Infant defibrillation

[Brandon Oto]

I always found it a little unnerving that the AHA's official recommendation on the use of AEDs for infants under the age of 1 was "no recommendation." I recognize it's due to an insufficient body of evidence, but at the end of the day if you have an infant in your arms in full arrest, you still have to either shock or not; you can't just take a rain check.

Everyone seems to punt on this one. My protocols don't address it at all. Realistically most providers I know seem to take the default attitude of not shocking, and I'm sympathetic to the idea that an arrest at this age is unlikely to be secondary to V-fib, but at some point you have to ask -- if you've tried everything else, and after however many rounds of CPR you want to bother with, does this fall under "might as well try"? I imagine most people would just haul ass for the ED, but that's not how we deal with a code in any other circumstances, so I'd hate to think we're just trying to do the safe thing (because we're scared of electrocuting babies) rather than the best care.

Does anyone have a protocol or system policy that addresses this? If not, what would your personal decision be in such a situation?

[HERBIE1]

Offhand, without any literature to back it up, I think that because in the VAST MAJORITY of cases of peds arrests, the arrhythmia is due to a a respiratory/metabolic problem that when fixed, negates the need for electricity. That said, I think your question is valid- always ask "what if".

[emtgrimreaper]

Like most ems servives, We do have infant pads for the aed. But for someone under one y/o, we load and go and contact medical command to see if there is anything else that can be done before shocking the infant.

[tniuqs]

Like most ems servives, We do have infant pads for the aed. But for someone under one y/o, we load and go and contact medical command to see if there is anything else that can be done before shocking the infant.

The new PALs guidelines are far more proactive for the use of electricity with the Advanced Life Support Provider the newer EBM studies are indicating that there is more fib than we previously believed or perhaps was reported ?

Biggest focus now is good CPR, if the heart rate less than 60 bpm.

The Problem is that these AEDs have preset joules hence the PALS guidelines > 1 year of age AED not advised.

For the PALs provider its 2J/kg then 4J/kg and I have no idea just what the "preset flash boxes" joules for children.

cheers

[Brandon Oto]

Here's one of the papers the 2005 recs cite: http://circ.ahajournals.org/cgi/content/full/107/25/3250?ijkey=af2ae50aebcf6ba19653bb2ebdbbe24a7a0462d7&keytype2=tf_ipsecsha

VF is an uncommon cause of out-of-hospital pediatric cardiac arrest in infants (<1 year of age), but its occurrence increases with growing age. Two studies reported VF as the initial rhythm in 19% to 24% of out-of-hospital pediatric cardiac arrests if sudden infant death syndrome (SIDS) deaths were excluded. In studies that included SIDS victims, however, the frequency dropped to 6% to 10%. The rationale for exclusion of SIDS patients is that SIDS is not amenable to treatment, so patients with SIDS should not be included in studies that may influence potential treatment strategies for cardiac arrest. A recent report, however, documented VF in a 3-month-old infant with SIDS who was subsequently diagnosed with prolonged QT syndrome.

Recent data suggest that VF is not a rare rhythm in pediatric arrest. This is encouraging because VF is the arrest arrhythmia associated with improved survival rate in most studies of children. For example, Mogayzel and colleagues16 reported that 5 of 29 children (17%) who presented with VF in a prehospital setting survived with good neurological outcome versus only 2 of 128 (2%) who presented with asystole/pulseless electrical activity (P<0.01).

In-hospital studies of pediatric CPR also indicate that VF is not a rare rhythm among children in cardiac arrest. Two recent comprehensive studies report the incidence of VF as the initial rhythm and the incidence of VF at some time during the arrest. Suominen et al reported initial VF in 11% of children in cardiac arrest and VF in 20% of children some time during the arrest. In a much larger study, cardiac arrest data submitted to the National Registry of CardioPulmonary Resuscitation reveal initial VF/VT in 12% of children and VF/VT at some time during 25% of the pediatric arrests.

But that doesn't distinguish between pedis older and younger than 1. And that's from 2003 anyway. If anyone has newer data it'd be nice to see.

[spenac]

Is this you?

"As of October, I’m working as an EMT-B for American Medical Response in Monterey County. AMR is the private ambulance provider with the contract to run EMS for the county’s 911 service; I partner with a paramedic and provide care and transport for folks who stub a toe or saw off their face, anywhere in the county."

[Brandon Oto]

Is this you?

"As of October, I’m working as an EMT-B for American Medical Response in Monterey County. AMR is the private ambulance provider with the contract to run EMS for the county’s 911 service; I partner with a paramedic and provide care and transport for folks who stub a toe or saw off their face, anywhere in the county."

Uh... that's from my website, but is not current. I'm off in Boston now. Why?

[spenac]

Uh... that's from my website, but is not current. I'm off in Boston now. Why?

Just wondering.

I had a report on the subject but can not find where I saved it to. If I find it I will post it.

[BEorP]

Does anyone have a protocol or system policy that addresses this? If not, what would your personal decision be in such a situation?

I would never want to be in the place of making a "personal decision" on this unless I got paid the big bucks and had MD/DO behind my name. That being said, our directive for infants >30 days is to shock up to four times at 20 J with two minutes of CPR between each analysis and transport being initiated on the first non-shockable rhythm analysis.

[armymedic571]

I am not generally a what if person. Mostly because you can what if till your blue in the face, and not find any solutions.

But that being said, this is a great question..

I would have to say that after securing the airway, obtaining IV access, and checking sugar, that epi would be the first step. After that...If you have more than a five minute transport, get on the phone and present your case. If you have attempted to rule out your differentials, and you are at the junction.. Depending on your Command Physician, they might let you try. I find that getting that second opinion Usually (depending on your relationship with command doc's) gives you additional insight on what might be going on or reaffirms your thought process.

That is one call though, I wouldn't want to make......