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• W2045332805 abstract "Source: Atkinson E, Mikysa B, Conway JA, et al. Specificity and sensitivity of automated external defibrillator rhythm analysis in infants and children. Ann Emerg Med. 2003;42: 185–196.Automated external defibrillators (AEDs) are now the first line of treatment for out-of-hospital cardiac arrest. They are increasingly being found in airports, exercise facilities and other public institutions. Prior to July, 2003, AEDs were only recommended for adults and children 8 years of age or older due to dose of energy delivered (150 to 200 joules) and because they used rhythm detection algorithms that were derived from adult rhythms. To evaluate the ability of one AED currently on the market to assess abnormal rhythms in children, 1,561 previously recorded rhythms from 203 pediatric patients were played through a LIFEPAK 500® AED and the “shock” or “no shock” decisions were recorded. These responses were then compared to a consensus decision of 3 experts who also, independently, classified the rhythms into shockable and non-shockable categories. The patients were younger than 8 years of age and came from 1 of 3 settings at Vanderbilt University Medical Center in Nashville, Tennessee; pediatric critical care unit, cardiovascular operating rooms, or electrophysiology laboratory.The AED recommended a shock for 72 of 73 rhythm samples that were classified as coarse ventricular fibrillation by the expert panel (sensitivity 99%; 95% CI, 93–100%). A decision of no shock was correctly reached for 1,465 of 1,472 rhythm samples (specificity 99.5%; 95% CI, 99.0–99.8%). Six of the 7 rhythm samples where a shock was incorrectly recommended by the AED came from one 10-day-old infant in sinus rhythm with a pulse of 160 to 170 beats per minute. A further analysis of these rhythms showed that the QRS complexes did not have enough amplitude and not enough isoelectric content to cause the AED to reach a no-shock decision. Sensitivities and specificities were also calculated for 3 different age groups: birth to 28 days, 29 days to <1 year, and 1 year to <8 years. The lowest sensitivity was for 1- to <8-year-old patients (97%; 95% CI, 85–100%). Although the birth to 28-day-old age group had 100% sensitivity, there were only 3 patients with coarse ventricular fibrillation (VF) resulting in a very wide 95% CI (29–100%). The lowest specificity was for the birth to 28-day-old age group (97.3%; 94.2–99.0%). The authors also reviewed rhythms from 2 electrode positions in 139 patients with perfusing non-shockable rhythms: sternal-apex position and anterior-posterior position. Both were found to have a specificity >99%.Out-of-hospital defibrillation within the first 3 minutes of witnessed adult VF has led to survival rates >50%.1 Although VF is uncommon in pediatric out-of-hospital arrests, its occurrence increases with age. The 2000 Pediatric Advanced Life Support (PALS) Task Force of the International Liaison Committee on Resuscitation (ILCOR) recommended that AEDs only be used on children that were ≥8 years of age or 55 pounds (25 kg).2 At that time, little was known about the ability of AEDs, which were designed for adult rhythm disturbances, to identify shockable rhythms in children. One recent study of 696 pediatric arrhythmias from children ≤12 years of age showed 100% specificity and 96% sensitivity for the detection of ventricular fibrillation.3 The new study above has added enough evidence for new ILCOR recommendations, published in July, 2003, that now include AED use in children, 1 to 8 years of age, who have no signs of circulation.4 The task force felt that there was insufficient evidence to support a recommendation for or against the use of AEDs in children <1 year of age.Ideally, the AED should deliver an energy dose that is appropriate for the pediatric patient. Using an AED that delivers the full adult energy dose would deliver an initial dose of 6 to 8 J/kg in an average 8-year-old who weighs 25 kg. Subsequent shocks of 200 to 360 joules would deliver up to 14 J/kg. The per kilogram dose would be much higher in a smaller child. Some AEDs are now being manufactured with a pediatric pad/cable that raise the impedance and diverts some of the delivered current away from the patient, essentially lowering the adult energy dose to 50 to 75 joules. Although the current study does not address issues of dose, it does provide further evidence that AEDs are capable of accurately reviewing pediatric arrhythmias to determine if a shockable rhythm is present. To determine if the same success in adult survivor rate will be found in children, a prospective analysis of clinical AED use in pediatric patients is needed.Pediatricians are fond of saying their patients “aren’t just little adults.” A child is a developing organism and may not respond well to treatments developed for adults. This is a particularly vexing problem when an effective lifesaving method such as AED is available to treat older people with ventricular fibrillation (VF), but was not originally intended for pediatric use. It would be marvelous to be able to just go ahead and use AED for children with VF and routinely convert this otherwise fatal arrhythmia. Yet the nagging question persists: in what unexpected adverse ways will children respond to AED?The peculiarities of the cardiovascular system of very young patients have promoted catastrophic responses to safe and effective adult arrhythmia treatments before. We are reminded of a situation 2 decades ago when intravenous verapamil was introduced for use in adults with supraventricular tachycardia (SVT).5 It was not long before off label use in children with SVT revealed that cardiovascular collapse often resulted from administration of intravenous verapamil to infants.6 Sobered by this and other similar experiences in pediatric arrhythmia management, pediatric cardiologists are wise to be cautious about other adult treatment modalities, such as AED, for rhythm disturbances in the immature myocardium. Two areas, energy dose and VF recognition, seem the most obvious points at which the extension of AED from adult to pediatric use would be apt to fail.The authors present excellent news on the automatic recognition of VF. The pediatric myocardium generates VF patterns that are reliably recognized by the AED system they tested, so we expect neither inappropriate shock administration nor inappropriate failure to shock in pediatric applications. Reassuring as this report is in regard to VF recognition, it does not address the issue of energy dosing and so cannot represent the final step in the extension of AED technology to use in children. The International Liaison Committee on Resuscitation has confidence that the evidence clearly favors AED use in children who are over a year old, but they include cautionary language about the high doses of energy AED delivers to a small child.7 Development of methods to deliver the ideal defibrillation energy dose to a child (and, indeed, work to discover just what that dose might be) would further enhance the safety of pediatric AED use. Ideally, this would occur prior to the discovery of unintended complications of its widespread use in smaller patients." @default.
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• W2045332805 title "Automated External Defibrillator Use In Children" @default.
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