This POTD is a sensitive one, it's one that I was actually asked to look into a week ago, but after the events of this weekend/this morning I felt it was even more appropriate to take a look at. I know that this may be too soon for some, I encourage you all to reach out to someone you trust, take some time for yourself, and take care of yourself. There is no one right way to process the tragedy we see on a regular basis especially after this weekend. If you need a listening ear, I am always here.
Today’s POTD is talking about when to terminate the pediatric traumatic arrest. When we think about traumatic arrests we think about penetrating traumatic arrests vs blunt traumatic arrests.
Blunt Traumatic:
Injuries that occur from forceful impact without penetrating the skin
Examples: MVCs, falls, assault
Penetrating Trauma:
Stab wounds, gunshots, impaled objects
Pediatric traumatic cardiac arrests:
Traumatic pediatric cardiac arrests accounts for 22% of all out of hospital cardiac arrests in pediatric patients
It has become more of an acceptable practice to terminate adult traumatic arrests in the field, though one study showed that this occurred less than <1% of the time
Intervening In traumatic arrests, in adult traumatic arrests, we must consider when to further intervene. When thinking about these different traumas we think about how to intervene, including with hemorrhage control, usually this starts with chest tubes, and can progress to a thoracotomy. Other hospitals also have REBOAs (resuscitative endovascular balloon occlusion of the aorta) which may also be used. At Maimo, we do not have REBOAs. With this in mind, a brief review of when to intervene for adult traumatic arrests:
Penetrating Trauma
Cardiac arrest with:
Signs of life (spontaneous respiratory effort, spontaneous motor function/movement, electric cardiac activity, blood pressure (palpable or measureable), carotid pulse palpable, pupillary response to light)
Cardiac arrest without signs of life and <15 minutes of CPR
>1500 ml of blood from the chest tube with persistent hypotension
Refractory shock despite adequate volume resuscitation
Blunt Trauma:
Cardiac arrest with at least one sign of life observed in the hospital or lost just prior to arrival at the hospital
<10 minutes of pre-hospital CPR
Refractory shock despite adequate volume resuscitation
>1500 ml from chest tube
Intervening for pediatric arrests:
Looking at NYC EMS Protocols specifically for pediatric patients: CPR is required for pediatric patients with:
Severe bradycardia (HR <60 bpm) AND signs of shock or AMS
CPR should be continued until any of the following:
ROSC: return of spontaneous circulation
Resuscitative efforts have been transferred to equal or higher level of training
Qualified physician assumes responsibility
Present of valid DNR/MOLST
So all of this brings us to the original question- when should we terminate pediatric arrests in the field?
A recent study looked at both neurological outcomes and ROSC in cases of out of hospital pediatric cardiac arrests. Poor neurological outcomes and termination of care were recommended when:
Unwitnessed arrest
Asystole
Arrest not due to drowning or electrocution
No sustained ROSC
No bystander CPR
So is this really applicable to our population?
Maybe? Terminating in the field should be considered with any obvious signs of death, extreme lividity, rigor mortis, tissue decompensation, obvious mortal injury, submersion >1 hour
For traumatic pediatric arrests:
Most studies do not support a thoracotomy though will be at the discretion of the trauma attending
With all things considered, it is possible and should be considered terminating pediatric arrests in the field. This should be done in conjunction with online medical control, the attending, and consideration of EMS who may stuck performing CPR/ALCS in front of crowds of strangers and loved ones who may not understand the nuance of stopping compressions in the field and why it may be necessary for their sakes to transport these patients.
Niemann M, Graef F, Hahn F, Schilling EC, Maleitzke T, Tsitsilonis S, Stöckle U, Märdian S. Emergency thoracotomies in traumatic cardiac arrests following blunt trauma - experiences from a German level I trauma center. Eur J Trauma Emerg Surg. 2023 Oct;49(5):2177-2185. doi: 10.1007/s00068-023-02289-7. Epub 2023 Jun 3. PMID: 37270467; PMCID: PMC10519862.
https://www.upstate.edu/surgery/pdf/healthcare/trauma/traumatic-arrest.pdf
https://www.annemergmed.com/article/S0196-0644(19)30448-2/pdf