When to stop: Termination of Resuscitation in Pediatric Traumatic Cardiac Arrest

Field termination of pediatric resuscitation is a difficult topic for EMS systems, prehospital providers, first responders, and the patient’s family. Clear guidelines exist for the termination of resuscitation of adults in cardiac arrest for both traumatic and non-traumatic etiologies, and routine transportation of adults in cardiac arrest all but guarantees poor outcomes. Unfortunately, for pediatric patients no clear guidelines exist to help drive the decision, so practically all pediatric patients suffering from traumatic cardiac arrest receive on-going resuscitation during transportation to hospital.

In this month’s Annals of Emergency Medicine, the American College of Surgeons, American College of Emergency Physicians, National Association of EMS Physicians, and American Academy of Pediatrics released a joint statement providing general guidelines for withholding or terminating resuscitative efforts in out-of-hospital pediatric traumatic cardiac arrest [1]. This paper undertook a review of all available literature on the topic in an attempt to form evidence based guidelines.

In total, 27 articles were identified which were relevant to the topic and contained data applicable to the guideline being developed. No Class I evidence was found, which is unsurprising as it is difficult to perform large randomized controlled trials on adult OOHCA, let alone pediatric OOHCA. These 27 papers contained outcome data on 1114 patients, with only 60 survivors (5.4%). Of the 60 pediatric patients who survived to discharge, only 19 (1.2%) had a good neurological outcomes.

Table 1 adapted from Ann Emerg Med 2014;63:504-515

Table 1 adapted from Ann Emerg Med 2014;63:504-515

The fact that outcomes from pediatric traumatic OOHCA are dismal should not be surprising. Traumatic cardiac arrest often requires immediate surgical interventions not possible in most US EMS systems. Even among physician based EMS systems, the rapid availability of more advanced resuscitative measures has not improved survival to discharge neurologically intact.

Patients who had resuscitation efforts longer than 30 minutes had nearly universally poor neurological outcomes if they survived to hospital discharge. Most suffered devastating head injuries. Patients with good neurological outcomes were associated with early bystander CPR, signs of life prior to their cardiac arrest, and early ROSC. Epinephrine usage was not associated with improved ROSC or neurological survival.

The literature review identified key points which can help determine if field termination of pediatric traumatic arrest resuscitation is appropriate:

  • Patients with primary signs of futility such as injuries incompatible with life or obvious death (e.g. decapitation, traumatic amputations involving the thorax and abdomen).
  • Traumatic arrest with secondary signs of futility (e.g. dependent lividity, rigor mortis, and decomposition).
  • Victims of drowning or lightning strikes with primary or secondary signs of futility.
  • Unwitnessed traumatic cardiac arrest with prolonged resuscitation efforts (30 minutes) and no signs of life during the resuscitation.

If any of these criteria are met, discussions with the family should be made regarding the futility of resuscitation and the appropriateness of termination of resuscitation.

The literature review identified the following criteria for when resuscitation should be initiated or continued:

  • Witnessed traumatic arrest with prior signs of life and early CPR.
  • A mechanism of injury which does not correlate with a traumatic cardiac arrest.
  • Provider doubt as to the circumstances or timing of the traumatic cardiac arrest.
  • Prolonged traumatic cardiac arrest by drowning or lightning strike with hypothermia.
  • Consultation with family members or medical control recommends resuscitation.

If any of these criteria are met, immediate transportation of the patient should be made to the appropriate facility for pediatric traumatic cardiac arrest. Hemorrhage control and defibrillation should occur on scene. Treatments such as airway management and vascular access should be made enroute to the facility.

Pediatric cardiac arrest is a difficult topic and many providers may be unwilling to, “give up,” on resuscitation efforts. It is appropriate to terminate resuscitation efforts in both adult and pediatric cardiac arrests where efforts are futile. Recognizing futile efforts is important, so we can ensure families are not given a false sense of hope. Resuscitation of all patients in cardiac arrest, regardless of etiology, should be evidence based and free from emotion. However, the author recognizes that this is easier said than done.

1. American College of Surgeons, American College of Emergency Physicians, National Association of EMS Physicians, American Academy of Pediatrics. Joint Statement: Withholding or Termination of Resuscitation in Pediatric Out-of-Hospital Traumatic Cardiopulmonary Arrest. Ann Emerg Med 2014; 63(4):504-15.

Questions

  • Does your service have termination of resuscitation guidelines?
  • Do they include pediatric patients?
  • Are you willing to terminate the resuscitation of pediatric patients in cardiac arrest who meet these guidelines?
  • What can be done to improve provider willingness to acknowledge these difficult decisions?

2 Comments

  • at least we’ve made it to the point where we’re choosing more wisely when to terminate with adults. we’ll get there with peds one day.

  • Brian says:

    This is the single biggest “fail” of using the term evidence based medicine I have ever witnessed.
    Both of these excerpts are from the guidelines. The guideline presents evidence as to why we should not transport…..and then says, just transport them with no evidence given.

    evidence base recommendation:
    “5.Immediate transportation to an ED should be considered for children who exhibit witnessed signs of life before traumatic cardiopulmonary resuscitation and have CPR ongoing or initiated within 5 minutes in the field, with resuscitation maneuvers including airway management and intravenous or intraosseous line placement planned during transport (Level 2).”

    from the discussion:

    “In addition to the cost concerns, the lights and siren run is associated with significant potential for injury to EMS personnel and the public.94, 95, 96, 97 Finally, the costs of supplies (often including precious blood products) and the emotional toll on ED providers who would not otherwise be exposed to the death, including the risk of post-traumatic stress disorder, are all important considerations that should not be ignored when choosing whether to transport a patient who is already dead or who will inevitably die (unpublished survey data; in process to submit for publication).”

    It is for these reasons that there is increasing acceptance of termination of resuscitation for adults when there is no hope for a good outcome.1, 91, 92, 98, 99, 100, 101, 102 Although the same justifications apply to children, especially in light of worse out-of-hospital resuscitation outcomes, children are routinely excluded from termination-of-resuscitation protocols, at least in the United States.1 Approximately half of states have formalized termination of resuscitation in statute or protocol, but only a few apply them to children. ”

    “Beyond the resource-saving benefits associated with termination of resuscitation, 2 small studies indicate that families of adult patients who die in the out-of-hospital setting may actually adapt better to their losses when there is cessation of futile resuscitative efforts in the field.103, 104 “

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