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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”

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”

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Fallet, 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.
Deasy C 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.
Hofbauer M 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.
Wide L 2010 USA	40 cases of traumatic head injury resulting in cardiac arrest in children < 16 years.	Case Series	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.
Capizzani AR 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
Crewdson K 2007 UK	80 cases of traumatic out of hospital cardiac arrest in children aged <16	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
Lin Y-R 2007 Taiwan	56 cases of out of hospital traumatic cardiac arrest in children <18.	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
Calkins CM 2002 USA	25 cases of cardiac arrest following blunt trauma in children < 16	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
Brindle SL 2001 USA	118 cases of cardiac or respiratory arrest in children under 13 following trauma.	Case Series	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
Li G 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 Audit	Survival To Discharge	2 children survived to discharge	Differences in practice between centres. No data on neurological outcome of the 2 survivors.
Suominen 1998 Finland	41 cases of traumatic cardiac arrest in children <16	Case Series ROSC Survival To Discharge 3 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
Hazinski MF 1994 USA	38 cases of traumatic cardiac arrests in children under 16 years of age	Case Series	Survival To Discharge	37 Patients died before discharge. The 1 survivor was left with "profound" neurological deficit at 6 years follow up.	Observational study with a range of injuries and care provided
Sheikh AA 1993 USA	23 cases of thoracotomy in children <16 presenting with traumatic cardiac arrest	Case Series	Survival To Discharge	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.

Comment(s)

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.

Editor Comment

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Clinical 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

1. 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 Pediatrics. April, 2014,133(4):e1104-16.
2. Deasy C, Bray J, Smith K Paediatric traumatic out-of-hospital cardiac arrests in Melbourne, Australia. Resuscitation J.Resuscitation 2012 Apr;83(4):471-5
3. Hofbauer M, Hüpfl M, Figl et al Retrospective analysis of emergency room thoracotomy in pediatric severe trauma patients. Resuscitation J.Resuscitation. Feb;82(2):185-9.
4. Widdel L, Winston KR Prognosis for children in cardiac arrest shortly after blunt cranial trauma. J Trauma. 2010 Oct;69(4):783-8
5. Capizzani AR, Drongowski R, Ehrlich PF. Assessment of termination of trauma resuscitation guidelines: are children small adults? J Pediatr Surg 2010 May;45(5):903-7
6. Crewdson K, Lockey D, Davies G. Outcome from paediatric cardiac arrest associated with trauma. Resuscitation. 2007 Oct;75(1):29-34.
7. 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 J Trauma Acute Care Surg 2013 Sep;75(3):439-47.
8. Calkins CM, Bensard DD, Partrick DA et al A critical analysis of outcome for children sustaining cardiac arrest after blunt trauma. J Pediatr Surg 2002 Feb;37(2):180-4.
9. 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. Pediatr Emerg Care 2011 Jul;27(7):616-21.
10. Li G, Tang N, DiScala C et al Cardiopulmonary resuscitation in pediatric trauma patients: survival and functional outcome. J Trauma 1999 Jul;47(1):1-7.
11. Suominen P, Räsänen J, Kivioja A. Efficacy of cardiopulmonary resuscitation in pulseless paediatric trauma patients. Resuscitation 1998 Jan;36(1):9-13.
12. Hazinski MF, Chahine AA, Holcomb GW 3rd et al. Outcome of cardiovascular collapse in pediatric blunt trauma. . Ann Emerg Med 1994 Jun;23(6):1229-35.
13. Sheikh AA, Culbertson CB. . Emergency department thoracotomy in children: rationale for selective application J Trauma. 1993 Mar;34(3):323-8.