Markers of futility of resuscitation for paediatric patients following a traumatic cardiac arrest:: a literature review to inform the PERUKI (PTCA) consensus study
Date First Published:
January 11, 2017
Last Updated:
January 20, 2017
Report by:
Dr Thomas Waterfield, ST7 Paediatric Emergency Medicine (RBHSC)
Search checked by:
Dr Julie-Ann Maney, RBHSC
Three-Part Question:
In [paediatric patients (<18years)] with a [traumatic cardiac arrest] what are the [markers of futility for starting and terminating the resuscitation?]
Clinical Scenario:
An 8 year old child is brought the emergency department following a high speed road traffic collision. He was unrestrained in the vehicle and has evidence of head trauma. He arrested at the scene and on arrival has undergone 15 minutes of CPR, has fixed pupils with no pulse and asystole on the cardiac monitor. Is it appropriate to stop resuscitation?
Search Strategy:
Medline 1985-01/2017 using the OVID interface. (("trauma"[All Fields] OR "traumatic"[All Fields]) AND ("cardiac arrest"[All Fields] OR "cardiopulmonary arrest"[All Fields])) AND ("futility"[All Fields] OR "termination"[All Fields])
A search of the Cochrane Library for all papers including the words “trauma” or “traumatic” or “arrest”
A search of the Cochrane Library for all papers including the words “trauma” or “traumatic” or “arrest”
Search Details:
Medline 1985-01/2017 using the OVID interface. (("trauma"[All Fields] OR "traumatic"[All Fields]) AND ("cardiac arrest"[All Fields] OR "cardiopulmonary arrest"[All Fields])) AND ("futility"[All Fields] OR "termination"[All Fields])
A search of the Cochrane Library for all papers including the words “trauma” or “traumatic” or “arrest”
A search of the Cochrane Library for all papers including the words “trauma” or “traumatic” or “arrest”
Outcome:
Altogether 58 papers were found in Medline and 64 in Cochrane, of which 3 were directly relevant to the three-part question and of sufficient quality. A further 10 papers were found by scanning the references of relevant papers. All relevant papers are summarized in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. American College of Surgeons Committee on Trauma; American College of Emergency Physicians Pe Fallat ME 2014 USA | All children under the age of 18 with a traumatic cardiac arrest either in hospital or in the emergency department from 1980 to 2011. A total number of 1114 patients were included for analysis. | Systematic Review | Survival To Discharge | 60 patients (5.4%) survived to discharge | All studies were observation and included small number s of patients . There was no standardised definition of a good or poor outcome and some instances no data was provided on the neurological status of the child following survival. There was no standardised system of grading neurological outcome between papers. |
| Paediatric traumatic out-of-hospital cardiac arrests in Melbourne, Australia. Resuscitation Deasy C, Bray J, Smith K 2012 Australia | 64 cases of out of hospital traumatic cardiac arrest in children aged <16 | Case Series | Survive to discharge | 1 patient | Observational study with only 1 survivor. No useful predictors of futility due to only one survivor. |
| Retrospective analysis of emergency room thoracotomy in pediatric severe trauma patients. Resuscitation Hofbauer M, Hüpfl M, Figl et al 2011 Austria | 12 cases of traumatic cardiac arrest managed with emergency thoracotomy in children aged < 16 years | Case Series | Survive to discharge | 1 child survived. The child had a penetrating stab wound to the chest. No children with blunt traumatic injury survived. Suggests Thoracotomy is poor prognostic sign especially in blunt trauma. | Observational single centred study. Small numbers of patients. |
| Prognosis for children in cardiac arrest shortly after blunt cranial trauma. Widdel L, Winston KR 2010 USA | 40 cases of traumatic head injury resulting in cardiac arrest in children < 16 years.t | Case Seriest | Survival To Discharge | 1 child survived to discharge | Single centre observational study with small numbers of patients looking at a specific injury type. |
| Neurological Outcome | The surviving child could walk but had cranial nerve deficits and learning difficulties. Suggests poor prognosis for traumatic brain injury resulting in cardiac arrest. | ||||
| Assessment of termination of trauma resuscitation guidelines: are children small adults? Capizzani AR, Drongowski R, Ehrlich PF. 2010 USA | 30 cases of traumatic cardiopulmonary arrest in children 18 years and younger. | Case Series | Predictors of futility of resuscitation | CPR greater than 15 minutes (P=0.011) and fixed pupils (P=0.022) were significantly more likely in non-survivors. The ECG rhythm and absent pulse were not significantly different between survivors and non-survivors. | Small numbers of survivors and underpowered to state that cardiac rhythm and presence of a pulse can predict futility of resuscitation. |
| Survival To Discharge | 6 patients survived to discharge | ||||
| Outcome from paediatric cardiac arrest associated with trauma. Crewdson K, Lockey D, Davies G. 2007 UK | 80 cases of traumatic out of hospital cardiac arrest in children aged <16t |
Case Series | Survival To Discharge | 7 children survived to discharge | Single centre observational study with incomplete data on neurological outcome. Offers little or no information on predictive factors of futility. |
| Neurological Outcome | 3 children were "functionally normal" at discharge | ||||
| Penetrating Vs Blunt Trauma as predictors of death | All children with penetrating injuries died | ||||
| Thoracotomy as predictor of death | 4 Children received thoracotomies (All penetrating injuries) - All died | ||||
| Predictors of survival and neurologic outcomes in children with traumatic out-of-hospital cardiac arrest during the early postresuscitative period Lin YR, Wu HP, Chen WL et al. 2007 Taiwan | 56 cases of out of hospital traumatic cardiac arrest in children <18.tt | Case Series | ROSC | 20 children achieved ROSC for greater than 20 minutes. | Observational study with a including both blunt and penetrating trauma. Details of why children subsequently died was not included. Suggests poorer outcome in children presenting in asystole. |
| Presenting Rhythm and ROSC | ROSC was significantly more likely in children with VF and PEA as compared to asystole (p=0.03) and (p=0.003) respectively. | ||||
| Time to ROSC | In 80% of cases ROSC was seen within 15 minutes of commencing CPR. ROSC beyond 30 minutes of CPR was seen in 8% of cases. | ||||
| Survival to discharge | Of the 20 children with ROSC only 1 survived to discharge | ||||
| A critical analysis of outcome for children sustaining cardiac arrest after blunt trauma. Calkins CM, Bensard DD, Partrick DA et al 2002 USA | 25 cases of cardiac arrest following blunt trauma in children < 16tt t |
Case Series | Survival To Discharge | 2 patients survived. Both initially had signs of life and arrested in the emergency department. | Observational study. Doesn't describe in the detail the differences between patients. No details given on duration of CPR in individual patients and no comparison of CPR time between survivors and non-survivors. |
| Neurological Outcome | Of the 2 survivors both were discharged without a need for rehabilitation | ||||
| Universally poor outcomes of pediatric traumatic arrest: a prospective case series and review of the literature. Brindis SL, Gausche-Hill M, Young KD et al. 2001 USA | 118 cases of cardiac or respiratory arrest in children under 13 following trauma.tt tttt |
Case Seriest | Survival To Discharge | 6 children survived to discharge | imited data on survivors. Not clear if they had cardiac or respiratory arrests. |
| Neurological Outcome | All children had a "poor" neurological outcome | ||||
| Cardiopulmonary resuscitation in pediatric trauma patients: survival and functional outcome. Li G, Tang N, DiScala C et al 1999 USA | 269 cases of pulseless cardiac arrest following trauma in children <15. Data collected from 80 trauma centres using a national trauma registry. | Retrospective Auditt | Survival To Discharge | 2 children survived to discharge | Differences in practice between centres. No data on neurological outcome of the 2 survivors. |
| Efficacy of cardiopulmonary resuscitation in pulseless paediatric trauma patients. Suominen P, Räsänen J, Kivioja A. 1998 Finland | 41 cases of traumatic cardiac arrest in children <16 | Case SeriestROSCt tttSurvival To Discharget3 Patients survived to discharge |
ROSC and thoracotomy | 10 patients had ROSC - 4/5 who underwent Thoracotomy and 6/36 who did not | Observational study with a range of blunt and penetrating injuries. Too few patients to determine if early thoracotomy improved survival |
| Outcome of cardiovascular collapse in pediatric blunt trauma. . Hazinski MF, Chahine AA, Holcomb GW 3rd et al. 1994 USA | 38 cases of traumatic cardiac arrests in children under 16 years of aget | Case Series | Survival To Discharget | 37 Patients died before discharge. The 1 survivor was left with "profound" neurological deficit at 6 years follow up.t | Observational study with a range of injuries and care provided |
| Emergency department thoracotomy in children: rationale for selective application Sheikh AA, Culbertson CB. . 1993 USA | 23 cases of thoracotomy in children <16 presenting with traumatic cardiac arrest tt | Case Seriestt | Survival To Discharget | 1 child survived and they had penetrating trauma and initial signs of live. All children with blunt trauma and all children with no signs of life at the scene died. | Observational study. No data on neurological outcome following discharge. |
Author Commentary:
There is no reliable data on how to predict the futility of resuscitation in children suffering a traumatic cardiac arrest. The overall survival is poor with the largest review of cases to date demonstrating that only 5.4% of patients with a traumatic cardiac arrest survive to dsicharge1. Most of these children have a poor neurological outcome2,4,6,8,9. It would appear that outcome is worse in children with prolonged resuscitation beyond 15-30 minutes and in children who are asystolic, pulseless and have fixed pupils1,5.
Bottom Line:
Prolonged resuscitation beyond 15 minutes, fixed pupils, asystole and an absent pulse are all associated with a very poor outcome in terms of survival and neurological outcome in survivors. Despite this however, there are case reports of small numbers of children having a good outcome despite prolonged resuscitation.
References:
- Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. American College of Surgeons Committee on Trauma; American College of Emergency Physicians Pe
- Deasy C, Bray J, Smith K . Paediatric traumatic out-of-hospital cardiac arrests in Melbourne, Australia. Resuscitation
- Hofbauer M, Hüpfl M, Figl et al. Retrospective analysis of emergency room thoracotomy in pediatric severe trauma patients. Resuscitation
- Widdel L, Winston KR. Prognosis for children in cardiac arrest shortly after blunt cranial trauma.
- Capizzani AR, Drongowski R, Ehrlich PF. . Assessment of termination of trauma resuscitation guidelines: are children small adults?
- Crewdson K, Lockey D, Davies G. . Outcome from paediatric cardiac arrest associated with trauma.
- Lin YR, Wu HP, Chen WL et al.. Predictors of survival and neurologic outcomes in children with traumatic out-of-hospital cardiac arrest during the early postresuscitative period
- Calkins CM, Bensard DD, Partrick DA et al . A critical analysis of outcome for children sustaining cardiac arrest after blunt trauma.
- Brindis SL, Gausche-Hill M, Young KD et al. . Universally poor outcomes of pediatric traumatic arrest: a prospective case series and review of the literature.
- Li G, Tang N, DiScala C et al . Cardiopulmonary resuscitation in pediatric trauma patients: survival and functional outcome.
- Suominen P, Räsänen J, Kivioja A. . Efficacy of cardiopulmonary resuscitation in pulseless paediatric trauma patients.
- Hazinski MF, Chahine AA, Holcomb GW 3rd et al. . Outcome of cardiovascular collapse in pediatric blunt trauma. .
- Sheikh AA, Culbertson CB. . . Emergency department thoracotomy in children: rationale for selective application