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A 2-year-old child presents to the emergency department (ED) after running into traffic. He chased a ball into the road and was struck by a car. An ambulance is dispatched to transport him to hospital, but he arrests en route. By the time he reaches your facility, he has been without a pulse for 10 min.
He is in cardiac arrest. There is an endotracheal (ET) tube in situ and bilateral finger thoracostomies have been performed. The paramedics placed a pelvic binder prior to transportation. Tibial intraosseous (IO) access has been obtained and he is receiving 10 mL/kg of balanced crystalloid. No pre-hospital blood products were available. A Code Red was put out prior to his arrival. On examination, you are informed that both of his pupils are fixed and dilated. He has not received any other interventions.
Structured clinical question
In a paediatric patient in traumatic cardiac arrest (TCA) (patient), are there markers (intervention) that can assist in determining futility, aiding clinicians in a decision to stop resuscitation? (outcome)
Systematic review of peer-reviewed published literature (table 1). Databases searched Medline, Cochrane and Embase including published data until January 2019. Inclusion criteria were patients <18 years old needing TPCPR (trauma related paedaitric CPR). Search terms for Medline and EMBASE were (trauma OR traumatic) AND (arrest or cardiopulmonary resuscitation) AND (futility OR termination OR cessation). Search terms for Cochrane: paper including terms ‘trauma’, ‘traumatic’ or ‘arrest’.
Paediatric TCA is rare. Less than 15 cases occur in the UK every year. Studies have suggested that as survival is poor, treating children in TCA is futile.1 There is limited evidence on this. Most is extrapolated from the adult population and suggests that early treatment of reversible causes may improve outcome.2 3
This review looks at some recent studies on paediatric TCA. Deciding to terminate resuscitation in any paediatric arrest is challenging. The authors were involved in six cases where resuscitation was prolonged, and return of spontaneous circulation (ROSC) eventually established. Unfortunately, all cases had a poor outcome. Review of these cases and the futility of the resuscitation attempts sparked much debate. We wanted to review the evidence for any markers of futility that could be used to aid the team leader in this difficult decision-making process.
The literature is sparse, reflecting the rarity of this event. This review contains a mixture of case series, retrospectively collected audits, a systematic review, a modified consensus development meeting and a prospectively collected case series. All but one study had data collected retrospectively. Few studies made comments on signs of futility,4 and were underpowered to provide robust data. One paper was a consensus-based study of the opinion of expert practitioners.
Survival with good neurocognitive outcome is poor.5–9 CPR duration greater than 15 min,4 9 asystole,7 no signs of life at scene, blunt trauma, fixed pupils and absent pulses4 6 7 9 were all predictors of poor outcome. Data are sparse, studies are underpowered and are not statistically significant enough to validate termination of resuscitation criteria.9 Such factors are probably predictors of poor outcome but should not be held as the only factors.
A lack of response to potentially life-saving interventions may be useful when considering the futility of treatment. A persistently low end tidal CO2 and cardiac standstill on bedside ultrasound appear to be markers of poor outcome.10 The use of POCUS (Point of care ultrasound) in this context by an experienced professional may be of some value to provide additional information on making a decision to stop resuscitation.
Out-of-hospital ROSC, as compared with the achievement of ROSC in hospital, appears to be related to better rates of survival with better neurological outcomes.7 9 10
CLINICAL BOTTOM LINE
There are limited definitive markers of futility in paediatric traumatic cardiac arrest. (Grade C)
A poor outcome is associated with cardiopulmonary resuscitation duration of over 15 min, asystole, cardiac arrest at scene and fixed pupils. (Grade C)
It is likely that children who achieve return of spontaneous circulation prior to arrival in hospital have better survival and neurological outcomes than those that only achieve it in hospital. (Grade C)
Patient consent for publication
Twitter @DrVickiCurrie1, @andrewjtagg, @DrKanaris
Contributors VC produced initial piece of work based on a literature search by CK. CK, AT and VC edited work to produce final article.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.