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This is the Pediatric EMS Podcast with the mission to provide case-based discussion with evidence-based recommendations by content experts in prehospital pediatric medicine in order to advance the care of children outside the hospital.

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  2. Your Hand is Their Heart

Jul 23, 2022

 

Your Hand is Their Heart

Brought to you by:

Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney

   

We are excited to be back with our second episode. In this episode, we tackle a really powerful topic in prehospital medicine, pediatric out of hospital cardiac arrest. Every paramedic will tell you that this is one of the toughest calls they’ll ever go on. But it doesn't have to be. Join us as we will breakdown all the important steps necessary to give your patient the best chance of survival. Our guests are experts in prehospital medicine, resuscitation, and critical care. Together,  we will guide you through this anxiety provoking topic and ensure that you have all the tools you need to successfully manage the next pediatric out of hospital cardiac arrest. But we wont stop there! We will take you into the ICU for post-cardiac arrest care and even discuss what the future holds for out of hospital cardiac arrest.  You won't hear me say this often but when it comes to pediatric out of hospital cardiac arrest, it's time to start treating children like little adults.

Website:

https://sites.libsyn.com/414020/your-hand-is-their-heart

Direct Download:

https://traffic.libsyn.com/34eda738-c0e3-471c-94e6-5d7bb718e70f/Episode_2_FINAL-_POHCA.mp3

 

Content Experts: Paul Banerjee, Katherine Remick, Steve Laffey, Gina Pellerito, Matt Murray, Helen Harvey 

B-side Narrator: Joseph Finney

Editing and Publication: Phil Moy and Joseph Finney 

 

Current Landscape of Pediatric Out of Hospital Cardiac Arrest: 

  • 5% bystander CPR (Atkins et al, 2009) 
  • Overall, >5,000/year (Atkins et al, 2009) 
  • Survival (Atkins et al, 2009)
    • Older children ~10% 
    • Infant ~3% 
  • Marked regional variation and associated with frequency of bystander CPR
  • PEA/Asystole is initial rhythm 80% of the time (Atkins et al, 2009)
  • No improvement in survival in last decade (Jayaram et al 2015) 
  • 1 in 12 survive to hospital discharge (Jayaram et al 2015) 

Resources

The Pediatric Readiness Project

https://emscimprovement.center/domains/pediatric-readiness-project/readiness-toolkit/

 

Check out this link for all the information your emergency department will need to ensure they are pediatric ready. We all need to make sure our hospital is ready for any patient and this means preparing for the next pediatric cardiac arrest. 

 

 

American Heart Association

https://www.heart.org/?s_src=22U5W1AEMG&s_subsrc=evg_sem&gclid=Cj0KCQjwuO6WBhDLARIsAIdeyDIcTX32jP4p9AfuoAzx-GL5li7mtInhOxkeeopw1t-ahn4tqjG40acaAl0tEALw_wcB&gclsrc=aw.ds

 

Here you can find information for training and education to make sure your agency has the knowledge and skills to manage a pediatric patient in cardiac arrest. We strongly encourage every agency to maintain certification in PALS. 

 

Literature Breakdown:

 

Early Epi is Key!!

Andersen LW, Berg KM, Saindon BZ, Massaro JM, Raymond TT, Berg RA, Nadkarni VM, Donnino MW; American Heart Association Get With the Guidelines–Resuscitation Investigators. Time to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest. JAMA. 2015 Aug 25;314(8):802-10. doi: 10.1001/jama.2015.9678. PMID: 26305650; PMCID: PMC6191294.​

  • Data analysis of AHA sponsored database 2000-2014​
  • US pediatric patients (<18yo)​
  • In-hospital Cardiac arrest with initial non-shockable rhythm​
  • Primary outcome: Survival to discharge​
  • Secondary outcomes​
  • ROSC, 24h survival, and neuro status

 

Findings:

  • Survival to discharge​
  • 487/1558 (31.3%)​
  • ROSC​
  • 993/1558 (63.7%)​
  • RR of 0.96 for every minute delay in EPI administration​
  • Favorable Neuro outcome (documented)​
  • 217/1395 (15.6)​
  • RR of 0.94 for every minute delay in EPI administration​
  • ​

Delay of epi >5min leads to decrease ROSC and decrease survival with favorable neurologic outcome

 

Thoughts: 

Get the epi in right away!

 

Get on scene and get to work: 

 

Banerjee PR, Ganti L, Pepe PE, Singh A, Roka A, Vittone RA. Early On-Scene Management of Pediatric Out-of-Hospital Cardiac Arrest Can Result in Improved Likelihood for Neurologically-Intact Survival. Resuscitation. 2019 Feb;135:162-167. doi: 10.1016/j.resuscitation.2018.11.002. Epub 2018 Nov 6. PMID: 30412719.

 

This is a study of Polk County Fire and Rescue EMS database pre and post intervention. Polk County is a huge EMS agency in Florida with robust QI and data collection that has prompted several high profile publications. ​

 

In the study, the first group of data was collected between 2012-2013 when standard practice was for ALS interventions to occur enroute to ED and the second group was between 2014-2015 when there was a change for this agency to perform ALS interventions on scene after specialized training​

 

There were 4  targeted Interventions instituted in 2014​

  1. Rapid insertion of advanced airway (ETT or Igel)​
  2. Immediate intra-osseous vascular access (deferring intravenous attempts)​
  3. Early epinephrine​
  4. Tight ventilation parameters (one breath every 10 seconds)​

 

Study Details

  • Primary outcome: Neuro intact survival​
  • 94 P-OHCA with median age 12mo​
  • 80% asystole initially ​
  • Arrest etiology was 85% respiratory, 8% trauma, 3% seizures, 2% choking and no significant difference between groups​

​

They found that Neuro intact survival increased from 0% to 23.2% between the two groups​

 

 

Time on Scene: 

Tijssen, Janice A et al. “Time on the scene and interventions are associated with improved survival in pediatric out-of-hospital cardiac arrest.” Resuscitation vol. 94 (2015): 1-7. doi:10.1016/j.resuscitation.2015.06.012 

  • Observational study  
  • ROC database 2005-2012  
  • Age 3 days to 19 years  
  • 2244 patients  
  • Study Aim: Identify which times on scene and which interventions were associated with improved survival 

They found: 

  • Time on scene of 10-35min had highest survival to hospital discharge (10.2%) 
  • Adolescents had longest scene times and best outcomes 
  • Infants had the shortest scene time, fewest interventions, and worst outcomes 
  • Survival improved for all groups over the course of the study but the least for infants 
  • Nuero outcome was unfortunately not reported 

 

Other interesting findings:  

  • IV/IO access and fluid administration associated with improved survival (OR 2.4) 
  • Advanced airway had no association with survival (OR 0.69) 
  • Resuscitation meds (epi) associated with worse outcomes (OR 0.24) 

 

****Important to note, patients were included if ANY EMS resuscitation was undertaken even if they were subsequently discontinued****, this matters because scene time less than 10 min had poor outcomes and it's unclear if this is because the resuscitation was deemed futile and terminated. Further, scene time <10min had fewer witnessed events, shockable rhythms, attempts at advanced airway, IV/IO attempts, and medications given compared to those with longer scene times. 

 

ETT vs SGA (in OHCA)

 

Hansen ML, Lin A, Eriksson C, Daya M, McNally B, Fu R, Yanez D, Zive D, Newgard C; CARES surveillance group. A comparison of pediatric airway management techniques during out-of-hospital cardiac arrest using the CARES database. Resuscitation. 2017 Nov;120:51-56. doi: 10.1016/j.resuscitation.2017.08.015. Epub 2017 Aug 22. PMID: 28838781; PMCID: PMC5660668. 

 

  • 3 year retrospective review of patients with non-traumatic OHCA <18yo using the CARES database 
  • 17 states, 55 cities 
  • 1724 OHCA 
  • Odds ratio survival to discharge 
  • ETI vs BVM 0.39 (95%CI 0.26-0.59) 
  • SGA vs BVM 0.32 (95%CI 0.12-0.84) 
  • ROSC 
  • BVM 18% (n 781) 
  • ETI 20% (n 727) 
  • SGA 27% (n 215) 
  • Survival to discharge 
  • BVM 14% (n 781) 
  • ETI 7% (n 727) 
  • SGA 10% (n 215) 
  • Good neuro outcome
  • (CPC 1 or 2) 
  • BVM 11% (n 781) 
  • ETI 5% (n 727) 
  • SGA 6% (n 215) 

Conclusion: BVM is associated with higher survival to hospital discharge and increased neuro-intact survival compared to ETI and SGA.

Special thank you to all our guests and content experts!

Sources:​

  • Jayaram, Natalie et al. “Survival After Out-of-Hospital Cardiac Arrest in Children.” Journal of the American Heart Association vol. 4,10 e002122. 8 Oct. 2015, doi:10.1161/JAHA.115.002122​
  • Atkins, Dianne L et al. “Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest.” Circulation vol. 119,11 (2009): 1484-91. doi:10.1161/CIRCULATIONAHA.108.80267​​​​​​​
  • Banerjee, Paul R et al. “Early On-Scene Management of Pediatric Out-of-Hospital Cardiac Arrest Can Result in Improved Likelihood for Neurologically-Intact Survival.” Resuscitation vol. 135 (2019): 162-167. doi:10.1016/j.resuscitation.2018.11.002​​​
  • Tijssen, Janice A et al. “Time on the scene and interventions are associated with improved survival in pediatric out-of-hospital cardiac arrest.” Resuscitation vol. 94 (2015): 1-7. doi:10.1016/j.resuscitation.2015.06.012​​​​​