Enhancing Pediatric Pre-Hospital Care: Termination of Resuscitation Criteria and Real-World Impact

Episode Summary:
In this episode of the Pediatric EMS Podcast, Dr. Joseph Finney and Dr. Joelle D’Onofrio-Udman are joined by Dr. Matt Harris and Dr. Jen Anders to explore groundbreaking developments in pediatric termination of resuscitation (TOR) protocols. Together, they discuss the Maryland Pediatric TOR criteria, insights from the largest pediatric cardiac arrest study to date, and practical strategies for EMS professionals to optimize care and outcomes.

The panel dives deep into the science, ethical considerations, and cultural challenges of TOR, offering actionable guidance for EMS clinicians and medical directors aiming to implement these protocols.

Episode Highlights:

1. Introduction to Pediatric TOR Criteria:

   • Key differences between BLS and ALS TOR protocols.
   • Unique considerations for pediatric medical and traumatic cardiac arrests.

2. Maryland Pediatric TOR Criteria:

   • The specific requirements for TOR in medical and trauma cases.
   • Emphasis on ensuring emotional and community support during field terminations.

3. Key Findings from the ESO Databank Analysis:

   • Analysis of over 1,500 pediatric cardiac arrest cases.
   • High specificity of TOR protocols, especially when excluding drowning cases.
   • The critical role of end-tidal CO2 monitoring in determining outcomes.

4. Exclusion of Drowning Cases:

   • Why drowning victims are not included in TOR protocols due to their high resuscitation and neurologic recovery rates.

5. Cultural Barriers to Pediatric TOR Implementation:

   • Addressing the belief that “everything must be done” for children.
   • Shifting the focus toward high-quality, on-scene resuscitation.

6. Real-World Impact of TOR in Maryland:

   • Adoption of TOR protocols in Maryland since 2020.
   • Improved ROSC and survival rates for pediatric cardiac arrest cases.
   • Collaborative efforts with community stakeholders to support families during TOR events.

7. Practical Guidance for EMS Agencies:

   • Steps to implement pediatric TOR protocols effectively.
   • Importance of education, community engagement, and support systems.

Key Takeaway:
Pediatric TOR protocols empower EMS professionals to deliver effective, evidence-based care while prioritizing the well-being of patients, families, and communities. By focusing on data-driven criteria and robust training, EMS teams can confidently navigate these critical, high-stress situations.

Resources:

Harris MI, Crowe RP, Anders J, D’Acunto S, Adelgais KM, Fishe J. Applying a set of termination of resuscitation criteria to paediatric out-of-hospital cardiac arrest. Resuscitation. 2021 Dec;169:175-181. doi: 10.1016/j.resuscitation.2021.09.015. Epub 2021 Sep 20. PMID: 34555488.

Shetty P, Ren Y, Dillon D, Mcleod A, Nishijima D, Taylor SL; CARES Surveillance Group. Derivation of a clinical decision rule for termination of resuscitation in non-traumatic pediatric out-of-hospital cardiac arrest. Resuscitation. 2024 Nov;204:110400. doi: 10.1016/j.resuscitation.2024.110400. Epub 2024 Sep 18. PMID: 39299508.

Study highlights:

• Study Purpose:
  The study aimed to derive a Pediatric Termination of Resuscitation (PToR) rule for non-traumatic out-of-hospital cardiac arrests (OHCA) in patients under 18 years of age, utilizing data from the CARES database (2013–2022).

• Study Population:

  • Analyzed 21,240 pediatric OHCA cases.
  • 11.0% of patients survived to hospital discharge, and 8.9% survived with favorable neurologic outcomes.

• Criteria Derived:
  The PToR rule for non-survival to hospital discharge includes:

  • Unwitnessed cardiac arrest.
  • Absence of sustained ROSC (return of spontaneous circulation).
  • Initial rhythm of asystole.
  • Arrest not caused by drowning or electrocution.

• Performance Metrics:

  • Specificity: 99.1%.
  • Positive Predictive Value (PPV): 99.8% for predicting non-survival to hospital discharge.
  • For non-survival or survival with unfavorable neurologic status, specificity was 99.1%, and PPV was 99.8%.

• Significance of Drowning/Electrocution Cases:

  • These etiologies were excluded from PToR due to improved survival outcomes compared to other causes of cardiac arrest.

• Model Validation:

  • The PToR criteria were validated on a test dataset, showing consistent high specificity and PPV.
  • Performance was stable across different age groups (infants, children, and adolescents).

• Comparison with Adult ToR Rules:
  The PToR criteria shared similarities with adult ToR rules but were tailored to pediatric cases, emphasizing improved predictive accuracy for this population.

• Implications for Practice:

  • The criteria provide a systematic framework to guide prehospital termination of resuscitation for pediatric patients, potentially reducing unnecessary transport and resource use.
  • Adoption may improve decision-making consistency among EMS providers while reducing emotional burden and ethical challenges.

• Limitations:

  • Retrospective design limits causation analysis.
  • Excluded field-terminated cases may have introduced selection bias.
  • ROSC duration criteria may differ from typical EMS practices, necessitating further prospective validation.

• Conclusions:
  The study offers robust PToR criteria with high specificity and PPV for prehospital decision-making. Future research should focus on prospective validation and understanding the criteria’s practical implementation and impact on patient care.