Improving the Quality of Pediatric Basic Life Support Cardiopulmonary Resuscitation With a Novel Method: The Maryland Hiccup.

Abstract

Prehospital high-performance cardiopulmonary resuscitation (CPR) has demonstrated remarkable improvements in the survival of adult patients after out-of-hospital cardiac arrest (OHCA). With a goal to improve pediatric survival rates, Maryland Emergency Medical Services (EMS) for Children created a pediatric-specific high-performance CPR protocol to align with the existing state protocol for adult CPR. While prehospital CPR for adults has moved toward continuous compressions, prehospital CPR for children without an advanced airway continues to adhere to American Heart Association (AHA)/International Liaison Committee on Resuscitation (ILCOR) guidance for two ventilations for every 15 compressions. The Maryland Hiccup (MH) is a novel approach to pediatric CPR. The method combines the goal of continuous compressions with AHA/ILCOR guidance for a 15:2 compression-to-ventilation ratio. In contrast to the two- to four-second pause after compression 15 of the AHA/ILCOR style, the "hiccup" of the MH method describes two brief pauses for ventilation during the upstrokes of compressions 14 and 15. We compare basic CPR quality metrics for two-rescuer high-performance CPR using the standard AHA/ILCOR 15:2 style compared to the MH style. We enrolled 38 Maryland EMS clinicians in two-person teams to perform simulated CPR on a pediatric manikin. We recorded compression and ventilation data for 76 two-minute cycles of high-performance CPR. Compression fraction was significantly improved using the MH when compared to the standard AHA style for high-performance CPR (median 98% vs 80%, p<0.001). When compressions per minute (CPM) were compared by 30-second epochs, 80% of epochs were out of range (<100 CPM or >120 CPM) using the AHA/ILCOR style, while only 32% of epochs were out of range for MH style. No significant differences were found between the two CPR styles in ventilation volume or compression depth. The MH is a novel method for pediatric basic life support two-provider CPR which improves CPR quality metrics among EMS clinicians regardless of their prior experience. The use of this method in simulation allows near-continuous compressions without the placement of an advanced airway. Future research is needed to explore whether the CPR quality improvements translate to improved patient outcomes in real-world use.