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Pediatric Resuscitation vs Adult – Cognitive Load and Quality

June 6, 2023

Written by Amanda Mathews

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In this cross-sectional simulation study of seven EMS agencies in Oregon, researchers found that resuscitation quality was significantly lower in pediatric out of hospital cardiac arrests (OHCA) compared to adult OHCA as measured by defect free resuscitations.

Why does this matter?
Pediatric cardiac arrests are more rare than adult arrests and associated with significant mental stress on first responders. Survival for pediatric OHCA has been at 10% for multiple years despite improvements in adult OHCA mortality rates during the same time. This study sought to compare first responder performance in both pediatric and adult OHCA to determine knowledge gaps and identify areas for quality improvement.

Kid resuscitations are not just little adult resuscitations…or are they?
This study was carried out with EMT and paramedic trained fire crews across 7 EMS agencies in Portland, Oregon. Each crew participated in four separate simulation scenarios presented to them in random order: 1) adult female in shockable arrest and ventricular fibrillation (VF), 2) adult female in pulseless electrical activity (PEA), 3) school aged child in VF and 4) infant in PEA. A pediatric emergency medicine or critical care trained physician observed each simulation and completed a performance assessment in real time based on critical action timestamps, ventilation, and CPR quality. Two study members specifically observed team work, and participants filled out a survey related to their task load saturation after each simulation event.

In both pediatric simulations, there were delays in time to CPR, time to BVM, vascular access, and time to initial epinephrine dose in comparison to adults. An incorrect mask size was used in 55% of pediatric simulations compared to 2% of adult simulations and approximately 20% of pediatric simulations had errors in epinephrine dosing and defibrillation joules. 58% of pediatric arrests had inadequate chest compression depth. 69% of adult simulations were defect free across both adult simulations. Only 12.8% of pediatric shockable rhythm simulations were defect free, and none of the pediatric PEA simulations were defect free. Participants did rate the pediatric PEA simulation as having the highest cognitive load using the NASA task load index (NASA-TLX) self-report.

This study provides an interesting comparison of adult and pediatric OHCAs and shows that pediatric arrests have higher cognitive load and are more prone to defects than adult arrests. Specific areas for improvement in pediatric arrests are determining correct mask size, compression depth, and weight based drug dosing and defibrillation joules.

Editor’s note: Peter Antevy appeals to EMS to actually think of pediatric resuscitations more like ‘little adult’ resuscitations. He notes that in pediatric resuscitation, we are using, what Nobel Prize winner Daniel Kahneman calls, “system 2” thinking vs “system 1” thinking. System 1 thinking is fast, built on pattern recognition and heuristics; it’s intuitive. He uses the example of facial expression recognition. You know immediately what certain expressions mean and what type of response is likely going to come from that person. System 1 is: What is 2+2? A system 2 example is: What is 17 x 24? This is not intuitive and is not a fast response from our brain. It takes work and memory. Antevy argues that we approach adult resuscitation with system 1 thinking and pediatric with system 2. He teaches that with some simple techniques, PALS can be system 1 as well. ~Clay Smith

Comparison of Resuscitation Quality in Simulated Pediatric and Adult Out-of-Hospital Cardiac Arrest. JAMA Netw Open. 2023 May 1;6(5):e2313969. doi: 10.1001/jamanetworkopen.2023.13969.