Supraglottic airway devices

Cite this article as:
Jessica Rogers. Supraglottic airway devices, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32780

Endotracheal intubation (ETI) in children is thankfully rare and our first pass success rate could definitely do with some improvement.

It is difficult to compare the efficacy of various advanced airway techniques in children. There are ethical implications, of course, but also marked differences in ages and in the potential aetiology of the arrest. There is often time to talk with the intensive care team and make a plan based on the best airway for that given situation. Similarly, the operating theatre, home of many an airway trial, is a very different environment. We’ll look at advanced airways in cases of cardiac/respiratory arrest. Be mindful there will always be a difference in timing and skill set between out-of-hospital cardiac arrest (OHCA) to in-hospital cardiac arrest (IHCA).

There are few actual studies comparing the advanced airway treatments used during cardiac arrest management in children. There are even fewer studies surrounding the use of supraglottic airways (SGAs) in children. Most of these are observational studies.

ILCOR currently recommends endotracheal intubation (ETI) as the ideal way to manage an airway during resuscitation. They also state that supraglottic airways are an acceptable alternative to the standard bag-valve-mask ventilation (BVM). There are very few clinical trials in children on which these recommendations are based (and certainly none of rigorous design in the last 20 years). Due to this lack of evidence, they commissioned a study as part of the Paediatric Life Support Task Force.

Lavonas EJ, Ohshimo S, Nation K, Van de Voorde P, Nuthall G, Maconochie I, Torabi N, Morrison LJ, DeCaen A, Atkins D, Bingham R. Advanced airway interventions for paediatric cardiac arrest: a systematic review and meta-analysis. Resuscitation. 2019 May 1;138:114-28.


Lavonas et al. (2018) carried out a systematic review and meta-analysis on the use of advanced airway interventions (ETI vs SGA), compared to BVM alone, for resuscitation of children in cardiac arrest. Only 14 studies were identified. 12 of these were suitable for inclusion in the meta-analysis. They were mostly focused on OHCA. There was a high risk of bias and so the overall quality of evidence was in the low to very low range. The key outcome measure was survival to hospital discharge with a good neurological outcome. The analysis suggested that both ETI and SGA were not superior to BVM.

So now, let’s cover some of the literature on the use of supraglottic airway devices. These are mostly based on studies in adults.

The ideal ventilatory device

  • …is easy to set up and insert by anyone so it doesn’t matter what the make-up of the team is
  • …is quick to set up and quick to insert. This reduces the time taken away from other important tasks and allowing that all-important ‘bandwidth’
  • …allows for minimal risk of aspiration
  • …provides a tight seal to allow for high airway pressures if needed
  • …is sturdy enough that the patient cannot bite through it and cut off their own oxygen supply
  • …provides an option to decompress the stomach via the same device
  • …has minimal risk of accidental misplacement or loss of airway once inserted

If this sounds too good to be true, it is. No one device combines all of these essential features. This leaves us deciding which is most suited to the patient in front of us.

sizing chart for supraglottic airway devices
Rather than tape the i-gel to the cheek it is often easier to use traditional tube ties to secure the airway

It is very difficult to compare SGAs with endotracheal tubes (ETT). An ETT is a ‘definitive airway’ that provides protection against aspiration. This does not mean that SGAs are a ‘lesser’ option. An SGA is still an ‘advanced airway’ and more effective than using a bag-valve-mask technique. It is important to remember that advanced airways have their pros and cons. Whilst they may improve a patients’ likelihood of survival with good neurological recovery, there can be associated complications.

Table showing advantages and challenges of bag-valve mask compared to supraglottic airway devices

The science behind supraglottic airways

So what does the science say? There are few trials in children but there have been several seminal papers released on advanced airway techniques in adults. Whilst not directly related to children, they do raise some interesting points of comparison between devices.

Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H. Effect of a strategy of a supraglottic airway device vs tracheal intubation during out-of-hospital cardiac arrest on functional outcome: the AIRWAYS-2 randomized clinical trial. Jama. 2018 Aug 28;320(8):779-91.

This multicentre, cluster randomised trial, was conducted by paramedics across four ambulance services in England. It compared supraglottic devices to tracheal intubation in adult patients with OHCA looking at their effect on functional neurological outcome. This study only included patients over the age of 18. They found no statistically significant difference in 30-day outcome (the primary outcome measure) or in survival status, rate of regurgitation, aspiration or ROSC (secondary outcomes). There was a statistically significant difference when it came to initial ventilation success. Supraglottic airways required less attempts, but their use also lead to an increased likelihood of the loss of an established airway

So what does this mean? The main concern that gets bandied around when discussing SGAs is the higher risk of aspiration. If there was no difference in risk, would that change your mind?

Jabre P, Penaloza A, Pinero D, Duchateau FX, Borron SW, Javaudin F, Richard O, De Longueville D, Bouilleau G, Devaud ML, Heidet M. Effect of bag-mask ventilation vs endotracheal intubation during cardiopulmonary resuscitation on neurological outcome after out-of-hospital cardiorespiratory arrest: a randomized clinical trial. Jama. 2018 Feb 27;319(8):779-87.

This was a multicentre, randomised clinical trial in France and Belgium looking at OHCA over a 2-year period. Again this study enrolled adults over 18 years old. They looked at the non-inferiority of BVM vs ETI with regard to survival with favourable neurological outcome at 28 days. Responding teams consisted of an ambulance driver, a nurse and an emergency physician. The rate of ROSC was significantly greater in the ETI group but there was no difference in survival to discharge. Overall, the study results were inconclusive either way.

If survival to discharge is unaffected, should we all be spending time training and maintaining competency or should endotracheal intubation be kept only for those who practice it regularly in their day job?

Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JC. Effect of a strategy of initial laryngeal tube insertion vs endotracheal intubation on 72-hour survival in adults with out-of-hospital cardiac arrest: a randomized clinical trial. Jama. 2018 Aug 28;320(8):769-78.


This cluster-randomised, multiple crossover design was carried out by paramedics/EMS across 27 agencies. It looked at adult patients receiving either laryngeal tube or endotracheal intubation and survival at 72 hours. Again, they only included adults over 18 with non-traumatic cardiac arrest. They found a ‘modest but significant’ improved survival rate in the LMA group and this correlated with a higher rate of ROSC. Unfortunately, this trial included a lot of potential bias and the study design may not be robust enough to back up the level of difference.

Could the survival rate be explained by first-pass success and less time spent ‘off the chest’ during initial resuscitation? No study is perfect. Always critically appraise for yourself and check if study results are applicable to your local population and own practice before changing anything.

More questions than answers

After reading the science (and please do go take a deeper dive into those papers and appraise them for yourselves), let’s tackle some common queries.

SGAs are so easy you can just whack it in and done!

No. Getting the SGA in is only the first step. Even then, you need to be sure you have picked the appropriate size and assessed for leaks. SGAs are much more likely to become dislodged and lead to an unexpected loss of airway. Generally, we are not as meticulous about securing them as we should be. Ideally, use a tube tie to secure it in place and monitor the position (in relation to the teeth). Some SGAs have a black line on the shaft that should line up with the incisors (beware this may only be present in the larger sizes). Just like ETTs, they require you to check for adequate ventilation via auscultation, ETCO2 and listening for an obvious leak.


It’s okay if there is a leak at the start as the gel will mould as it heats up

No. There is no evidence to suggest the shape of i-gels (this is usually the model clinicians are referring to in this instance) will mould to the inside of the larynx. Researchers have tried heating up the material and there is no statistical change in the leak. If you do have a significant leak, consider re-positioning, swapping out for a different size or using a different model. You may find a small leak that disappears over time. Over time, the airway jiggles around and sits better.


You should always decompress the stomach when you put in an LMA

Possibly. This is not routinely found in guidelines as it is seen as more of a fine-tuning procedure. It can take time and resources away from other critical tasks (such as chest compressions, IV access, optimal ventilation) but if you have the resources to do so, without affecting the basics of good resuscitation care, then it is a good option if ventilation is not as optimal as it could be. This is particularly important in children. We know that they are at higher risk of diaphragmatic splinting from overzealous ventilation so the early insertion of a nasogastric tube can really improve things.

Laryngoscopy should be used before every SGA insertion

Possibly. Some places have started to mandate laryngoscopy because they have missed obstruction by a foreign body, or to allow better suctioning and improve the passage for insertion. There is an argument that the SGA may sit better if inserted with the aid of a laryngoscope as, in a number of cases, it hasn’t been inserted deeply enough. Laryngoscopy is a complex skill, that takes regular practice and comes with its own challenges (damage to mouth/teeth, additional time taken, higher skill set needed).

Once inserted, SGAs can be used alongside continuous chest compressions

Possibly. This really needs to be considered on a case-by-case basis. SGAs are an advanced airway and can be used with continuous chest compressions to increase cerebral perfusion pressures. It is up to the individual clinician to monitor and decide if the ventilatory support they are giving is adequate during active compressions. In cases where the arrest is secondary to hypoxia (as in many paediatric arrests) it may be easier, and more useful, to continue with a 30:2 or 15:2 ratio to ensure good tidal volumes are reaching the lung. Some studies have shown little difference comparing the 30:2 approach to continuous ventilation.

Troubleshooting

This is the same in both SGAs and ETTs.

  • Patient issues – vomit, secretions, bronchospasm, position, change in intrathoracic / intrabdominal pressures, and in SGAs there is a risk the epiglottis has moved and is covering the opening of the device
  • Device issues – position, size, biting/kinking of an ETT
  • Equipment issues – ventilator settings, connections, oxygen supply

Remember, if you are really struggling, take a second to consider if you might be in a “can’t intubate, can’t ventilate” type of situation. Check out this article, which takes a closer look at this rare scenario.

The bottom line is, we just do not know what is best in our paediatric population. Due to lack of scientific evidence, we often have to rely more on operator skill, available equipment and previous experience.

Selected resources on supraglottic airways

Check out the ‘Roadside to Resus: Supraglottic airways’ podcast from The Resus Room

PHEMcast also have podcasts on ‘The LMA’ and ‘The collapsed infant’

The 49th Bubble Wrap

Cite this article as:
Currie, V. The 49th Bubble Wrap, Don't Forget the Bubbles, 2021. Available at:
https://dontforgetthebubbles.com/the-49th-bubble-wrap/

With millions upon millions of journal articles being published every year it is impossible to keep up.  Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.

Article 1: The associations between initial serum pH value and outcomes of paediatric out-of-hospital cardiac arrest

Okada A, Okada Y, Kandori K, Nakajima S, Okada N, Matsuyama T, Kitamura T, Hiromichi N, Iiduka R. Associations between initial serum pH value and outcomes of pediatric out-of-hospital cardiac arrest. Am J Emerg Med. 2021 Feb;40:89-95. doi: 10.1016/j.ajem.2020.12.032. Epub 2020 Dec 17. PMID: 33360395.

What’s it about? 

This paper reviewed the association between initial pH, obtained via intra-arrest VBG, and patient outcomes to evaluate if pH can be used to prognosticate in paediatric out of hospital cardiac arrest.

The authors reviewed a large, multicentre, prospective register of out-of-hospital cardiac arrests in 87 hospitals in Japan. They included paediatric out-of-hospital cardiac arrest patients younger than 16 between June 2014- December 2017 (458 patients included in the analysis – however over 35,000 listed in the registry). The primary outcome was 1-month survival. They divided the patients into four groups (based on initial pH on blood gas) and compared this to the patient’s ultimate outcome.

Interestingly, the median age of the patients was one year of age. Just over 6 in 10 of the patients were male. In 7 out of 10 patients, the first monitored rhythm was asystole. Cardiogenic arrest occurred in 4 out of 10 patients.

Mortality, and survival with good neurologic function, were lookd for. The overall survival rate at one month was just over 1 in 10 patients. In the group with pH > 6.82 survival rate was around 4 in 10 patients. However, with a pH< 6.47, thesurvival rate was 1 in 100 patients.

Of particular interest, in the entire study population of 458 patients, there were no patients who survived with good neurological function with a pH <6.8.

Why does it matter? 

Deciding when to stop resuscitation in a paediatric cardiac arrest can be difficult. Guidance is sparse and there are no universally recommended measures to help providers decide when to stop resuscitative measures. This is a stark contrast to adult cardiac arrest management where there are many validated termination of resuscitation rules based on measurements such as end-tidal CO2 s.

This is the first study to assess the association between pH and prognosis in paediatric out-of-hospital cardiac arrest. It presents robust evidence to support an objective, easily obtained measure that can be used to assist decision making around the termination of resuscitation. Important exclusions in this study were patients where resus was not attempted at a hospital, unknown age, traumatic or arrest secondary to hanging and those with no pre-hospital data.

This is an exciting paper providing guidance in an area sorely lacking any previous data. It gives providers a valuable tool that can substantially assist when making a difficult decision.

Clinically Relevant Bottom Line:

In out of hospital paediatric cardiac arrest, according to this study, no patients with a pH <6.8 survived with a neurologically favourable outcome. Survival in general was significantly lower in patients with an initial pH <6.8.

Reviewed by: Sean Croughan

Article 2: Should we be using focused cardiac ultrasound to guide therapy in children with sepsis?

Arnoldi s, Glau CL et al. integrating focused cardiac ultrasound into Pediatric septic shock assessment. Pediatr Crit Care Med. 2021 mar 1;22(3):262-274

What’s it about? 

This paper looks at whether the integration of FCU (focused cardiac ultrasound) in clinical assessment of children with sepsis would alter clinician’s evaluation of their haemodynamic characteristics.

The authors conducted a retrospective, observational study from January 2014 – December 2016 in a large PICU in America. They reviewed 74 PICU patients who received FCU within 72 hours of sepsis pathway initiation. Assessment by clinicians prior to FCU was compared to assessment after FCU in 46 patients, to determine if there was a difference in the haemodynamic characterisation of patients.

They demonstrated that incorporation of FCU changed the clinician characterisation of haemodynamic assessment made prior to FCU in more than 2 out of 3 of cases. The most common new finding identified post-FCU was myocardial dysfunction in (7 out of 22) cases. The most commonly ruled-out physiologies by clinician after FCU performance were obstructive physiology (5 in 8 cases), fluid responsiveness (13 in 26 cases).

Why does it matter? 

Sepsis in children continues to be one of the leading causes of mortality and morbidity worldwide.  Most children who die of sepsis suffer from refractory shock and/or multiple organ dysfunction within the initial 48 -72 hours of treatment, thus demonstrating the need for early and targeted interventions.

The previous method of classifying patients as having either ‘warm shock’ or ‘cold shock’ to guide therapy has been demonstrated to have poor correlation with cardiac function and systemic vascular resistance, and has not led to improved outcomes. It is now recommended that more advanced techniques such as focused cardiac ultrasound (FCU) be used alongside clinical assessment to identify haemodynamic status and direct therapy.  This is already widely the case in adult practice and algorithms have been created for its integration into patient management. 

Although this is a small study, it makes us think about the use of cardiac ultrasound alongside clinical assessment of children with sepsis in order to understand the haemodynamic characterisation of these patients.

This may be particularly useful in relation to fluid responsiveness, as half of the children who were thought to be fluid responsive pre-FCU, were found not to be after a FCU was performed. We know that children with sepsis often receive significantly more fluid per kilogram than adults which is associated with worse outcomes.

Clinically Relevant Bottom Line:

FCU, when incorporated into shock assessment, has the potential to identify myocardial dysfunction earlier and could result in reduced fluid administration as well as more targeted therapy based on haemodynamic status. However, further work is needed to determine how this can be used within paediatric practice.

Reviewed by: Laura Duthie

Article 3: Don’t forget the planet

Di Cicco, M.E., Ferrante, G., Amato, D., Capizzi, A., De Pieri, C., Ferraro, V.A., Furno, M., Tranchino, V., La Grutta, S. (2020) Climate Change and Childhood Respiratory Health: A Call to Action for Paediatricians. Int J Environ Res Public Health, Vol 24;17(15):5344

What’s it all about?

The authors conducted a systematic review looking at papers which examined the connection between respiratory illnesses in children aged 0 – 18 years. Keywords used separately and in combination were (allergic rhinitis, rhinitis, asthma, bronchitis, pneumonia, infections) and key environmental phrases (climate change, pollution, particulate matter, ozone, nitrogen dioxide, allergen, pollen). There was no limitation on the date of paper or country of origin.

Whilst much of the research at this stage is not completely conclusive key points from the review include:

  • Several studies from different countries found a connection between the increased prevalence of rhinitis and asthma, as well as the frequency of symptoms with increased global temperatures, which has changed many plant species’ lifecycles and led to longer pollen seasons
  • Positive correlations between the incidence of pneumonia and other acute respiratory tract infections in the context of increased extreme weather events such as heatwaves, fires and floods
  • Positive associations between the increased relative humidity and increased activity of respiratory viruses such as respiratory syncytial virus

Why does it matter?

Climate change is the long-term shift in weather conditions (temperature, humidity, winds and extreme weather events) and is often talked about in regards to protecting our wildlife or preventing further damage to our oceans and forests. It is less talked about when considering the impact on our own health. A child born in 2020 will live in a world that is more than 4 degrees warmer than the pre-industrial average, and subsequently will be at greater risk of a variety of acute illnesses as well as long term health consequences.

The Bottom Line:

More research needs to be done to accurately define the burden of climate change on our health. In the interim, we can all be environmental champions, from making changes in our own lives to reduce our carbon footprint as well as educating and influencing our colleagues and patients to do the same.

 …And for those with spare time; conducting research into the direct effects of climate change on specific health conditions along with contributing to government policies to create change at a higher level and reducing the carbon footprint of our healthcare systems are excellent places to start! 

Reviewed by: Tina Abi Abdallah

Article 4: Domo arigato, Mr Roboto

Littler BKM, Alessa T, Dimitri P, et al Reducing negative emotions in children using social robots: systematic reviewArchives of Disease in Childhood  Published Online First: 08 March 2021. doi: 10.1136/archdischild-2020-320721

What’s it about?

The paper looks at a number of studies that have used social robots in paediatric outpatient settings to interact and provide multi-sensory experiences to patients. The author postulates that using social robots provides better interaction and distraction for children, thus reducing anxiety and distress during the visit.

This systematic review managed to find ten studies that used social robots ranging from humanoid-based robots to ones simulating toy bears, dinosaurs and seals. The robots interact verbally and physically, and can respond to patient cues and tactile stimulation. They were used before or during the intervention. The studies included randomised controlled trials, exploratory trials, pilot and an observational study, with patient numbers varying from 2 to 73 (320 in total).

Why does it matter?

For lots of children a visit to the hospital can be a stressful and anxiety inducing event. There has been research to suggest that social robots have a positive impact on supporting adults with dementia and in children with autism they have been a useful tool in conducting therapy. The outcomes of this study were measured by observation, and by recording levels of distress, anxiety, pain and emotion using a variety of behavioural questionnaires. Overall, the feedback from the studies showed positive engagement from patients with their robots, reducing negative emotions, distress and pain.

The bottom line

There is promising data to suggest that robots may improve the experience of children in the healthcare environment. However, the evidence is weak due to the nature of the studies, lack of uniformity in the measurements, and low patient numbers. More research is needed on this topic to be able to really change practice but this sci-fi intervention may well become a reality in the not so distant future.

Reviewed by: Laura Riddick

Article 5: Children visiting the Paediatric emergency department during Ramadan

Sawaya,R., Wakil, C., et al (2021) Pediatric emergency department utilisation during Ramadan: a retrospective cross- sectional study. Archives of Disease in Childhood 2021;106:272-275.

What’s it about?

 This study looks to investigate the impact of Ramadan on patient characteristics, diagnoses and metrics in the paediatric emergency department (PED). There is limited data on how Ramadan impacts paediatric ED’s.

Why does it matter?

The authors looked at patient and illness characteristics as well as PED metrics including peak patient load, presentation timings, length of stay, time taken to order tests, receive samples and reporting of results to see how these were affected during the months of Ramadan and those before and after. 

This is a retrospective cross-sectional study on paediatric patients from 0 – 18 years presenting to a PED tertiary centre in Lebanon. Data was collected from all PED visits with any complaint at any time during Ramadan and the months (30days) before and after in 2016 and 2017. A bivariate analysis was performed between the Ramadan and non-Ramadan groups. The main outcomes were illness severity, chief complaints, final diagnoses, PED metrics including peak patient load, presentation timings, length of stay, and PED efficiency metrics such as time to order tests, times to samples being received and reported. 5711 patients were included and 1672 of these presented during Ramadan. There was no significant difference between age, gender or illness severity between the Ramadan or non-Ramadan group. This study found a significant difference in the number of GI complaints during Ramadan (39%) compared with the non-Ramadan group (35%). 

Trauma related complaints increased during Ramadan (3 in 100) vs (2 in 100) in non-Ramadan periods. Especially during the non-fasted periods of Ramadan (4 in 100) vs (2 in 100) during the fasted period of Ramadan. The number of daily visits during Ramadan (28.3) was reduced compared with non-Ramadan attendances (31.5). The Ramadan group did not have to wait longer for tests to be ordered or to have samples collected. 

This study was a single centre- and the charts that were reviewed did not have information on the patients individual fasting status. This would be interesting to see if the patient’s individual status affected diagnosis. The team used months immediately before and after Ramadan to reduce the confounding effects of seasonal bias.

Clinically Relevant Bottom Line:

This study revealed that there were some changes in GI and trauma presentations during the Ramadan period. There was also a reduction in cases presenting in this centre- this could help to influence staffing during this time if the patient population reflected that of the population in this study.

Reviewed by: Vicki Currie

If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments!

That’s it for this month. Many thanks to all of our reviewers who have taken the time to scour the literature so you don’t have to.

All articles reviewed and edited by Vicki Currie

Post ROSC care

Cite this article as:
Costas Kanaris. Post ROSC care, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29109

Or some pointers on clinical management following the successful return of spontaneous circulation in children. 

It’s 5:40 am at Bubblesville ED. The red phone rings. The paramedic crew informs you that they are five minutes away with a 7 kg, 6-month-old, previously thriving, baby boy called Tarquin. He has had a witnessed out of hospital cardiac arrest at home and there was no prodromal illness according to the family. He choked during a breastfeed, turned blue, and stopped breathing. He had 5 minutes of CPR by the parents by the time the ambulance arrived and had ROSC by the paramedic team after a further 8 minutes. The rhythm strip was consistent with a PEA arrest. They are hand-ventilating him through an LMA.

This is his capillary gas on arrival in the ED
  1. What are your clinical priorities?
  2. What clinical problems do you anticipate in the immediate post-arrest phase?
  3. Who do you call for help?
  4. What do you do with the family whilst you’re managing the patient?
  5. What investigations do you need?

A systematic, collaborative, well-led approach to advanced paediatric life support can maximize the chances of the clinical team achieving a return of spontaneous circulation in a child that has arrested. We’ve seen the drill be before. We can go through our algorithms expertly and the 5-H’s and 5-T’s roll off the tongue, even under duress. The return of a pulse is heralded as the “hallelujah moment”, almost as if the patient is now healthy and safe and all we have to do is wait for the paediatric critical care retrieval team to arrive.

Whilst traditional APLS teachings are vital for the dissemination of knowledge and it’s application in everyday clinical life, their main focus is on the initial phase of achieving a pulse with very little attention placed on the all-important post-resuscitation phase.  This part of care is crucial, not only if we are to minimize secondary brain injury to the child but also to improve the chances of permanent returns of spontaneous circulation. Good short and long term outcomes rely heavily on how well we manage the post-resuscitation stage. 

There are four phases of cardiac arrest:-

Phase one: Prevention. This is the pre-arrest phase. Child safety and injury prevention strategies are in place to recognize deterioration. Adequate monitoring by using early warning systems and a pro-active approach to management is likely to contribute to avoiding an arrest.

Phase two: No flow arrest. This is a period of cardiac arrest prior to us commencing CPR. Our aim here is to minimize the time it takes to start life support. It is key that we involve the cardiac arrest team quickly, we start chest compressions early, and that we do not delay defibrillation if this is needed. 

Phase three: Low flow resuscitation. This phase describes when CPR is in progress. The aim is to achieve high-quality CPR in order to allow adequate coronary and cerebellar perfusion. Maintaining good ventilation and oxygenation whilst avoiding aggressive over-ventilation is paramount. It is during this phase that we systematically approach and threaten the reversible causes of cardiac arrest. 

Phase four: This is the post-resuscitation phase after ROSC has been achieved. Our aim here is to optimize coronary and cerebral perfusion. Neuroprotection and treatment of arrhythmias as well as treatment of post-cardiac arrest syndrome come under this phase. 

Adult v paediatric arrest: What’s the difference?

Out of hospital cardiac arrests in children >16 years of age are relatively rare – reported at 8-20/100000/ year. The incidence is only comparable to that of the adult population, estimated at 70/100000/year. The incidence of in-hospital paediatric arrests is much higher, with a nearly one-hundred-fold increase, compared to the out-of-hospital incidence for the <16’s. 

Survival, and especially a “good” survival from a neurological perspective still remain poor. Out of hospital survival rates are estimated to be 5 – 12%. Only 0.3 to 4% of those that survive have no long-term neurological insult.

Children have cardiac arrests due to severe respiratory insult or circulatory collapse, in the main. Either can lead to a respiratory arrest coupled with hypoxia, which then results in a cardiac arrest. The overwhelming majority of cardiac arrests present with a non-shockable rhythm.  It is also worth noting that almost half of the paediatric population that have a cardiac arrest have other chronic comorbidities such as respiratory conditions e.g. asthma, congenital cardiac disorders, or neurodisability. 

In the adult population, cardiac arrest is more likely due to long-term comorbidities such as ischaemic heart disease. This contributes to the development of an acute myocardial insult and (usually) a shockable rhythm. Understanding the difference in pathology leading to a cardiac arrest between adults and children is vital. Reversing the cause of the respiratory compromise can make the impalpable pulse palpable, allowing us to perfuse our patient once again. 

The recommended CPR ratio of 15:2 for children aims to provide adequate ventilation for oxygenation as well as satisfactory cardiac compressions to maintain sufficient perfusion of the coronary and cerebral circulation. Adult studies looking at compression-only CPR in patients with VF arrest have shown that success in achieving ROSC is due to pre-existing pre-arrest aortic blood oxygen and pulmonary oxygen stores.  As a mere 14% of cardiac arrests are due to a shockable rhythm, combining ventilation and compressions is vital. 

What is the Post Cardiac Arrest Syndrome (PCAS)? 

PCAS describes the period in which our patients are at the highest risk of developing ventricular arrhythmias and reperfusion injuries after ROSC. This is secondary to prolonged ischaemia then reperfusion of vital organs, primarily the myocardium and central nervous system. Its systemic effects are not dissimilar to those encountered in severe sepsis. There are four stages to PCAS:

  • Immediate post-arrest – First 20 minutes. 
  • Early post-arrest – 20 minutes to 6-12 hours. 
  • Intermediate phase – 6-12 hours up to 72 hours.
  • Recovery phase – From 72h onwards. 

Neuroprotection

Even high-quality closed-chest CPR can only achieve 50% of normal cerebral blood flow at best. It is not a secret that the brain does not tolerate hypoxia or ischaemia, the effects on both of these processes are exponential during a cardiac arrest, the longer the downtime, the worse the neurological hit

The pathophysiological cascade for neurodegeneration following cardiac arrest is complex and multi-factorial. Following a hypoxic or ischaemic period the brain develops cerebral oedema and cerebral hyperaemia. There is impaired cerebral vascular reactivity and like any other organ trying to reperfuse, the post-ischaemic biochemical cascade is activated. All these factors contribute to a secondary brain injury. Of course, the duration of hypoxia will in large part dictate how severe the primary brain injury is and whether the patient is likely to survive or not. Brain injury can manifest as myoclonus, stroke, seizures, coma, or brain death. 

We can minimize the extent of secondary brain injury with simple proactive, neuroprotective measures:

  • Strict normothermia
  • Aggressive seizure prophylaxis
  • Avoiding hypoxia and hyperoxia
  • Tight circulatory monitoring and support
  • Patient position
  • Eucapnia and normoventilation
  • Vigilant glucose monitoring
  • Frequent neurological assessment, especially before the administration of anaesthetic agents and paralysis

Strict normothermia

Therapeutic hypothermia following a cardiac arrest during the intermediate phase (after VF in adults), as well as newborns with birth asphyxia, has shown some correlation with better neurological outcomes and reduced neurodisability.  Similarly, there is strong evidence linking core temperature above 38° with worse neurological outcomes in patients following cardiac arrest. There is a wide variation in practice in relation to therapeutic hypothermia.  Mild hypothermia after paediatric cardiac arrest is in the policy of some PICU’s. Patients are cooled to 33-34°C for 1 – 2 days and are then gradually rewarmed. Paralysis can be used as an adjunct to stop shivering. Temperatures below 32°C should be avoided as they are associated with worse survival, immunosuppression, arrhythmias, coagulopathies, and infections.  The decision to “cool” must be made early and in conjunction with your critical care transport team. You have many tools at your disposal to achieve this such as cold IV fluids, cooling blankets, and catheters. 

What is, and should be, more aggressively targeted is strict normothermia (temperatures between 36-37°C), and depending on local practice hypothermia can be targeted to 33-36°C. Avoidance of pyrexia is crucial. Fever can result in an increased metabolic demand of the brain. This contributes to more ischemic injury and more infarcts as the threshold for ischemia in the injured brain is lower than that of the normal brain. The brain can no longer auto-regulate the mismatch between cerebral blood flow and metabolic demand.

Aggressive seizure prophylaxis

Seizures after paediatric cardiac arrest can occur in up to 47% of cases. 35% of these can lead to refractory status epilepticus.  Whilst CFAM/EEG monitoring is unlikely to be available in your local PED, it is important to have a low threshold to administer a long-acting anti-epileptic or a continuous infusion of a short-acting medicine to prevent/avoid this from happening. Ideally, a continuous infusion of midazolam +/- levetiracetam (less arrhythmogenic than phenytoin but both will work) and standard national guidelines should be followed. 

Clues as to whether a patient is still fitting include:

  • Unexpected changes in the pupillary size (beware of the child that had atropine on induction with the “fixed dilated pupils”).
  • Sudden changes in BP or heart rate.  

If you have given a paralytic for intubation, do not fall into the trap of thinking that the patient is not seizing, only an EEG or CFAM can tell you that. It is better to err on the side of caution.

Avoiding hypoxia and hyperoxia

Avoiding hypoxia and hyperoxia are also key components in minimizing secondary brain injury.  Whilst hypoxia will further exacerbate secondary brain injury, hyperoxia  (PaO2 > 40 kPa) is also be associated with worse survival due to oxygen free-radical formation that can inactivate intracellular enzymes, damage DNA, and destroy lipid membranes. It is reasonable to have high concentration oxygen therapy during the low-flow resuscitation and early post-resuscitation phases (as the commonest causes are respiratory). In the subsequent phases, we should target oxygen saturations between 94 and 96% and be proactive in how we reduce the FiO2 whilst avoiding hypoxia. There is a caveat in cases of severe anaemia or carbon monoxide poisoning. Then it is clinically appropriate for the highest concentration of oxygen to be administered.

Tight circulatory monitoring and support

Inotropic support may also be needed early. A degree of myocardial dysfunction/stunning is expected following CPR. To ensure adequate cerebral perfusion we need to target an age-specific, physiologically normal blood pressure. Both hypo and hypertension can exacerbate secondary brain injury. Because of this, monitoring the blood pressure through an arterial line is preferred. If the local set-up or skillset does not allow for arterial line placement, especially in smaller children, having non invasive blood pressure on 1-2 minute cycles can be a useful proxy.  

The paediatric myocardium is much more resilient than its adult counterpart.  If the arrest is not secondary to congenital heart disease the paediatric heart can regain normal function within 12-24 hours.  During the first 20 minutes following ROSC poor cardiac function is due to profound systemic vasoconstriction and cellular acidosis. We can support the myocardium by supplying adequate fluid resuscitation, targeting normal (age-appropriate) blood pressure and inotropic support. Point of care ultrasound, CVP monitoring, or assessing for hepatomegaly/rales if there is no access to the former, can help us prevent fluid overload

Inotrope choice is usually made with the help of the critical care team and depends on the balance between the need for inotropy and vasoconstriction.  Adrenaline is preferred for inotropy, noradrenaline for vasoconstriction.  Be aware that severe acidosis can cause catecholamine resistance, so giving some bicarbonate if the pH <7 may help your inotropes work better. Routine administration of bicarbonate has not been shown to improve clinical outcomes. There are some special circumstances in which we should consider its use such as cases of hyperkalaemia or hypermagnesaemia and arrests due to tricyclic antidepressant overdose. 

Patient position

The patient position that can achieve optimum cerebral perfusion is with the patient semi-sat up at a 30-45 degree angle.

Eucapnia and normoventilation

Avoidance of hypercapnia or hypocapnia is important in preventing secondary brain injury. It is, therefore, recommended that eucapnia is achieved by targeting a PaCO2 between 4.5 and 5.5 kPa. Hyperventilation can cause hypoxia and increase intracranial pressure due to hyperaemia, it can also cause further cerebral ischemia. As the intrathoracic pressures increase, cardiac venous return is impaired. Since the myocardium is already injured this can have catastrophic effects causing the BP to plummet and subsequently impair cerebral perfusion.

Vigilant glucose monitoring 

Following ROSC, children are also at risk of developing hypoglycemia (glucose <3 mmol/L). There is good evidence to suggest that hypoglycaemia negatively impacts neurological outcome and cause hypoglycaemic seizures, especially in the younger ages. Vigilant glucose monitoring and correction as per APLS guidelines is important. If regular dextrose boluses are needed, consider a continuous glucose infusion. If the patient mounts an adequate stress response, they may become hyperglycaemic.  There is no evidence to suggest that aggressive glucose control with insulin in the non-diabetic patient is beneficial; wait with watchful deliberation and the glucose will usually return to normal levels with no intervention.

Frequent neurological assessment

It is important to frequently assess neurological status frequently after ROSC as this can help us prognosticate. Take the time to do a very quick assessment ideally before the administration of anaesthetic agents and paralysis. Document clearly pupillary size/reactivity, GCS (and its break down) and any respiratory effort or gasping. 

Adjunctive investigations

Following ROSC a number of investigations will be needed to guide diagnosis and therapy. Routine bloods such as renal function, electrolytes, liver function tests, full blood count, and clotting are a basic standard. In cases of lactaemia and/or severe metabolic acidosis ammonia and toxicology is useful. Arterial blood sampling is invaluable to allow quick correction of any electrolyte abnormalities and help titrate ventilation settings and (in part) guide inotropic support. Arterial samples will also help uncover any exposure to carbon monoxide, especially in burns cases. 

From an imaging perspective, a chest X-ray is vital in ascertaining tube positioning and lung pathology as well as cardiac contours in case a congenital or acquired heart disease is suspected. Head CT is obviously useful in cases in keeping with traumatic arrest and NAI but timing of the CT and whether it should take place pre-departure to PICU or after depends largely on local trauma network protocols so should ideally be discussed with the regional trauma team lead and paediatric critical care transport team. 

Children that die or arrest unexpectedly in the UK are subject to a sudden unexpected death in infancy investigation (SUDI) so the appropriate referrals need to be made to the child protection team, police and social care. It is important to clarify that even near-miss cases merit triggering the same SUDI process to ensure that any NAI cases don’t slip through the net. 

Transport pearls

After ROSC the patients will need stabilisation and transfer to PICU for on-going management. Depending on the geographical location of your hospital and the availability of a critical care retrieval service you may have to transfer the patient yourselves or look after them until he/she is retrieved by transport team. A good transport and adequate neuroprotection can be achieved by applying these simple pearls: 

  1. Aggressive temperature monitoring and control between 33°C and 37°C.
  2. Monitor for seizures and pre-empt with long-acting antiepileptic accordingly.
  3. Correct electrolytes and hypoglycaemia and monitor frequently.
  4. Nurse the patient a 45° degree angle.
  5. Aim for a higher end of normal BP and use inotropes to achieve this. If you can’t insert an arterial line, have the NIVBP cycle every couple of minutes. 
  6. In cases of trauma, blood products should be used for volume. In an atraumatic arrest, balanced solution boluses are less harmful than 0.9% saline; don’t forget that you are still likely to need blood products. 
  7. Aim for a pCO2 of 4.5-5.5 kPa; use your continuous EtCO2 monitor to titrate ventilation. 
  8. Vigilant and through history/examination to rule out NAI. Free up a member of the team to do a thorough history from the family, always suspect NAI until proven otherwise especially in children under 6 months. 
  9. Know your anaesthetic drug side-effects (atropine dilates pupils for example so impairs our ability to monitor for seizures). Primum non nocere. 
  10. Intraosseous access can be used instead of a central line, have a low threshold to insert one and do it early.
  11. Have a member of the team check-in with the family every 10-15 minutes to explain what is happening, this is a bad day at work for you but probably the worst day of their lives. 

Conclusion

Achieving ROSC is an important step to give our patients a shot at survival. In some cases, achieving ROSC can only give us enough time to prognosticate and understand that survival is not possible. In some other cases ROSC can be the stepping-stone for a good, meaningful survival with a good quality of life. To achieve that, we must be able to apply good quality post–ROSC care and aggressive, pre-emptive neuroprotection. Learn the PCAS disease process to beat the PCAS disease process.  The APLS algorithm has become the bread and butter of anyone that is involved in paediatric care. Understanding and applying the principles of post-cardiac arrest syndrome is equally vital in improving survival outcomes for our patients. Learn the pearls, use them, teach them and I guarantee that it will make a difference.

Coaching in Paediatric Resus

Cite this article as:
Andrew Tagg. Coaching in Paediatric Resus, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16514

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.


Population

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.

Intervention

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

Comparitor

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

Outcomes

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. 

Unsure

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

Yes

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).

Yes.

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.

The ideal paediatric resuscitation

Cite this article as:
Ben Lawton. The ideal paediatric resuscitation, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11246

The first few minutes of a paediatric resuscitation are intimidating and crucial. Every basic life support update we do drills the DRSABCD mnemonic.

Test yourself - What does DRSABCD stand for?

D – Danger – put on some PPE and think situational awareness.

R – Response – pinch the child’s trapezius while asking them to open their eyes..

S – Shout/Send for help – what is the number to call in your hospital?

A – Airway – open it and look for obstructions

B – Breathing – 2 rescue breaths

C – Compressions – 2:15 ratio with breaths, rate 100-120/min, depth 1/3 of the chest. N.B the two thumb technique is recommended in the current guidelines

D – Défibrillation – 4js/kg, manual defib if you have one, AED with attenuated leads next best, standard AED if no alternative.

The team from Princess Margaret in Perth have made this excellent video of what it ought to look like. Enjoy.

If you want to be able to run a calmer resuscitation come and listen to Tim Horeczko of the Pediatric Emergency Playbook at DFTB17

Mechanical CPR in children

Cite this article as:
Andrew Tagg. Mechanical CPR in children, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11177

Sometimes a single tweet can stir up something deep inside me that I want to know the answer to.  This time it was Jim DuCanto, airway guru.

Since this is a blog about paediatrics I won’t go into my opinions about mechanical CPR (mCPR) in grown ups. I’ll leave it to Robbie Simpson to rant for me. I have very limited experience in its use which really leads to opinion based rather than evidence based medicine.

My limited experience

I have been at the airway end when it was used as a bridge to ECMO and the cath lab in a case of VF storm in a man younger than me. He walked out of the hospital neurologically intact (N=1). I have also seen many, many dead – if not for the rhythmic mechanical thumping on the chest – that I have had to pronounce when they get to hospital instead of them being left in their own home/residential facility.

Cardiorespiratory arrests in kids are rare with an incidence of around 1-20 per 100,000 person years. The majority are respiratory or due to progressive circulatory shock and occur when physiological compensation can no longer occur. Other than a few rare instances cardiopulmonary resuscitation is liable to be futile. One large study of paediatric arrests found that of those children transported to hospital by EMS survival to discharge was 7.8% (3.5% of infants, 10.4% of children and 12.6% of adolescents). According to the ROC Epistry – Cardiac Arrest the incidence of a shockable rhythm was 4-5% in infants and 15% in adolescents.

 

Jim posited that mCPR might buy staff breathing room to plan interventions, but the intervention that is most likely to be effective is airway control and ventilation.

Both devices in current use – the Autopulse and LUCAS-2 – specifically mention paediatric arrests as a contraindication to use. And it is easy to see why. With such variability in sizes it would be near impossible to build a machine that could work on every size of child. So is there an alternative?

Perhaps, rather than relying on technology to do our job better we should focus on incremental gains – doing the basics well.

 

Airway

Even in a large Melbourne quaternary paediatric centre endotracheal intubation is a rare event with only 71 reported events over a one year time period. The majority of these were due to trauma or status epilepticus rather than cardiac arrest. Even then, the first pass success rate was 78%. Other studies have shown an even lower incidence of first pass success when video review was used. They also are associated with prolonged pauses in CPR. You might think that using video laryngoscopy might improve things but that doesn’t seem to be the case in simulation based studies.

 

Breathing

Once the tube has gone through the cords we often breath a sigh of relief. If you are anything like me you may have been holding your breath for the attempt and there is a tendency to hyperventilate the patient. A review of simulated paediatric codes found that every single one of them ended up with the patient being bagged around a rate of 40 breaths per minutes rather than the recommended 8-20 breaths. If we want to up our game perhaps we could consider adding an impedance threshold device. These valves attach to the endotracheal tube and limit air entering the lung during the passive expansion phase. This creates a reduction in negative intrathoracic pressure thus improving venous return.

 

Circulation

There still seems to be a fear, amongst some healthcare providers, of inserting an intraosseous needle.  It can be confronting, crunching through the outer cortex of bone, but it can (and should) be completed in seconds.

 

High quality chest compressions

Most studies of paediatric CPR involve small numbers of patients and the heterogenous nature of the circumstances surrounding the arrests make it difficult to combine the data in a meta-analysis. The higher quality studies rely upon video review of the events rather than bystander or scribe feedback. A number of common themes emerge. Chest compressions are performed more slowly than recommended around 10% of the time and too fast around 44% of the time. Once simple low-tech way of improving this is the use of a metronome (or a metronome app if you are so inclined).

We are used to practicing CPR on adult mannequins and know how far to compress the chest. This is less obvious in children and we have a tendency to lean on the chest during the decompression phase. Force transduce/accelerometer technology can provide real time feedback

It’s hard to get real time feedback regarding the quality of compressions and so practitioners could take a leaf from the world of adult resuscitation and use end tidal CO2 as a surrogate marker for perfusion.

Low dose, high frequency training can help staff retain their skills. Rather than mandated tri-yearly refresher courses, brief booster training has been shown to be equally as effective in improving skill retention.

One other effect of technology has not been considered. It is that it removes us from our patients. It distances us at a time when our empathy needs to be at its greatest. When CPR fails (and it will) how will we feel if we had done everything, using a machine to pump on the chest? Would we feel better or worse than if we had laid on hands? Would it make our young patient more of a person, of a life lived, or less, in our eyes?

 

So how can we create a calmer resuscitation? Come to DFTB17 and listen to Tim Horeczko to find out.

References


Atkins DL, Everson-Stewart S, Sears GK, Daya M, Osmond MH, Warden CR, Berg RA, Resuscitation Outcomes Consortium Investigators. Epidemiology and outcomes from out-of-hospital cardiac arrest in children. Circulation. 2009 Mar 24;119(11):1484-91

Leman P, Morley P. Review article: Updated resuscitation guidelines for 2016: A summary of the Australian and New Zealand Committee on Resuscitation recommendations. Emergency Medicine Australasia. 2016 Aug 1;28(4):379-82.

Long E, Sabato S, Babl FE. Endotracheal intubation in the pediatric emergency department. Pediatric Anesthesia. 2014 Dec 1;24(12):1204-11.

Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, Mittiga MR. Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Annals of emergency medicine. 2012 Sep 30;60(3):251-9.

Niebauer JM, White ML, Zinkan JL, Youngblood AQ, Tofil NM. Hyperventilation in pediatric resuscitation: performance in simulated pediatric medical emergencies. Pediatrics. 2011 Nov 1;128(5):e1195-200

Schuerner P, Grande B, Piegeler T, Schlaepfer M, Saager L, Hutcherson MT, Spahn DR, Ruetzler K. Hands-off time for endotracheal intubation during CPR is not altered by the use of the C-MAC video-laryngoscope compared to conventional direct laryngoscopy. A randomized crossover manikin study. PloS one. 2016 May 19;11(5):e0155997.

Milander MM, Hiscok PS, Sanders AB, Kern KB, Berg RA, Ewy GA. Chest compression and ventilation rates during cardiopulmonary resuscitation: the effects of audible tone guidance. Academic Emergency Medicine. 1995 Aug 1;2(8):708-13.

Sutton RM, Niles D, Meaney PA, Aplenc R, French B, Abella BS, Lengetti EL, Berg RA, Helfaer MA, Nadkarni V. Low-dose, high-frequency CPR training improves skill retention of in-hospital pediatric providers. Pediatrics. 2011 Jul 1;128(1):e145-51.

Bhende MS, Thompson AE. Evaluation of an end-tidal CO2 detector during pediatric cardiopulmonary resuscitation. Pediatrics. 1995 Mar 1;95(3):395-9.