by Melissa Puffenbarger MD
Expert review/editor Joelle Donofrio DO (@PEMEMS) & Hawnwan Moy MD (@Pecpodcast)
It’s eerily quiet in the Pediatric Emergency Department (ED) and everyone implicitly hopes that the peace will linger for the last hour of your overnight shift. However, as an experienced Pediatric Emergency Medicine (PEM)/Emergency Medical Services (EMS) physician, you know that's probably not going to happen.
Within minutes, your staff receives an emergent call from EMS. “We’re inbound with a 6-month-old male in cardiac arrest, compressions in progress, not intubated but being bagged, IO placed, 1 round of epi given, last rhythm check 2 minutes ago was PEA, and ETA 2 minutes.” You can visibly see the anxiety build in the ED as everyone starts to shakes off their fatigue to get ready for this patient.
On arrival, EMS rushes the tiny patient into the resuscitation room. As compressions are handed over to the Peds ED staff, the visibly shaken paramedic slowly drifts to the corner of the room looking on in concern. As the resuscitation continues, you have a brief thought...with all the emphasis on adult prehospital cardiac arrest, what evidence do we have to provide the best care for pediatric out of hospital cardiac arrest (p-OHCA) patient?
Literature Review:
When you hear about OHCA, the conversation will inevitably mention topics like pit crew CPR, the Cardiac Arrest Registry for Enhanced Survival (CARES) database, and the Resuscitation Outcomes Consortium (ROC). Yet, p-OHCA is often absent in these conversations, not because there is a lack of passion (there are a LOT of eager pediatric EM/EMS researchers out there), but because there are a lot of unanswered clinical questions concerning this topic. Why is that? First off, the number of p-OHCA is low. The incidence of p-OHCA is around 8 per 100,000 person-years with a dismal 6% survival to hospital discharge [7]. Additionally, only 13% of EMS runs are for pediatric patients [1]. As a result, not only do our EMS providers receive minimal pediatric clinical experience, but the low incidence makes p-OHCA research more difficult.
Nonetheless, to start to improve outcomes, we have to know where the baseline lies. In a recent observational study utilizing data from the ROC, Fink et al. attempted to define how p-OHCA survival rates have changed in a 5-year time span from July 1, 2007, to June 30, 2012, by studying 1738 children with OHCA. Unfortunately, the study showed that mortality rates and neurologic outcomes for pediatric out-of-hospital cardiac arrest have not improved [2]. Annual survival rates for p-OHCA were 6.7-10.2%, compared to a reported increase in survival rate of in-hospital cardiac arrest at 14-43% [2]. This large difference in survival between in-hospital and out-of-hospital arrests is likely related to multiple factors. These factors include time to compressions for an unwitnessed arrest, quality of bystander CPR, and a low frequency of initial shockable rhythms in pediatric patients.
Although these findings are not a huge surprise, the real interesting data arises when this manuscript compares survival to discharge of the different regions of the ROC study. For a brief refresher, the ROC is a collaboration of 10 regional sites in the United States and Canada. Thus, when the authors compared regions to each other, ROSC rates of p-OHCA ranged from 2.5% to 34.7%. Additionally, survival to discharge rates ranged from 2.6% to 14.7%. We need to determine why ROSC and survival to discharge varied so widely across regions in order to replicate best practices in p-OHCA. Fink et al. found that “...the regions with the greatest increases in survival over time exhibited increases in EMS-witnessed OHCA, increased the frequency of bystander CPR, and increased EMS-defibrillation compared to regions that did NOT see increases in survival over time [2].”
What might be the first step in improving our p-OHCA ROSC and survival to discharge? One place would be increasing provider knowledge and comfort when taking care of pediatric patients. When EMS providers were asked to self-identify educational priorities, Paramedics, EMT-Basics, and first responders prioritized pediatric airway management, anxiety when working with children, and general pediatric skills as primary areas for targeted education [3]. Specifically, these providers identified a need for training regarding IV and IO access, when and how to perform an advanced airway, recognizing normal neonatal vital signs, and prevention of hypothermia [3]. Intuitively, targeting education to these areas and providing a foundation for continuously updating EMS skills and pediatric protocols can help bridge these knowledge gaps and perhaps help improve p-OHCA outcomes.
The scant amount of literature available on p-OHCA supports the self-identified educational needs of our EMS providers. One study assessed pediatric airway management from a large database that included EMS encounters in 40 states and identified that EMS airway management should be a target for continuing skill development [4]. This study showed that endotracheal intubation (ETI) was the most commonly used advanced airway technique among EMS encounters. There was a significantly lower success rate for out-of-hospital ETI vs. in-hospital (81.1% success rate for out-of-hospital in this series vs. reported 97-99% success rate among PEM physicians), and alarmingly low use of CO2-based placement confirmation [4]. The higher in-hospital success rate likely reflects access to adjunctive airway equipment as well as very different levels of experience with the pediatric airway. One series reported that paramedic students received only 6-10 intubation attempts in the OR during training, and most of these were adults [5]. Pediatric patients in full arrest are unique in that they most commonly have a primary respiratory issue, and focusing on providing adequate ventilation and oxygenation is the key to their resuscitation. While improving the EMS provider’s advanced airway skills may help patients in more extreme situations, the biggest impact will likely be seen in striving for perfection with basic airway management: positioning to open the airway, providing a good seal during BVM, and ventilating at an appropriate rate and volume. Currently, there is no good data supporting prehospital pediatric intubation.
In addition to skills in pediatric airway management, EMS CPR quality has also been shown to require improvement. A large prospective observational study demonstrated that prehospital CPR only met AHA guidelines during p-OHCA resuscitations 16% of the time and less than 25% of events met both rate and CPR fraction target [6]. While we know that many, many factors affect p-OHCA survival, this study identifies that consistently performing high-quality CPR is critical. The goals of high-quality CPR are the same for both pediatric and adult patients with a focus on providing adequate depth and rate of compressions, minimizing interruptions to compressions, and providing effective oxygenation and ventilation. Processes that may help maintain high-quality CPR in the field include asking EMS partners to coach, praise and correct each other as needed when performing CPR, periodic skill sessions, and staying up to date on any AHA guideline changes.
Remaining up-to-date on the most recent practice guidelines as well as maintaining proficiency of certain skills should be approached as a team effort. EMS physicians should provide scheduled educational sessions that meet the expressed needs of EMS providers and periodically review how to care for special patient populations such as the arresting child. EMS providers should continue to improve pre-hospital care in their communities by evaluating themselves and each other, and remain involved in community outreach projects focused on prevention of injuries and improved bystander CPR. As an example, a bill in California was passed that mandates high schools with a health requirement to graduate to require CPR training [8]. To take this one step further, as part of the San Diego EMS County cardiac arrest task force’s agenda, fire and EMS are even teaching middle schoolers the art of bystander CPR. It's actions like these that can really help our sick pediatric patients and EMS providers. Finally, a culture of open dialogue with direct and timely feedback between ED personnel and EMS providers after transporting a critically ill patient will create an environment where all parties involved help improve the pre-hospital care of the pediatric patient.
Take Home Points:
Although a rare event, in the case of pediatric out of hospital cardiac arrest, factors that have been shown to increase ROSC and survival to discharge include EMS-witnessed OHCA, increased frequency of bystander CPR, and increased EMS-defibrillation. Additionally solid CPR mechanics, BASIC airway management, solid CPR education of the youth in our community and consistent, great pediatric education of our EMS providers allows us to provide the best care for the children in our communities. As the old proverb goes, “It takes a village to raise a child.” So too does it take a village- from our EMS providers, our community, our pediatric EMS researchers, to our medical directors- to save a child.
References
1. Shan, MN. et al. The epidemiology of emergency medical services use by children: an analysis of the National Hospital Ambulatory Medical Care Survey. Prehosp Emerg Care. 2008 Jul;12(3):269-76
2. Fink, E.L., Prince, D.K., et al. Unchanged pediatric out-of-hospital cardiac arrest incidence and survival rates with regional variation in North America. Resuscitation. 2016;107:121-128
3. Hansen, M., Meckler, G., et al. Children’s safety initiative: A national assessment of pediatric educational needs among emergency medical services providers. Prehosp Emerg Care. 2015; 19(2):287-291
4. Hansen, M., Lambert, W., et al.Out-of-hospital pediatric airway management in the United States. Resuscitation. 2016;90:104-110
5. Johnson, B.D., Seitz S.R., et al. Limited opportunities for paramedic student endotracheal intubation training in the operating room. Acad Emerg Med. 2006;13:1051-5
6. Sutton, R., Case, E., et al. A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality – A report from the ROC epistry-cardiac arrest. Resuscitation. 2015;93:150-157
7. Atkins DL, Everson-Stewart S, Sears GK, et al. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. Circulation 2009;119:1282-91.
8. "Text." Bill Text - AB-1719 Pupil Instruction: Cardiopulmonary Resuscitation. Web. 10 Jan. 2017.
Images from:
1. http://www.ukprogressive.co.uk/wp-content/uploads/2016/12/hospital-emergency-room-1.jpg
2. http://www.christianitytoday.com/images/46719.png
3. http://cosmouk.cdnds.net/15/31/1600x800/landscape-1438173668-cute-success-kid.jpg
4. http://www.thedebutanteball.com/wp-content/uploads/2015/11/117dfdafbd688ea2f7745cb21b742895.1000x998x1.jpg