Download Ventricular Fibrillation and the Use of Automated External

POLICY STATEMENT
Ventricular Fibrillation and the Use
of Automated External Defibrillators
on Children
Organizational Principles to Guide and
Define the Child Health Care System and/or
Improve the Health of All Children
Committee on Pediatric Emergency Medicine and Section on Cardiology and Cardiac Surgery
ABSTRACT
The use of automated external defibrillators (AEDs) has been advocated in recent
years as one part of the chain of survival to improve outcomes for adult cardiac
arrest victims. When AEDs first entered the market, they had not been tested for
pediatric usage and rhythm interpretation. In addition, the presumption was that
children do not experience ventricular fibrillation, so they would not benefit from
the use of AEDs. Recent literature has shown that children do experience ventricular fibrillation, which has a better outcome than do other cardiac arrest
rhythms. At the same time, the arrhythmia software on AEDs has become more
extensive and validated for children, and attenuation devices have become available to downregulate the energy delivered by AEDs to allow their use on children.
Pediatricians are now being asked whether AED programs should be implemented,
and where they are being implemented, pediatricians are being asked to provide
guidance on the use of them on children. As AED programs expand, pediatricians
must advocate on behalf of children so that their needs are accounted for. For
pediatricians to be able to provide guidance and ensure that children are included
in AED programs, it is important for pediatricians to know how AEDs work, be
up-to-date on the literature regarding pediatric fibrillation and energy delivery,
and understand the role of AEDs as life-saving interventions for children.
INTRODUCTION
Early defibrillation has been shown to be the most effective treatment for adult
out-of-hospital cardiac arrest attributable to ventricular fibrillation (VF).1,2 The
likelihood of survival decreases by approximately 7% to 10% with each minute of
delay to defibrillation after cardiac arrest. Strategies to decrease the time to
defibrillation that have been shown to be effective include the use of an automated
external defibrillator (AED) by prehospital care providers and nonmedical personnel.3–6
For children, use of defibrillation traditionally has been downplayed, with a
focus on early airway and ventilatory assistance as a result of data that showed that
asystole was the predominant rhythm and that VF rarely occurred.7 Although not
the most common rhythm, VF does occur in children. In addition, the chance of
survival after VF is greater than that from other nonperfusing rhythms, which
makes treatment of VF a priority in pediatric resuscitation.8
Although the incidence of VF in the pediatric population is low, there is a need for
developing strategies to provide early defibrillation to patients younger than 8 years.
This strategy may include the need for an AED that is suitable for use in pediatric
www.pediatrics.org/cgi/doi/10.1542/
peds.2007-2676
doi:10.1542/peds.2007-2676
All policy statements from the American
Academy of Pediatrics automatically expire
5 years after publication unless reaffirmed,
revised, or retired at or before that time.
Key Words
automated external defibrillator,
ventricular fibrillation, emergency medical
services, cardiac resuscitation, school
emergency care
Abbreviations
VF—ventricular fibrillation
AED—automated external defibrillator
EMS— emergency medical services
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright © 2007 by the
American Academy of Pediatrics
PEDIATRICS Volume 120, Number 5, November 2007
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patients from birth to 8 years of age with either an attenuated adult-dosage AED tested for efficacy and safety in
children or an AED specifically designed for defibrillation
of young children and infants. In the absence of either of
such devices, standard nonattenuated adult-dosage AEDs
should be used on children on the basis of protocols for use
developed with medical oversight. Because of the limited
data on effective energy dose, emergency medical services
(EMS) systems, medical directors, and pediatric researchers
should make efforts to gather information regarding pediatric uses of AEDs and report it by using the pediatric
Utstein style,9 which represents an internationally accepted
standard method of collecting and reporting respiratory
and cardiac arrest and resuscitation data. In addition, because the use of AEDs on children may be a new concept
to many responders, EMS and physician leaders should
work with professional organizations, community organizations, and researchers to educate their community members regarding the benefits of early pediatric defibrillation
and the use of available varieties of AEDs.
The message for the public and for EMS systems is to
recognize the existence of VF in infants and children and
use methods to treat it as early as possible to improve the
survival of children and infants after sudden cardiac
arrest. In addition, this possible life-saving therapy
should not be withheld purely on the basis of absolute
weight and size issues. The key is to pursue a long-term
goal of providing devices that will support rapid pediatric
and adult defibrillation. This approach would include the
ability to treat infants and children without compromising adult care while minimizing training issues and minimizing the use of limited financial and personnel resources.
RECOMMENDATIONS
1. Although the incidence of VF in children is far less
than that in adults, the outcome for VF is better than
that for other nonperfusing rhythms and is improved
with early defibrillation. Therefore, strategies and
equipment availability for treatment of pediatric arrest
should be focused on shortening the intervals from
collapse to recognition of VF and to defibrillation.
2. Although most data available on the correct energy for
defibrillation of children are from animal studies, data
suggest that the immature heart is less susceptible to
energy-related damage and that there is a wide therapeutic range of defibrillation energy doses. In addition, although using a fixed adult-energy AED on
some children has a theoretical potential for harm, not
treating VF has the proven potential for even greater
harm: death of the child. On the basis of this risk/
benefit assessment, prehospital programs and publicaccess AED programs should not withhold defibrillation because of weight or age criteria alone.
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AMERICAN ACADEMY OF PEDIATRICS
3. Children and infants of all ages who suffer VF must
be provided defibrillation as soon as possible after
arrest. The following approach to achieve this goal
should be used:
a. Immediately provide defibrillation to all infants and
children from birth to 8 years of age with either an
attenuated adult-dosage AED tested for efficacy
and safety in children or an AED specifically designed for defibrillation of young children and infants, depending on which device is available first.
In the absence of the devices listed above, standard
nonattenuated adult-dosage AEDs should be used
on infants and children from birth to 8 years of age.
Protocols for use of adult-dosage AEDs should be
developed with medical oversight.
b. For children 8 years of age and older, immediately provide defibrillation with an adult-dosage
AED or manual defibrillation.
4. EMS systems must have protocols to allow for pediatric defibrillation in the timeliest fashion and by
all levels of responders. These protocols include pediatric AED capability and, in the interim, protocols
for the use of an adult AED on infants and children.
5. Although a cost/benefit assessment of public-access
defibrillation specifically for children has not been
established, when a community or facility chooses
to establish a public-access defibrillation program,
the AED chosen for that program must have pediatric capability.
6. Although a cost/benefit assessment of school-based
AEDs has not been established yet, school systems
must, in their assessment of need for an AED, consider the benefit of AED purchase to adult staff
members and adult visitors and as another component of school-based emergency care.
7. When determining the need for a school-based AED
program, the following factors should direct the decision10:
a. The frequency of cardiac arrest events is such
that there is a reasonable probability of AED use
within 5 years of rescuer training and AED placement. This probability can be established if 1
cardiac arrest has been known to have occurred
at the site within the last 5 years or can be estimated on the basis of population demographics.
b. There are children attending the school or adults
working at the school who are thought to be at
high risk of sudden cardiac arrest (eg, children with
conditions such as congenital heart disease and a
history of abnormal heart rhythms, children with
long QT syndrome, children with cardiomyopathy,
adults or children who have had a heart transplant,
and adults with a history of heart disease).
c.
An EMS call-to-shock interval of less than 5 minutes cannot be achieved reliably with conventional EMS services, and a collapse-to-shock interval of less than 5 minutes can be achieved
reliably (in ⬎90% of cases) by training and
equipping lay people to function as first responders by recognizing cardiac arrest, telephoning 911
(or other appropriate emergency response number), starting cardiopulmonary resuscitation, and
attaching and operating an AED.
8. When placed in schools, AEDs must be part of a
comprehensive emergency care plan that includes:
a. pediatric medical oversight;
b. staff training in basic first aid and cardiopulmonary resuscitation; and
c. integration with local EMS.
9. Any legislation that mandates placement of an AED
also must provide the funding for such devices, including costs of staff training and maintenance of
the equipment.
10. AED legislation must allow for pediatric AED usage
and liability protection for those who use these devices and for the physicians who provide the medical oversight for these programs.
COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, 2005–2006
Steven E. Krug, MD, Chairperson
Thomas Bojko, MD, MS
Margaret A. Dolan, MD
Karen S. Frush, MD
Patricia J. O’Malley, MD
Robert E. Sapien, MD
Kathy N. Shaw, MD, MSCE
Joan Shook, MD, MBA
Paul E. Sirbaugh, DO
Loren G. Yamamoto, MD, MPH, MBA
LIAISONS
Jane Ball, RN, DrPH
EMSC National Resource Center
Kathleen Brown, MD
National Association of EMS Physicians
Kim Bullock, MD
American Academy of Family Physicians
Dan Kavanaugh, MSW
Maternal and Child Health Bureau
Sharon E. Mace, MD
American College of Emergency Physicians
Susan Eads Role, JD, MSLS
EMSC National Resource Center
David W. Tuggle, MD
American College of Surgeons
Tina Turgel, BSN, RN-C
Maternal and Child Health Bureau
CONTRIBUTOR
*David Markenson, MD
STAFF
Susan Tellez
SECTION ON CARDIOLOGY AND CARDIAC SURGERY, 2006 –2007
Robert H. Beekman III, MD, Chairperson
Peter B. Manning, MD
Seema Mital, MD
William R. Morrow, MD
Frank M. Galioto, Jr, MD
Thomas K. Jones, MD
LIAISONS
Gerard R. Martin, MD
American College of Cardiology
Reginald L. Washington, MD
NCE Planning Group
STAFF
Lynn Colegrove, MBA
*Lead author
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3. Watts DD. Defibrillation by basic emergency medical technicians:
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