Induced hypothermia should be done at a facility able to provide comprehensive neonatal care, following studied protocols, initiated within hours of birth and continued for 72 hours For infants born at centers unable to provide such care, early identification of potential candidates and consultation with experts is critical Ideally, medical centers skilled in hypothermia management and community hospitals should develop educational programs and procedures for transfer FIGURE 9.19 Left diaphragmatic hernia radiograph Pneumothorax Pneumothorax is a potentially lethal problem in the neonate because it can rapidly progress to a tension pneumothorax It is often the result of PPV, excessive PEEP, or aggressive resuscitation Pneumothorax is more common in premature infants with surfactant deficiency or meconium aspiration If significant respiratory distress is present and a pneumothorax is suspected, rapid decompression may be achieved with a large syringe, 20-gauge needle, or catheter over needle using a three-way stopcock The needle is advanced at the fourth intercostal space in the anterior axillary line or the second interspace in the midclavicular line Subsequently, a chest tube (8F) may be placed using a standard technique (see Chapter 130 Procedures ) Congenital Diaphragmatic Hernia CDH is a true neonatal emergency; the diagnosis is confirmed by a chest radiograph showing bowel gas within the thorax ( Fig 9.19 ) Infants with CDH require emergent ET intubation to avoid excessive amounts of air accumulation in the bowel A nasogastric tube should be rapidly placed to decompress the stomach The infant must be rapidly evaluated by a pediatric surgeon after ventilation is stabilized and venous access is achieved TEAMWORK IN RESUSCITATION FOR ALL PEDIATRIC PATIENTS Existing resuscitation curricula of the AHA incorporate learning modules on leadership, role clarity, and communication Effective leaders and team members must have cognitive (fund of knowledge), technical and procedural, and behavioral skills Postresuscitation team debriefing is increasingly recognized as a critical component in maintaining effective teamwork and communication skills in pediatric resuscitations Recent information reveals lack of effective teamwork skills and its negative impact on outcomes Effective education includes challenging hands-on active exercises, such as role play and high-fidelity simulation A formal process for the review of video recordings of resuscitations provides another avenue for identifying opportunities for improving care processes and for providing constructive feedback on team management skills Maintenance of competency for physicians working in ED settings includes procedural and leadership competencies Developing and maintaining the ability to effectively lead a multidisciplinary team in a high-stakes, high-risk, error-prone environment is necessary and must be thoughtfully considered in this era of decreasing frequency of individual exposure to these patients Finally, parental presence in the resuscitation room is recommended by the AAP and should be routine practice All EDs should have a written policy and a process in place, and all families should be offered this opportunity for family presence (see Chapter A General Approach to the Ill or Injured Child ) DISCONTINUATION OF LIFE SUPPORT IN CHILDREN If well-executed resuscitative measures fail to achieve ROSC, discontinue resuscitative efforts unless the patient is deemed to be a good candidate for ECPR There is good evidence to support that there is little chance for meaningful survival in patients with unwitnessed arrest who remain unresponsive to airway intervention, chest compressions, and two doses of epinephrine Thus, a brief, well-executed resuscitation is indicated for the child who arrives to the ED with cardiopulmonary arrest During this time, the leader can review the history and complete the primary and secondary survey Prolonged resuscitation efforts past 20 minutes, without ROSC, are usually futile unless other treatable problems exist such as hypothermia, drug overdose, or VT/VF Prolonged resuscitation may be indicated for witnessed collapsed arrest, with short onset of effective BLS/ACLS, especially if a cardiac etiology is suspected Ultimately, the diagnosis of death and subsequent discontinuation of resuscitative efforts is a judgment that is made by the team leader in conjunction with the team A decision not to begin resuscitation is generally not made in the ED unless there is a written do-not-resuscitate (DNR) document provided by the child’s parent or guardian A well-prepared ED should consider and have a plan in place for issues such as advanced directives, palliative care, bereavement measures and postmortem care, survivor follow-up, and request for autopsy and organ donations as outlined in the AAP guidelines Proper documentation of a death is essential, as is notification of medical legal authorities, donor programs, and referring physicians and consultants CEREBRAL RESUSCITATION Cerebral injury remains the leading etiology for morbidity in those who survive cardiopulmonary arrest Permanent brain damage following arrest is determined by many factors and includes arrest time (no-flow state), CPR time (low-flow state), and temperature Cardiopulmonary–cerebral resuscitation is needed to prevent brain injury Oxygen stores are depleted within 20 seconds following arrest, and glucose and adenosine are depleted within minutes During no-flow states, multiple complex chemical derangements occur that contribute to the death of neurons With ROSC, there is impaired cerebral blood flow Therapeutic interventions to prevent postanoxic brain injury have yielded disappointing results to date, outside of prevention of pyrexia Hypothermia The use of mild hypothermia after OHCA due to VF in adults has been associated with improved neurologic outcome and is generally tolerated without any significant complication Current AHA recommendations are to begin targeted temperature management with a consistent goal of between 32° and 36°C for all adult patients after arrest who remain comatose, regardless of presenting rhythm or location of arrest (though recommended in those patients with initial shockable rhythm from OHCA and suggested for all other populations) Data from large, multicenter, randomized controlled trials have demonstrated that therapeutic hypothermia for asphyxiated newly born infants ≥36 weeks’ gestation can reduce death and neurologic disability when initiated within hours of birth AHA guidelines recommend that all such infants with moderate to severe hypoxicischemic encephalopathy be offered therapeutic hypothermia However, the data for pediatric patients is less clear Recent large, randomizedcontrolled trials of targeted temperature management found no difference in neurologic outcome between hypothermia (32° to 34°C) and normothermia (36° to 37.5°C) Current AHA guidelines state that either targeted temperature management to normothermia (36° to 37.5°C) for days, or hypothermia (32° to 34°C) for days followed by days of normothermia may be considered for children who remain comatose after return of spontaneous circulation following cardiac arrest Fever adversely affects recovery from ischemic brain injury, and should be treated aggressively; avoiding temperatures of 38°C or higher is recommended QUALITY IMPROVEMENT EDs represent a high-risk environment for the medical care of patients due to factors such as clinical uncertainty, frequent interruptions, and the need for haste Children are at particular risk in emergency care because of their physical and developmental vulnerabilities, their inability to accurately describe symptoms or past medical history, the complexity of weight-based treatment, and the relative discomfort of some providers in treating pediatric patients This risk is particularly heightened during emergency resuscitation, which is a teamdependent and information-intensive process of rapidly treating acute life- and organ-threatening diseases The medical resuscitation environment is especially prone to medical errors due to its fast-paced, complex environment Therefore, ongoing surveillance of resuscitation events is vital; with an eye toward process and system changes which can support the resuscitation team, minimize distraction from patient care and maximize protocol adherence A video review process in which all resuscitation events are video-recorded, and a subset is ... infant must be rapidly evaluated by a pediatric surgeon after ventilation is stabilized and venous access is achieved TEAMWORK IN RESUSCITATION FOR ALL PEDIATRIC PATIENTS Existing resuscitation... treatment, and the relative discomfort of some providers in treating pediatric patients This risk is particularly heightened during emergency resuscitation, which is a teamdependent and information-intensive... recognized as a critical component in maintaining effective teamwork and communication skills in pediatric resuscitations Recent information reveals lack of effective teamwork skills and its negative