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Cotton BA. Facing futility in hemorrhagic shock: when to say 'when' in children and adults. Trauma Surg Acute Care Open 2024; 9:e001448. [PMID: 38646027 PMCID: PMC11029276 DOI: 10.1136/tsaco-2024-001448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 04/03/2024] [Indexed: 04/23/2024] Open
Affiliation(s)
- Bryan A Cotton
- Surgery, University of Texas John P and Katherine G McGovern Medical School, Houston, Texas, USA
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2
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Schuster A, Klute L, Kerschbaum M, Kunkel J, Schaible J, Straub J, Weber J, Alt V, Popp D. Injury Pattern and Current Early Clinical Care of Pediatric Polytrauma Comparing Different Age Groups in a Level I Trauma Center. J Clin Med 2024; 13:639. [PMID: 38276145 PMCID: PMC10816860 DOI: 10.3390/jcm13020639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 12/07/2023] [Accepted: 01/17/2024] [Indexed: 01/27/2024] Open
Abstract
Introduction: Pediatric polytrauma is a complex condition with unique characteristics and requirements for early clinical care. This study aimed to analyze the injury patterns, early clinical care, and outcomes of pediatric polytrauma patients in a Level I trauma center. The focus was on evaluation between different age groups and the recognition of injuries as potential factors influencing outcomes. Methods: A prospective cohort study model of pediatric polytrauma patients (ISS ≥ 16) was conducted over a 13-year period, stratified by age groups (Group A: 0-5 years; Group B: 6-10 years; Group C: 11-15 years; and Group D: 16-18 years). A comparison of the groups was conducted to examine variations in early clinical care, trauma mechanisms, distribution of affected body regions (as per AIS and ISS criteria), and trauma-related mortality. Additionally, factors contributing to mortality were evaluated. Results: The median age of patients was 16 years, with a male predominance (64.7%). The Injury Severity Score (ISS) varied across age groups, with no significant difference. The 30-day mortality rate was 19.0%, with no significant age-related differences. Trauma mechanisms varied across age groups, with motor vehicle accidents being the most common mechanism in all age groups except 0-5 years, where falls were prevalent. Analysis of injury patterns by AIS body regions indicated that head trauma was a significant predictor of mortality (Hazard Ratio 2.894, p < 0.001), while chest, abdominal, and extremity trauma showed no significant association with mortality. Multiple regression analysis identified the ISS and preclinical GCS as valid predictors of mortality (p < 0.001 and p = 0.006, respectively). Conclusions: While age-related differences in injury severity and clinical interventions were limited, head trauma emerged as a critical predictor of mortality. Early recognition and management of head injuries are crucial in improving outcomes. Additionally, the ISS and preclinical GCS were identified as valid predictors of mortality, emphasizing the importance of early assessment and resuscitation. A tailored approach to pediatric polytrauma care, considering both age and injury patterns, might contribute to survival benefits in this vulnerable population.
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Affiliation(s)
- Anna Schuster
- Department of Trauma Surgery, University Medical Centre Regensburg, 93053 Regensburg, Germany (J.S.); (J.W.); (V.A.)
| | - Lisa Klute
- Department of Trauma Surgery, University Medical Centre Regensburg, 93053 Regensburg, Germany (J.S.); (J.W.); (V.A.)
| | - Maximilian Kerschbaum
- Department of Trauma Surgery, University Medical Centre Regensburg, 93053 Regensburg, Germany (J.S.); (J.W.); (V.A.)
| | - Jürgen Kunkel
- Department of Pediatrics, KUNO University Children’s Hospital Regensburg, 93053 Regensburg, Germany
| | - Jan Schaible
- Conradia Radiologie München, 80798 München, Germany;
| | - Josina Straub
- Department of Trauma Surgery, University Medical Centre Regensburg, 93053 Regensburg, Germany (J.S.); (J.W.); (V.A.)
| | - Johannes Weber
- Department of Trauma Surgery, University Medical Centre Regensburg, 93053 Regensburg, Germany (J.S.); (J.W.); (V.A.)
| | - Volker Alt
- Department of Trauma Surgery, University Medical Centre Regensburg, 93053 Regensburg, Germany (J.S.); (J.W.); (V.A.)
| | - Daniel Popp
- Department of Trauma Surgery, University Medical Centre Regensburg, 93053 Regensburg, Germany (J.S.); (J.W.); (V.A.)
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Currie V, Tagg A, Kanaris C. What information can we use to help determine futility in paediatric patients presenting in traumatic cardiac arrest? Arch Dis Child 2022; 107:archdischild-2022-324138. [PMID: 35551048 DOI: 10.1136/archdischild-2022-324138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 04/22/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Victoria Currie
- Paediatrics, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Andrew Tagg
- Emergency, Western Hospital, Footscray, Melbourne, Australia
- School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Constantinos Kanaris
- Paediatric Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Blizard Institute, Queen Mary University of London, London, UK
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Shi D, McLaren C, Evans C. Neurological outcomes after traumatic cardiopulmonary arrest: a systematic review. Trauma Surg Acute Care Open 2021; 6:e000817. [PMID: 34796272 PMCID: PMC8573669 DOI: 10.1136/tsaco-2021-000817] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/10/2021] [Indexed: 12/26/2022] Open
Abstract
Background Despite appropriate care, most patients do not survive traumatic cardiac arrest, and many survivors suffer from permanent neurological disability. The prevalence of non-dismal neurological outcomes remains unclear. Objectives The aim of the current review is to summarize and assess the quality of reporting of the neurological outcomes in traumatic cardiac arrest survivors. Data sources A systematic review of Embase, Medline, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and ProQuest databases was performed from inception of the database to July 2020. Study eligibility criteria Observational cohort studies that reported neurological outcomes of patients surviving traumatic cardiac arrest were included. Participants and interventions Patients who were resuscitated following traumatic cardiac arrest. Study appraisal and synthesis methods The quality of the included studies was assessed using ROBINS-I (Risk of Bias in Non-Randomized Studies - of Interventions) for observational studies. Results From 4295 retrieved studies, 40 were included (n=23 644 patients). The survival rate was 9.2% (n=2168 patients). Neurological status was primarily assessed at discharge. Overall, 45.8% of the survivors had good or moderate neurological recovery, 29.0% had severe neurological disability or suffered a vegetative state, and 25.2% had missing neurological outcomes. Seventeen studies qualitatively described neurological outcomes based on patient disposition and 23 studies used standardized outcome scales. 28 studies had a serious risk of bias and 12 had moderate risk of bias. Limitations The existing literature is characterized by inadequate outcome reporting and a high risk of bias, which limit our ability to prognosticate in this patient population. Conclusions or implications of key findings Good and moderate neurological recoveries are frequently reported in patients who survive traumatic cardiac arrest. Prospective studies focused on quality of survivorship in traumatic arrest are urgently needed. Level of evidence Systematic review, level IV. PROSPERO registration number CRD42020198482.
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Affiliation(s)
- Daniel Shi
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Christie McLaren
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Chris Evans
- Emergency Medicine, Queen's University, Kingston, Ontario, Canada
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5
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. [Paediatric Life Support]. Notf Rett Med 2021; 24:650-719. [PMID: 34093080 PMCID: PMC8170638 DOI: 10.1007/s10049-021-00887-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine, Faculty of Medicine UG, Ghent University Hospital, Gent, Belgien
- Federal Department of Health, EMS Dispatch Center, East & West Flanders, Brüssel, Belgien
| | - Nigel M. Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Niederlande
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Tschechien
- Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Tschechien
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spanien
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brüssel, Belgien
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, Großbritannien
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin – Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, Frankreich
| | - Florian Hoffmann
- Pädiatrische Intensiv- und Notfallmedizin, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität, München, Deutschland
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Kopenhagen, Dänemark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Faculty of Medicine Imperial College, Imperial College Healthcare Trust NHS, London, Großbritannien
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation 2021; 161:327-387. [PMID: 33773830 DOI: 10.1016/j.resuscitation.2021.02.015] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine Ghent University Hospital, Faculty of Medicine UG, Ghent, Belgium; EMS Dispatch Center, East & West Flanders, Federal Department of Health, Belgium.
| | - Nigel M Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Czech Republic
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spain
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brussels, Belgium
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, UK
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin - Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Florian Hoffmann
- Paediatric Intensive Care and Emergency Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London, UK
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Campwala RT, Schmidt AR, Chang TP, Nager AL. Factors influencing termination of resuscitation in children: a qualitative analysis. Int J Emerg Med 2020; 13:12. [PMID: 32171233 PMCID: PMC7071657 DOI: 10.1186/s12245-020-0263-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/21/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Pediatric Advanced Life Support provides guidelines for resuscitating children in cardiopulmonary arrest. However, the role physicians' attitudes and beliefs play in decision-making when terminating resuscitation has not been fully investigated. This study aims to identify and explore the vital "non-medical" considerations surrounding the decision to terminate efforts by U.S.-based Pediatric Emergency Medicine (PEM) physicians. METHODS A phenomenological qualitative study was conducted using PEM physician experiences in terminating resuscitation within a large freestanding children's hospital. Semi-structured interviews were conducted with 17 physicians, sampled purposively for their relevant content experience, and continued until the point of content saturation. Resulting data were coded using conventional content analysis by 2 coders; intercoder reliability was calculated as κ of 0.91. Coding disagreements were resolved through consultation with other authors. RESULTS Coding yielded 5 broad categories of "non-medical" factors that influenced physicians' decision to terminate resuscitation: legal and financial, parent-related, patient-related, physician-related, and resuscitation. When relevant, each factor was assigned a directionality tag indicating whether the factor influenced physicians to terminate a resuscitation, prolong a resuscitation, or not consider resuscitation. Seventy-eight unique factors were identified, 49 of which were defined by the research team as notable due to the frequency of their mention or novelty of concept. CONCLUSION Physicians consider numerous "non-medical" factors when terminating pediatric resuscitative efforts. Factors are tied largely to individual beliefs, attitudes, and values, and likely contribute to variability in practice. An increased understanding of the uncertainty that exists around termination of resuscitation may help physicians in objective clinical decision-making in similar situations.
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Affiliation(s)
- Rashida T Campwala
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mail Stop 113, Los Angeles, CA, 90027, USA. .,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Anita R Schmidt
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mail Stop 113, Los Angeles, CA, 90027, USA
| | - Todd P Chang
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mail Stop 113, Los Angeles, CA, 90027, USA.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Alan L Nager
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mail Stop 113, Los Angeles, CA, 90027, USA.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Horst K, Andruszkow H, Weber CD, Pishnamaz M, Knobe M, Bläsius FM, Lichte P, Lefering R, Hildebrand F. Surgical treatment strategies in pediatric trauma patients: ETC vs. DCO-an analysis of 316 pediatric trauma patients from the TraumaRegister DGU ®. Eur J Trauma Emerg Surg 2019; 45:801-808. [PMID: 30758537 DOI: 10.1007/s00068-019-01092-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 02/07/2019] [Indexed: 01/31/2023]
Abstract
PURPOSE External fixation within the damage control concept in unstable multiple trauma patients is widely accepted. Literature about its usage in the pediatric trauma population, however, is rare. The aim of the present study was to elucidate the factors associated with the application of external fixation in the severely injured child. METHODS Patients with severe trauma aged 0-54 years documented in the TraumaRegister DGU® were included in this study. Demographic data, pattern of injury, injury severity, use of the damage control orthopedics (DCO) or early total care (ETC) concept, duration of mechanical ventilation, intensive care stay, and total hospital stay as well as the occurrence of complications and mortality were evaluated. Statistical evaluation was performed using SPSS (Version 21.0.0) using Chi square tests and linear regression models. RESULTS While injury severity was comparable between children and adults, type of accident and injury patterns showed significant differences, Overall, the majority of surgical fracture stabilization in AISExtremity ≥ 3 injuries followed the DCO concept in adults (60.3%) and the ETC protocol in children (49.4%). Conservative treatment was chosen for only 11.6% of all children and 9.6% of all adults. An increasing injury severity, AISExtremity ≥ 3 and AISExtremity ≥ 3 in ≥ 2 body regions, and a more advanced age were found to be independent factors in the use of the DCO concept in children. CONCLUSION Use of external fixation increases with age and plays a minor role in the very young trauma population. However, this does not produce a difference in outcome between children and adults.
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Affiliation(s)
- Klemens Horst
- Department of Trauma and Reconstructive Surgery, RWTH Aachen University, Pauwelsstreet 30, 52074, Aachen, Germany.
| | - Hagen Andruszkow
- Department of Trauma and Reconstructive Surgery, RWTH Aachen University, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Christian David Weber
- Department of Trauma and Reconstructive Surgery, RWTH Aachen University, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Miguel Pishnamaz
- Department of Trauma and Reconstructive Surgery, RWTH Aachen University, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Matthias Knobe
- Department of Trauma and Reconstructive Surgery, RWTH Aachen University, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Felix Marius Bläsius
- Department of Trauma and Reconstructive Surgery, RWTH Aachen University, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Philipp Lichte
- Department of Trauma and Reconstructive Surgery, RWTH Aachen University, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Rolf Lefering
- IFOM, Institute for Research in Operative Medicine, Faculty of Health, University Witten/Herdecke, Ostmerheimer Straße 200, 51109, Cologne, Germany
| | - Frank Hildebrand
- Department of Trauma and Reconstructive Surgery, RWTH Aachen University, Pauwelsstreet 30, 52074, Aachen, Germany
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Can We Identify Futility in Kids? An Evaluation of Admission Parameters Predicting 100% Mortality in 1,292 Severely Injured Children. J Am Coll Surg 2018; 226:662-667. [PMID: 29325878 DOI: 10.1016/j.jamcollsurg.2017.12.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 12/18/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Objective parameters predicting futility of care in severely injured pediatric patients are lacking. Although futility of care has been investigated in a limited number of studies in trauma patients, none of these studies achieves a 100% success rate in a large cohort of pediatric patients. The purpose of the current study was to identify extreme laboratory values that could be used to predict 100% mortality in severely injured children. STUDY DESIGN We evaluated a registry-based, historical cohort of all severely injured children (Level I trauma, younger than 16 years old) who were not dead on arrival between January 2010 and December 2016 from a single Level I trauma center. Extreme arrival laboratory data were evaluated both alone and in conjunction with traumatic brain injury. RESULTS There were 1,292 patients who met inclusion criteria, of which 1,169 (90.5%) survived and 123 (9.5%) died. Those who died were significantly younger, with higher head Abbreviated Injury Scale scores and overall Injury Severity Scores. Single extreme laboratory values were identified that predicted mortality perfectly (100% positive predictive value): international normalized ratio ≥3.0, pH ≤6.95, base excess ≤ -22, platelet count ≤30,000, hemoglobin ≤5.0 g/dL, rapid thromboelastography ≤30 mm, and rapid thromboelastography lysis at 30 minutes ≥50%. When 2 laboratory values or the presence of traumatic brain injury were added, lower thresholds for futility were noted. CONCLUSIONS Extreme admission laboratory values are capable of predicting 100% mortality and futility of additional care in severely injured children with a high level of accuracy. Validation of these single-center findings is warranted and, if supported, should initiate a discussion within the pediatric trauma community about application and cessation of resuscitation efforts to optimize resource use.
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10
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Kuo KW, Barbaro RP, Gadepalli SK, Davis MM, Bartlett RH, Odetola FO. Should Extracorporeal Membrane Oxygenation Be Offered? An International Survey. J Pediatr 2017; 182:107-113. [PMID: 28041665 DOI: 10.1016/j.jpeds.2016.12.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 10/26/2016] [Accepted: 12/07/2016] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To assess the current attitudes of extracorporeal membrane oxygenation (ECMO) program directors regarding eligibility for ECMO among children with cardiopulmonary failure. STUDY DESIGN Electronic cross-sectional survey of ECMO program directors at ECMO centers worldwide within the Extracorporeal Life Support Organization directory (October 2015-December 2015). RESULTS Of 733 eligible respondents, 226 (31%) completed the survey, 65% of whom routinely cared for pediatric patients. There was wide variability in whether respondents would offer ECMO to any of the 5 scenario patients, ranging from 31% who would offer ECMO to a child with trisomy 18 to 76% who would offer ECMO to a child with prolonged cardiac arrest and indeterminate neurologic status. Even physicians practicing the same specialty sometimes held widely divergent opinions, with 50% of pediatric intensivists stating they would offer ECMO to a child with severe developmental delay and 50% stating they would not. Factors such as quality of life and neurologic status influenced decision making and were used to support decisions for and against offering ECMO. CONCLUSIONS ECMO program directors vary widely in whether they would offer ECMO to various children with cardiopulmonary failure. This heterogeneity in physician decision making underscores the need for more evidence that could eventually inform interinstitutional guidelines regarding patient selection for ECMO.
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Affiliation(s)
- Kevin W Kuo
- Division of Pediatric Critical Care, Department of Pediatrics, University of Michigan, Ann Arbor, MI.
| | - Ryan P Barbaro
- Division of Pediatric Critical Care, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | | | - Matthew M Davis
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, IL
| | | | - Folafoluwa O Odetola
- Division of Pediatric Critical Care, Department of Pediatrics, University of Michigan, Ann Arbor, MI
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11
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Rotering VM, Trepels-Kottek S, Heimann K, Brokmann JC, Orlikowsky T, Schoberer M. Adult "termination-of-resuscitation" (TOR)-criteria may not be suitable for children - a retrospective analysis. Scand J Trauma Resusc Emerg Med 2016; 24:144. [PMID: 27927227 PMCID: PMC5142344 DOI: 10.1186/s13049-016-0328-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 11/12/2016] [Indexed: 11/16/2022] Open
Abstract
Background Only a small number of patients survive out-of-hospital-cardiac-arrest (OHCA). The duration of CPR varies considerably and transportation of patients under CPR is often unsuccessful. Termination-of-resuscitation (TOR)-criteria aim to preclude futile resuscitation efforts. Our goal was to find out to which extent existing TOR-criteria can be transferred to paediatric OHCA-patients with special regard to their prognostic value. Methods We performed a retrospective analysis of an eleven-year single centre patient cohort. 43 paediatric patients admitted to our institution after emergency-medical-system (EMS)-confirmed OHCA from 2003 to 2013 were included. Morrison’s BLS- and ALS-TOR-rules as well as the Trauma-TOR-criteria by the American Association of EMS Physicians were evaluated for application in children, by calculating sensitivity, specificity, negative and positive predictive value for death-, as well as survival-prediction in our cohort. Results 26 patients achieved ROSC and 14 were discharged alive (n = 7 PCPC 1/2, n = 7 PCPC 5). Sensitivity for BLS-TOR-criteria predicting death was 48.3%, specificity 92.9%, the PPV 93.3% and the NPV 46.4%. ALS-TOR-criteria for death had a sensitivity of 10.3%, specificity of 100%, a PPV of 100% and an NPV of 35%. Conclusion Retrospective application of the BLS-TOR-rule in our patient cohort identified the resuscitation of one later survivor as futile. ALS-TOR-criteria did not give false predictions of death. The proportion of CPRs that could have been abandoned is 48.2% for the BLS-TOR and only 10.3% for the ALS-TOR-rule. Both rules therefore appear not to be transferable to a paediatric population.
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Affiliation(s)
- Victoria Maria Rotering
- Klinik für Kinder- und Jugendmedizin, Sektion Neonatologie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Sonja Trepels-Kottek
- Klinik für Kinder- und Jugendmedizin, Sektion Neonatologie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Konrad Heimann
- Klinik für Kinder- und Jugendmedizin, Sektion Neonatologie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | | | - Thorsten Orlikowsky
- Klinik für Kinder- und Jugendmedizin, Sektion Neonatologie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Mark Schoberer
- Klinik für Kinder- und Jugendmedizin, Sektion Neonatologie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
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12
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Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Ann Emerg Med 2014; 63:504-15. [PMID: 24655460 DOI: 10.1016/j.annemergmed.2014.01.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This multiorganizational literature review was undertaken to provide an evidence base for determining whether or not recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. 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. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care, because the evidence suggests that either death or a poor outcome is inevitable.
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13
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Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Pediatrics 2014; 133:e1104-16. [PMID: 24685948 DOI: 10.1542/peds.2014-0176] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. 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. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.
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Figueiredo Junior I, Carvalho MVD, Lima GMD. Pediatric trauma due to motor vehicle accidents on high traffic roadway. EINSTEIN-SAO PAULO 2012; 10:29-32. [DOI: 10.1590/s1679-45082012000100007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE: To outline a profile of pediatric trauma victims and verify the likelihood of trauma in children on a high traffic roadway. METHODS: A descriptive cohort study of the records of emergency medical service activations on the Rio-Niterói Bridge, a high traffic roadway in Rio de Janeiro, Brazil. Descriptive statistics were expressed as absolute and relative frequencies. The estimated risk of trauma in children aged < 12 years was calculated by means of odds ratios, with a 95% confidence interval. RESULTS: Trauma accounted for 514 of 1,244 activations (41.31%) of the Rio-Niterói Bridge emergency medical service between March 2002 and March 2003. Response to incidents involving children aged < 12 years accounted for 52 of these (4.18%). Half of victims were between the ages of 6 and 12 years (n = 26), and 55.76% were male (n = 29). Of the 52 victims, 37 (71.15%) were involved in motor vehicle accidents (OR: 3.70; 95%CI: 1.94-7.13; p < 0.0001). Of these, 28 were vehicle-vehicle collisions (75.67%). The most common sites of injury were the extremities (n = 12; 32.43%), face (n = 10; 27.02%), and head (n = 9; 24.32%). Pre-hospital procedures were performed on 23 of the 37 patients (62.16%), and 44.23% (n = 23/52) required hospital transportation. There were no deaths during the study period. CONCLUSIONS: In this study, children were at significantly higher odds of being treated for trauma while on a highway with heavy traffic flow. The most common sites of injury in this sample were the lower extremities and the head, face, and neck complex.
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Glick RP, Ksendzovsky A, Greesh J, Raksin P. Initial observations of combination barbiturate coma and decompressive craniectomy for the management of severe pediatric traumatic brain injury. Pediatr Neurosurg 2011; 47:152-7. [PMID: 21934277 DOI: 10.1159/000330709] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 07/08/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE In the pediatric population, treatment of severely injured children presenting with low Glasgow Coma Score (GCS) and fixed and dilated pupils is controversial. The combination of barbiturate coma and decompressive craniectomy as an aggressive means of controlling intracranial pressure is limited to few studies. In the present series, we report our experience with aggressive combination therapy resulting in good outcomes in pediatric patients with severe traumatic brain injury (TBI). PATIENTS AND METHODS Six TBI patients, aged <18 years, either presented with or deteriorated to a GCS <5 with fixed and dilated pupils and CT evidence of surgical lesions with brain edema. Despite hyperventilation, anesthesia, and mannitol, intracranial pressures remained elevated and all patients underwent decompressive craniectomy and external ventricular drainage and were subsequently placed into barbiturate coma for 72 h. RESULTS One patient died and 1 patient remained vegetative. Two patients had excellent recoveries (GOS 5/Rankin 1 or 0, no cognitive deficits) and 2 patients had good recoveries (GOS 4/Rankin 1, mild cognitive deficits). CONCLUSIONS Combination of barbiturate coma with decompressive craniectomy and external ventricular drainage led to good outcomes in a small group of pediatric patients with severe TBI. Based on this series we recommend further investigation into aggressive combination management.
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Affiliation(s)
- Roberta P Glick
- Department of Neurosurgery, Mount Sinai Hospital, Rush Medical College, University of Illinois College of Medicine, Chicago, IL 60608, USA.
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Wyen H, Jakob H, Wutzler S, Lefering R, Laurer HL, Marzi I, Lehnert M. Prehospital and Early Clinical Care of Infants, Children, and Teenagers Compared to an Adult Cohort : Analysis of 2,961 Children in Comparison to 21,435 Adult Patients from the Trauma Registry of DGU in a 15-Year Period. Eur J Trauma Emerg Surg 2010; 36:300-7. [PMID: 26816034 DOI: 10.1007/s00068-010-1124-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2010] [Accepted: 06/15/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although the incidence of pediatric patients in emergency services is as low as 5-10%, trauma remains one of the leading causes of death during childhood. Only a few reports exist about the quality of the initial treatment of pediatric trauma patients. Therefore, we tested the hypothesis of whether prehospital treatment and emergency management in pediatric trauma patients is similar to the treatment that is provided for adult patients. MATERIALS AND METHODS We performed a retrospective data analysis of the German Trauma Registry of the DGU from January 1993 to December 2007. Exclusion criteria were missing information about injury severity and/or age and patients older than 50 years. All pediatric patients were subdivided into five groups (infants 0-1 year, toddlers 2-5 years, children 6-9 years, pupils 10-13 years, teenagers 14-17 years) with regard to their age and were compared with the adult cohort (18-50 years). From 24,396 patients, 2,961 were below 18 years of age, thus, about 12% of the whole population of injured patients below the age of 50 years. RESULTS 66.4% of infants sustained relevant head injuries (Abbreviated Injury Scale [AIS] ≥3), and this rate declined with increasing age. The mean Injury Severity Score (ISS) increased from 21.0 (±11.6) in the group of infants to 26.7 (±13.9) in the adult cohort. In all groups, the majority of patients were male. The injury pattern differed according to age, with predominant traumatic brain injury (TBI) in infants. During the preclinical treatment, infants were less often intubated and this was contrasted by a higher rate of cardiopulmonary resuscitation in this group (infants 16.2%, toddlers 6.8%, adults 3.1%). Diagnostic multislice computed tomography (CT) examination was less often performed in infants as compared to the other groups (infants 57.1%, toddlers 77.2%, adults 77.8%). Mortality and quality indicators such as timelines show no significant differences between children and adults. CONCLUSION We observed typical age-dependent differences regarding the injury pattern and severity and differences referring to the preclinical and initial treatment. With respect to the high rate of serious TBI in the infants and toddlers age groups, a more focused education and training of emergency physicians and paramedics should be considered.
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Affiliation(s)
- Hendrik Wyen
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe University, Frankfurt, Germany. .,Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe University, Theodor Stern Kai 7, D-60590, Frankfurt, Germany.
| | - Heike Jakob
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Sebastian Wutzler
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Rolf Lefering
- IFOM, Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany
| | - Helmut L Laurer
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Mark Lehnert
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe University, Frankfurt, Germany
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