Training of Physicians in Advanced Life Support for

Children

Deena R Zimmerman MD MPH

Every Physician’s Nightmare

But Most Physicians Are Unprepared

• Lack of knowledge– Pediatric residents– Family physicians

• Lack of equipment– General emergency departments– Offices

Lack of KnowledgePediatric residents

• Telephone survey of 73 pediatric residents in Wales• Problem subjects – percentage correct:

– Compromised upper airway (55%) – Fluid management of hemorrhagic shock (49%) – Only (26%) mentioned the intra-osseous route as a

means of obtaining vascular access in a child in extremis.

• Low confidence (41%) • Need more formal training (94%)

Buss PW, McCabe M, Evans RJ, Davies A, Jenkins H. A survey of basic resuscitation knowledge among resident paediatricians. Arch Dis Child. 1993 Jan;68(1):75-8.

Lack of KnowledgePediatric Residents

• A telephone questionnaire of 57 residents to test their knowledge of European Resuscitation Council guidelines.

• Correct sequence of management for asystole (26%)

• Correct use of adrenaline (14%)• Identification of ventricular fibrillation (32%)

Buss PW, Evans RJ, McCarthy G, Scorrer T, Kumar V.Paediatricians' knowledge of cardiac arrest guidelines. Arch Dis Child. 1996 Jan;74(1):47-9.

Lack of KnowledgeFamily Physicians

• Questionnaires to 169 community practices regularly treating children

• Average 4 or more pediatric emergencies in a year

• FP had fewer resuscitation and stabilization items than pediatricians (5.7 vs 8.6 items, P <.001)

• FP were less prepared in terms of PALS training (19% vs 51%, P <.001).

• Family physicians considered it is less important

Mansfield CJ, Price J, Frush KS, Dallara J. Pediatric emergencies in the office: are family physicians as prepared as pediatricians? J Fam Pract. 2001 Sep;50(9):757-61

Lack of Equipment

• Ambulances

• General emergency departments

• Offices

Improvement - Equipment

• Pediatric Office Emergencies and Emergency Preparedness in a Small Rural State

Barry W. Heath, Jean S. Coffey, Patrick Malone and James Courtney

Pediatrics 2000;106;1391-1396http://www.pediatrics.org/cgi/content/full/106/6/1391

• 1 event per office in year of study

Need for Improvement of Knowledge

Thompson BM, Rice T, Jaffe J, Aprahamian C, Horwitz L, Torphy D.

"PALS for life!" A required trauma-oriented pediatric advanced life support course for pediatric and emergency medicine housestaff. Ann Emerg Med. 1984 Nov;13(11):1044-7.

Improvement - Equipment

Those with PALS training more likely to have intraosseous needle

Braselow tape

conducted a mock code.

Mansfield CJ, Price J, Frush KS, Dallara J. Pediatric emergencies in the office: are family physicians as prepared as pediatricians? J Fam Pract. 2001 Sep;50(9):757-61

Teaching Helps

• Telephone survey of 94 resident paediatricians in England.

• Adherence to guidelines in clinical scenarios • There were significantly more correct answers to

9/10 questions in 1999 compared to 1992. • The 1999 doctors who had attended a course

scored significantly better in 3/10 questions and achieved a higher total score (5.43 versus 4.55).

Carapiet D, Fraser J, Wade A, Buss PW, Bingham R. Changes in paediatric resuscitation knowledge among doctors. Arch Dis Child. 2001 May;84(5):412-4.

Teaching Helps?• Course to pediatric residents at CHOP

– Standardized test from PALS– Short answer test on clinical problem-solving skills. – Skills workshop

• High scores on the PALS test (93.2%+/-5.5) • Less well on short answers (60.0%+/-9.9) • No resident was able to successfully perform

both basic and advanced airway skills, • Only 11% successfully completed both vascular

skills

Nadel FM, Lavelle JM, Fein JA, Giardino AP, Decker JM, Durbin DR. Assessing pediatric senior residents' training in resuscitation: fund of knowledge, technical skills, and perception of confidence. Pediatr Emerg Care. 2000 Apr;16(2):73-6

Pediatric Advanced Life Support Course - PALS

HowHowSick?Sick?

How How Quick?Quick?

Pediatric Assessment Triangle

Circulation to SkinCirculation to Skin

AppearanceAppearance Work ofWork of BreathingBreathing

The Triangle is a rapid way to determine physiologic stability

APLS vs PALS

• AAP and ACEP• Advance Pediatric

Life Support – The Pediatric Emergency Medicine Course – Recognize the ill child before he is critical

• AHA• Pediatric

Advanced Life Support – Primarily Resuscitation of the Critically Ill Child

2005 Resuscitation Guidelines

http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-167In contrast to adults, sudden cardiac

arrest in children is uncommon, and cardiac arrest does not usually result from a primary cardiac cause

Does knowledge last?• Comparison test scores for the same group of trainees

(mean training 3 years) at time intervals after the course. • Prior to the course, few of the 23 candidates had adequate

knowledge of:– cervical spine management (17%)– fluid resuscitation in meningococcal septicemia (52%)– shock dose in ventricular fibrillation (61%)– management of anaphylactic shock (35%).

• There was a significant improvement in the knowledge of the group after the course, with median test scores increasing from 19 to a maximum of 22 (P < 0.001).

• This knowledge was retained at 4 months after the course

Durojaiye L, O'Meara M Improvement in resuscitation knowledge after a one-day paediatric life-support course. J Paediatr Child Health. 2002 Jun;38(3):241-5.

APLS - Netherlands

• Questionnaires after course and to control group

• Perceived self-efficacy increased (p<0.01) in candidates for all skills and remained increased for at least 6 months.

Turner NM, Dierselhuis MP, Draaisma JM, ten Cate OT The effect of the Advanced Paediatric Life Support course on perceived self-efficacy and use of resuscitation skills. Resuscitation. 2007 Jun;73(3):430-6.

Israeli Experience• 128 physicians, 158 nurses, and 84

paramedics.• Passing 85.9% for physicians, 78.5% for

nurses, and 89.3% for paramedics. • The pediatric advanced life support course

significantly increases immediate short-term knowledge of pediatric resuscitation for all professional groups.

Waisman Y, Amir L, Mimouni M.. Does the pediatric advanced life support course improve knowledge of pediatric resuscitation? Pediatr Emerg Care. 2002 Jun;18(3):168-70

Israeli Experience

BACKGROUND: The Pediatric Advanced Life Support course of the American Heart Association/American Academy of Pediatrics was established in Israel in 1994 and has since been presented to over 3,108 medical and paramedical personnel.

Waisman Y, Amir L, Mor M, Mimouni M. Pediatric advanced life support (PALS) courses in Israel: ten years of experience. Isr Med Assoc J. 2005 Oct;7(10):639-42

• Paramedics 16 points less after 2 years

• Most still passed• However, see 3-4 patients per

month

Wolfram RW, Warren CM, Doyle CR, Kerns R, Frye S. Retention of Pediatric Advanced Life Support (PALS) course concepts. J Emerg Med. 2003 Nov;25(4):475-9

Course is not enough• PALS is successful in providing basic resuscitation

knowledge to pediatric residents, is not sustained.

• The course does not provide for the expected level of competency in relevant technical skills.

• These findings support the hypothesis that the PALS course alone is insufficient to provide pediatric residents with competency in cardiopulmonary resuscitation.

Grant EC, Marczinski CA, Menon K. Using Pediatric Advanced Life Support in pediatric residency training: Does the curriculum need resuscitation? Pediatr Crit Care Med. 2007 Jul 31

Need Continued Practice

• Resuscitation course + 3 practice mock resuscitations

• The intervention group scored better on the short answer test (P<.001).

• A larger number of IG were successful in – ancillary airway maneuvers (P =.02) – femoral vascular access (P =.02) – endotracheal intubation (P =.004) – intraosseous access (P =.002)

Nadel FM, Lavelle JM, Fein JA, Giardino AP, Decker JM, Durbin DR. Teaching resuscitation to pediatric residents: the effects of an intervention. Arch Pediatr Adolesc Med. 2000 Oct;154(10):1049-54

Need Practice

“The results of this study support the recommendation that mock codes should be performed in the pediatric primary care setting to improve practitioner confidence and decrease practitioner anxiety”

Toback SL, Fiedor M, Kilpela B, Reis EC. Impact of a pediatric primary care office-based mock code program on physician and staff confidence to perform life-saving skills. Pediatr Emerg Care. 2006 Jun;22(6):415-22.

Not Taking Course• Majority of PALS students not physicians.

• Pediatricians in general office practice accounted small percentage of participants

• Further research should be conducted to determine attitudes toward PALS training and the barriers that exist to the office-based pediatrician participating in PALS training.

van Amerongen R, Klig S, Cunningham F Jr, Sylvester L, Silber S. Pediatric advanced life support training of pediatricians in New Jersey: cause for concern? Pediatr Emerg Care. 2000 Feb;16(1):13-7

TEREM – APLS COURSE

• Deena R Zimmerman MD MPH– Course Director

• Nahum Kovalski MD– Audiovisual Director

• Fred Carol MD– Equipment Director

• Instructors Next course Dec 18/19 2007For more information contact dl@terem.com

Day One

• Approach to the critically ill child • CPR and arrhythmias• Respiratory emergencies • Trauma• Airway skills • Cardiovascular skills• IV access• Wound Management

Day Two

• Surgical emergencies• Environmental emergencies• Fever and… (Medical emergencies)• Radiology• CNS emergencies• Toxicology• Mock Codes• Written test