Extracorporeal membrane oxygenation (ECMO) is a mode of extracorporeal life support that augments oxygenation, ventilation and/or cardiac output via cannulae connected to a circuit that pumps blood through an oxygenator and back into the patient. ECMO has been used for decades to support cardiopulmonary disease refractory to conventional therapy. While not robust, there are promising data for the use of ECMO in acute hypoxemic respiratory failure, cardiac arrest, and cardiogenic shock and the potential indications for ECMO continue to increase. This review discusses the existing literature on the potential use of ECMO in critically ill patients within the emergency department.

An inexpensive, discussion-based seminar series successfully provided pediatric residents with basic information regarding end-of-life care and significantly increased their confidence as clinicians caring for seriously ill and dying children.

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Hyperammonemia following hematopoietic cell transplantation (HCT) has been characterized as idiopathic and is associated with a very high mortality. A causal relationship between Ureaplasma infection and hyperammonemia in immunocompromised lung transplant recipients has recently been described. We document the first case of hyperammonemia following HCT associated with Ureaplasma parvum. The initiation of appropriate antibiotics resulted in rapid resolution of hyperammonemic encephalopathy and eradication of the implicating organism.

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Objectives After completing this article, readers should be able to: 1. List preventive efforts that may decrease drowning rates in the pediatric population. 2. Name the physiologic consequences of hypoxic-ischemic injury in drowning victims. 3. Explain the importance of bystander cardiopulmonary resuscitation for pediatric drowning victims. 4. Discuss the appropriate interventions for each stage of drowning-associated cardiac arrest. 5. Specify which pediatric drowning victims may be discharged from the emergency department. Definitions Terminology used to describe drowning often has been confusing and inconsistent. To alleviate this confusion, an international consensus conference was convened at the 2002 World Congress on Drowning with the goal of developing uniform terminology. The recently published recommendations define drowning as "a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium." (Idris et al. 2003) Accordingly, the term "drowning" should be used regardless of the outcome. In addition, the consensus document specifically recommends that confusing and inconsistent terms, such as "near-drowning," "secondary drowning," "passive drowning," "silent drowning," "wet drowning," and "dry drowning" be abandoned. Epidemiology Drowning is a major source of pediatric mortality and morbidity worldwide. Although differences in lifestyle and exposure to water may affect the circumstances under which drowning occurs in different countries, drowning consistently remains a leading cause of death throughout the world. In the United States in 1998, more than 1,500 children younger than 20 years of age died from drowning, making it the second leading cause of accidental childhood death. For children 12 to 23 months of age, drowning was the leading cause of accidental death and the second leading cause of death overall. There is less information concerning morbidity, but it is estimated that for each drowning death, there are one to four nonfatal drowning events requiring hospitalization. Such hospitalizations often result in prolonged disability requiring considerable monetary and emotional resources. Within the pediatric population, rates of drowning peak during both the toddler and adolescent years. Age also influences the circumstances of drowning. Among younger children, drowning usually occurs within the home, often during brief lapses in adult supervision. Infants drown in bathtubs most frequently, either when they are left unattended or as the result of abusive injury. Toddlers typically drown in swimming pools. For both infants and toddlers, physical and cognitive immaturity limits their ability to rescue themselves from water. Adolescent drowning frequently occurs in natural bodies of water and is associated with risk-taking behavior and intoxication. Although most drownings occur in previously healthy children, certain pre-existing medical conditions may play a role. Children who have seizure disorders have a risk of drowning four times that of the general populatio...

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Initiation of extracorporeal membrane oxygenation (ECMO) is stressful, especially for inexperienced extracorporeal life support providers. The main objective of this study was to create a novel, reusable mannequin for high-fidelity simulation of ECMO initiation. We modified a Laerdal neonatal mannequin (SimNewB; Stavanger, Norway) so that it could be used to simulate an ECMO initiation. A simulation of a neonatal patient suffering from meconium aspiration was performed in the pediatric intensive care unit, and participants included new extracorporeal life support specialists in addition to the composition of the clinical ECMO team. A total of 17 individuals participated in the neonatal ECMO initiation simulation. Questionnaire results showed that 88% of participants felt better prepared to assist in an ECMO initiation after the simulation. All participants (100%) agreed that the modified mannequin and the environment were realistic and that this simulation helps teamwork and communication in future initiations of ECMO. Simulation can be used for the prevention, identification, and reduction of anxiety-related crisis situations that novice providers may infrequently encounter during routine clinical use of mechanical circulatory support. Use of a reusable, high-fidelity mannequin may be beneficial for effective team training of complex pediatric ECMO-related procedures.