reviewed in detail by an open, multidisciplinary committee provides an
opportunity to improve. The review process focuses on time to critical events
(completion of primary/secondary survey, vascular access, fluid/med
administration, etc.), adherence to expected protocols, teamwork measures
(including closed loop communication, ambient noise, anticipation of medications
and equipment, etc.), specific role performance, and identification of barriers and
facilitators to care. Specific resuscitation events are chosen for review by a
combination of provider request and identification of the highest-risk scenarios,
including the most complex and least common events. Process and system issues,
educational deficits, and other barriers to protocol-compliant care identified
through the video review process are addressed on an ongoing basis.
Interventions to improve quality of care in the resuscitation room can include
changes in the physical resources available, such as medications, fluids and
equipment, or personnel available. For example, movement of the EZ-IO
introducer and needles to the bed during room preparation prior to patient arrival
can decrease the time to vascular access. Assigning a second senior physician to
supervise CPR and other procedures in resuscitation events requiring CPR, can
decrease the burden on the leader physician and increase protocol compliance
with CPR. Using a Learning Healthcare System model, the continuous collection
of system and care process data in addition to important team- and patient-level
outcomes allows for ongoing identifications of new areas to be addressed and
effects of interventions. Other interventions to improve care may include
simulated resuscitative events to allow for practice of uncommon events and
identification of system and process weaknesses. Multidisciplinary simulations
that occur in the actual resuscitation environment are most likely to maximize
learning and identify latent barriers to care. In addition, participation in video
resuscitation review simulates cognitive decision making for the viewer. Finally,
intermittent group review of important findings from the quality improvement
efforts, targeted group education modules, and personal feedback on given
resuscitation events can support improvements in provider behavior to maximize
protocol adherence and decrease variability in resuscitation care. It is important

that EDs identify a feasible means to monitor resuscitation care and provide
ongoing local quality improvement to insure that optimal care is provided in this
high-stakes, error-prone environment.

ETHICAL ISSUES IN PEDIATRIC CARDIOPULMONARY
RESUSCITATION


There are many ethical issues surrounding pediatric resuscitation: When are
resuscitation attempts futile? Is the ED physician obligated to provide care at the
families’ insistence? How do family religious beliefs play a role in decision
making? What is the role of parental presence? Should procedures be performed
on the recently dead? Can resuscitation research be performed without informed
consent? Some of these issues have been addressed in policy statements made by
professional organizations, but each question needs to be considered in
discussions that occur at the local ED level.
In response to these varied, complex, and often highly charged issues,
postresuscitation debriefing has become a vital component of the pediatric
resuscitation. Consider taking a few minutes for critical reflection following the
completion of the resuscitation event; this has the potential to enhance teamwork
and communication, and provides an opportunity to improve future performance
through group reflection on the shared experience.
KEY POINTS
The vast majority of out of hospital pediatric cardiac arrests (OHCAs)
are asphyxial and both survival and neurologic outcomes are poor.
Recognition of impending respiratory and circulatory failure and
immediate intervention can be truly lifesaving.
VT/VF is estimated to occur in less than 10% of pediatric OHCA.
IO is the preferred access for arrested patients, as well as for patients
with severe hypotension or other severely ill patients where attempt at

IV access is prolonged.
Resuscitation of newly born infants follows an algorithm with notable
differences from that of older infants and children.
Airway management and high-quality chest compressions are the key
resuscitation interventions.
All EDs should have program for continuous quality improvements
around the care of critically ill children.
Strong leadership and teamwork with closed-loop communication are
essential.
EDs should have practice simulations and skills sessions to assure
competency in knowledge and critical resuscitation skills.


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