Pediatric Life Support Update 2015 American Heart Association Highlights

CME REVIEW ARTICLE

Carson Gill, MSc* and Niranjan Kissoon, MD, FAAP†

review to a new, continuous, Web-based evidence evaluation pro- Abstract: Despite improving survival rates for pediatric cardiac arrest cess.2 The first release of the Web-based Integrated Guidelines is victims, they remain strikingly low. Evidence for pediatric cardiopulmonary re- currently available online (ECCguidelines.heart.org). suscitation is limited with many areas of ongoing controversy. The American Survival from pediatric cardiac arrest is improving, espe- Heart Association provides updated guidelines for life support based on cially in the in-hospital setting;3 however, many knowledge gaps comprehensive reviews of evidence-based recommendations and expert and areas of controversy still exist and out-of-hospital cardiac ar- opinions. This facilitates the translation of scientific discoveries into daily rest outcomes remain poor.4,5 The Pediatric Task Force reviewed patient care, and familiarization with these guidelines by health care pro- all questions submitted by the ILCOR member councils in 2010 viders and educators will facilitate the widespread, consistent, and effective and through a rigorous systematic review process updated the pe- care for patients. diatric basic life support and pediatric advanced life support Key Words: CPR, life support, cardiac arrest, resuscitation (PALS) guidelines in 2015.6 Clinicians and educators should be – familiar with these guidelines to provide the most effective and (Pediatr Emer Care 2017;33: 585 595) evidence-based care and training available. This article will provide an overview of the 2015 AHA guideline updates for pediatric TARGET AUDIENCE basic life support and PALS. This CME activity is intended for health care providers in For the purpose of this article and the AHA guidelines: hospital and prehospital settings who administer care to infants, children, and adolescents. Emergency physicians and nurses, pe- • Infant guidelines apply to infants younger than approximately diatricians, physician assistants, resident physicians, medical stu- 1yearofage dents, and paramedics who assess and treat pediatric patients in • Child guidelines apply to children approximately 1 year of age cardiopulmonary distress, as well as basic and advanced life sup- until puberty (breast development in females and presence of port educators, will find this information particularly useful. axillary hair in males) • Adult guidelines apply at and beyond puberty LEARNING OBJECTIVES After the completion of this article, the reader will be better All recommendations in the update have undergone a rigor- equipped to: ous evaluation for benefits and risks, which is accounted for in the class (strength) of the final recommendation as outlined: 1. Discuss an approach to basic and advanced life support. 2. Initiate evaluation and management of a patient in cardiac arrest. Class (strength) of recommendation Benefit vs Risk Class I (strong) Benefit >> > Risk he publication of the 2015 American Heart Association Class IIa (moderate) Benefit >> Risk T (AHA) Guidelines Update for Cardiopulmonary Resuscita- Class IIb (weak) Benefit ≥ Risk tion (CPR) and Emergency Cardiovascular Care (ECC) marks Class III: no benefit (moderate) Benefit = Risk 15 years since the AHA began collaborating with other resuscita- Class III: harm (strong) Benefit < Risk tion councils throughout the world, via the International Liaison Committee on Resuscitation (ILCOR). Since 2000, experts from the ILCOR member councils have evaluated and reported their In- ternational Consensus on CPR and ECC Science with Treatment PEDIATRIC BASIC LIFE SUPPORT Recommendations (CoSTR) in 5-year cycles.1 The 2015 AHA Initial recognition and response to cardiac arrest are the fun- Guidelines Update for CPR and ECC serves as an update to the damental aspects of basic life support (BLS), which is the founda- 2010 AHA Guidelines for CPR and ECC, rather than a complete tion for saving lives after an arrest. The steps of BLS consist of a revision, and marks the transition from a 5-year cycle of evidence series of sequential assessments and actions that focus on the early activation of the emergency response system, CPR, and defibrilla- Medical Student (Gill), *Faculty of Medicine, University of British Columbia; tion with an automated external defibrillator. The 2015 AHA and Professor (Kissoon), †Department of Pediatrics, Critical Care and Global Guidelines Update for Pediatric BLS and CPR Quality focuses ’ Child Health, BC Children s Hospital, University of British Columbia, Vancouver, on initial actions for rescuers, CPR quality measures, and algo- British Columbia, Canada. The authors, faculty, and staff in a position to control the content of this CME rithm modifications for lone- and multiple-rescuer CPR. activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interest in, any commercial organizations pertaining to this educational activity. C-A-B Sequence Reprints: Niranjan Kissoon, MD, FAAP,Department of Pediatrics, Critical Care Conventional CPR involves chest compressions and rescue and Global Child Health, BC Children’s Hospital, University of British breaths in the sequence of A-B-C (airway-breathing-compressions). Columbia, Room B245, 4480 Oak St, Vancouver, British Columbia V6H 3 V4, Canada (e‐mail: [email protected]). However, the 2010 AHA guidelines recommended a change to the Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. C-A-B sequence (compressions-airway-breathing) for adult and ISSN: 0749-5161 pediatric patients to reduce time to first compressions and the

Pediatric Emergency Care • Volume 33, Number 8, August 2017 www.pec-online.com 585

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Gill and Kissoon Pediatric Emergency Care • Volume 33, Number 8, August 2017 period of “no blood flow.”7 While this allows for uniformity of children,15,27 given that insufficient data are available to make any CPR recommendations across all ages and etiologies, it fails to new recommendations.6,11 In addition, it is appropriate to follow recognize the inherent differences of adult and pediatric cardiac adult compression depth guidelines for adolescents with emphasis arrest. Indeed, asphyxial cardiac arrest is much more common on achieving adequate depth over the modest risks of harming pa- than primary cardiac events in infants and children than adults, tients.11,22 To optimize adequate compression depth in association which necessitates ventilation as part of effective pediatric with these guidelines, CPR feedback devices may be useful.28–30 CPR.4,6,8 Recent adult and pediatric manikin studies demonstrated that a C-A-B approach delayed the time to first ventilation Treatment Recommendations 9,10 by only 6 seconds when compared with an A-B-C approach. It is reasonable for pediatric patient rescuers to provide com- However, no human studies exist that compare C-A-B and A- pressions that depress the chest at least one third the anteroposterior B-C approaches for initial management and outcomes of cardiac 11 diameter of the chest, which equates to approximately 4 cm in in- arrest. Further research is required to establish the best approach fants and 5 cm in children (class IIa). For adolescents of average to initiating CPR in infants and children. adult size, the new recommended adult compression depth guidelines of at least 5 cm, but not exceeding 6 cm, should be applied Treatment Recommendations (class I).11 Pediatric evidence comparing C-A-B versus A-B-C approaches is limited; therefore, it may be reasonable to maintain Chest Compression Rate the C-A-B sequence from the 2010 AHA guidelines to simplify Pediatric evidence regarding compression rate optimization training, provide consistency for teaching, and potentially increase 11 is extremely limited. The 2010 AHA guidelines recommended a bystander CPR rates (class IIb). compression rate of at least 100 compressions per minute15,19; however, recent adult studies suggest that the optimal compression rate lies between 100 compressions per minute and 120 compres- Compression-Only CPR 31,32 Chest compression-only CPR is recommended for lay res- sions per minute. Compression depth becomes progressively 12,13 insufficient as compression rate increases beyond 120 compres- cuers because adults with ventricular fibrillation (VF) account 31 for the vast majority of cardiac arrest victims requiring CPR and in sions per minute and is associated with decreased survival. As whom compressions are more important than ventilations.14,15 a result, the 2015 AHA guidelines for adult and pediatric BLS However, pediatric arrest is commonly due to asphyxia and evi- have been updated accordingly. dence suggests that resuscitation outcomes for asphyxial arrest are better with a combination of ventilation and chest compres- Treatment Recommendations sions.16,17 Nevertheless, compression-only CPR may be as effec- In the absence of sufficient pediatric evidence and to simplify tive as conventional CPR in pediatric patients with a primary CPR training, it is reasonable for rescuers to use the adult BLS- cardiac event.16 If rescuers are unable to provide rescue breaths, recommended chest compression rate of 100 compressions per they should at least perform compressions, especially for a sud- minute to 120 compressions per minute for infants and children den, witnessed collapse, because such an event is likely to have (class IIa).11 a cardiac etiology.11 This may aid in improving bystander CPR rates for out-of-hospital cardiac arrests, which continues to remain Algorithms for Lone-Rescuer and low in children at an estimated 61%.18 Multiple-Rescuer CPR Algorithms for 1- (Fig. 1) and 2-person (Fig. 2) pediatric Treatment Recommendations health care provider CPR have been updated and separated to Given the asphyxial nature of the majority of pediatric cardiac guide rescuers in an era where mobile telephones with a speaker arrests, conventional CPR (chest compressions and rescue breaths) are common. This technology allows a single rescuer to activate should be performed (class I). If rescuers are unwilling or unable to the emergency response system while initiating CPR. It remains deliver rescue breaths, they should perform compression-only CPR imperative to obtain an automated external defibrillator quickly for infants and children in cardiac arrest because it is effective in pa- for a witnessed collapse as such an event is likely to have a tients with a primary cardiac event (class I).11 cardiac etiology.11

Chest Compression Depth PEDIATRIC ADVANCED LIFE SUPPORT The 2010 AHA Adult BLS Guidelines recommended a com- Advanced life support (ALS) in cardiac arrest care builds on pression depth greater than 5 cm (2 inches) and no upper limit for high-quality CPR, monitoring the patient's physiologic response to CPR.19 Although favorable outcomes are consistently associated BLS and titrating additional care to optimize outcomes. It is impor- with achieving a depth of approximately 5 cm,20,21 recent evi- tant to recognize that not all patients will respond to standard BLS dence also suggests some harm is associated with chest compres- and ALS care and that some interventions may be limited to spe- sions deeper than 6 cm (2.4 inches) in adults.22 The 2015 AHA cific settings due to resource availability. The 2015 AHA Guidelines Guideline Updates for Adult BLS reflect this, recommending that Update for Pediatric ALS focuses on pre-arrest, intra-arrest, and rescuers perform chest compressions to a depth of at least 5 cm, post-arrest interventions that were selected by the ILCOR for re- but not exceeding 6 cm.23 view to improve pediatric cardiac arrest care and outcomes. Limited pediatric evidence suggests that compression depth is often inadequate during pediatric cardiac arrest24 and that efforts to increase depth may be associated with improved outcomes in in- PRE-ARREST CARE fants25 and children.26 It is reasonable to maintain the 2010 AHA Pediatric BLS Guidelines to compress at least one third of the Fluid Resuscitation in Septic Shock anteroposterior diameter of the chest, corresponding to approxi- Although the incidence of pediatric sepsis has steadily risen mately 4 cm (1.5 inches) in infants and 5 cm (2 inches) in over the last 2 decades in the United States, mortality has

FIGURE 1. BLS Health Care Provider Pediatric Cardiac Arrest Algorithm for the Single Rescuer–2015 Update.11 decreased.33,34 During this time, guidelines have emphasized the and weak pulse, cold extremities, and capillary refill longer than role of early and rapid fluid administration in treating septic 3 seconds.39 Without all 3 clinical features of shock patients have shock35 based on early observational data.36 The 2010 AHA Pedi- nonspecific circulatory impairment, and while they should be prior- atric ALS Guidelines recommended treating signs of shock with a itized for a full assessment and receive maintenance fluids appropri- bolus of 20 mL/kg of isotonic crystalloid or colloid and to give ad- ate for age, weight, and disease process, they should not receive any ditional boluses of 20 mL/kg if systemic perfusion fails to im- rapid fluid infusions. Bolus fluid therapy may not be safe for all prove.35 However, a large randomized controlled trial of fluid patients in all settings and individualized patient evaluation and resuscitation in sub-Saharan Africa recently found intravenous fluid reassessment must be undertaken to determine the underlying boluses to be harmful in infants and children with severe febrile ill- pathophysiology and appropriate management of pediatric pa- ness and some signs of shock. In this resource-limited setting with- tients with signs of impaired circulation or shock.38,39 out access to some critical care interventions, the administration of 20 mL/kg or 40 mL/kg fluid boluses was associated with decreased survival compared with maintenance fluids alone.37 In light of this Treatment Recommendations new evidence, the World Health Organization (WHO) has reviewed Administration of an initial fluid bolus of 20 mL/kg of either and updated the Emergency Triage, Assessment, and Treatment isotonic crystalloids or colloids to infants and children in shock Guidelines for fluid management of pediatric patients who present is reasonable, including those with severe sepsis (class IIa). with shock.38 Shock is a complex entity with multiple etiologies, However, individualized treatment and frequent clinical reassess- and is clinically defined by the WHO as the presence of a fast ment after every fluid bolus (class I) cannot be overemphasized,

FIGURE 2. BLS Healthcare Provider Pediatric Cardiac Arrest Algorithm for 2 or More Rescuers–2015 Update.11 especially in settings with limited access to critical care resources However, it may be reasonable for practitioners to administer atro- because it may be harmful (class IIb).40 pine prophylactically in specific emergency intubations with a higher risk of bradycardia (class IIb). A dose of 0.02 mg/kg with 40 Atropine for Emergency Endotracheal Intubations no minimum dose is appropriate (class IIb). Pediatric intubation often results in bradycardia as a direct result of some induction medications, as well as a vagal response to hypoxia and laryngoscopy.41 Historically, atropine was proposed INTRA-ARREST CARE to blunt this bradycardia42 and practitioners often prophylactically medicate with atropine before attempting intubation.40 However, Invasive Hemodynamic Monitoring During CPR current evidence does not support the routine use of atropine in in- Although previous AHA guidelines have recommended that tubations43 and is conflicting with regards to reducing the inci- 44,45 the waveform from an indwelling arterial catheter can be used as dence of arrhythmias or postintubation shock. Nevertheless, feedback to evaluate effectiveness of CPR including hand position it may be reasonable for practitioners to use preintubation atropine and chest compression depth,35,47 specific systolic blood pressure in specific emergency intubations when there is increased risk of targets during CPR in humans have not been studied.40 Two ran- bradycardia. Previous guidelines recommended a minimum dose domized controlled trials in animals recently found improvements of 0.1 mg intravenously after a report of paradoxical bradycardia 46 in return of spontaneous circulation (ROSC) and survival with the in infants. However, preintubation doses of 0.02 mg/kg with use of invasive hemodynamic monitoring.48,49 In children, if inva- no minimum dose have been shown to be safe and effective in in- 6 44,45 sive hemodynamic monitoring is already in place, they may ben- fants and children. efit from its use in conjunction with other CPR feedback devices (see BLS Chest Compression Depth above) to guide CPR qual- Treatment Recommendations ity.40 However, establishing and maintaining high-quality CPR There is insufficient pediatric evidence to support the routine without interruption must take precedence over obtaining hemo- use of preintubation atropine in critically ill infants and children. dynamic values invasively by which to titrate CPR.6

Treatment Recommendations POST-ARREST CARE Although specific target values for blood pressure have not been established in children, it may be reasonable for rescuers to Targeted Temperature Management use blood pressure waveforms to guide CPR quality for patients Therapeutic hypothermia has been shown to be neuroprotec- with invasive hemodynamic monitoring in place at the time of car- 63 64 40 tive in adults after cardiac arrest and asphyxiated neonates. As diac arrest (class IIb). such, the 2010 AHA Pediatric ALS Guidelines suggested a role for targeted temperature management after an arrest35 given that post- arrest fevers are common and associated with poor outcomes.65 A Vasopressors and Antiarrhythmic Drugs in recent multicenter randomized controlled trial of pediatric out-of- Cardiac Arrest hospital cardiac arrests found no difference in survival with good functional outcome in comatose patients treated with therapeutic hy- The use of vasopressors during cardiac arrest remains contro- pothermia (32°C to 34°C) compared with normothermia (36°C to versial. Although their use is intended to augment cerebral perfu- 37.5°C).66 A small retrospective review of pediatric patients with an sion and restore spontaneous circulation, they carry a significant out-of-hospital or in-hospital cardiac arrest found therapeutic hypo- risk of ischemia with increased vasoconstriction, myocardial thermia to improve mortality at hospital discharge, but no difference workload, and myocardial oxygen consumption.6,50 A recent ran- in neurologic outcomes.67 Results are pending for a multicenter randomized controlled trial in adults found that epinephrine was asso- domized controlled trial that was recently completed comparing tem- ciated with increased ROSC and survival to hospital admission, perature management for pediatric patients with an in-hospital but not to hospital discharge, after an arrest.51 Available pediatric cardiac arrest (Therapeutic Hypothermia After Pediatric Cardiac Ar- evidence is inconclusive regarding the efficacy of vasopressors in rest: www.THAPCA.org). Although there is currently insufficient ev- cardiac arrest.52,53 Nevertheless, vasopressors continue to be rec- idence to recommend a specific temperature range and duration for ommended by resuscitation councils because any changes are infants and children, post-arrest fevers must strictly be avoided given too speculative.6,35 their potential for harm.6,40 The 2005 and 2010 AHA Pediatric ALS Guidelines recommended amiodarone as the first-line antiarrhythmic treatment for Treatment Recommendations shock-refractory VF and pulseless ventricular tachycardia cardiac After an out-of-hospital or in-hospital cardiac arrest, temper- arrest.35,47 This recommendation is based on limited pediatric ev- 54 55 ature should be monitored continuously and fever treated aggres- idence and data extrapolated from adult studies. A recent pedi- sively in pediatric patients (class I). Furthermore, for infants and atric in-hospital observational study found improved ROSC and children who remain comatose after an out-of-hospital cardiac arrest, 24-hour survival with the use of lidocaine as compared with ami- it is reasonable for practitioners to maintain either 5 days of normo- odarone.56 However, neither lidocaine nor amiodarone improve 35,56 thermia (36°C to 37.5°C) or 2 days of initial continuous hypothermia survival to hospital to discharge. (32°C to 34°C) followed by 3 days of normothermia (class IIa). There is currently insufficient data to recommend hypothermia over normothermia for a pediatric in-hospital cardiac arrest.40 Treatment Recommendations It is reasonable to continue to administer epinephrine during Fluids and Inotropes pediatric cardiac arrest (class IIa). Furthermore, amiodarone or lido- Postresuscitation myocardial dysfunction and hemodynamic caine may be used for the treatment of shock-resistant VF and 68–70 pulseless ventricular tachycardia in pediatric patients (class IIb).40 instability are common. This results in hypotension that if prolonged may lead to multiple organ failure71 and ultimately is asso- The PALS Cardiac Arrest Algorithm (Fig. 3) has been 72,73 updated accordingly. ciated with increased morbidity and mortality. Post-ROSC hypotension in pediatric patients, defined as a systolic blood pressure less than the fifth percentile for age and sex, was recently shown to be associated with increased mortality and decreased Extracorporeal CPR neurologic outcomes at hospital discharge.74 However, optimal The 2010 AHA Pediatric ALS Guidelines suggested using hemodynamic goals remain undefined and management can be extracorporeal membrane oxygenation with CPR (ECPR) for pe- challenging as there are no studies evaluating vasoactive agents diatric cardiac arrest refractory to conventional interventions after ROSC in infants or children. Nevertheless, identifying and given the resources and expertise.35 No overall benefit of using treating post-ROSC hypotension should remain a priority despite any unknown harms that may be associated with fluids, inotropes, ECPR compared with CPR without extracorporeal membrane ox- 6 – or vasopressors. ygenation has been shown;57 60 however, outcomes for pediatric patients with surgical cardiac diagnoses or underlying cardiac disease are better than for those with noncardiac disease during an ar- Treatment Recommendations rest for which ECPR is used.61,62 Therefore, if a cardiac arrest After ROSC, continuous arterial pressure monitoring is rec- occurs in a supervised setting, such as an intensive care unit, it ommended to maintain a systolic blood pressure greater than the is reasonable to consider the use of extracorporeal life support dur- fifth percentile for age using parenteral fluids and/or inotropes ing and after resuscitation.6 or vasoactive drugs (class I).40

PaO2 and PaCO2 Treatment Recommendations Titration of oxygen delivery to infants and children after It may be reasonable to consider ECPR for pediatric patients ROSC must be balanced against the risk of inadvertent hypoxemia with an underlying cardiac condition who have an in-hospital car- and ideally should be appropriate to the specific patient condi- 6 diac arrest, provided the appropriate equipment, expertise, and tion. Post-arrest hypoxia (decreased levels of tissue Po2)has protocols are available (class IIb).40 well-established detrimental effects on resuscitation outcomes.75

FIGURE 3. Pediatric ALS Cardiac Arrest Algorithm–2015 Update.40

Conversely, hyperoxia (increased levels of tissue Po2) can result in Partial pressure of arterial CO2 (Paco2) is a major regulator of oxidative stress that may potentiate a postresuscitation syn- cerebral vasculature and blood flow.80 Indeed, hypocapnia may re- drome76 and is associated with increased mortality in adults.77,78 sult in a reduction of cerebral blood flow and is associated with The 2010 AHA Pediatric ALS Guidelines recommended maintain- poor outcomes in adult patients after cardiac arrest80,81 and in pe- ing an oxyhemoglobin saturation of 94% or greater to avoid post- diatric patients after hypoxic82 and traumatic83 brain injuries. arrest hypoxemia;35 however, recent pediatric evidence found that Conversely, a recent observational study of pediatric in-hospital normoxemia (60 mm Hg ≤ Pao2 <300mmHg)maybeassociated cardiac arrest found hypercapnia (Paco2 ≥ 50 mm Hg) to be asso- with improved survival when compared with hyperoxemia ciated with worse survival to discharge.84 However, pediatric data 79 (Pao2 >300mmHg). Because an arterial oxyhemoglobin satu- evaluating Paco2 targets and clinical outcomes following cardiac ration of 100% corresponds to a Pao2 between 80 and 500 mm arrest is extremely limited and another recent observational study Hg, it may be reasonable for rescuers to wean oxygen to target of both pediatric in-hospital and out-of-hospital cardiac arrests, an oxyhemoglobin saturation of less than 100%, but 94% or demonstrated no association between hypercapnia or hypocapnia 85 greater. This should strictly avoid hypoxemia and reduce exposure (Paco2 < 30 mm Hg) and clinical outcomes. Therefore, it is im- to hyperoxemia.40 portant for practitioners to limit exposure to hypercapnia or

hypocapnia and target a PaCO2 that is appropriate and specific to 11. Atkins DL, Berger S, Duff JP, et al. Part 11: Pediatric Basic Life Support the patient condition. and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132:S519–S525. Treatment Recommendations 12. ECC Committee, Subcommittees and Task Forces of the American Rescuers should target normoxemia after ROSC, ensuring to Heart Association. Part 4: Adult Basic Life Support. Circulation.2005; strictly avoid hypoxemia with an oxyhemoglobin saturation of 112:IV–19. 94% to 99%. Moreover, exposure to severe hypercapnia and hypocapnia should be avoided. Ideally, however, it is reasonable 13. Sayre MR, Berg RA, Cave DM, et al. Hands-only (compression-only) for practitioners to target a Pao and Paco after ROSC that is ap- cardiopulmonary resuscitation: a call to action for bystander response to 2 2 adults who experience out-of-hospital sudden cardiac arrest: a science propriate to the specific patient condition (class IIb).40 advisory for the public from the American Heart Association Emergency Cardiovascular Care Committee. Circulation. 2008;117:2162–2167. CONCLUSIONS 14. Rea TD, Cook AJ, Stiell IG, et al. Predicting survival after out-of-hospital cardiac arrest: role of the Utstein data elements. Ann Emerg Med.2010; Successful resuscitation depends on coordinated and prompt 55:249–257. rescuer actions, high-quality CPR, and optimized ALS care. Al- though survival from pediatric arrests is improving, there is still 15. Berg MD, Schexnayder SM, Chameides L, et al. Part 13: pediatric basic tremendous potential for improvement. Multiple factors must be life support: 2010 American Heart Association Guidelines for considered when prognosticating outcomes of cardiac arrest, and Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S862–S875. monitoring quality-of-care metrics and patient-centered outcomes provides the greatest opportunity through quality improvement to 16. Kitamura T, Iwami T, Kawamura T, et al. Conventional and save the most lives. The 2015 AHA Guidelines Update for CPR chest-compression-only cardiopulmonary resuscitation by bystanders and ECC marks the transition to a more continuous process of ev- for children who have out-of-hospital cardiac arrests: a prospective, idence evaluation and guideline optimization to rapidly translate nationwide, population-based cohort study. Lancet. 2010;375: – new science into resuscitation practice and education, to ulti- 1347 1354. mately save more lives.2 17. Goto Y, Maeda T, Goto Y. 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