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Markers of futility of resuscitation for paediatric patients following a traumatic cardiac arrest:: a literature review to inform the PERUKI (PTCA) consensus study

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
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 ReviewSurvival To Discharge60 patients (5.4%) survived to dischargeAll 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
64 cases of out of hospital traumatic cardiac arrest in children aged <16Case SeriesSurvive to discharge1 patientObservational study with only 1 survivor. No useful predictors of futility due to only one survivor.
Hofbauer M
12 cases of traumatic cardiac arrest managed with emergency thoracotomy in children aged < 16 yearsCase SeriesSurvive to discharge1 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
40 cases of traumatic head injury resulting in cardiac arrest in children < 16 years. Case Series Survival To Discharge1 child survived to dischargeSingle centre observational study with small numbers of patients looking at a specific injury type.
Neurological OutcomeThe 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
30 cases of traumatic cardiopulmonary arrest in children 18 years and younger. Case SeriesPredictors 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 Discharge6 patients survived to discharge
Crewdson K
80 cases of traumatic out of hospital cardiac arrest in children aged <16 Case SeriesSurvival To Discharge7 children survived to dischargeSingle centre observational study with incomplete data on neurological outcome. Offers little or no information on predictive factors of futility.
Neurological Outcome3 children were "functionally normal" at discharge
Penetrating Vs Blunt Trauma as predictors of deathAll children with penetrating injuries died
Thoracotomy as predictor of death4 Children received thoracotomies (All penetrating injuries) - All died
Lin Y-R
56 cases of out of hospital traumatic cardiac arrest in children <18. Case SeriesROSC20 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 dischargeOf the 20 children with ROSC only 1 survived to discharge
Calkins CM
25 cases of cardiac arrest following blunt trauma in children < 16 Case SeriesSurvival To Discharge2 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 OutcomeOf the 2 survivors both were discharged without a need for rehabilitation
Brindle SL
118 cases of cardiac or respiratory arrest in children under 13 following trauma. Case Series Survival To Discharge6 children survived to dischargeimited data on survivors. Not clear if they had cardiac or respiratory arrests.
Neurological OutcomeAll children had a "poor" neurological outcome
Li G
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 Discharge2 children survived to dischargeDifferences in practice between centres. No data on neurological outcome of the 2 survivors.
41 cases of traumatic cardiac arrest in children <16Case Series ROSC Survival To Discharge 3 Patients survived to discharge ROSC and thoracotomy10 patients had ROSC - 4/5 who underwent Thoracotomy and 6/36 who did notObservational study with a range of blunt and penetrating injuries. Too few patients to determine if early thoracotomy improved survival
Hazinski MF
38 cases of traumatic cardiac arrests in children under 16 years of age Case SeriesSurvival 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
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.


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


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.


  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.