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.
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
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.
1. "The child didn't have any ST elevations or depressions, so I figured the ECG was OK."
2. "Fontanelle? No, I didn't check her fontanelle."
3. "Sure, I'd love to be the medical director for the AEDs at the local school!"
4. "I gave lots of high-dose epi, because I really wanted this child to make it."
5. "I had no reason to suspect the child was hypoglycemic."
6. "He just kept getting harder to ventilate with each attempt to intubate. I figured he had orrible lung disease or something."
7. "I wanted to know more about what was going on before I called for the transport team."
8. "I called for fresh frozen plasma, but there was a lab delay."
9. "The family just flipped out when I told them their child had died. I couldn't believe it. Most kids like this die."
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."
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.