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Calcium Use During In-hospital Pediatric Cardiopulmonary Resuscitation: A Report From the National Registry of Cardiopulmonary Resuscitation

^a Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
^b Department of Pediatrics, Morgan Stanley Children's Hospital of New York-Presbyterian and Columbia University Medical Center, New York, New York
^c Department of Pediatrics, Steele Children's Research Center, University of Arizona, Tucson, Arizona

	ABSTRACT

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OBJECTIVES. Specific patterns of calcium use during in-hospital pediatric cardiopulmonary resuscitation have not been reported since publication of pediatric advanced life support guidelines by the American Heart Association in 2000 recommended that calcium use during cardiopulmonary resuscitation be limited to select circumstances. We hypothesized that calcium is used frequently during in-hospital pediatric cardiopulmonary resuscitation and that its use is associated with worse survival to hospital discharge.

METHODS. We reviewed 1477 consecutive pediatric cardiopulmonary resuscitation index events (for patients younger than 18 years) submitted to the National Registry of Cardiopulmonary Resuscitation from January 2000 through July 2004. The primary outcome was survival to hospital discharge. Secondary outcomes included survival of event and neurologic outcome. Multivariable logistic regression was performed to analyze the association between calcium use and outcomes.

RESULTS. Calcium was used in 659 (45%) of 1477 events. Calcium was more likely to be used during cardiopulmonary resuscitation in the settings of pediatric facilities, ICUs, cardiac surgery, cardiopulmonary resuscitation duration of 15 minutes, asystole, and concurrently with other advanced life support medications: epinephrine, vasopressin, sodium bicarbonate, and magnesium sulfate. The use of calcium during cardiopulmonary resuscitation adjusted for confounding factors was associated with decreased survival to discharge and was not associated with favorable neurologic outcome.

CONCLUSIONS. Calcium is used frequently during in-hospital pediatric cardiopulmonary resuscitation. Although epidemiologic associations do not necessarily indicate causality, calcium use during cardiopulmonary resuscitation is associated with decreased survival to hospital discharge and unfavorable neurologic outcome.

Key Words: cardiopulmonary resuscitation • pediatrics • calcium • survival

Abbreviations: CPR—cardiopulmonary resuscitation • AHA—American Heart Association • NRCPR—National Registry of Cardiopulmonary Resuscitation • PCPC—pediatric cerebral performance category • OR—odds ratio • CI—confidence interval • aOR—adjusted OR

The role of calcium administration during cardiopulmonary resuscitation (CPR) remains controversial. Although calcium ions play a critical role in myocardial contractile performance and impulse formation, limited retrospective and prospective studies of calcium administration during CPR have not shown any benefit.^1–9 Furthermore, high serum calcium levels induced by calcium administration may be detrimental. Several studies have implicated cytoplasmic calcium accumulation in the final common pathway of cell death.^10–13 Calcium accumulation results from calcium's entering cells after ischemia and during reperfusion of ischemic organs; increased cytoplasmic calcium concentration activates intracellular enzyme systems, resulting in cellular necrosis. In 2000, the American Heart Association (AHA) published guidelines limiting the recommended use of calcium to selected resuscitation circumstances: documented hypocalcemia, hyperkalemia, hypermagnesemia, and calcium channel blocker overdose.¹⁴ These guidelines also explicitly stated that calcium should not be used routinely to support circulation in the setting of cardiac arrest (class III recommendation: not useful and may cause harm).

Specific patterns of calcium use during in-hospital pediatric CPR, and their effect on survival have not been reported since these guidelines were published. Recently, a limited, single-center study reported an association between calcium use during CPR performed in the PICU and increased mortality.¹⁵ The National Registry of Cardiopulmonary Resuscitation (NRCPR) is a large, multicenter database that prospectively and rigorously documents adult and pediatric in-hospital cardiac arrests.¹⁶ We conducted this study using the NRCPR database to characterize patterns of calcium use during in-hospital pediatric CPR. We hypothesized that calcium continues to be used frequently during in-hospital pediatric CPR and that its use varies by hospital-specific, patient-specific, and event-specific characteristics. We also hypothesized that calcium use during in-hospital pediatric CPR is associated with worse survival to hospital discharge, and worse event survival and unfavorable neurologic outcome.

	METHODS

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Design
The NRCPR is a prospective, multisite, in-hospital resuscitation registry sponsored by the AHA with voluntary, fee-based membership. At each participating institution, research coordinators abstract information about each cardiopulmonary arrest from hospital medical charts. The resulting database contains precisely defined variables derived from the Utstein-style data reporting guidelines for cardiac arrest.^17,18 Data abstractors must complete a certification examination consisting of multiple-choice questions and a mock scenario covering operational definitions and criteria for inclusion and exclusion. Case study methods are used to evaluate data abstraction, the accuracy of entries, and compliance with operational definitions before data are accepted. The 6 major categories of variables are facility data, patient demographic data, pre-event data, event data, outcome data, and quality improvement data. Explicit operational definitions have been generated for every data element. Each patient is assigned a unique code, and specific patient identifiers are not transmitted to the central database repository, which is in compliance with the Health Insurance Portability and Accountability Act. The data are securely submitted to a central data repository (Digital Innovation, Forest Hill, MD). The AHA oversees the entire process of data collection, analysis, and reporting through its national center staff, scientific advisory board, and executive database steering committee. The primary purpose of the NRCPR is quality improvement by benchmarking against national and peer standards; participating hospitals are therefore not required to obtain approval from their institutional review boards. Nevertheless, this study was approved by the institutional review board at Children's Hospital of Philadelphia.

Inclusion and Exclusion Criteria
Data were analyzed from 167 participating NRCPR hospitals that recorded cardiopulmonary arrests of patients who were younger than 18 years and provided >6 months of data from January 1, 2000, through July 31, 2004. All patients who were younger than 18 years and experienced cardiopulmonary arrest that required CPR at participating institutions were eligible for this study. An event was defined as an arrest that required chest compressions and/or defibrillation. An index event was defined as the patient's first cardiopulmonary arrest that required CPR during hospitalization. Only index events were eligible for inclusion in the study. Out-of-hospital arrests, arrests that occurred in the delivery room or NICU, arrests in patients with "do not attempt resuscitation" orders, and arrests that were resolved by implantable cardioverter-defibrillator shocks were excluded.

Outcome Measures
The prospectively selected primary outcome measure was survival to hospital discharge.^17–19 The secondary outcome measures included survival of event (defined as return of spontaneous circulation for >20 minutes) and neurologic outcome. The neurologic outcome was determined according to the pediatric cerebral performance category (PCPC) scale as follows: (1) a normal neurologic state, (2) mild disability, (3) moderate disability, (4) severe disability, (5) coma or vegetative state, and (6) death.^20,21 Neurologic status before the arrest and at discharge was determined by chart review. A favorable neurologic outcome was defined by a PCPC score of 1, 2, or 3 or no change from baseline PCPC scores.²²

Statistical Analysis
All statistical analyses were performed with a commercially available statistical package (Stata 8, College Station, TX). Summary results are presented as means ± SD for variables that are distributed normally. Variables that were not distributed normally are presented as medians and interquartile ranges. Differences between groups were analyzed by the Wilcoxon rank-sum test for continuous variables and the ² test for dichotomous variables. Hospital, patient, and event variables associated with calcium use by univariate analysis (P < .20) were included in stepwise multivariable logistic regression analysis. Finally, all factors associated with primary and secondary outcomes on univariate analysis (P < .20) were included in stepwise multivariable logistic regression to describe the association of calcium use with outcome measures adjusted for confounding factors. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported. The sample size was not planned. All P values are 2-sided.

	RESULTS

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A total of 1477 index children in 167 participating centers received CPR for in-hospital cardiopulmonary arrest. Of these, 659 (45%) received calcium during CPR (Fig 1). The incidence of calcium use by age was 310 (44%) of 703 infants who were younger than 1 year, 184 (48%) of 385 children who were aged 1 to 7 years, and 165 (42%) of 389 children who were aged 8 to 17 years. The incidence of calcium use during CPR in the year 2000 (before the publication of the guidelines) was 86 (50%) of 173 events and in subsequent years ranged from 42% to 46% of events that required CPR (Fig 2).

View larger version (12K): [in this window] [in a new window]   FIGURE 1 Enrollment and outcomes.

View larger version (9K): [in this window] [in a new window]   FIGURE 2 Year-wise calcium use during CPR. Arrow indicates publication of 2000 AHA Guidelines for Pediatric Advanced Life Support.

The factors that were significantly associated with calcium use during in-hospital pediatric CPR after controlling for duration of CPR for 15 minutes by stepwise multivariable logistic regression are shown in Table 3. Calcium use during CPR was associated with arrests that occurred in pediatric facilities and ICUs. Notably, calcium use during CPR continued to demonstrate an independent association with asystole as the first documented rhythm during the arrest (adjusted OR [aOR]: 1.3; 95% CI: 1.1–1.8). In addition, use of calcium during CPR was independently associated with the concurrent use of other advanced life support medications.

Finally, we examined the effect of calcium administration on outcomes in patients who received CPR for <15 minutes (n = 501). After adjustment for potentially confounding factors, calcium use remained associated with worse survival to discharge (aOR: 0.7; 95% CI: 0.4–0.9) and was not associated with favorable neurologic outcome (aOR: 0.6; 95% CI: 0.3–0.9).

	DISCUSSION

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This report of in-hospital pediatric cardiopulmonary arrests in 1477 consecutive children documents calcium administration during resuscitation of 659 (45%) children. This study shows that calcium use during CPR is strongly influenced by hospital-specific, patient-specific, and arrest-specific characteristics. The data from this large national registry also clearly establish that calcium use during in-hospital pediatric CPR is associated with decreased survival to discharge and poor neurologic outcome.

Previous studies of adults had speculated that calcium administration during CPR might benefit a subset of patients with asystole and pulseless electrical activity^1,2; however, subsequent limited prospective and retrospective adult studies of calcium administration during resuscitation in these settings failed to demonstrate any benefit.^3–7 Later studies that consisted of large prospective cohorts of adults who sustained both in-hospital and out-of-hospital cardiac arrests did not show any association between the use of standard advanced cardiac life support medications (including calcium) and survival.^8,9 On the basis of these data, the AHA in 2000 issued advanced life support guidelines that recommended limiting the use of calcium to select resuscitation circumstances.¹⁴ Few pediatric studies have examined the effects of calcium administration during CPR on survival and neurologic outcome. de Mos et al¹⁵ reported the association of calcium administration during CPR with increased hospital mortality among 91 pediatric cardiac arrests in their PICU (aOR: 5.4; 95% CI: 1.1–25.0). The authors did not specifically account for factors associated with calcium use and speculated that this association might reflect increased arrest duration in nonsurvivors. Compared with our study, this single-center study included patients with nonperfusing rhythms only and had a greater proportion of postcardiac surgical patients. In addition to calcium use, risk factors that were associated with increase in hospital mortality included preexisting renal failure (aOR: 6.1; 95% C: 1.8–31) and being on epinephrine infusion at the time of arrest (aOR: 9.5; 95% CI: 1.5–62).¹⁵ A study that described the outcomes of in-hospital ventricular fibrillation in 859 children observed that calcium use during CPR was associated with reduced survival to discharge and poor neurologic outcome but did not specifically examine indications for calcium use or patterns of use during CPR.²³ Our study has a much larger number of patients from multiple centers with multiple illness categories represented and thus lends itself to greater generalizability to in-hospital pediatric cardiac arrests across the United States.

Specific indications for calcium use during CPR (hyperkalemia, documented hypocalcemia, hypermagnesemia, and calcium channel blocker overdose) are captured in the NRCPR under the categories of metabolic/electrolyte abnormalities and toxicologic abnormalities. This study revealed that calcium was administered to 45% of children who were treated with CPR. The combined incidence of metabolic/electrolyte and toxicologic abnormalities (as both preexisting conditions and immediate precipitating causes) in the NRCPR database is only 25%. Also, calcium was administered in 49% of events with asystole and 42% of events with pulseless electrical activity. This suggests that calcium is often used in circumstances other than those recommended by the pediatric advanced life support guidelines. After publication of the guidelines in 2000, calcium use during in-hospital pediatric CPR decreased slightly from 50% to 42% of events the next year but since then has continued to range between 42% and 46% every year. This finding emphasizes that the published guidelines have had minimal impact on subsequent behavior and practice with regard to calcium administration during CPR.

There are several reasons that calcium might be used so frequently during CPR in children. In neonates and infants, the immature myocardium depends more on extracellular calcium levels because intracellular calcium stores are limited.²⁴ This age group has significant risk factors such as cardiac bypass surgery, sepsis, and prematurity that have a significant impact on myocardial function and extracellular ionized calcium concentrations. Perhaps in part because of these factors, practitioners chose to provide calcium in 44% of events involving neonates and infants in this study. Nevertheless, in this age category, those who received calcium during CPR had worse survival to discharge (26%) compared with those who did not (55%; P < .001). Specifically, in the population of postcardiac surgical infants, after adjustment for confounding factors, the use of calcium during CPR was associated with worse event survival; however, calcium use during CPR was not significantly associated with reduced survival to hospital discharge (aOR: 0.6; 95% CI: 0.3–1.2) or unfavorable neurologic outcome (aOR: 0.6; 95% CI: 0.3–1.3). Additional studies are necessary to evaluate the impact of calcium administration during CPR in the postcardiac surgical infant and long-term outcomes.

The frequent use of calcium during CPR in other age and diagnostic categories may reflect medical futility and a "last-ditch" attempt to try all possible therapies during resuscitation. For example, calcium was administered during 56% of events that required CPR for 15 minutes, whereas it was used during 27% of events that required CPR for <15 minutes (P < .001). Calcium use in nonsurvivors to discharge was 53% compared with 28% in survivors to discharge (P < .001). Previous studies indicated that duration of CPR for >15 minutes was associated with poor outcomes from in-hospital pediatric CPR.^23,25 Similarly, in this study, the median duration of CPR in nonsurvivors to discharge was 25 minutes (interquartile range: 12–45) compared with 12 minutes (interquartile range: 5–25) in those who survived to discharge (P < .001). In addition, in this study, calcium use during CPR was significantly associated with administration of other advanced cardiac life support medications, suggesting its use as part of the last-ditch resuscitative efforts. Irrespective of event duration, calcium use during CPR was associated with worse survival to discharge and unfavorable neurologic outcome. This finding has important implications because of the widely known role of calcium in mediating reperfusion injury in the setting of ischemia resulting in cell death.

An important limitation of the study results from the lack of explicit documentation of specific indications for calcium use and details of calcium dosing during CPR as captured in the NRCPR. A dose-response effect, if observed, could have provided stronger evidence for the effect of calcium administration on outcome. Another important limitation is the inability to adjust for variation in facility characteristics and physician and nurse staffing in different settings, resulting in our inability to use hierarchical cluster modeling. Other potential limitations pertain to the integrity and validity of the data and sampling bias. Uniform operational definitions, uniform data collection, rigorous abstractor training, detailed periodic reabstraction, and large sample size were instituted prospectively to address data integrity and validity. Sampling bias was minimized by the use of strict inclusion and exclusion criteria, comprehensive methods to verify all arrests as entered into the NRCPR, a large sample, and the multicenter design. Finally, it is possible that the existing NRCPR data elements fail to capture other, unmeasured confounders of outcomes, despite the use of suitable analytical techniques. Thus, the observed association between calcium use and poor outcomes may not necessarily reflect a causal relationship, and the possibility that calcium is used more often for children who have a lower probability of survival cannot be excluded.

This study has important implications. First, the results emphasize that calcium continues to be used frequently during in-hospital pediatric CPR, despite guidelines that recommend limiting the use of calcium to specific circumstances. Pediatric advanced life support guidelines published by the AHA in 2005 continue to restrict the use of calcium to specific circumstances, including hyperkalemia, documented hypocalcemia, hypermagnesemia, and calcium channel blocker overdose.²⁵ Second, the use of calcium during CPR without such indications is associated with worse survival to discharge and unfavorable neurologic outcome, perhaps because of reperfusion injury to the ischemic brain, heart, and other organs mediated by calcium.

	CONCLUSIONS

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Calcium is administered during CPR in nearly half of all in-hospital pediatric cardiopulmonary arrests. The use of calcium during CPR is strongly influenced by hospital-specific, patient-specific, and arrest-specific characteristics. Although epidemiologic associations do not necessarily indicate causality, calcium use during CPR is associated with worse survival to hospital discharge and unfavorable neurologic outcome.

	ACKNOWLEDGMENTS

 
The Endowed Chair of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, and the AHA Emergency Cardiovascular Care Committee provided funding for the completion of this study but did not influence the design, conduct, management, analysis, or interpretation of the study.

The AHA National Registry of Cardiopulmonary Resuscitation investigators include the authors and M. E. Mancini, M. A. Peberdy, E. Allen, R. S. Braithwaite, B. Eigel, E. Hunt, W. Kaye, G. L. Larkin, J. P. Ornato, G. Nichol, J. Potts, M. Smythe, and T. Lane-Truitt.

We gratefully acknowledge Charles Schleien, MD for research mentorship; Richard Lin, MD, Kathryn Roberts, RN, and Carey Roth-Bayer, PhD, for assistance; and all of the data abstractors, staff, and investigators who work so hard to contribute data to the AHA NRCPR.

	FOOTNOTES

 
Accepted Sep 28, 2007.

Address correspondence to Vijay Srinivasan, MD, Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104. E-mail: srinivasan{at}email.chop.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

What's Known on This Subject The use of calcium administration during cardiac arrest is controversial. Since 2000, American Heart Association guidelines have limited use of calcium to specific circumstances during cardiac arrest: documented hypocalcemia, hyperkalemia, hypermagnesemia and calcium channel blocker overdose.

 

What This Study Adds Published guidelines have had minimal impact on the frequency of calcium administration during in-hospital pediatric cardiac arrest. Calcium is often administered during cardiac arrest, even in circumstances where its use may be harmful and associated with worse outcomes.

 

	REFERENCES

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1. Stueven HA, Thompson B, Aprahamian C, Tonsfeldt DJ, Kastenson EH. The effectiveness of calcium chloride in refractory electromechanical dissociation. Ann Emerg Med. 1985;14 (7):626 –629[CrossRef][ISI][Medline]
2. Harrison EE, Amey BD. The use of calcium in cardiac resuscitation. Am J Emerg Med. 1983;1 (3):267 –273[CrossRef][Medline]
3. Stueven H, Thompson BM, Aprahamian C, Darin JC. Use of calcium in prehospital cardiac arrest. Ann Emerg Med. 1983;12 (3):136 –139[ISI][Medline]
4. Stueven HA, Thompson BM, Aprahamian C, Tonsfeldt DJ. Calcium chloride: reassessment of use in asystole. Ann Emerg Med. 1984;13 (9 pt 2):820 –822[CrossRef][ISI][Medline]
5. Stueven HA, Thompson B, Aprahamian C, Tonsfeldt DJ, Kastenson EH. Lack of effectiveness of calcium chloride in refractory asystole. Ann Emerg Med. 1985;14 (7):630 –632[CrossRef][ISI][Medline]
6. Donovan PJ, Propp DA. Calcium and its role in cardiac arrest: understanding the controversy. J Emerg Med. 1985;3 (2):105 –116[CrossRef][Medline]
7. Thompson BM, Stueven HS, Tonsfeldt DJ, et al. Calcium: limited indications, some danger. Circulation. 1986;74 (6 pt 2):IV90 –IV93[Medline]
8. van Walraven C, Stiell IG, Wells GA, Hebert PC, Vandemheen K. Do advanced cardiac life support drugs increase resuscitation rates from in-hospital cardiac arrest? The OTAC Study Group. Ann Emerg Med. 1998;32 (5):544 –553[CrossRef][ISI][Medline]
9. Stiell IG, Wells GA, Hebert PC, Laupacis A, Weitzman BN. Association of drug therapy with survival in cardiac arrest: limited role of advanced cardiac life support drugs. Acad Emerg Med. 1995;2 (4):264 –273[ISI][Medline]
10. Katz A, Reuter H. Cellular calcium and cardiac cell death. Am J Cardiol. 1979;44 (1):188 –190[CrossRef][ISI][Medline]
11. Nayler WG. Calcium and cell death. Eur Heart J. 1983; (4 suppl C):33 –41
12. Nayler WG. The role of calcium in the ischemic myocardium. Am J Pathol. 1981;102 (2):262 –270[Abstract]
13. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 10: pediatric advanced life support. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Circulation. 2000;102 (8 suppl):I291 –I342[Medline]
14. de Mos N, van Litsenburg RR, McCrindle B, Bohn DJ, Parshuram CS. Pediatric in-intensive-care-unit cardiac arrest: incidence, survival, and predictive factors. Crit Care Med. 2006;34 (4):1209 –1215[CrossRef][ISI][Medline]
15. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003;58 (3):297 –308[CrossRef][ISI][Medline]
16. Zaritsky A, Nadkarni V, Hazinski MF, et al. Recommended guidelines for uniform reporting of pediatric advanced life support: the pediatric Utstein Style—a statement for healthcare professionals from American Academy of Pediatrics, the American Heart Association, and the European Resuscitation Council. Circulation. 1995;92 (7):2006 –2020[ISI][Medline]
17. Jacobs I, Nadkarni V, Bahr J, et al. International Liaison Committee on Resuscitation; American Heart Association; European Resuscitation Council; Australian Resuscitation Council; New Zealand Resuscitation Council; Heart and Stroke Foundation of Canada; InterAmerican Heart Foundation; Resuscitation Councils of Southern Africa; ILCOR Task Force on Cardiac Arrest and Cardiopulmonary Resuscitation Outcomes. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries—a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa). Circulation. 2004;110 (21):3385 –3397[CrossRef][ISI][Medline]
18. Cummins RO, Chamberlain DA, Abramson NS, et al. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style. Ann Emerg Med. 1991;20 (8):861 –874[CrossRef][ISI][Medline]
19. Fiser DH. Assessing the outcome of pediatric intensive care. J Pediatr. 1992;121 (1):68 –74[CrossRef][ISI][Medline]
20. Fiser DH, Long N, Roberson PK, Hefley G, Zolten K, Brodie-Fowler M. Relation of pediatric overall performance category and pediatric cerebral performance category scores at pediatric intensive care unit discharge with outcome measures collected at hospital discharge and 1- and 6-month follow-up assessments. Crit Care Med. 2000;28 (7):2616 –2620[CrossRef][ISI][Medline]
21. Reis AG, Nadkarni V, Perondi MP, Grisi S, Berg RA. A prospective investigation into the epidemiology of in-hospital pediatric cardiopulmonary resuscitation using the international Utstein reporting style. Pediatrics. 2002;109 (2):200 –209[Abstract/Free Full Text]
22. Samson RA, Nadkarni VM, Meaney PA, et al. Outcomes of in-hospital ventricular fibrillation in children. N Engl J Med. 2006;354 (22):2328 –2339[Abstract/Free Full Text]
23. Nakanishi T, Seguchi M, Takao A. Development of the myocardial contractile system. Experientia. 1988;44 (11–12):936 –944[CrossRef][ISI][Medline]
24. Slonim AD, Patel KM, Ruttimann UE, Pollack MM. Cardiopulmonary resuscitation in pediatric intensive care units. Crit Care Med. 1997;25 (12):1951 –1955[CrossRef][ISI][Medline]
25. ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005;112 (24 suppl):IV1 –IV203[ISI][Medline]

This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via CrossRef Google Scholar Articles by Srinivasan, V. PubMed PubMed Citation Articles by Srinivasan, V. Related Collections Office Practice

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