Pre-Hospital Pediatric Cardiac Arrest: Should Children Be Treated Like Small Adults?

By Louis Fornage, MD

Over the last 10 years, advances in out of hospital cardiac arrest (OHCA) have resulted in significant improvements in patient outcome. While this has definitely been the case for adult cardiac arrest, this unfortunately has not translated to improved outcomes in pediatric cardiac arrest, which continues lag behind. Even in cases with improved bystander CPR – a known positive prognostic factor in adults – pediatric outcomes are still not meeting their adult counterparts [1]. It is uncertain why this phenomenon occurs. Do we, as pre-hospital providers, need to significantly change how we care for children in cardiac arrest? 

On-Scene Resuscitation

In 2019, Banerjee, et al studied the effect of prolonged scene times in pediatric cardiac arrest. They hypothesized that rapid transport was a disservice to patient care because critical interventions would have to be performed en route. By prolonging on-scene time, they would give the medics a better chance of success with chest compressions, securing an airway, and obtaining vascular access. They studied this by implementing a new protocol that mandated IO access, iGel placement, and administration of epinephrine before initiating transport. Education was provided to the medics before implementation of this new protocol, along with education on preventing hyperventilation during airway management. The results were impressive. Over this 4 year prospective period, rates of return of spontaneous circulation (ROSC) increased from 5.3% to 30.4% and neurologically intact outcomes increased from 0% to 23.2% (both of which were statistically significant). [1] There was no difference in the number of patients who received bystander CPR, incidence of shockable rhythm, and time to arrival of ALS between the pre-and post-study groups. Interestingly, the additional interventions did not significantly increase the amount of on-scene time. [1] They also noted that absence of adult field termination criteria (non-shockable rhythm and unwitnessed arrest) were not predictive of better outcomes. This further supports the need for further study before we can implement pediatric field termination protocols.

Medications

For the most part, medications used in cardiac arrest are the same for pediatric and for adult patients – one of which is epinephrine. A 2019 study by Matsuyama, et al. uses the Japanese nationwide OHCA registry to examines the use of epinephrine in pediatric patients to look for any correlation between epinephrine use and patient outcome. Unlike prior studies, which showed improvement in both rates of ROSC and neurological outcome [3,6], this study had a larger patient population and used propensity matching in order to control for confounders such as resuscitation time and other interventions. They were able to conclude that epinephrine administration in pediatric cardiac arrest improves return of spontaneous circulation (ROSC), but does not lead to improvement in other patient-centric outcomes such as neurological outcome. However, this study is limited in some ways. First, it is retrospective. Second, there are major differences between the Japanese system and domestic EMS agencies including the absence of prehospital IOs in Japan and the more restrictive age range for prehospital IV epinephrine administration in cardiac arrest – the patients had to be at least 8 years old. Unfortunately, the exclusion of the younger half of pediatric patients due to local standards of care limits the external validity of this study’s results. Similarly, other studies on medications used during pediatric cardiac arrest, such as sodium bicarbonate, have demonstrated similar findings.[7] In summation, current evidence supports the statement that pediatric cardiac arrest patients respond to pharmacologic treatment as the adult population.

Therapeutic Hypothermia

In 2015, Moler et al. studied the use of therapeutic hypothermia, following the work that had been done in adults a decade earlier. The equivocal results in the adult population, which showed no improvement in neurological outcomes, concerned pediatric providers, who until then only had observational studies to guide their practice. Furthermore, it has been documented to show harm in pediatric TBI patients. [9] As such, it was imperative to conduct a randomized clinical trial to better elucidate potential benefits.  

Moler et al. evaluated the effects of therapeutic hypothermia in 260 unconscious pediatric patients with OHCA (all-comers, not pre-selected based on presenting rhythm) who had complete data recorded. This study took place at 38 hospitals in the US and Canada. Exclusion criteria included inability to consent, severe concurrent trauma, existing DNR, high dose epinephrine infusion prior to randomization, certain blood disorders and pregnancy to name a few. Patients were either randomized to 120 hours of normothermia at 36.8 degrees C or 48 hours of cooling to 33 degrees C, followed by 16 hours of rewarming and the rest at normothermia, until they reached the 120th hour mark. Unfortunately, despite all their efforts, there was no difference in functional scores between the two groups at 12 months. Their 1 year survival was also the same. There was no significant difference in life-threatening adverse effect between both groups (such as bleeding, arrhythmia at 7 days or 28 day mortality). [10]

Discussion

All in all, there is a strong case to be made that it is safe to approach pediatric cardiac arrest in the same way we treat adult cardiac arrest. This means several things. First, it will allow for better translation of paramedic skill and experience from adult OHCA care to pediatric OHCA. Second, this can lead to increased paramedic confidence in treating this high risk/low incidence condition, which is particularly important because, as has been seen in athletes, a confident provider will perform better than one that doubts their ability to perform. [4] The hope is that education on these findings will lead to similar improvements in neurological outcome as seen in the Banerjee study.

As a final note, it is important to not only use evidence to build similar protocols and to monitor results, but also to continue to look at ways to improve pediatric cardiac arrest outcomes. Here are some possible areas for additional research:

• If non traumatic pediatric OHCA victims are more likely to survive if taken to a pediatric ED versus a general ED [8]

• Review of the ideal timing of epinephrine administration (some evidence suggests longer intervals between doses lead to better outcomes) [2,5,11]

In conclusion, this may be one of the few situations where thinking of pediatric patients as small adults might be best, especially if it allows us to bring out the best in our paramedics and allow them to excel in this high stakes situation.

Editor: Alison Leung, MD (@alisonkyleung)

References

1. Banerjee, Paul R., et al. “Early On-Scene Management of Pediatric Out-of-Hospital Cardiac Arrest Can Result in Improved Likelihood for Neurologically-Intact Survival.” Resuscitation, vol. 135, 2019, pp. 162–167., doi:10.1016/j.resuscitation.2018.11.002.

2. Faria, João Carlos Pina, et al. “Epinephrine in Pediatric Cardiorespiratory Arrest: When and How Much?” Einstein (São Paulo), vol. 18, 2020, doi:10.31744/einstein_journal/2020rw5055.

3. Fukuda, Tatsuma, et al. “Time to Epinephrine and Survival after Paediatric out-of-Hospital Cardiac Arrest.” European Heart Journal – Cardiovascular Pharmacotherapy, vol. 4, no. 3, 2017, pp. 144–151., doi:10.1093/ehjcvp/pvx023.

4. Hays, Kate, et al. “The Role of Confidence in World-Class Sport Performance.” Journal of Sports Sciences, vol. 27, no. 11, 2009, pp. 1185–1199., doi:10.1080/02640410903089798.

5. Hoyme, Derek B., et al. “Epinephrine Dosing Interval and Survival Outcomes during Pediatric in-Hospital Cardiac Arrest.” Resuscitation, vol. 117, 2017, pp. 18–23., doi:10.1016/j.resuscitation.2017.05.023.

6. Loomba, Rohit S., et al. “Use of Sodium Bicarbonate During Pediatric Cardiac Admissions with Cardiac Arrest: Who Gets It and What Does It Do?” Children, vol. 6, no. 12, 2019, p. 136., doi:10.3390/children6120136.

7. Matsuyama, Tasuku, et al. “Pre-Hospital Administration of Epinephrine in Pediatric Patients With Out-of-Hospital Cardiac Arrest.” Journal of the American College of Cardiology, vol. 75, no. 2, 2020, pp. 194–204., doi:10.1016/j.jacc.2019.10.052.

8. Michelson, Kenneth A., et al. “Cardiac Arrest Survival in Pediatric and General Emergency Departments.” Pediatrics, vol. 141, no. 2, 2018, doi:10.1542/peds.2017-2741.

9. Moler, Frank W., et al. “Rationale, Timeline, Study Design, and Protocol Overview of the Therapeutic Hypothermia After Pediatric Cardiac Arrest Trials.” Pediatric Critical Care Medicine, vol. 14, no. 7, 2013, doi:10.1097/pcc.0b013e31828a863a.

10. Moler, Frank W., et al. “Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest in Children.” New England Journal of Medicine, vol. 372, no. 20, 2015, pp. 1898–1908., doi:10.1056/nejmoa1411480.

11. Warren, Sam A., et al. “Adrenaline (Epinephrine) Dosing Period and Survival after in-Hospital Cardiac Arrest: A Retrospective Review of Prospectively Collected Data.” Resuscitation, vol. 85, no. 3, 2014, pp. 350–358., doi:10.1016/j.resuscitation.2013.10.004.