UMEM Educational Pearls - By Jenny Guyther

This was a retrospective analysis of pediatric cardiac arrests that occurred out of hospital in Japan, where no pediatric termination of resuscitation is allowed.  1007 arrests were included.  Patients that were placed on ECMO were excluded.  This study included both medical and traumatic arrests looking at a primary outcome of 1 month moderate or better neurological disability.  CPR time for both EMS and the hospital prior to ROSC were included.  Bystander CPR was not included in these calculations.  Possible downtime prior to CPR was not taken into consideration.

Overall, less than 1% of pediatric patients exhibited one-month moderate disability or better neurological outcome when total CPR duration is more than 64 minutes.

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A few states have pediatric out of hospital termination of resuscitation protocols.  This study used CARES data to create a termination protocol that was not only linked to ROSC, but also to neurological outcomes.  This study only included medical arrests.
 

21240 children were included in the study where 2326 patients survived to hospital discharge.  A total of 1894 survived with a favorable neurological outcome.  The criteria developed for pediatric TOR in this study had a specificity of 99.1% and a PPV of 99.8% for patient death.  Another set of criteria had a 99.7% specificity and PPV of 99.9% for predicting death or survival with poor neurological outcome.

TOR criteria of death consisted of:

1. unwitnessed arrest

2. asystole

3. arrest not due to drowning or electrocution

4. no sustained ROSC

TOR criteria of death or survival with poor neurological outcome:

1. unwitnessed arrest

2. asystole

3. arrest not due to drowning or electrocution

4. no sustained ROSC

5. no bystander CPR

Bottom line: Pediatric termination of resuscitation in the out of hospital setting can be appropriate under the right set of conditions.

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This was a retrospective cohort study of the national trauma data bank that included about 64000 pediatric trauma patients in the derivation group and the same amount in the validation group.  The authors empirically created upper and lower cut off values for the shock index based on age.  They compared the shock index based on age cut offs with major trauma as defined by the standardized triage assessment tool criteria.  

The empirically derived age adjusted values had a sensitivity of 43.2% and a specificity of 79.4% for major trauma.  The sensitivity of the pediatric shock index (PSI) in that same group was 33.9% with a specificity of 90.7%. The pediatric-adjusted shock index (SIPA) had a 37.4% sensitivity and 87.8% sensitivity for 4-16 year olds.

Shock index = (Heart Rate / Systolic BP)  

• Shock Index, Pediatric Adjusted (SIPA)
  • 4-6 years = 1.2
  • 6-12 years = 1
  • > 12 years = 0.9
  • Patients with an elevated SIPA had a 3.82 odds of major trauma compared to those with a normal SIPA.

Pediatric Shock Index (PSI)

For children age 1-12 years

SI > 1.55 - (0.5) x (age in years)

Patients with an elevated shock index had a 5.02 greater odds of major trauma in this study.  

This study used age specific cut offs such as:

1 yr to < 3 years = lower limit of 0.73 and an upper limit of 1.40

(see article for a full table).

Patients with a shock index below the lower limit had a 1.55 greater offs of major trauma and patients with a shock index above the upper limit had a 3.97 greater risk of major trauma.  

Bottom line: Shock index alone has a limited role in the identification of major trauma in children.  Of these three methods for calculating/interpreting shock index, PSI seemed to do better.

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Previous studies have suggested that a single dose of epinephrine in out of hospital cardiac arrests compared to multiple dose protocols result in a similar survival to hospital discharge rate.  This study aimed to see if single dose epinephrine compared to multiple doses improved survival in the subset of patients that were 1) in a shockable rhythm or 2) received bystander CPR.

This study looked at patients from 5 EMS systems in North Carolina before and after a protocol change from multiple dose epinephrine to single dose epinephrine in cardiac arrest.  1690 patients were included, 19.2% with a shockable rhythm and 38.9% who received bystander CPR.

The study found:

- Survival to hospital discharge was higher in the single dose epinephrine group who received bystander CPR

- Survival rates were similar in the single and multiple dose epinephrine groups for patients who were initially in shockable rhythms, in asystole/PEA and who did NOT receive bystander CPR.

Bottom Line: More studies are needed to support prehospital protocol changes.

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This was a retrospective, multicenter cross-sectional study of pediatric sedations over 3 years using the Pediatric Sedation Research Consortium database.

85,599 pediatric sedations were included.  These sedations did include the operating rooms.  

8.7% of sedations required an intervention for airway/breathing/circulation in patients who did NOT have procedural oxygenation while 10.1% of patients in the group that did have procedural oxygenation required an intervention.  The majority of these interventions were minor, ie airway repositioning.  The group that did have procedural oxygenation did have a lower rate of hypoxia compared to the group without procedural oxygenation (2.5% vs 4.5%).

The authors concluded that preemptive procedural oxygenation did NOT decrease the overall need for interventions in the ABCs compared to no procedural oxygenation.

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Previous studies have shown that an on scene time of 10-35 minutes was associated with improved survival in pediatric out of hospital cardiac arrests compared to an on scene time of > 35 minutes.  There was no significant difference in overall survival between < 10 minutes and 10-35 minutes of on scene time.

This study involved a total of 2854 pediatric cardiac arrests in the US and Canada.  The patients who had a cardiac arrest during transport were compared to patients who received on scene CPR by equal minutes.

Among patients < 1 year, intra-arrest transport was associated with lower survival to hospital discharge compared to those that were resuscitated on scene.  There was no association for patients > 1 year.

Bottom line: This study supports resuscitating in place for pediatric cardiac arrests, especially in patients < 1year.

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Infants are typically obligate nasal breathers and the increased mucus production associated with bronchiolitis can impair both breathing and feeding.  AAP bronchiolitis guidelines state that the routine use of deep suctioning may not be beneficial.    

This was an observational study of 121 infants aged 2-23 months with bronchiolitis who received either nasal suction (31), deep suction (68) or a combination (52).  Groups were based on clinician discretion.  Respiratory scores and pulse ox were obtained pre-suction and at 30 and 60 minutes post suction.  

There was no difference between suction type and respiratory score.  However, there was an improvement in respiratory score between the 0-30 and 0-60 time point with any suctioning.  Suction type had no effect on pulse ox, airway adjunct escalation, length of stay or outpatient outcomes.

The study also showed no association between albuterol use and respiratory scores (albuterol is not recommended by the AAP in the management of bronchiolitis).

Bottom line: In this small study, nasal aspiration and deep suction appear to be equal in improving respiratory scores up to 1 hour post suction suggesting that deep suctioning may not be needed.

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This was a review of the cardiac arrest registry of Norway between 2016-2021.  The incidence of pediatric out of hospital cardiac arrests was 4.6 per 100,000 child years and significantly higher in children < 1 year (20.9 per 100,000 child years).  There was an overall 18% one year survival rate in the 308 patients included.  

Leading causes of arrests were choking, respiratory disease, drowning and SIDS, making up 67% of cases.

73% of the arrests were initially asystolic and 14% were PEA on EMS arrival.  The presence of shockable rhythms increased with age and VT/VF were the initial rhythm in up to 15% of the 13-17 year age group.  

88% of patients received bystander CPR ( with 68% receiving both chest compressions and ventilations).  A minority of these patients were in a shockable rhythm, but 7 total patients were in refractory VF.  Mechanical CPR devices were used in 35 patients aged 11-17.  ECMO was started in 19 cases.

Bottom line: The rate of bystander CPR in this study was very high and other jurisdictions can attempt to learn from the system in place in Norway to increase their local prehospital interventions.

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This article was a review of randomized control trials using intranasal (IN) fentanyl.  There were 8 studies included that showed IN fentanyl was superior to controlling pain compared to other pain medications at the 15-20 minute mark, but not at the 30 and 60 minute marks.  There were less reports of nausea and vomiting with IN fentanyl, but no difference in dizziness or hallucinations compared to the other medications included in the various trials (ie morphine, ketamine, po narcotics, ect)

The bioavailability of IN fentanyl ranges from 71-89% with effects noted in 2 minutes with maximal concentrations noted at 7 minutes.  The half life is approximately 60 minutes.

Bottom line: Consider IN fentanyl for quick acute pain management in the pediatric patient.

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CHECK-CALL-COMPRESS  is the recommended algorithm by the International Liaison Committee on Resuscitation to teach school age children.  Several studies show that school aged children are highly motivated to learn and perform CPR.  They also serve as CPR multipliers meaning they go home, talk about what they have learned and inspire others to learn.

By age 4, children are able to assess the first step in the chain of survival - CHECK - assessing for responsiveness and breathing.  By age 6, children can dial the emergency number and give the correct information for the location of the call.  By age 10-12 children are able to get correct chest compression depths and ventilation volumes in CPR manikins.  Hands-on training is more beneficial compared to verbal only instruction.

Areas where CPR is taught to school age children as a part of the school curriculum have higher rates of bystander CPR.

Bottom line: CPR should be introduced to elementary school children.

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Question

EMS may call the hospital to obtain online medical direction when a patient does not wish to come to the hospital.  One difficult task faced by the physician at the hospital is determining the decision making capacity of the patient.  There is currently no nationally recognized standard protocol for physicians providing EMS oversight in this situation.  

The four components involved in the determination of capacity are: understanding, appreciation, reasoning and expression of choice.  This study used a modified Delphi approach with 19 physician experts to develop standardized steps to guide best practices for physicians who are called in real time about a patient refusing EMS transport.  Consensus was defined as 80% agreement.  

The example worksheet with the compilation of recommendations is attached.

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Attachments

• Refusal checklist table-670fb6a9192a8.docx (105 Kb)

This study looked at the success rates of femoral vs proximal tibial IOs in the prehospital setting.  Over a 9 year period, there were 163 pediatric patients who received either a tibial or femoral IO.  Femoral IOs were introduced into the EMS protocol in this study area in 2015 as a location option and were the recommended site starting in 2019.  The success rate of femoral IO placement was 89% and for proximal tibial sites was 84.7%.  After further data analysis the study found an adjusted odds ratio of 2 for successful IO placement in the distal femur compared to the proximal tibia.  The complication rates for both sites were similar.  

Bottom line: This study suggests that the distal femur is a reasonable site for IO access in the pediatric population.

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This study looks at the efficacy of ketamine vs. midazolam for the prehospital sedation of acutely agitated patients, examining the need for repeat sedation (by EMS or in the ED), adverse events and length of stay.

A greater number of patients required repeat sedation within 90 minutes with initial ketamine dosing compared to midazolam. There was no difference in patients receiving repeat sedation within 20 minutes between the two groups.

There were no significant differences in time to repeat sedation, total sedation doses (by EMS or in the ED), use of bag valve mask ventilation or intubation, use of physical restraints, admission location/level of care, or length of stay in the Emergency Department (ED), hospital, or Intensive Care Unit.

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This was an observational study where ultrasound was used to evaluate if the diaphragm came into view at the 5th intercoastal space (ICS) at the midaxillary line in pediatric patients during maximal respiration. A convenience sample of pediatric patients who presented to the an academic pediatric emergency department was used.

In 10.3% of patients, the diaphragm crossed the 5th ICS during normal respirations and 27.2% crossed during maximal respirations.  This was a more common occurrence on the right compared to the left.  An increase in body mass index was also associated with an increased risk of the diaphragm crossing the during both tidal respiration and maximal respirations.

Bottom line: Using a blind insertion of a chest tube at the 5th ICS, midaxillary line in the pediatric patient poses a not insignificant risk of piercing the diaphragm.  this study recommends using ultrasound prior to chest tube placement.

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Emergency department visits for pediatric mental health and behavioural concerns have been increasing.  This study attempted to further characterize medications, both home and for sedation, that were given to these patients.  

This study included 670,911 youth with a mental or behavioral health diagnosis over a 9 year inclusion period.  The most common diagnses were depressive disorder, suicide or self injury and disruptive, impulse control and conduct disorder.  During this time, a total of 12.3% of patients had a psychotropic medication given while in the ED.  The percentage and odds of administering these medications increased from 7.9% in 2013 to 16.3% in 2022.  Those with intellectual disability and autism spectrum disorder had the highest frequency of medication administration.  

Bottom line: As mental health visits in pediatrics continue to increase along with boarding times, clinicians should become more familiar with psychotropic medications used in this population and become comfortable in making sure that these patients have their home medications and have a plan for chemical sedation if other areas of de escalation fail.

Early administration of antibiotics for open fractures can reduce serious bone and soft tissue infections, with a common goal being antibiotic administration within one hour of injury.

In this study, there were 523 patients treated by EMS who had an open extremity fracture.

The median time from EMS dispatch until antibiotic administration was 31 minutes.  99% of the patients who received antibiotics received them within one hour of EMS dispatch.  Prehospital times were on average 10 minutes longer for those patients who received antibiotics.  The majority of these patients received cefazolin, followed by ceftriaxone, ampicillin, gentamicin and piperacillin/tazobactam.  None of these patients required management for an allergic reaction or anaphylaxis.  Five patients (1%) who received prehospital antibiotics and 159 patients who did not (1.4%) had a subsequent infection based on ICD codes.

Bottom line: In this small group, it was safe to administer antibiotics to a patient with an isolated open extremity fracture and the medication was able to be delivered earlier.  Larger studies will be needed to see the impact of this practice on the development of osteomyelitis or soft tissue infections.

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Teaching has circulated that a temperature of 40 degrees Celsius or above (hyperpyrexia), was associated with a greater incidence of serious bacterial infection.  However, this teaching originated in a time prior to the availability of childhood vaccinations. In fact, the largest retrospective study to support this used data from 1966-1974.  

2565 WELL APPEARING patients between the ages of 61 days and their 18th birthday who presented to a single tertiary care pediatric emergency department with the chief complaint of fever were included.  The prevalence of serious bacterial infection was compared to the presence of hyperpyrexia, age, chronic conditions, gender and vaccination status.

Serious bacterial infections (SBIs) included: deep space infections, appendicitis, pneumonia, mastoiditis, lymphadenitis, acute bacterial rhinosinusitis, urinary tract infection, pyelonephritis, cholecystitis, tubo-ovarian abscess, septic arthritis, osteomyelitis, bacteremia or bacterial meningitis.

There was NO statistically significant association between hyperpyrexia and SBIs. Older age and make sex were associated with a higher risk of SBIs.

Bottom line: In well appearing children 61 days and older, having a temperature >/= to 40 degrees was not associated with serious bacterial infections.

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Several studies have shown that patients who require a resuscitative thoracotomy (RT)  have a higher odds of survival if they are transported by police or in private vehicles.  This study examined 195 patients who required RT to see if prehospital intubation and out of hospital time (OOHT) affected ROSC rates.

There was no association between OOHT and ROSC and no association of OOHT and survival.  The mean OOHT for this study was only 25 minutes which is faster than other studies.  

The odds of ROSC were lower in patients who had ANY intubation attempts prior to arrival.

Bottom line: BLS airway management (or supraglottic placement) may be more beneficial for the trauma arrest patient in the prehospital setting.

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This was a cross sectional study examining insurance data to determine if there is seasonality related to ED visits and psychiatric hospitalizations related to suicidality.

Suicidality includes both suicidal ideation and suicide attempts (but not suicide).  One survey showed that up to 12% of US adolescents reported serious thoughts of suicide.  This study included 73,123 patients where 19.4% were direct inpatient admissions and 80.6% were ED visits, 44% of whom were subsequently admitted.

Metrics for suicidality in 10-18 year olds peaked in April and October with a nadir in June.  Incidentally, in the Spring of 2020 when US schools closed due to COVID, there was a decrease in both ED visits and hospitalizations with April and May having the lowest rates across the study period.

School is believed to increase stress with risk factors such as bullying and peer pressure, academic and extracurricular stressors and poor sleep hygiene.

Bottom line: There has been an increase in adolescent suicidality over the recent years, many of whom present to the ED for evaluation.  More mental health resources are needed, especially during the school year.

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Maternal morbidity continues to increase in the US with a mortality rate in 2021 of 39.2 deaths/100,000 live births.  There has been an intense focus on training and quality improvement within hospitals, but not much has changed in the prehospital education arena.  This study aimed to quantify the complications encountered by EMS clinicians.  

In the 2018-2019 EMS dataset used, there were a total of 56,735,977 EMS activations which included 8641 out of hospital deliveries, 1712 documented delivery complications and 5749 records of newborns.

1% of the out of hospital deliveries had a documented complication for the mother.  Of these complications, 94% were for hemorrhage, 6% for abnormal presentation, 0.2% for shoulder dystocia, and 0.4% for nuchal cord.  

Few patients had medications given, including 0.4% receiving oxytocin.  no patients received prehospital blood transfusion or TXA.  Of note, in the years since this data was obtained, TXA and whole blood have started to appear on more medic units, but it is still not necessarily commonplace.

Bottom line: While still rare, prehospital delivery does occur and EMS should be prepared for any possible complications.  Medical directors should look at their jurisdictional/state protocols to see if oxytocin/TXA or whole blood should be included (if not already available).  EMS clinicians should be educated on up to date management of OB emergencies.

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