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Fica ZT, Marquez A, Ehrhart J, Sloane C. Survival of Out-of-Hospital Pediatric Blunt Traumatic Arrest With Full Neurologic Recovery: Case Report. Air Med J 2024; 43:253-255. [PMID: 38821708 DOI: 10.1016/j.amj.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 06/02/2024]
Abstract
We present the case of a 10-year-old previously healthy male who suffered an out-of-hospital cardiac arrest because of abdominal trauma and survived with excellent neurologic outcomes and near complete return to baseline functional status at hospital discharge. The rapid response and efficient mobilization of resources led to an excellent patient outcome despite the severity of injuries, including intra-abdominal injuries with expected mortality, out-of-hospital traumatic arrest, coagulopathy, and an extended pediatric intensive care unit stay. This case underscores the significance of timely advanced trauma life support interventions, especially early blood product administration, efficient transport, and airway management, while sharing a remarkable case of out-of-hospital pediatric traumatic arrest with near full recovery.
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Affiliation(s)
- Zachary T Fica
- Department of Emergency Medicine, University of California San Diego, San Diego, CA.
| | - Amy Marquez
- Mercy Air-Air Methods, Greenwood Village, CO
| | | | - Christian Sloane
- Department of Emergency Medicine, University of California San Diego, San Diego, CA
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2
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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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3
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Beni CE, Rice-Townsend SE, Esangbedo ID, Jancelewicz T, Vogel AM, Newton C, Boomer L, Rothstein DH. Outcome of Extracorporeal Cardiopulmonary Resuscitation in Pediatric Patients Without Congenital Cardiac Disease: Extracorporeal Life Support Organization Registry Study. Pediatr Crit Care Med 2023; 24:927-936. [PMID: 37477526 DOI: 10.1097/pcc.0000000000003322] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
OBJECTIVES To describe the use of extracorporeal cardiopulmonary resuscitation (ECPR) in pediatric patients without congenital heart disease (CHD) and identify associations with in-hospital mortality, with a specific focus on initial arrest rhythm. DESIGN Retrospective cohort study using data from pediatric patients enrolled in Extracorporeal Life Support Organization (ELSO) registry between January 1, 2017, and December 31, 2019. SETTING International, multicenter. PATIENTS We included ECPR patients under 18 years old, and excluded those with CHD. Subgroup analysis of patients with initial arrest rhythm. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified 567 patients: neonates (12%), infants (27%), children between 1 and 5 years old (25%), and children over 5 years old (36%). The patient cohort included 51% males, 43% of White race, and 89% not obese. Most suffered respiratory disease (26%), followed by acquired cardiac disease (25%) and sepsis (12%). In-hospital mortality was 59%. We found that obesity (adjusted odds ratio [aOR], 2.28; 95% CI, 1.21-4.31) and traumatic injury (aOR, 6.94; 95% CI, 1.55-30.88) were associated with greater odds of in-hospital mortality. We also identified lower odds of death associated with White race (aOR, 0.64; 95% CI, 0.45-0.91), ventricular tachycardia (VT) as an initial arrest rhythm (aOR, 0.36; 95% CI, 0.16-0.78), return of spontaneous circulation before cannulation (aOR, 0.56; 95% CI, 0.35-0.9), and acquired cardiac disease (aOR, 0.43; 95% CI, 0.29-0.64). Respiratory disease was associated with greater odds of severe neurologic complications (aOR, 1.64; 95% CI, 1.06-2.54). CONCLUSIONS In children without CHD undergoing ECPR, we found greater odds of in-hospital mortality were associated with either obesity or trauma. The ELSO dataset also showed that other variables were associated with lesser odds of mortality, including VT as an initial arrest rhythm. Prospective studies are needed to elucidate the reasons for these survival differences.
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Affiliation(s)
| | | | - Ivie D Esangbedo
- Department of Pediatrics, Section of Cardiac Critical Care, University of Washington, Seattle, WA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Department of Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Adam M Vogel
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Christopher Newton
- Department of Surgery, University of California San Francisco Benioff Children's Hospital Oakland, Oakland, CA
| | - Laura Boomer
- Department of Surgery, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, VA
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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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Vora S, Li J, Kou M, Ng V, Price A, Claudius I, Kant S, Sanseau E, Madhok M, Auerbach M. ACEP SimBox: A Pediatric Simulation-Based Training Innovation. Ann Emerg Med 2021; 78:346-354. [PMID: 34154842 DOI: 10.1016/j.annemergmed.2021.03.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/12/2021] [Accepted: 03/30/2021] [Indexed: 11/27/2022]
Abstract
Thirty million pediatric visits (<18 years old) occur across 5,000 US emergency departments (EDs) each year, with most of these cases presenting to community EDs. Simulation-based training is an effective method to improve and sustain EDs' readiness to triage and stabilize critically ill infants and children, but large simulation centers are mostly concentrated at academic hospitals. The use of pediatric simulation-based training has been limited in the community ED setting due to the high cost of equipment and limited access to content experts in pediatric critical care. We designed an innovative "off-the-shelf" simulation-based training resource, "American College of Emergency Physicians (ACEP) SimBox," that provides a free low-technology manikin along with teaching aids and train-the-trainer materials to community EDs to run a simulation drill in their own workspaces with local educators. The goal was to develop an "off-the-shelf," free, open-access, simulation-based resource to improve the readiness of community EDs to triage, resuscitate, and transfer critically ill infants as measured by presimulation and postsimulation surveys measuring opinions regarding the scenario, session experience, and most valuable aspect of the session. Between January 2018 and December 2019, 179 ACEP SimBoxes were shipped across the United States, reaching 36 of 50 states. Facilitators and participants who completed the postsimulation survey evaluated the session as a valuable use of their time. All facilitator respondents reported that the low-technology manikins, paired with their institution-specific equipment, were sufficient for learning, thus reducing costs. All participant respondents reported an increased commitment to pediatric readiness for their ED after completing the simulation session. This innovation resulted in the implementation of a unique simulation-based training intervention across many community EDs in the United States. The ACEP SimBox innovation demonstrates that an easy to use and unique simulation-based training tool can be developed, distributed, and implemented across many community EDs in the United States to help improve community ED pediatric readiness.
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Affiliation(s)
- Samreen Vora
- Department of Emergency Medicine, Children's Minnesota Hospital, Minneapolis, MN.
| | - Joyce Li
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Maybelle Kou
- Department of Emergency Medicine, Inova Fairfax Medical Campus/Inova Children's Hospital, Falls Church, VA
| | - Vivienne Ng
- Department of Emergency Medicine, The University of Arizona, Tucson, AZ
| | - Amanda Price
- Division of Pediatric Emergency Medicine, Medical University South Carolina, Charleston, SC
| | - Ilene Claudius
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Shruti Kant
- Department of Emergency Medicine, Benioff Children's Hospital, San Francisco, CA
| | - Elizabeth Sanseau
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Manu Madhok
- Department of Emergency Medicine, Children's Minnesota Hospital, Minneapolis, MN
| | - Marc Auerbach
- Department of Pediatrics, Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
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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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7
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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: 174] [Impact Index Per Article: 58.0] [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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Li J, Roosevelt G, McCabe K, Preotle J, Pereira F, Takayesu JK, Porter JJ, Monuteaux M, Bachur RG. Critically Ill Pediatric Case Exposure During Emergency Medicine Residency. J Emerg Med 2020; 59:278-285. [PMID: 32536497 DOI: 10.1016/j.jemermed.2020.04.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/03/2020] [Accepted: 04/28/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Eighty-eight percent of pediatric emergency department (ED) visits occur in general EDs. Exposure to critically ill children during emergency medicine (EM) training has not been well described. OBJECTIVE The objective was to characterize the critically ill pediatric EM case exposure among EM residents. METHODS This is a secondary analysis of a multicenter retrospective review of pediatric patients (aged < 18 years) seen by the 2015 graduating resident physicians at four U.S. EM training programs. The per-resident exposure to Emergency Severity Index (ESI) Level 1 pediatric patients was measured. Resident-level counts of pediatric patients were measured; specific counts were classified by age and Pediatric Emergency Care Applied Network diagnostic categories. RESULTS There were 31,552 children seen by 51 residents across all programs; 434 children (1.3%) had an ESI of 1. The median patient age was 8 years (interquartile range [IQR] 3-12 years). The median overall pediatric critical case exposure per resident was 6 (IQR 3-12 cases). The median trauma and medical exposure was 2 (IQR 0-3) and 3 (IQR 2-10), respectively. For 13 out of 20 diagnostic categories, at least 50% of residents did not see any critical care case in that category. Sixty-eight percent of residents saw 10 or fewer critically ill cases by the end of training. CONCLUSION Pediatric critical care exposure during EM training is very limited. These findings underscore the importance of monitoring trainees' case experience to inform program-specific curricula and to develop strategies to increase exposure and resident entrustment, as well as further research in this area.
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Affiliation(s)
- Joyce Li
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Emergency Medicine and Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Genie Roosevelt
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado; University of Colorado School of Medicine, Denver, Colorado
| | - Kerry McCabe
- Department of Emergency Medicine, Boston Medical Center, Boston, Massachusetts; Boston University School of Medicine, Boston, Massachusetts
| | - Jane Preotle
- Department of Emergency Medicine, Hasbro Children's Hospital, Providence, Rhode Island; Alpert Medical School of Brown University, Providence, Rhode Island
| | - Faria Pereira
- Division of Emergency Medicine, Texas Children's Hospital, Houston, Texas; Baylor College of Medicine, Houston, Texas
| | - James K Takayesu
- Division of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Emergency Medicine and Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Michael Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Emergency Medicine and Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Emergency Medicine and Pediatrics, Harvard Medical School, Boston, Massachusetts
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Paediatric traumatic out-of-hospital cardiac arrest: A systematic review and meta-analysis. Resuscitation 2020; 149:65-73. [PMID: 32070780 DOI: 10.1016/j.resuscitation.2020.01.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 01/19/2020] [Accepted: 01/29/2020] [Indexed: 11/20/2022]
Abstract
AIM In this study, we sought to quantitatively describe the survival outcomes, incidence rates, and predictors of survival after paediatric traumatic out-of-hospital cardiac arrest (OHCA). METHODS We systematically searched MEDLINE, EMBASE, EMCARE, and CINAHL to identify observational or interventional studies reporting relevant data for paediatric traumatic OHCA. The Joanna Briggs Institute critical appraisal tool for prognostic studies was used to assess study quality. We analysed the survival outcomes and pooled incidence rates per 100,000 person-years using random-effect models. RESULTS Nineteen articles met the eligibility criteria involving 705 Emergency Medical Service (EMS)-attended and 973 EMS-treated traumatic paediatric OHCAs across an estimated serviceable population of 15.2 million. Four studies were conducted in the Asia-pacific region, seven in Europe, and eight in North America. Nine studies were assessed as low quality. Overall pooled survival to hospital discharge or 30-day survival for the EMS-treated cases was 1.2% (n = 6 studies; 95% confidence interval (CI): 0.1%, 3.1%; I2 = 26.1%). The pooled rate of return of spontaneous circulation in four studies was 22.1% (95% CI: 18.4%, 26.1%; I2 = 0.0%), and the pooled rate of event survival was 18.8% (n = 3 studies; 95% CI: 15.2%, 22.7%; I2 = 0.0%). The pooled incidence of EMS-treated paediatric traumatic OHCA was 1.6 cases per 100,000 person-years (n = 10 studies; 95% CI: 1.1, 2.2; I2 = 98.1%). No study reported on the impact of epidemiological or clinical factors on survival. CONCLUSION Survival outcomes of paediatric traumatic OHCA are poor and existing studies report varying incidence rates. The absence of large prospective and international registry data hinders the development of novel strategies to improve survival rates.
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Varghese M. Prehospital trauma care evolution, practice and controversies: need for a review. Int J Inj Contr Saf Promot 2020; 27:69-82. [DOI: 10.1080/17457300.2019.1708409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Mathew Varghese
- Department of Orthopaedic Surgery, St Stephen’s Hospital, Delhi, India
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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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Prehospital traumatic cardiac arrest: Management and outcomes from the resuscitation outcomes consortium epistry-trauma and PROPHET registries. J Trauma Acute Care Surg 2017; 81:285-93. [PMID: 27070438 DOI: 10.1097/ta.0000000000001070] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traumatic arrests have historically had poor survival rates. Identifying salvageable patients and ideal management is challenging. We aimed to (1) describe the management and outcomes of prehospital traumatic arrests; (2) determine regional variation in survival; and (3) identify Advanced Life Support (ALS) procedures associated with survival. METHODS This was a secondary analysis of cases from the Resuscitation Outcomes Consortium Epistry-Trauma and Prospective Observational Prehospital and Hospital Registry for Trauma (PROPHET) registries. Patients were included if they had a blunt or penetrating injury and received cardiopulmonary resuscitation. Logistic regression analyses were used to determine the association between ALS procedures and survival. RESULTS We included 2,300 patients who were predominately young (Epistry mean [SD], 39 [20] years; PROPHET mean [SD], 40 [19] years), males (79%), injured by blunt trauma (Epistry, 68%; PROPHET, 67%), and treated by ALS paramedics (Epistry, 93%; PROPHET, 98%). A total of 145 patients (6.3%) survived to hospital discharge. More patients with blunt (Epistry, 8.3%; PROPHET, 6.5%) vs. penetrating injuries (Epistry, 4.6%; PROPHET, 2.7%) survived. Most survivors (81%) had vitals on emergency medical services arrival. Rates of survival varied significantly between the 12 study sites (p = 0.048) in the Epistry but not PROPHET (p = 0.14) registries.Patients in the PROPHET registry who received a supraglottic airway insertion or intubation experienced decreased odds of survival (adjusted OR, 0.27; 95% confidence interval, 0.08-0.93; and 0.37; 95% confidence interval, 0.17-0.78, respectively) compared to those receiving bag-mask ventilation. No other procedures were associated with survival. CONCLUSIONS Survival from traumatic arrest may be higher than expected, particularly in blunt trauma and patients with vitals on emergency medical services arrival. Although limited by confounding and statistical power, no ALS procedures were associated with increased odds of survival. LEVEL OF EVIDENCE Prognostic study, level IV.
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Lin YR, Syue YJ, Buddhakosai W, Lu HE, Chang CF, Chang CY, Chen CH, Chen WL, Li CJ. Impact of Different Initial Epinephrine Treatment Time Points on the Early Postresuscitative Hemodynamic Status of Children With Traumatic Out-of-hospital Cardiac Arrest. Medicine (Baltimore) 2016; 95:e3195. [PMID: 27015217 PMCID: PMC4998412 DOI: 10.1097/md.0000000000003195] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The postresuscitative hemodynamic status of children with traumatic out-of-hospital cardiac arrest (OHCA) might be impacted by the early administration of epinephrine, but this topic has not been well addressed. The aim of this study was to analyze the early postresuscitative hemodynamics, survival, and neurologic outcome according to different time points of first epinephrine treatment among children with traumatic OHCA.Information on 388 children who presented to the emergency departments of 3 medical centers and who were treated with epinephrine for traumatic OHCA during the study period (2003-2012) was retrospectively collected. The early postresuscitative hemodynamic features (cardiac functions, end-organ perfusion, and consciousness), survival, and neurologic outcome according to different time points of first epinephrine treatment (early: <15, intermediate: 15-30, and late: >30 minutes after collapse) were analyzed.Among 165 children who achieved sustained return of spontaneous circulation, 38 children (9.8%) survived to discharge and 12 children (3.1%) had good neurologic outcomes. Early epinephrine increased the postresuscitative heart rate and blood pressure in the first 30 minutes, but ultimately impaired end-organ perfusion (decreased urine output and initial creatinine clearance) (all P < 0.05). Early epinephrine treatment increased the chance of achieving sustained return of spontaneous circulation, but did not increase the rates of survival and good neurologic outcome.Early epinephrine temporarily increased heart rate and blood pressure in the first 30 minutes of the postresuscitative period, but impaired end-organ perfusion. Most importantly, the rates of survival and good neurologic outcome were not significantly increased by early epinephrine administration.
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Affiliation(s)
- Yan-Ren Lin
- From the Department of Emergency Medicine (Y-RL, C-FC, C-YC, CHC), Changhua Christian Hospital, Changhua, Taiwan; School of Medicine (Y-RL), Kaohsiung Medical University, Kaohsiung, Taiwan; School of Medicine (Y-RL), Chung Shan Medical University, Taichung, Taiwan; Department of Anesthesiology (Y-JS), Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Biological Science and Technology (WB, C-YC, W-LC), National Chiao Tung University, Hsinchu, Taiwan; Interdisciplinary Graduate Program in Genetic Engineering (WB), Graduate School, Kasetsart University, Bangkhen campus, Bangkok, Thailand; Bioresource Collection and Research Center (H-EL), Food Industry Research and Development Institute, Hsinchu, Taiwan; Department of Emergency Medicine (C-JL), Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan; and Department of Public Health (C-JL), College of Health Science, Kaohsiung Medical University, Kaohsiung, Taiwan
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Monsieurs K, Nolan J, Bossaert L, Greif R, Maconochie I, Nikolaou N, Perkins G, Soar J, Truhlář A, Wyllie J, Zideman D. Kurzdarstellung. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0097-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Nikolaou NI, Perkins GD, Soar J, Truhlář A, Wyllie J, Zideman DA, Alfonzo A, Arntz HR, Askitopoulou H, Bellou A, Beygui F, Biarent D, Bingham R, Bierens JJ, Böttiger BW, Bossaert LL, Brattebø G, Brugger H, Bruinenberg J, Cariou A, Carli P, Cassan P, Castrén M, Chalkias AF, Conaghan P, Deakin CD, De Buck ED, Dunning J, De Vries W, Evans TR, Eich C, Gräsner JT, Greif R, Hafner CM, Handley AJ, Haywood KL, Hunyadi-Antičević S, Koster RW, Lippert A, Lockey DJ, Lockey AS, López-Herce J, Lott C, Maconochie IK, Mentzelopoulos SD, Meyran D, Monsieurs KG, Nikolaou NI, Nolan JP, Olasveengen T, Paal P, Pellis T, Perkins GD, Rajka T, Raffay VI, Ristagno G, Rodríguez-Núñez A, Roehr CC, Rüdiger M, Sandroni C, Schunder-Tatzber S, Singletary EM, Skrifvars MB, Smith GB, Smyth MA, Soar J, Thies KC, Trevisanuto D, Truhlář A, Vandekerckhove PG, de Voorde PV, Sunde K, Urlesberger B, Wenzel V, Wyllie J, Xanthos TT, Zideman DA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary. Resuscitation 2015; 95:1-80. [PMID: 26477410 DOI: 10.1016/j.resuscitation.2015.07.038] [Citation(s) in RCA: 568] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Koenraad G Monsieurs
- Emergency Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, Bristol, UK
| | | | - Robert Greif
- Department of Anaesthesiology and Pain Medicine, University Hospital Bern, Bern, Switzerland; University of Bern, Bern, Switzerland
| | - Ian K Maconochie
- Paediatric Emergency Medicine Department, Imperial College Healthcare NHS Trust and BRC Imperial NIHR, Imperial College, London, UK
| | | | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jonathan Wyllie
- Department of Neonatology, The James Cook University Hospital, Middlesbrough, UK
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Maconochie IK, Bingham R, Eich C, López-Herce J, Rodríguez-Núñez A, Rajka T, Van de Voorde P, Zideman DA, Biarent D, Monsieurs KG, Nolan JP. European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2015; 95:223-48. [DOI: 10.1016/j.resuscitation.2015.07.028] [Citation(s) in RCA: 217] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Hillman CM, Rickard A, Rawlins M, Smith JE. Paediatric traumatic cardiac arrest: data from the Joint Theatre Trauma Registry. J ROY ARMY MED CORPS 2015; 162:276-9. [PMID: 26116000 DOI: 10.1136/jramc-2015-000464] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 06/06/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Traumatic cardiac arrest (TCA) in children is associated with a low probability of survival and poor neurological outcome in survivors. Since 2003, over 600 seriously injured local national children have been treated at deployed UK military medical treatment facilities during the Iraq and Afghanistan conflicts. A number of these were in cardiac arrest after sustaining traumatic injuries. This study defined outcomes from paediatric TCA in this cohort. METHODS A retrospective database review was undertaken using the UK Joint Theatre Trauma Registry. This includes UK military, coalition military, civilians and local security forces personnel who prompted trauma team activation. All children in this series were local nationals. Patients aged less than 18 years who presented between January 2003 and April 2014, and who underwent cardiopulmonary resuscitation, were included. RESULTS 27 children with TCA were included. Four children survived to discharge from the medical treatment facility (14.8%), though limited data are available regarding the long-term neurological outcome in these patients. CONCLUSIONS This study demonstrates that the outcomes for paediatric TCA in our military field hospitals were similar to other paediatric civilian and adult military studies, despite patients being injured by severe blast injuries. Further work is needed to define the optimal management of paediatric TCA.
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Affiliation(s)
| | - A Rickard
- Emergency Department, Derriford Hospital, Plymouth, UK
| | - M Rawlins
- Clinical Information & Exploitation Team, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK
| | - J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK
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Cardiopulmonary Resuscitation in Resource-limited Health Systems-Considerations for Training and Delivery. Prehosp Disaster Med 2014; 30:97-101. [PMID: 25407562 DOI: 10.1017/s1049023x14001265] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In the past 50 years, cardiopulmonary resuscitation (CPR) has gained widespread recognition as a life-saving skill that can be taught successfully to the general public. Cardiopulmonary resuscitation can be considered a cost-effective intervention that requires minimal classroom training and low-cost equipment and supplies; it is commonly taught throughout much of the developed world. But, the simplicity of CPR training and its access for the general public may be misleading, as outcomes for patients in cardiopulmonary arrest are poor and survival is dependent upon a comprehensive "chain-of-survival," which is something not achieved easily in resource-limited health care settings. In addition to the significant financial and physical resources needed to both train and develop basic CPR capabilities within a community, there is a range of ethical questions that should also be considered. This report describes some of the financial and ethical challenges that might result from CPR training in low- and middle-income countries (LMICs). It is determined that for many health care systems, CPR training may have financial and ethically-deleterious, unintended consequences. Evidence shows Basic Life Support (BLS) skills training in a community is an effective intervention to improve public health. But, health care systems with limited resources should include CPR training only after considering the full implications of that intervention.
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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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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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Vallipakorn SAO, Plitapolkarnpim A, Suriyawongpaisal P, Techakamolsuk P, Smith GA, Thakkinstian A. Risk prediction score for death of traumatised and injured children. BMC Pediatr 2014; 14:60. [PMID: 24575982 PMCID: PMC3939810 DOI: 10.1186/1471-2431-14-60] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 02/20/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Injury prediction scores facilitate the development of clinical management protocols to decrease mortality. However, most of the previously developed scores are limited in scope and are non-specific for use in children. We aimed to develop and validate a risk prediction model of death for injured and Traumatised Thai children. METHODS Our cross-sectional study included 43,516 injured children from 34 emergency services. A risk prediction model was derived using a logistic regression analysis that included 15 predictors. Model performance was assessed using the concordance statistic (C-statistic) and the observed per expected (O/E) ratio. Internal validation of the model was performed using a 200-repetition bootstrap analysis. RESULTS Death occurred in 1.7% of the injured children (95% confidence interval [95% CI]: 1.57-1.82). Ten predictors (i.e., age, airway intervention, physical injury mechanism, three injured body regions, the Glasgow Coma Scale, and three vital signs) were significantly associated with death. The C-statistic and the O/E ratio were 0.938 (95% CI: 0.929-0.947) and 0.86 (95% CI: 0.70-1.02), respectively. The scoring scheme classified three risk stratifications with respective likelihood ratios of 1.26 (95% CI: 1.25-1.27), 2.45 (95% CI: 2.42-2.52), and 4.72 (95% CI: 4.57-4.88) for low, intermediate, and high risks of death. Internal validation showed good model performance (C-statistic = 0.938, 95% CI: 0.926-0.952) and a small calibration bias of 0.002 (95% CI: 0.0005-0.003). CONCLUSIONS We developed a simplified Thai pediatric injury death prediction score with satisfactory calibrated and discriminative performance in emergency room settings.
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Affiliation(s)
- Sakda Arj-ong Vallipakorn
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Rama VI Road, Rajathevi, Bangkok 10400, Thailand
- Child Safety Promotion and Injury Prevention Research Center (CSIP), and Safe Kids Thailand, Bangkok 10400, Thailand
| | - Adisak Plitapolkarnpim
- Pediatric Ambulatory Units, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
- Child Safety Promotion and Injury Prevention Research Center (CSIP), and Safe Kids Thailand, Bangkok 10400, Thailand
| | - Paibul Suriyawongpaisal
- Department of Community Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Pimpa Techakamolsuk
- Department of Disease Control, Ministry of Public Health, Nonthaburi, 11000 Thailand
| | - Gary A Smith
- Center for Injury Research and Policy, Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Ammarin Thakkinstian
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Rama VI Road, Rajathevi, Bangkok 10400, Thailand
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Predictors of survival and neurologic outcomes in children with traumatic out-of-hospital cardiac arrest during the early postresuscitative period. J Trauma Acute Care Surg 2013; 75:439-47. [PMID: 24089114 DOI: 10.1097/ta.0b013e31829e2543] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The outcome of children with traumatic out-of-hospital cardiac arrest (OHCA) is poor, and the information regarding survival in the postresuscitative period is limited. The aim of this study was to determine the clinical features during the early postresuscitative period that may predict survival or neurologic outcomes in children with traumatic OHCA. METHODS Information on 362 children (<19 years) who presented to the emergency departments of three medical centers and experienced traumatic OHCA during the study period (January 2003 to December 2010) were retrospectively included. The postresuscitative clinical features during the early postresuscitative period, defined as the first hour after achieving sustained return of spontaneous circulation, which correlated with survival and neurologic outcomes were analyzed. RESULTS Among 152 children (42%) who achieved sustained return of spontaneous circulation, 34 (9.4%) survived to discharge, and 11 (3%) had good neurologic outcomes (Pediatric Cerebral Performance Category Scale, 1 or 2). Early postresuscitative clinical features, which reflected initial cardiac output and end-organ perfusion, can predict the chance of survival. Such features included the following: high or normal blood pressure, normal heart rate, sinus rhythm, urine output of more than 1 mL/kg per hour, and noncyanotic skin color (all p < 0.05). Initial Glasgow Coma Scale (GCS) score of greater than 7 predicted a good neurologic outcome in survivors (p = 0.008). CONCLUSION Predictors of survival were high or normal blood pressure, normal heart rate, sinus rhythm, urine output of more than 1 mL/kg per hour, and noncyanotic skin color. Most importantly, initial GCS score of greater than 7 predicted a good neurologic outcome in survivors. LEVEL OF EVIDENCE Prognostic study, level III.
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Ethical Challenges in Emergency Medical Services: Controversies and Recommendations. Prehosp Disaster Med 2013; 28:488-97. [DOI: 10.1017/s1049023x13008728] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractEmergency Medical Services (EMS) providers face many ethical issues while providing prehospital care to children and adults. Although provider judgment plays a large role in the resolution of conflicts at the scene, it is important to establish protocols and policies, when possible, to address these high-risk and complex situations. This article describes some of the common situations with ethical underpinnings encountered by EMS personnel and managers including denying or delaying transport of patients with non-emergency conditions, use of lights and sirens for patient transport, determination of medical futility in the field, termination of resuscitation, restriction of EMS provider duty hours to prevent fatigue, substance abuse by EMS providers, disaster triage and difficulty in switching from individual care to mass-casualty care, and the challenges of child maltreatment recognition and reporting. A series of ethical questions are proposed, followed by a review of the literature and, when possible, recommendations for management.BeckerTK, Gausche-HillM, AsweganAL, BakerEF, BookmanKJ, BradleyRN, De LorenzoRA, SchoenwetterDJ for the American College of Emergency Physicians’ EMS Committee. Ethical challenges in Emergency Medical Services: controversies and recommendations. Prehosp Disaster Med. 2013;28(5):1-10.
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Abstract
BACKGROUND Several studies recommend not initiating advanced life support in traumatic cardiac arrest (TCA), mainly owing to the poor prognosis in several series that have been published. This study aimed to analyze the survival of the TCA in our series and to determine which factors are more frequently associated with recovery of spontaneous circulation (ROSC) and complete neurologic recovery (CNR). METHODS This is a cohort study (2006-2009) of treatment benefits. RESULTS A total of 167 TCAs were analyzed. ROSC was obtained in 49.1%, and 6.6% achieved a CNR. Survival rate by age groups was 23.1% in children, 5.7% in adults, and 3.7% in the elderly (p < 0.05). There was no significant difference in ROSC according to which type of ambulance arrived first, but if the advanced ambulance first, 9.41% achieved a CNR, whereas only 3.7% if the basic ambulance first. We found significant differences between the response time and survival with a CNR (response time was 6.9 minutes for those who achieved a CNR and 9.2 minutes for those who died). Of the patients, 67.5% were in asystole, 25.9% in pulseless electrical activity (PEA), and 6.6% in VF. ROSC was achieved in 90.9% of VFs, 60.5% of PEAs, and 40.2% of those in asystole (p < 0.05), and CNR was achieved in 36.4% of VFs, 7% of PEAs, and 2.7% of those in asystole (p < 0.05). The mean (SD) quantity of fluid replacement was greater in ROSC (1,188.8 [786.7] mL of crystalloids and 487.7 [688.9] mL of colloids) than in those without ROSC (890.4 [622.4] mL of crystalloids and 184.2 [359.3] mL of colloids) (p < 0.05). CONCLUSION In our series, 6.6% of the patients survived with a CNR. Our data allow us to state beyond any doubt that advanced life support should be initiated in TCA patients regardless of the initial rhythm, especially in children and those with VF or PEA as the initial rhythm and that a rapid response time and aggressive fluid replacement are the keys to the survival of these patients. LEVEL OF EVIDENCE Therapeutic study, level IV; epidemiologic study, level III.
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Matos RI, Watson RS, Nadkarni VM, Huang HH, Berg RA, Meaney PA, Carroll CL, Berens RJ, Praestgaard A, Weissfeld L, Spinella PC. Duration of Cardiopulmonary Resuscitation and Illness Category Impact Survival and Neurologic Outcomes for In-hospital Pediatric Cardiac Arrests. Circulation 2013; 127:442-51. [DOI: 10.1161/circulationaha.112.125625] [Citation(s) in RCA: 196] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Pediatric cardiopulmonary resuscitation (CPR) for >20 minutes has been considered futile after pediatric in-hospital cardiac arrests. This concept has recently been questioned, although the effect of CPR duration on outcomes has not recently been described. Our objective was to determine the relationship between CPR duration and outcomes after pediatric in-hospital cardiac arrests.
Methods and Results—
We examined the effect of CPR duration for pediatric in-hospital cardiac arrests from the Get With The Guidelines–Resuscitation prospective, multicenter registry of in-hospital cardiac arrests. We included 3419 children from 328 US and Canadian Get With The Guidelines–Resuscitation sites with an in-hospital cardiac arrest between January 2000 and December 2009. Patients were stratified into 5 patient illness categories: surgical cardiac, medical cardiac, general medical, general surgical, and trauma. Survival to discharge was 27.9%, but only 19.0% of all cardiac arrest patients had favorable neurological outcomes. Between 1 and 15 minutes of CPR, survival decreased linearly by 2.1% per minute, and rates of favorable neurological outcome decreased by 1.2% per minute. Adjusted probability of survival was 41% for CPR duration of 1 to 15 minutes and 12% for >35 minutes. Among survivors, favorable neurological outcome occurred in 70% undergoing <15 minutes of CPR and 60% undergoing CPR >35 minutes. Compared with general medical patients, surgical cardiac patients had the highest adjusted odds ratios for survival and favorable neurological outcomes, 2.5 (95% confidence interval, 1.8–3.4) and 2.7 (95% confidence interval, 2.0–3.9), respectively.
Conclusions—
CPR duration was independently associated with survival to hospital discharge and neurological outcome. Among survivors, neurological outcome was favorable for the majority of patients. Performing CPR for >20 minutes is not futile in some patient illness categories.
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Affiliation(s)
- Renée I. Matos
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - R. Scott Watson
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Vinay M. Nadkarni
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Hsin-Hui Huang
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Robert A. Berg
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Peter A. Meaney
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Christopher L. Carroll
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Richard J. Berens
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Amy Praestgaard
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Lisa Weissfeld
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Philip C. Spinella
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
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