Coaching in Paediatric Resus

Cite this article as:
Andrew Tagg. Coaching in Paediatric Resus, Don't Forget the Bubbles, 2018. Available at:

Paediatric resuscitation is, thankfully, a rare event. When it happens we want to take every advantage of the training afforded to us and so we often turn to simulation. Any resuscitation can create a feeling of overwhelm, of cognitive overload, and so it makes some sense to offload some of the tasks of the team leader to someone else – a coach.

Cheng A, Duff JP, Kessler D, Tofil NM, Davidson J, Lin Y, Chatfield J, Brown LL, Hunt EA, Nye M, Gaither S. Optimizing CPR Performance with CPR Coaching for Pediatric Cardiac Arrest: A Randomized Simulation-based Clinical Trial. Resuscitation. 2018 Aug 24.


Paediatric health care providers from either the ICU or the Emergency Department from one of the four hospitals involved. They were recruited into teams of five. These were made up of a team leader, an airway person, 2 CPR providers and either a coach or extra provider depending on study arm.


Each group watched a standard orientation video then completed a scenario that included two confederates. They then ran through a standard simulated arrest scenario. The group was made up of leader, airway, 2 providers and a coach.

What is a CPR coach?

The role of coach is an interesting one.  Dr. Betsy Hunt and her team at Johns Hopkins Children’s Centre introduced the concept of a CPR Coach. They stand by the defibrillator and focus on the quality of CPR providing positive reinforcement and encouragement using a number of techniques.

  • Alert team members to CPR feedback device output
  • Provide verbal corrective feedback based on data provided. e.g. press faster, deeper, slower.
  • Reinforce positive performance
  • Coordinate the correct ratio of ventilations to compressions
  • Help reduce peri-procedural pauses in compressions


This was the standard group set up comprised of a team leader, airway person, and 3 bedside CPR providers.


Both groups were run through a complex 18 minute paediatric arrest scenario that progressed from hyperkalemia to pulseless VT then VF and finally to PEA. A CPR feedback device attached to the mannequin and the defibrillator recorded a number of data points.

The primary outcome measure was percentage of overall excellent CPR – defined as appropriate depth AND rate of chest compressions as recommended by the AHA.

The secondary outcome measures included percentage of compressions at the correct depth OR correct rate, the chest compression fraction, the duration of pre-, peri- and post-shock pauses and the mean rate and depth of compressions during each event.



Before we get carried away let’s take a sceptical look at the methodology. This was a prospective, multicentre, randomized control trial and so I’ll use the BEEM RCT critical appraisal device.

1.The study population included or focused on those in the ED.

It certainly did as participants were drawn from both ICU and ED.

2.The participants were adequately randomized.

Participants were randomized by team rather than by individual and was stratified by site. The authors do not mention how this randomization took place.

3.The randomization process was concealed. 


4. The teams were analyzed in the groups to which they were randomized. 


5. The study groups were recruited consecutively (i.e. no selection bias).

How individuals were actually recruited is not mentioned in the paper. Perhaps these willing volunteers were already pretty confident of their skillset in one institution due to a robust training program and were less confident at an alternate site?

6. The members of both groups were similar with respect to prognostic factors.  

Demographic data is provided in table 1. Statistical significance is not reported for any of the variance between groups so I wondered if this might have an impact on outcome measures. What interested me most was the number of female participants in the coaching group (83%) vs the control group (75%) and the number of instructors in each group (18% in the coached group vs 8% in the controls). At first glance these may look like significant differences but they are not.

7. All participants (patients, clinicians, outcome assessors) were unaware of group allocation.

Clearly all of the participants knew if there was a coach in the group. Given that outcome assessment was performed by a machine it is unlikely that it knew.

8. Both groups were treated equally except for the intervention.

CPR coaches received an hour of individual extra training. Given that the focus of this training – on the quality of CPR – was not provided to the control groups then it is possible that they would be less focussed on outcomes. There is also the potential that coaches could have spoken to their teams regarding the training they received given that it was provided up to 48 hours prior to the assessment session.

9. Follow-up was complete (i.e. at least 80% for both groups).


10. All patient-important outcomes were considered. 

This is a simulation study and, as such, can only really tell us how good the team is at trying to bring a piece of plastic back to life. The group have previously looked at translation of simulated practice into real life scenarios.

11. The treatment effect was large enough and precise enough to be clinically significant.

With regard to the primary outcome measure the coached team performed much better than the control group – 63.3% (53.3 – 73.3) excellent CPR compared with 31.5% (21.5-41.5). Breaking down individual elements by looking at the secondary outcome measures there was also a marked improvement across all groups.


My thoughts

All in all this was a well done study that makes me think about how I can utilize the role of CPR coach in both my paediatric and adult practice. The coach in this study used a proprietary feedback device that relayed information to the defib/monitor about both rate and depth of compressions. Is the role still a valid one if such information is not available? Running a paediatric arrest can be very confronting for all involved and the opportunity to cognitively offload even some of the burden seems tempting. We know that the key tenet of effective resuscitation is performing quality CPR and reducing the time off the chest by minimising pauses in compressions. The data suggests that the coach can reduce these pauses and so might be a valuable role even without the feedback device.

In my experience, whenever there is a paediatric arrest staff miraculously appear from out of the woodwork. Nurses, doctors and social workers appear from all over the hospital to help out and perhaps some of these folk could be trained in the coaching role?



COI declaration: I had a wonderful morning with Betsy Hunt on here recent Australian tour when she took a small group of us through the technique.

Where to from here?

Cite this article as:
Team DFTB. Where to from here?, Don't Forget the Bubbles, 2018. Available at:

As #DFTB18 comes to a close in Melbourne the question on everyone’s lips is where to from here. Although it is a lot of work the four of us really love the opportunity to bring Don’t Forget The Bubbles out of the virtual and into the real world.

And so we are excited to announce the world’s worst kept secret….

We have had so many e-mails from our friends in the Northern hemisphere that we thought it was about time we did something for them. So book your leave now.

We’ve already got some amazing keynote speakers lined up and we hope to announce a cracking line up when tickets go on sale in November.


The 21st Bubble Wrap – Live

Cite this article as:
Team DFTB. The 21st Bubble Wrap – Live, Don't Forget the Bubbles, 2018. Available at:

With millions upon millions of journal articles being published every year it is impossible to keep up.  Every month we usually ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye. This time we are doing something different. To coincide with DFTB18 in Melbourne here are the papers chosen by our Bubble Wrap Live! team.

Tell me a story…

Cite this article as:
Team DFTB. Tell me a story…, Don't Forget the Bubbles, 2018. Available at:

“He held up a book then. “I’m going to read it to you to help you relax.”

“Does it have any sports in it?”

“Fencing. Fighting. Torture. Poison. True Love. Hate. Revenge. Giants. Hunters. Bad men. Good men. Beautifulest Ladies. Snakes. Spiders… Pain. Death. Brave men. Cowardly men. Strongest men. Chases. Escapes. Lies. Truths. Passion. Miracles.”

“Sounds okay,” I said and I kind of closed my eyes.”

William Goldman, The Princess Bride

Non-Toxic Exposures

Cite this article as:
Joe Rotella. Non-Toxic Exposures, Don't Forget the Bubbles, 2018. Available at:

Mary had a little taste…

Common non-toxic exposures (and what to expect)

As clinicians, we will occasionally come across someone with a case of Toxicophobia – the fear of being poisoned. In paediatrics, this usually presents in the parents of a little one who has explored their way into something they shouldn’t have. Whilst developmentally normal, it can be hard to tell what to be worried about (and given the last post, there are definitely things to be worried about!). It may seem that something will surely happen (you can blame television for that feeling), but in many cases, a patient is going to be just fine.

Before looking further into the various substances that can cause problems for our young patients, I thought it would be interesting and a bit of fun to talk about some of the non-toxic exposures the Poison Information Centre receives calls about – sometimes on a daily basis. In the instances where patients and their parents find themselves in front of you, it’s useful to know a little about what you needn’t worry about. Or in some cases, only worry about a little…


Topical antiseptics  and hand sanitisers

With all this talk about hand hygiene and killing germs, it’s not surprising that someone would worry about someone getting into one of these.

From a Toxicology perspective, there are two ingredients in these products that can be problematic – the first are quaternary ammonium compounds. A prime example is benzalkonium chloride, found in products such as Dettol. The concentrations for most household products are low (less than 7.5%) and likely to cause GI irritation at best with perhaps a vomit and some diarrhoea so supportive treatment will suffice.

Not surprisingly, deliberate overdoses can be clinically more significant with sequelae including corrosive injury, hypotension, renal injury and aspiration. Hand sanitisers containing alcohol, typically ethanol, and can cause intoxication if a large amount is ingested. In scenarios, where a child has had a taste, lick or swallow, significant toxicity is very unlikely

In the end, Paracelsus still holds true – the dose makes the poison and in the vast majority of these cases, it will not be a problem.


Silica gel packets

Containing sodium silicate to prevent excess moisture build-up and food spoilage, these little white packets are everywhere you look in the pantry. It is not surprising people get worried when they read the warning ‘DO NOT EAT’ all over the packet. Fortunately, silica is non-toxic however; it can be a choking hazard so a medical assessment is recommended if there are any signs suggestive of inhalation (e.g. cough, wheeze).


Dish-washing detergents

Dishwashing detergents contain soaps to help get rid of dirt and grease but luckily not people. Like other household products, they only cause mild GI upset, a ‘scratchy’ throat and aspiration if vomiting occurs.


Toilet bowl cleaners

The usual suspects are the toilet discs (see below). Given their job is to help clean yucky organic matter from the inside of a toilet; these are rather pretty in appearance.

As a parent, I do not know what would horrify me more – my child putting his finger into a disc or into the toilet! Maybe the latter…

These discs contain detergent and perfume but the method of exposure is usually a ‘finger dip’ so minimal exposure occurs. If anything, mild GI upset may occur with a larger ingestion. Important advice for parents is that the next poo might be a more psychedelic colour than usual.  


Glow sticks

I suspect the majority of calls come around New Year’s or Moomba (if you live in Melbourne). Glow sticks glow thanks to an ester called cyalume, which luminesces when mixed with hydrogen peroxide. Some products have a plastic casing that contains an inner glass capsule that when broken allows the cyalume (in the glass capsule) to mix with the hydrogen peroxide (surrounding the capsule). An accidental chew will lead to a bitter taste, a dry mouth and perhaps a vomit with some nausea, but not much else.


Creams and Lotions

Whilst they keep your skin looking healthy and young, eating these will not do much to your insides apart from a GI upset. Some of these contain small amounts of ethanol but normally not enough to cause clinically significant toxicity.


Perfumes, colognes and after-shaves

Similar to creams and lotions, these products are often in reach of little hands. Little people often do not drink much, if any, due to their strong odour and taste. Small ingestions are irritant in nature but larger ingestions can result in ethanol intoxication. However a lot of these products can be 60-80% ethanol and given the taste, it would be a very rare event for a child to swallow enough to become intoxicated.

As these are volatile products, off gassing of fumes can occur and causes a chemical pneumonitis in larger ingestions but the taste and smell of these is such that this is a rare occurrence.



Suddenly I find myself back in high school, swinging from my chair in the back row whilst chatting with friends. The typical patient is a young teenager sucking on a pen. The anticipated adverse effects include discoloration of the tongue, faeces and clothing often with a sense of embarrassment but nothing more.



Whilst we ask you not to forget about the bubbles, I’m happy to add ‘Don’t worry about the bubbles’.  These often contain a soap or mild detergent to produce these clear spheres of pure delight so a drink from a container will result only in GI upset and perhaps some irritation if other parts of the body make contact (e.g. eyes). Not to be confused with the champagne variety.


Don’t forget to check out the other posts in this series…

Special thanks to Jeff Robinson for his review and input



Hammond, K., Graybill, T., Spiess, S. E., Lu, J., & Leikin, J. B. (2009). A complicated hospitalization following dilute ammonium chloride ingestion. Journal of Medical Toxicology, 5(4), 218–222.

Joseph, M. M., Zeretzke, C., Reader, S., & Sollee, D. R. (2011). Acute ethanol poisoning in a 6-year-old girl following ingestion of alcohol-based hand sanitizer at school. World Journal of Emergency Medicine, 2(3), 232–233.

Disclaimer: The information published in this post is for medical education only and does not constitute formal Toxicology advice. The information is current at the time of writing and may change with emerging evidence over time. If you have concerns about an individual who may be poisoned, please call your local Poisons Information Centre (13 11 26 for Australia).

DFTB – Fin

Cite this article as:
Team DFTB. DFTB – Fin, Don't Forget the Bubbles, 2018. Available at:

And so we have come to the end. It has been almost a year to the day since the opening of our first conference in Brisbane. We’ve put out 55 podcasts in total from that great event. The astute amongst you may have noticed some of the talks conspicuous by their absence. Some of the sessions, whilst great if you were there, don;t really fit the podcast format. And so you won’t see Craig Hacking’s radiology session or the fantastic debate of a handful of topic paediatric papers.


There is still time to grab a ticket to DFTB18 if you have not yet done so. Head on over to for more details. And don’t worry, plans are already in place for 2019.

Pulled elbows

Cite this article as:
Tessa Davis. Pulled elbows, Don't Forget the Bubbles, 2018. Available at:

Annie is a 2 year old who has a painful arm. Her mum was holding her hand as she walked along the pavement. Annie tripped and Annie’s mum tried to stop the fall. Since then she hasn’t been using the arm as much.


Thanks to Simon Craig for his post-publication contribution.



The medial and lateral collateral ligaments each hold the humerus and ulna together (one on either side).

The annular ligament hold the radius and ulna together.

In a pulled elbow, the annular ligament slips of the head of the radius and can get trapped in between the radius and humerus. This causes restriction of movement and pain on pronation and supination.

from Wikipedia


If you want to review your anatomy then check out our elbow radiology section.


The mechanism is usually from a pull of the arm e.g. when the child fall down while holding the parent’s hand and the parent tries to stop them falling by pulling the arm.



The child most commonly presents as not using their arm and on assessment has the arm hanging limply by their side. When asked, they may point to distal radius as the point of pain, which can lead us to suspect a buckle fracture. There will be pain on pronation and supination.



There are two main techniques to reduce a pulled elbow.

The first is hyper-pronation. For this technique apply pressure over the radial head, then hyper-pronate the arm.


The second technique is supination-flexion. Again apply pressure over the radial head, supinate the arm, and then flex the elbow (while the arm is still supinated).


A 2017 Cochrane review found low quality evidence that the hyperpronation technique had a better success rate at first attempt reduction that the supination technique (NNT 6).


And as Simon Craig nicely illustrated – the Yin and Yang of pulled elbows:

Failed reduction

Sevencan et al (2015) looked at 66 patients presenting with pulled elbows. 57 were successfully reduced on first attempt. A first attempt successful reduction was more likely in patients presenting within 2 hours of the injury. After two year follow up 24% had recurrence (but they will eventually grow out of it).

After a successful reduction, the child should be using the arm normally within 10-15 minutes. If the reduction fails on the first attempt, then try again using the other technique. If the child is still not using the arm, then get an x-ray.

Sometimes you feel like the reduction was successful (you may have felt a click) but the child is not using the arm normally. This may be because the annular ligament was torn when the elbow was pulled and it may take time to heal. In these cases, put the child in a broad arm sling and review them again in a few days.


Annie’s pulled elbow was successfully reduced on the first attempt using the hyper-pronation technique. Five minutes later she was using her arm normally. She was discharged from ED.

Lyme Disease

Cite this article as:
Emily O'Connor. Lyme Disease, Don't Forget the Bubbles, 2018. Available at:

A nine year old girl, Skye, comes to see you with her parents. She has a two day history of a red, circular and enlarging rash on her right calf, which they describe as looking like a ‘bull’s eye’.  She has also been feeling generally unwell with headaches, muscle aches, fatigue and a fever. They tell you in passing that they came back from holiday, in Scotland, a week ago.

Josh Francis: Paediatrics in East Timor at DFTB17

Cite this article as:
Team DFTB. Josh Francis: Paediatrics in East Timor at DFTB17, Don't Forget the Bubbles, 2018. Available at:

And so we come to the final talk of the final day of DFTB17 in Brisbane.

You can check out any of our other conference talks on our YouTube channel.

Podcast: sleep and airway obstruction

Cite this article as:
Emily Pascoe. Podcast: sleep and airway obstruction, Don't Forget the Bubbles, 2018. Available at:

This month’s Podcast of the Month is from The GP Show.

In a 50 minute podcast – the kid bit is the first 30 minutes – David McIntosh (Ear Nose and Throat Surgeon, Queensland Australia) discusses sleep and airway obstruction in kids, adults and pregnant women; and their impacts on cognition, behaviour and physical health.

Is mouth breathing normal in kids?

If you only concentrate on one podcast this month, make it this one.

Listen to the podcast.