Out of hospital pediatric cardiac arrest management
Reviewing the pediatric evidence for stay and play or load and go
Clinical scenario. You are dispatched to a 5-month-old cardiac arrest. Upon arrival, you are told that the mother went to check on her after laying her down for a nap, to find her pulseless and apneic. She immediately called 911 and was coached by the dispatcher to perform CPR. You arrive on scene approximately 6 minutes after the initial call to find fire department members performing CPR with an AED, BVM and manual chest compressions. On report, the AED has not advised any shocks, and they have been performing compressions and ventilations with an oral airway in place at a ratio of 15:2. You assume the code leader position, your paramedic partner applies a cardiac monitor and you notice asystole on the monitor.
Do you: stay and play or load and go?
The actual answer to that question will depend on a plethora of variables, including local protocols, paramedic training and comfort, and local hospital and community resources. But let’s look at some of the evidence out there.
A review of the current American Heart Association (AHA) Pediatric Advanced Life Support (PALS) guidelines shows an emphasis on high-quality effective chest compressions, paired with adequate ventilation management . These guidelines are very similar to the adult Advanced Cardiac Life Support (ACLS) guidelines, with some minor changes for increased ventilation for multiple rescuers working on pediatric patients. At this time, there is no recommendation in PALS on stay at the scene or transport to the emergency department.
Adult cardiac arrest review
Looking at the adult data, there are many quality studies that have shown improved outcomes for patients when EMS crews remain on scene and continue resuscitation prior to transport. ACLS uses the BLS guideline of high-quality chest compression, with limited interruptions in compressions as the basis of their resuscitation. Their target goal is > 80% chest compression fraction (CCF) time. Meaning that >80% of the time, high quality chest compressions should be performed .
Grunau, et. al., recently studied over 43,000 patients who suffered from out of hospital cardiac arrest . Data was compared from those who had ACLS protocol applied and stayed on scene versus those who were transported to an emergency department. In this study, survival to hospital discharge was increased from 7% for intra arrest to 9% for those in which resuscitation was provided on scene. Neuro intake survival was also noted to increase from 3% for intra-arrest transport to 4% for on scene resuscitation. This data shows a significant improvement in survival to hospital discharge as well as neurologically intact survival for those patients who received CPR on scene until ROSC was achieved .
Studies such as this one have added to the development of many cardiac arrest protocols in the EMS system to stay on scene to work cardiac arrest patients, but these protocols are primarily focused on adult patients. Some things that can be improved while on scene include:
- Increased safety for providers. Performing CPR while in a moving vehicle (ambulance) usually requires providers to be unrestrained, increasing their chances of being injured in an accident.
- Increased risk of a MVC. Most cardiac arrest calls are transported to the hospital using lights and sirens transport. This increases the chance of being involved in an MVC. Combined with the first point, this increases the risk of EMS providers being injured or killed in these situations.
- Decreased CPR effectiveness. Performing CPR while in a moving ambulance has shown to have decreased chest compression effectiveness. The basic foundation of CPR is high quality CPR, and this is the component that is primarily decreased in ambulance transport.
- Increase pauses in chest compression. Transporting the patient requires moving the patient multiple times. Each move has the potential to increase the pauses in chest compressions. The AHA target for CCF is >80%, and this can be quickly eroded with the inclusion of multiple moves.
In a 2016 review of out of hospital cardiac arrest termination of resuscitation, Lulla and Svancarek determined :
● Most non-traumatic cardiac arrests who do not achieve ROSC prior to transport have a very poor outcome
● BLS and ALS termination criteria from the OPALS study (which most cardiac arrest protocols are based on) have been validated
● Determining which patients have a low likelihood of survival can decrease provider risk of using lights and sirens
● While no definitive time of on-scene resuscitation has been published, most guidelines range from 25-60 minutes
So this begs the question, Should we be doing the same for pediatrics?
Science behind pediatric cardiac arrest studies
To begin answering this question, we must first look at any data that is available regarding out of hospital resuscitation for pediatric patients.
In a study by Banerjee, et. al., neurological survival is improved with those patients who are initially managed on scene. It is thought that targeted training, physiologically driven procedures and trusted encouragement likely played the most significant roles in increased resuscitation. While these are not exclusive to on scene management, these things are lost in the motions of transport to the ED. Having resources that stay in place for the duration of the resuscitation is part of the benefit of resuscitation in the ED also.
A Polk County Fire Rescue initiative of resuscitation on scene study showed a ROSC rate from 5% to 30% and neurologically intact survival increased from 0% to 23%. This revamp of pediatric cardiac arrest management focused on better team dynamics, better interaction with bystanders and family, and the confidence and reassurance to the family on scene .
In a 2,244-patient study by Tijssen, et. al., on scene times of 10-35 minutes were associated with the highest rate of survival . This was especially true among the adolescent patients. While intubation was not associated with increased survival, intravascular access, such as IV or IO access, was associated with increased survival.
A recent review of pediatric cardiac arrest by Fornage concluded that cardiac arrest may be one of the few situations where looking at pediatric patients as small adults might be best . A large benefit of this, outside of improved clinical outcome, can include paramedics having increased confidence in one of the most high stakes situations they can be placed in. They also have additional practice with this skill, as they can translate adult cardiac arrest with a very high stress situation.
Thinking of pediatric patients as small adults in this situation might be best, especially if it allows us to bring out the best in our paramedics and allow them to excel in this high stakes situation.
Pre-hospital pediatric cardiac arrest: Should children be treated like small adults?
Exploring the medication and treatments that allow for the best translation of paramedic skill and experience from adult OHCA care to pediatric OHCA
As with any change in EMS protocols, it is always important to evaluate all sides of the coin. Possible disadvantages or drawbacks for on scene management of any cardiac arrest patients would include public opinion and optics of the EMS crews. While something like this should not be driving EMS protocols, it should always be considered in drastic changes of procedure. Public education, town hall meetings and information sessions, especially those backed with the scientific information of improved outcomes, can be helpful to EMS systems. As an agency, it is important to always have the patients’ best interest in mind and reinforce that to the public during these sessions.
Another thing to consider is the training and comfort level of your EMS providers. Pediatric calls have historically caused an increased amount of stress for EMS providers, and pediatric cardiac arrest is among the most stressful situations an EMS clinician could potentially be placed in. Ensuring that every clinician is well versed in the protocol, trained appropriately and supplied with the resources they would need to handle the physical, clinical and psychological stresses that are associated with pediatric cardiac arrest is important to the overall functionality of the EMS agency.
- American Heart Association (2020). Highlights of the 2020 American Heart Association guidelines for CPR and ECC.
- Grunau B, Kime N, Leroux B, et. al. Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest. JAMA. 2020;324(11):1058–1067. doi:10.1001/jama.2020.14185
- Lulla, A. & Svancarek, B (2016). Time To Stop Beating A Dead Horse: Termination Of Resuscitation In The Field.
- Banerjee, P, Ganti, L, Paul E. Pepe, P, Vittone, R, Loscar, T. (2019a). Child’s Play: Scoop-and-Run May Not Be Best for Kids in Cardiac Arrest.
- Banerjee PR, Ganti L, Pepe PE, Singh A, Roka A, Vittone RA. Early On-Scene Management of Pediatric Out-of-Hospital Cardiac Arrest Can Result in Improved Likelihood for Neurologically-Intact Survival. Resuscitation. 2019 Feb;135:162-167. doi:10.1016/j.resuscitation.2018.11.002. Epub 2018 Nov 6. PMID: 30412719.
- Tijssen, J. A., Prince, D. K., Morrison, L. J., Atkins, D. L., Austin, M. A., Berg, R., Brown, S. P., Christenson, J., Egan, D., Fedor, P. J., Fink, E. L., Meckler, G. D., Osmond, M. H., Sims, K. A., Hutchison, J. S., & Resuscitation Outcomes Consortium (2015). Time on the scene and interventions are associated with improved survival in pediatric out-of-hospital cardiac arrest. Resuscitation, 94, 1–7.
- Fornage, L.. NAEMSP. Pre-Hospital Pediatric Cardiac Arrest: Should Children Be Treated Like Small Adults?