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Is Rapid Fluid Resuscitation Appropriate in Paediatric Traumatic Cardiac Arrest?

Three Part Question

In [paediatric patients in (traumatic) cardiac arrest] does [rapid volume replacement compared to non-rapid volume replacement] [improve survival]?

Clinical Scenario

A child suffers major trauma resulting in cardiac arrest.

Search Strategy

OVID interface on the world wide web: Medline (1946 Sept week 2 2015) and Medline: In process & other non-indexed citations and Embase (1947 21/09/2015)


Terms: (Initial strategy using MeSH headings turned up far fewer papers)
(cardi* or arrest* or "ventricular fibrillation" or VF or "ventricular tachy*" or VT or asystol* or pulseless or dea* or PEA).m_titl.
AND
(traum* or injuries or injured).m_titl.
AND
(paediatric or pediatric or child* or infant* or teenag* or adolescent*).m_titl.
Total number of papers = 450 (abstracts reviewed)
There were no specific papers concerned with fluid administration so the search strategy was widened to pick up any studies on adults that may have included children.
(cardi* or arrest* or "ventricular fibrillation" or VF or "ventricular tachy*" or VT or asystol* or pulseless or dea* or PEA).m_titl.
AND
(traum* or injuries or injured).m_titl.
AND
(fluid* or saline or hartmann* or ringers or crystalloid or colloid or dextran* or gelofusin or albumin or HAS or blood or transfus* or "red cell*" or platelet* or plasma or factor).mp. [mp=ti, ab, hw, tn, ot, dm, mf, dv, kw, nm, kf, px, rx, an, ui]
AND
(paediatric or pediatric or child* or infant* or teenag* or adolescent*).mp. [mp=ti, ab, hw, tn, ot, dm, mf, dv, kw, nm, kf, px, rx, an, ui]
Total number of papers = 65 (abstracts reviewed)
A third search was performed
(paediatric or pediatric or child* or infant* or teenag* or adolescent*).m_titl.
AND
Trauma*. m_titl.
AND
hypothermi* or cold* or cool*). m_titl.

Total number of papers = 98 (titles reviewed)

2) Additional resources
Search term: paediatric/pediatric traumatic cardiac arrest
Cochrane Library Database
Best Bets Website
Pubmed
Google
MedlinePlus
No additional papers of relevance were identified

Search Outcome

There are no trials that directly attempt to address this question. Research identified predominantly addresses epidemiological questions or focussed on establishing outcome in this group of patients.

There is little attempt in the literature to discriminate between mechanisms of injury, physiological derangement or injuries sustained.

Distinction between 'in-hospital' and 'out of hospital' arrests was not made.

Most studies looking at outcomes in paediatric traumatic cardiac arrest have focussed on non-interventional prognostic factors, with little data about interventions. This is particularly true regarding fluid and or blood administration.

One study of limited relevance was found. Leis et al (2012) performed a retrospective cohort study of treatment benefits in 167 TCAs. The mean quantity of pre-hospital clear fluid replacement was significantly greater (p<0.05) for patients with ROSC compared to no ROSC (colloids and crystalloids were compared separately and the difference applied to both, however, statistics were only reported for overall volume). There was no significant difference in fluid volumes between those who ultimately obtained complete versus incomplete neurological recovery. Of note patients were only included if they had at least ten minutes of resuscitation. Unfortunately the patient group included both adults and children (their respective number was not reported) and the data regarding fluid use was analysed for all ages together.

There is data on low-volume versus high volume resuscitation in paediatric trauma patients (severely injured but not in cardiopulmonary arrest). This seems to follow the trend of the adult data- i.e. an association between high volume resuscitation and increased mortality. However, the numbers in this study were small and this difference did not reach statistical significance.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses

Comment(s)

This is a difficult and emotive topic where outcomes are typically poor. Little research is available, and of variable quality.

Editor Comment

Trauma

Clinical Bottom Line

Fluid resuscitation in paediatric cardiac arrest might mirror that of adults, with excessive volume leading to worse outcomes, but there is undoubtedly a need for international consensus and further study of this topic.

References

  1. Leis C, Hernandez C, Garcia-Ochoa Blanco MJ, Covadonga P, Hernandez R, Torres E Traumatic cardiac arrest: Should advanced life support be initiated? 74(2) p634 (2013)
  2. Hussman B, Lefering R, Kauther MD, Ruchholtz S, Moldzio P, Lendemans (3) Influence of prehospital volume replacement on outcome in polytraumatized Critical Care 2012 16:R201 (2012)