Pediatric traumatic arrest: When to withhold or terminate resuscitation
Coalition releases policy statement based on comprehensive review of research on complex and emotionally charged pediatric emergencies
A coalition of physician organizations has released a policy statement on withholding or terminating resuscitation of traumatic cardiac arrest in pediatric patients. The American College of Surgeons, the American College of Emergency Physicians, the National Association of EMS Physicians and the American Academy of Pediatrics teamed up to publish the policy in the April 2014 edition of Pediatrics.
The policy statement was developed after an extensive review of research articles published between 1980 and 2011. The reviewers found 28 articles that contained data pertinent to traumatic arrest in pediatric patients.
Pediatric survival from traumatic cardiac arrest is low
An important initial finding of the research review is that the overall survival of pediatric traumatic cardiopulmonary arrest is only 5.4 percent, and many children that do survive live with devastating neurologic disability. While survival from other causes of arrest in children may be enjoying improved survival rates, traumatic arrest has not seen similar advances.
Additionally, pediatric cardiac arrest is more common than we may realize. Each year in the United States, 16,000 children suffer cardiac arrest and nearly one-third of all pediatric deaths occur in the prehospital setting. One study found that 2 percent of EMS calls to children in an urban setting were related to cardiac arrest.
Indications for a successful resuscitation
After sifting through the data presented in the 28 articles, researchers concluded that in general, “indicators of potential successful outcomes included a witnessed arrest, early bystander CPR, an initial shockable rhythm, and return of spontaneous circulation (ROSC) within 20 minutes.” They reported that when these are not present, the chances of a good outcome are “extraordinarily unlikely.”
More specifically, survivors of traumatic arrest tend to have early (<5 minutes) CPR, ROSC in the field after brief resuscitation, and a sinus rhythm on arrival in the emergency department. Most of the survivors that had more than 20 minutes of resuscitation had poor neurologic outcomes.
Many potential complications to field termination
The policy statement goes on to point out the myriad of issues that complicate termination in the field including anecdotal reports of unlikely survivals, lack of grief counseling resources, educational deficits, cultural differences, organ transplantation concerns, and new technologies being used in hospitals like extracorporeal membrane oxygenation (ECMO). These issues must be balanced against issues of resource utilization, transportation safety, healthcare costs and emotional impact on family and care providers.
The authors condensed their review into eight evidence-based treatment conclusions outlining:
- Cases when resuscitation should be withheld
- Special circumstances where resuscitation should NOT be withheld
- Indications for immediate transportation
- Triggers for considering termination of resuscitation in the field
1. The withholding of resuscitative efforts should be considered in pediatric victims of penetrating or blunt trauma with injuries obviously incompatible with life, such as decapitation or hemicorporectomy.
2. The withholding of resuscitative efforts should be considered in pediatric victims of penetrating or blunt trauma with evidence of a significant time lapse after pulselessness, including dependent lividity, rigor mortis, and decomposition.
3. Initiation of standard resuscitation should be considered for cardiopulmonary arrest patients in whom the mechanism of injury does not correlate with a traumatic cause of arrest unless (1) or (2) above applies.
4. Initiation of standard resuscitation should be considered in cardiopulmonary arrest victims of lightning strike or drowning in whom there is significant hypothermia unless (1) or (2) applies.
5. Immediate transportation to an ED should be considered for children who exhibit witnessed signs of life before traumatic CPR and have CPR ongoing or initiated within five minutes in the field, with resuscitation maneuvers including airway management and intravenous or intraosseous line placement planned during transport.
6. After blunt and penetrating trauma in victims in whom there is an unwitnessed traumatic cardiopulmonary arrest, a longer period of hypoxia may be presumed to have occurred, and an acceptable duration of CPR (including bystander CPR) of less than 30 minutes may be considered with medical director input.
7. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility.
8. The inclusion of children in state termination-of-resuscitation protocols should be considered, including children who are victims of blunt and penetrating trauma who have or in whom there is EMS-witnessed cardiopulmonary arrest and at least 30 minutes of unsuccessful resuscitative efforts, including CPR.
Several policy and protocol considerations are also outlined as items for future research or inclusion by services adopting their eight treatment conclusions. These include implementation of guidelines at the state level, education for the public and healthcare workers, availability of counseling resources, and monitoring with quality improvement activities. Additional study should focus on the implementation of the protocol, acceptance by families and differences in resuscitations and outcomes of different populations.
Pediatric resuscitations are usually emotionally charged scenes. We fail to “do no harm” if we continue to approach these calls the same as we always have. This policy statement leaves some questions unanswered and gives EMS a solid place to begin important discussions about pediatric traumatic cardiac arrest.
1. Withholding or Termination of Resuscitation in Pediatric Out-of-Hospital Traumatic Cardiopulmonary Arrest. (2014). Pediatrics, 133(4), E1104-E1116. Retrieved December 16, 2014, from pediatrics.aappublications.org
About the Author
Michael Fraley, BS, NRP has been active in EMS for over 20 years in a wide variety of roles including flight paramedic, educator, manager and coroner. He is currently the coordinator of a regional trauma advisory council and EMS coordinator for a county-based EMS. Michael has special interest in trauma care and quality improvement.