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Three Part Question

In [paediatric patients in (traumatic) cardiac arrest], [palpation of pulses] OR [auscultation of heart sounds] or [ultrasound] (or combinations of these) most accurately [confirms cardiac arrest].

Clinical Scenario

You are the most senior doctor in the Emergency Department when you receive an alert call from the pre-hospital medical team. They are bringing an 8 year old boy who was a pedestrian struck by a bus. He is displaying signs of hypovolaemia due to suspected ongoing internal bleeding, with tachycardia and hypotension despite fluid resuscitation. You are concerned that he is at risk of cardiac arrest, but are unsure of the optimal method of identifying cardiac arrest in such patients to help you decide when to start your traumatic cardiac arrest protocol.

Search Strategy

Medline 1966 to 11/15 using the OVID interface.


[Cardiac AND arrest] OR standstill) AND confirm* AND [auscult*OR (palpat* AND pulse) OR ultrasound OR echo*] AND trauma* AND [pediatr* OR paediatr*]

Search Outcome

59 papers were identified and abstracts were reviewed after which 8 were deemed relevant and of sufficient quality; 2 on palpation of pulses and 6 on the use of ultrasound. No papers were found on the use of auscultation to confirm cardiac standstill in paediatric traumatic cardiac arrest. When this search was extended by removing the search terms paediatric and trauma, only papers exploring confirmation of position of endo-tracheal tube were added. The search strategy revealed no papers specific to the paediatric population on the use of ultrasound therefore this was also extended to include the adult population with 6 papers identified that were deemed relevant to the question posed.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Tibballs and Russell 2009 Australia	209 Docs and nurses called to PICU for other reasons and asked to decide pulses present/absent within 10 seconds on 16 children on ECMO or LVAD; age range 1 week-13 years	Prospective cohort study	Pulse palpation is unreliable to diagnose paediatric cardiac arrest	Rescuer pulse palpation accuracy was 78% (95% CI 70–82), sensitivity 0.86 (95% CI 0.77–0.90) and specificity 0.64 (95% CI 0.53–0.74)	Variety of anatomical sites for pulse check chosen Similarity of cardiac arrest patient and patient on ECMO- may be influencing factors in clinical appearance Short time allowed- did not look at relation of time taken to assess pulse.
Tibballs and Weeranatnac 2010 Australia	Blinded doctors/nurses (monitors covered) palpated brachial pulse in 17 children with non-pulsatile extracorporeal circulation for cardiac arrest. Times compared with non-blinded decisions	Prospective blinded case control study	Diagnosis of cardiac arrest by pulse palpation alone is unreliable. At least 30 seconds was optimum time but accuracy and speed are related to clinical experience.	Experienced doctors were 85% accurate, inexperienced doctors 82%, experienced nurses 80%, inexperienced nurses 52%. Rescuers diagnosing quickly (<10 s) had 90% accuracy, in 11–20 s 77% accuracy and in 21–30 s 62.5% accuracy (p = 0.015).	Effect of test environment on speed of decision? Experienced vs inexperienced doesn’t take into account varied career paths and clinical experience
Blaiva et al. 2001 USA	169 Patients presenting to ED with ongoing CPR > 18yo. USS on arrival and at each pulse check. Trauma and non-cardiac arrest excluded.	Prospective observational study	Patients presenting to ED in cardiac standstill on USS do not survive.	Cardiac standstill on USS had a positive predictive value of 100% for death in the ED, with a negative predictive value of 58%	Adult, non-trauma only. Patients enrolled on convenience basis Small study size
Cureton et al 2012 USA	318 adult trauma patients presenting to ED without pulses. Results of cardiac USS compared with ECG rhythm and survival	Retrospective study	Absence of cardiac motion on USS and electrical activity highly predictive of death	Sensitivity of absence of cardiac motion on USS to predict survival to hospital admission was 86% (specificity, 91%; positive predictive value, 30%; negative predictive value, 99%).	Adult only Lack of standardisation of how cardiac motion quantified Difficult categorisation of patients with and without cardiac activity
Ferrada et al. 2014 USA	Review of charts of 37 non-surviving patients arriving in trauma centre with TCA. Comparisons between those undergoing transthoracic echocardiography (TTE) and those who did not	Retrospective chart review	TTE decreased time in trauma bay and avoided thoracotomy in non-surviving trauma patients	Patients with TTE showed trend toward fewer blood transfusions and fewer invasive procedures i.e. decreased use of available resources.	Adult only Small study size Only looked at non-survivors
Shoenberger et al. 2007 USA	116 returned surveys from graduated ED physicians who had been trained in USS use during specialisation.	Survey	53% of population who have USS available use it in cardiac arrest and believe it shortens time to confirmation of cardiac standstill.	Ultrasound was used to shorten the code time (63%) and reassure and confirm the presence of cardiac standstill for the physician (88%) and the resuscitation team (59%)	Opinion of those responding to survey only.
Chardoli et al. 2012 China	100 adult patients presenting in PEA cardiac arrest randomised into receiving ACLS protocol or ACLS plus echocardiography	Randomised Control Trial	No significant difference between the two groups in outcome of resuscitation despite identifying of reversible cause in echo group.	Cardiac USS can identify some reversible causes of PEA and presence or absence of ventricular activity.	Small study size
Bhat et al. USA 2015	57 prehospital providers given an hours training on use of USS to identify pericardial effusion, pneumothorax and cardiac standstill. Pre-test scores compared with post-test scores after lecture and 1 week later	Prospective observational study	Potential feasibility of training pre-hospital providers to identify cardiac standstill	Significant rise in post test scores compared to pre-test scores for all conditions.	Adult trainees only Small, convenience sample of participants Ability to transpose knowledge in test to pre-hospital setting

Comment(s)

There is very little evidence available to guide the optimal method of confirming cardiac arrest in children, and no evidence specific to the population of children experiencing cardiac arrest secondary to traumatic causes. The lack of evidence evaluating the efficacy of auscultation may be due to the environment in which this question is based. A loud, busy resuscitation event may dissuade a clinician or researcher from probing the usefulness of this approach in confirming the absence of an audible heart beat. Palpation of pulses appears useful, but there are limitations related to the clinical experience of the practitioner, the time taken to palpate the pulse, and the anatomical location of the pulse chosen. Incorrect decisions on the presence or absence of a pulse can lead to either unnecessary cardio-pulmonary resuscitation, or withholding resuscitation when it is indicated. If we extrapolate evidence from adult studies, adding cardiac point of care ultrasound (POCUS) may increase the accuracy of identification of cardiac arrest, but POCUS is not universally available and its accuracy is operator dependent. We found no papers which attempted to correlate electrical activity and POCUS findings, and no papers were found that compared POCUS to other methods – instead they appear to assume that POCUS should be seen as the gold standard test. Further work is required to explore how POCUS may be used to guide decision making during resuscitations. However there is no other modality currently available which gives a dynamic view of the heart other than exploratory thoracotomy. Clinicians need to determine whether a paediatric trauma patient is in cardiac arrest rapidly, often in a busy resuscitation room, whilst other team members perform procedures or interventions. Methods of confirmation therefore need to be quickly and easily undertaken. A combination of methods (e.g. palpating a pulse and using POCUS) may aid decision making.

Editor Comment

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Clinical Bottom Line

Palpation of pulses is the only universally available method for which evidence exists, but this is unreliable – ensuring that the operator has sufficient clinical experience is essential. POCUS may increase diagnostic accuracy when available. Further work is needed in this area to be able to determine the optimal method or combination of methods for assessing cardiac arrest. In clinical settings, these methods are likely to be combined with other elements including clinical examination and physiological measurements in order to decide whether a cardiac arrest protocol should be initiated.

References

1. Tibballs J, Russell P. Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Resuscitation 2009 Jan;80(1):61-4. doi: 10.1016/j.resuscitation.2008.10.002. Epub 2008 Nov 6.
2. Tibballs J, Weeranatna C. The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation. Resuscitation 2010 Jun;81(6):671-5. doi: 10.1016/j.resuscitation.2010.01.030. Epub 2010 Mar 15.
3. Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardiogram. Academic Emergency Medicine 2001 Jun;8(6):616-21.
4. Cureton EL, Yeung LY, Kwan RO, Miraflor EJ, Sadjadi J, Price DD, Victorino GP. The heart of the matter: utility of ultrasound of cardiac activity during traumatic arrest. J Trauma Acute Care Surg 2012 Jul;73(1):102-10.
5. Ferrada P, Wolfe L, Anand RJ, Whelan J, Vanguri P, Malhotra A, Goldberg S, Duane T, Aboutanos M. Use of limited transthoracic echocardiography in patients with traumatic cardiac arrest decreases the rate of nontherapeutic thoracotomy and hospital costs. Journal of Ultrasound Medicine 2014 Oct;33(10):1829-32.
6. Shoenberger JM, Massopust K, Henderson SO. The use of bedside ultrasound in cardiac arrest. Cal J Emerg Med. 2007 May;8(2):47-50.
7. Chardoli M, Heidari F, Rabiee H, Sharif-Alhoseini M, Shokoohi H, Rahimi-Movaghar V. Echocardiography integrated ACLS protocol versus conventional cardiopulmonary resuscitation in patients with pulseless electrical activity cardiac arrest. Chin J Traumatol. 2012;15(5):284-7.
8. Bhat SR, Johnson DA, Pierog JE, Zaia BE, Williams SR, Gharahbaghian L Prehospital Evaluation of Effusion, Pneumothorax, and Standstill (PEEPS): Point-of-care Ultrasound in Emergency Medical Services. West J Emerg Med. 2015 Jul;16(4):503-9