Groh WJ, Newman MM, Beal PE, et al. Limited response to cardiac arrest by police equipped with automated external defibrillators: Lack of survival benefit in suburban and rural Indiana - The police as responder automated defibrillation evaluation (PARADE). Acad Emerg Med 2001;8:324-330. (Casecontrol study; 388 out-of-hospital cardiac arrests)
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Becker L, Eisenberg M, Fahrenbruch C, et al. Public locations of cardiac arrest. Implications for public access defibrillation. Circulation 1998;97:2106-2109. (Retrospective database review; 1130 cardiac arrests in public locations)
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Zipes DP, Wellens HJ. Sudden cardiac death. Circulation 1998;98:2334-2351. (Review)
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Lerner EB, Billittier AJ, Newman MM, et al. Automated external defibrillator (AED) utilization rates and resons fire and policefirst responders did not apply AEDs. Prehosp Emerg Care 2002;6:378-382. (Retrospective record review; 1025 cases)
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Brown L. Mandating automated external defibrillators in schools: Fire, ready, aim! Can J Emerg Med 2004;6:431-433. (Editorial)
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National Conference of State Legislatures. State laws on heart attacks, cardiac arrest & defibrillators: Encouraging community access and use. November 20, 2004. Available at: http://www. ncsl.org/programs/health/aed.htm. Accessed September 30, 2005. (Web-based review)
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* Mogayzel C, Quan L, Graves JR, et al. Out-of-hospital ventricular fibrillation in children and adolescents: Causes and outcomes. Ann Emerg Med 1995;25:484-491. (Retrospective cohort study; 29 subjects who demonstrated ventricular fibrillation)
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* Sirbaugh PE, Pepe PE, Shook JE, et al. A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric ardiopulmonary arrest. Ann Emerg Med 1999;33:174-184. (Prospective, population-based observational study; 300 children with out-of-hospital cardiopulmonary arrest)
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Brown L. Typographical error alert! In the article by Sirbaugh et al (referenced in number 43), the numbers in Figure 1 do not add up correctly. Under "Noninjury," n = 213. If you add up the numbers from "Rigor" (n = 42), "No ROSC" (n = 149), "Nonsurvival" (n = 7), "Neurologic Deficit" (n= 4), and "No Neurologic Deficit" (n = 1), you get 203 not 213. The authors mention someof these numbers in the text. The 213 is mentioned. The authors mention 6 survivors (1 of whom had sustained an injury or submersion and so is not included in the 213). This supports the "Neurologic Deficit" and "No Neurologic Deficit" numbers. The authors mention 45 patients with rigor mortis in the text. Given that there were 3 cases of rigor mortis in the traumatized group, this supports the "Rigor" number of 42. I think the best way to make the numbers add up is to assume that the authors meant to report that the "Nonsurvival" number is 17, not 7. That would be an easy typographical error to miss. Therefore, this is what I have written in the text. (L Brown, MD, September 28, 2005)
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* Young KD, Gausche-Hill M, McClung CD, et al. A prospective, population-based study of the epidemiology and outcome of out-of-hospital pediatric cardiopulmonary arrest. Pediatrics 2004;114:157-164. (Secondary analysis of a prospectively collected database; 601 pediatric cardiac arrests)
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De Maio V, Stiell IG, Vaillancourt C, et al. Locations of pediatric cardiac arrest: implications for public access defibrillation [abstract]. Prehosp Emerg Care 2004;8(1):80. Presented at the National Association of EMS Physicians, Tucson, AZ, January 2004. (Secondary analysis of an existing database; 268 pediatric cardiac arrests)
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De Maio V, Stiell I, Vaillancourt C, et al. Predicting the utility of public access defibrillation: Why most public access defibrillation programs will not save lives [abstract]. Emerg Med Australasia 2004;16(Suppl):A35. (Secondary analysis of an existing database; 7667 cardiac arrests)
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* De Maio VJ, Stiell IG, Vaillancourt C, et al. The epidemiology of cardiac arrest in schools: limited potential for PAD in a low-risk setting [abstract]. Acad Emerg Med 2004;11(5):607. Presented at the Society for Academic Emergency Medicine, Orlando, FL, May 2004. (Secondary analysis of an existing database; 23 cardiac arrests in elementary or secondary schools)
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Gundry JW, Comess KA, DeRook FA, et al. Comparison of naïve sixth-grade children with trained professionals in the use of an automated external defibrillator. Circulation 1999;100:1703-1707.(Controlled trial involving a simulated cardiac arrest scenario; 15 children and 22 emergency medical technicians)
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Hubble MW, Bachman M, Price R, et al. Willingness of high school students to perform cardiopulmonary resuscitation and automated external defibrillation. Prehosp Emerg Care 2003;7:219- 224. (Convenience sample survey; 683 students)
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Bradley RN, Hamilton WH, Boyle MR, et al. Public access defibrillation programs without training are ineffective. Acad Emerg Med 2003;10(5):502-503. Abstract available at: http://www.aemj.org/cgi/content/abstract/10/5/502-b. Accessed September 30, 2005. (Prospective study of a simulated cardiac arrest in an airport; 30 subjects)
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Cummins RO. From concept to standard-of-care? Review of the clinical experience with automated external defibrillators. Ann Emerg Med 1989;18:1269-1275. (Editorial/Review)
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Gaba DM, Talner NS. Myocardial damage following transthoracic direct current countershock in newborn piglets. Pediatr Cardiol 1982;2:281-288. (Animal study)
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Dahl CF, Ewy GA, Warner Ed, et al. Myocardial necrosis from direct current countershock: Effect of paddle electrode size andtime interval between discharges. Circulation 974;50:956-961. (Animal study)
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König B, Benger J, Goldsworthy L. Automatic external defibrillation in a 6 year old. Arch Dis Child 2005;90:310-311. (Case report)
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* Automated defibrillator cleared for use in infants and children. FDA Consum 2001;35:4. (Review)
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* Knight S, Vernon DD, Fines RJ, et al. Prehospital emergency care for children at school and nonschool locations. Pediatrics 1999;103:e81. (Retrospective record review; 12,603 EMS runs involving school-aged children)
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Allen K, Ball J, Helfer B. Preventing and managing childhood emergencies in schools. J Sch Nurs 1998;14:20-24. (Review)
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Hohenhaus SM. Pediatric emergency preparedness in schools: A report from the 2001 Southeastern regional EMSC annual meeting.J Emerg Nurs 2001;27:353-356. (Review)
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Kyle JM, Leaman J, Elkins GA. Planning for scholastic cardiac emergencies: The Ripley project. W V Med J 1999;95:258-260. (Review)
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Sapien RE, Allen A. Emergency preparation in schools: a snapshot of a rural state. Pediatr Emerg Care 2001;17:329-333. (Questionnaire; 230 school nurses)
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Bobo N, Hallenbeck P, Robinson J. Recommended minimal emergency equipment and resources for schools: national consensus group report. J Sch Nurs 2003;19:150-156. (Review of a consensus group report using a modified Delphi technique)
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Jones J, Hunter D. Consensus methods for medical and health services research. BMJ 1995;311:376-380. (Review)
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* Hazinski MF, Markenson D, Neish S, et al. Response to cardiac arrest and selected life-threatening medical emergencies: The medical emergency response plan for schools. A statement for healthcare providers, policymakers, school administrators, and community leaders. Pediatrics 2004;113:155-168. (Policy statement)
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Hazinski MF, Markenson D, Neish S, et al. Response to cardiac arrest and selected life-threatening medical emergencies: The medical emergency response plan for schools. A statement for healthcare providers, policymakers, school administrators, and community leaders. Ann Emerg Med 2004;43:83-99. (Policy statement)
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Hazinski MF, Markenson D, Neish S, et al. Response to cardiac arrest and selected life-threatening medical emergencies: The medical emergency response plan for schools. A statement for healthcare providers, policymakers, school administrators, and community leaders. Circulation 2004;109:278-291. (Policy statement)
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Letter from H Leon Greene, MD. Re: Yearly Report 2003. June 5, 2003. Available at: http://www.fda.gov/ohrms/dockets/dailys/03/Jun03/061203/95s-0158-rpt0011-01-vol19.pdf. Accessed September 18, 2005. (Letter)
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Coris EE, Miller E, Sahebzamani F. Sudden cardiac death in division I collegiate athletics: Analysis of automated external defibrillation utilization in National Collegiate Athletic Association division I athletic programs. Clin J Sport Med 2005;15:87-91. (Phone survey; 16 athletic departments that had previously reported a sudden cardiac death event at their institution)
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Marco CA, Larkin GL. Public education regarding resuscitation: effects of multimedia intervention. Ann Emerg Med 2003;42:256- 260. (Prospective interventional study; 310 participants)
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Van den Bulck JJM. The impact of television fiction on public expectations of survival following inhospital cardiopulmonaryresuscitation by medical professionals. Eur J Emerg Med 2002;9:325-329. (Questionnaire; 820 secondary school students)
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Kostoulakos NM, Bradley DR. Overestimation of the effectiveness of cardiopulmonary resuscitation. Precept Mot Skills 1997;84:1409-1410. (Survey; 38 respondents)
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Jones GK, Brewer KL, Garrison HG. Public expectations of survival following cardiopulmonary resuscitation. Acad Emerg Med 2000;7:48-53. (Survey; 269 respondents, 67% response rate)
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Lewis RJ. Emergency medicine's "Illusion of Efficacy" and the public perception of resuscitation research. Acad Emerg Med 1999;6:771-772. (Editorial)
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Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television: Miracles and isinformation. N Engl J Med 1996;334:1578-1582. (Researchers watched television shows and recorded the details of fictional cardiopulmonary arrests; 60 fictional, dramatized cardiopulmonary arrests)
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* Sayre MR, Travers AH, Daya M, et al. Measuring survival rates from sudden cardiac arrest: The elusive definition. Resuscitation 2004;62:25-34. (Retrospective database review; 472 cardiac arrests)
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Gordon PN, Williamson S, Lawler PG. As seen on TV: Observational study of cardiopulmonary resuscitation in British television medical dramas. BMJ 1998;317:780-783. (Researchers watched 64 episodes of 3 major British television medical dramas; 52 fictional, dramatized cardiopulmonary arrests)
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Link MS. Mechanically induced sudden death in chest wall impact (commotio cordis). Prog Biophys Mol Biol 2003;82:175-186. (Review)
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Link MS, Maron BJ, Stickney RE, et al. Automated external defibrillator arrhythmia detection in a model of cardiac arrest due to commotio cordis. J Cardiovasc Electrophysiol 2003;14:83-87.(Animal study)
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Link MS, Maron BJ, VanderBrink BA, et al. Impact directly over the cardiac silhouette is necessary to produce ventricular fibrillation in an experimental model of commotio cordis. J Am Coll Cardiol 2001;37:649-654. (Animal study)
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Link MS, Maron BJ, Wang PJ, et al. Reduced risk of suddendeath from chest wall blows (commotio cordis) with safety baseballs. Pediatrics 2002;109:873-877. (Animal study)
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McCrory P. Commotio cordis. Br J Sports Med 2002;36:236-237. (Review)
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Maron BJ, Estes NAM III, Link MS. Task Force 11: Commotio cordis. J Am Coll Cardiol 2005;45:1371-1373. (Consensus report)
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Maron BJ, Gohman TE, Kyle SB, et al. Clinical profile and spectrum of commotio cordis. JAMA 2002;287:1142-1146. (Database review; 128 subjects)
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Nesbit AD, Cooper PJ, Kohl P. Rediscovering commotio cordis. Lancet 2001;357:1195-1197. (Review)
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Valani R, Mikrogianakis A, Goldman R. Cardiac concussion (commotio cordis). Can J Emerg Med 2004;6:428-430. (Review)
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Strasburger JF, Maron BJ. Images in clinical medicine: Commotio cordis. N Engl J Med 2002;347:1248. (Case report)
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