It's been drilled into you, "children are not little adults," and it's true. The pediatric patient is different and knowing those differences will make you a better care provider. However, when it comes to cardiac arrest and resuscitation, the management for children and adults is almost exactly the same. You already know what to do! Pediatric cardiac arrest cases are intimating and impactful. They are low volume and high stress. Do not let the situation scare you into inaction. Begin with a deep, centering breath and start with your basics; quality CPR and effective BVM. The Handtevy App will soon be available to you and it has proven useful in guiding pediatric cardiac arrest response. Our doc spot has some additional tips and tricks. Also join us for PETOS today (see below) on the same topic.

Hilary Hewes MD

Associate Professor, Pediatric Emergency Medicine

Primary Children's Hospital Emergency Department Attending Physician

The Many Challenges and Controversies of Managing Pediatric Out of Hospital Cardiac Arrest

This is a tough topic for many reasons. Few calls are more emotional than a peds arrest. Luckily, skills used during these encounters are some of the least frequently used because these calls are infrequent. Because there will always be unique features to every case, one could write a PhD dissertation on the subject without really being able to reach a clear conclusion on the very best way to manage an out of hospital peds arrest. We all know the outcomes are most often poor, even with excellent care provided by our teams.

Prep for Scene: Start assigning roles to your team. Discuss what meds you can prepare before arrival. Discuss airway management strategies; always with a back-up plan. If you have an estimated age, you can start to predict doses/weight using a system such as Handtevy to estimate weight. Pull up a few doses of code-dose epi for your estimated weight, or get your epi bottles, syringes, and length-based tape ready to go.

ABC’s (or CABs): We know that pediatric non-traumatic arrest tends to stem from a primary respiratory cause unless it is something such as an athlete with a witnessed collapse. Peds patients tend to be in asystole or PEA more often than a shockable rhythm because of their etiologies for arrest. We must prioritize airway management, but remember to follow PALS guidelines to start compressions immediately with no more than a 10 second delay for pulse-check. If you have extra hands, consider IV/IO access part of circulation, and preferentially start an IO over IV in a full arrest while other members start bag-mask ventilation and compressions.

There are no more important interventions than immediate high-quality CPR and BMV. There is always controversy about whether to continue BMV vs. intubation or other advanced airway placement. Multiple studies have confirmed equal if not better mortality and neurologic outcomes with high quality BMV vs. intubation, and other studies have shown equivalence between intubation and supraglottic airway device outcomes. Continue BMV if you are able to get good chest rise and allow for exhalation/ventilation, especially with shorter transport times. You could also use the advanced airway device with which you are most comfortable but make sure you're ready with a back-up plan or can revert back to BMV if your advanced airway attempt fails. There is also a lot of discussion about epi administration and if it has benefits in cardiac arrest. In peds, it does seem that giving children epi as soon as possible leads to increased success in achieving ROSC and might even result in improved neurologic outcomes.

You got ROSC, now what? If you achieve ROSC, remember to maximize your patient’s care post-arrest. Aim for end-tidal CO2 of around 40. Being hypo or hypercarbic are both bad and can compromise blood flow to the brain. Try to keep a minimal systolic blood pressure above the lower end of normal for age and maybe a little higher for a head injury patient, again to ensure good cerebral blood flow. This may require fluid boluses, push-dose epi doses, or a pressor drip. Check blood sugar and correct if needed, place an OG/NG if you haven’t yet to help with ventilation by decompressing the stomach. Remember to keep peds patients warm. Normothermia is optimal. Fever is bad and can cause ongoing damage to the brain and being cold can lead to bradycardia and acidosis. Keep sats at a goal of around 95%, but not 100 as hyper-oxygenation can cause inflammatory damage as well.

The elephant in the room: scoop and run vs. stay and play

This is the million-dollar question, and the answer is probably somewhere in the middle. Many adult studies have shown poorer outcomes when adults are transported with active CPR than when ROSC is achieved in the field prior to transport. The evidence is not as robust in peds patients and there are many other factors that need to be considered. One of the best studies showed survival was highest in pediatric patients when scene time ranged between 10-35 minutes (rather than <10 minutes or >35 minutes). If you have not been able to achieve ROSC after 30 minutes on scene, it is unlikely to happen. If you are on scene for fewer than 10 minutes, it is unlikely you have had time to do at least a few rounds of high-quality CPR, establish an airway with BMV or other method, obtain access, administer epi, and administer fluid or other medications. It's hard to separate whether the improved outcomes are related to longer scene times, or more efficiency in performing the interventions just listed. In addition, patients where ROSC is achieved quickly will likely have better outcomes regardless of scene time as they have likely had less hypoxic down-time.

There are situations, such as blunt trauma with abdominal bleeding when a patient needs blood products and a surgeon or hypothermic arrest after cold water immersion where a patient may benefit from ECMO warming. In these cases, minimizing time on scene and getting the patient to definitive care can no doubt make a difference in survival. There are also other reasons to transport even when you know the outcome won't be good. It is very hard to call a peds patient in a public space. Consider the benefit of giving the family a private space to grieve. Even if the child later dies after a prolonged resuscitation, it will allow the family some time to process the event and even consider organ donation before withdrawing care.

It seems most reasonable to suggest that every patient in cardiac arrest should, at minimum, have some basic interventions initiated before departing the scene. (At least two rounds of high-quality CPR, initiation of BMV or advanced airway placement, IO/IV access, at least one dose of epi, and of course other immediate interventions such as tourniquet placement.) After that, it's up to the crew to evaluate each situation individually and decide what is right for the family, the patient, and the EMS team. Keeping up on your skills, such as practicing good BMV and IO placement with simulation or whenever you can, preparing medication dosing in route when possible, and debriefing as a team after a pediatric arrest are all important ways to be as prepared as possible to deal with this highly emotional event.

References:

• Lee J, et al. Clinical survey and predictors of outcomes of pediatric out-of-hospital cardiac arrest admitted to the emergency department. Sci Rep. 2019 May 7;9(1):7032.
• Donoghue AJ, et al. Out-of-hospital pediatric cardiac arrest: an epidemiologic review and assessment of current knowledge. Ann Emerg Med. 2005 Dec;46(6):512-22.
• De Maio VJ, et al. Epidemiology of out-of-hospital pediatric cardiac arrest due to trauma. Prehosp Emerg Care. Apr-Jun 2012;16(2):230-6.
• Fukuda T, et al. Type of advanced airway and survival after pediatric out-of-hospital cardiac arrest. Resuscitation. 2020 May;150:145-153.
• Lavonas EJ, et al. Advanced airway interventions for paediatric cardiac arrest: A systematic review and meta-analysis. Resuscitation. 2019 May;138:114-128.
• Hansen M, et al. Time to epinephrine administration and survival from nonshockable out-of-hospital cardiac arrest among children and adults. Circulation. 2018 May 8;137(19):2032-2040.
• Matsuyama, et al. Pre-hospital administration of epinephrine in pediatric patients with out-of-hospital cardiac arrest. J Am Coll Cardiol. 2020 Jan 21;75(2):194-204.
• Tijssen JA, et al. Time on the scene and interventions are associated with improved survival in pediatric out-of-hospital cardiac arrest. Resuscitation. 2015 Sep;94:1-7.

On Topic

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Our program manager, Brianne Glenn, has accepted a position with Huntsman Cancer Institute and left EMSC effective at the end of last month. Even though she was only with us for a year, she made great strides in navigating the challenges of COVID-19. We wish her the best in her new career! The posting for her position closed on February 7. We look forward to hiring another manager soon. In the meantime, Mark Herrera, NRP, FP-C, Rural EMS Liaison/EMS Education Specialist within the Bureau of EMS and Preparedness will be steering the ship. markherrera@utah.gov

EMSC sent out a letter to all EMS agency leadership detailing our plan to distribute the Handtevy Mobile App throughout the state. The letter requested a response. It is not too late! Our timeline for implementation is early 2021. Encourage your agency leadership to respond. Contact our interim program manager MarkHerrera@utah.gov if you need another copy of the letter.

Want more information?

• Our January 11 PETOS topic was Handtevy. Those in attendance had an opportunity to use the demo and practice with the App.
• In September 2020, Dr. Peter Antevy and EMSC held a virtual demo to introduce the App. Follow this link https://register.gotowebinar.com/recording/4248070236387080459

Utah vaccine administration is going well

Recent news articles have made several inaccurate claims and the Utah Department of Health issued a formal response to it, which can be viewed here: https://coronavirus.utah.gov/utah-vaccine-transparency/.

The vaccine and kids

The COVID-19 vaccines have not been widely tested on children and teens. Vaccine manufacturers only recently started including children as young as 12 in their trials. At this time, we don’t know how the vaccine affects people in these age groups. The Pfizer/BioNTech vaccine has only been authorized for use in people 16 years of age and older, however, the Moderna and Johnson and Johnson vaccines have only been authorized for people age 18 and older.

Studies on children's ages 12-17 should finish by the end of June. They will then submit results to the Food and Drug Administration (FDA) which may approve the vaccines for teens by fall for distribution in late 2021 per Dr. Andrew Pavia, chief of pediatric infectious disease at University of Utah Health. Nationally Dr. Anthony Fauci predicted a sooner time frame of late spring or summer. Currently there are no trials underway for children 0-11 years.

Covid-19 Trackers

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Utah Department of Health

We have a 100% response rate to the EMS for Children Survey! Utah this! You are AMAZING and we appreciate this SO MUCH! https://www.emscsurveys.org/

Why was this important?
The answers to this survey help identify priorities for funding and tell us what agencies are doing well and what challenges they are facing. This survey is important and the results are used to make real decisions at the state and national level.

Do you have a question for our EMSC Medical Director, Hilary Hewes, MD, PCH, ER Attending Physician about this newsletter topic or anything related to pediatrics? Shoot an email to the following address tdickson@utah.gov.

Contact PCH EMS Liasion Lynsey Cooper at Lynsey.Cooper@imail.org

If you are a pediatric advocate within your agency, we need you. Please contact our interim program manager, Mark Herrera (markherrera@utah.gov) to find out how you can help.

Pediatric Education for the Prehospital Provider

Register online at www.peppsite.com. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($18.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at eandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, no matter where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth