Pediatric Small Talk – The 1,3,5 Approach to Pediatric Cardiac Arrest

Welcome back to Small Talk.  Every first Wednesday of the month we will release high yield PEM content written by PEM talent from around the country.  We hope you enjoy these reviews. Comments, questions, accolades or concerns: feel free to reach out to Joe Ravera, MD (pemgemspod@gmail.com).

Author: Joe Ravera MD (@pemuvm1, Director of Pediatric Emergency Medicine, Assistant Professor of Surgery, Division of Emergency Medicine, University of Vermont Medical Center) // Reviewed by: Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

Case 

The paramedics make base contact for a 5-month-old with CPR in progress.  The child was placed down for a nap about an hour prior.  They are 5 minutes out.

Introduction and Demographics

Hearing this radio call has a dichotomous effect on everyone in the Emergency Department: simultaneously, everyone’s heart both races and sinks. Fewer things in emergency medicine are as stressful or emotionally taxing as a pediatric cardiac arrest. While this situation is rare- about 10 per 100,000 children – the outcomes are typically poor.  Less than 10% of pediatric patients survive cardiac arrest, and only about a third of those who do survive will have a good neurologic outcome. Despite the major improvements in adult cardiac arrest resuscitation and associated improved survivability, the pediatric rates remained relatively fixed likely owing to the nature of the arrest.  Only a small fraction of pediatric arrests have a primary cardiac etiology, and the presenting rhythm is often PEA or asystole (both of which carry a poor prognosis).¹

These dismal statistics often exacerbate the difficulty of these cases- we enter the room knowing the outcome is likely to be poor and emotionally devastating.  Given this setup, our best management as EM providers is typically, running a smooth code and ensuring everyone in the ED does their best, while minimizing the trauma for the family. In this authors opinion these are the cornerstones of a good pediatric code (if there is such a thing).

The 1,3,5 Approach

Coding kids are accompanied by a flood of emotions and what can feel like hundreds of tasks to accomplish.  A chaotic room only adds to the stress of the situation. To stay organized, I use what I call the “1,3,5 method.”  I think the most successful way to run a pediatric code is to prioritize which tasks should be accomplished by 1 minute, 3 minutes, and 5 minutes.

The 1 Minute Goals: The Starting Block

Establish an Accurate Weight or Use Length-Based Resuscitation

This is of the utmost importance since the child’s resuscitation equipment and medication doses will be based on the weight and age or estimated with length-based reduction. While accurately measured weight is ideal, in situations where this is not feasible (like a cardiac arrest), a length-based estimate is a rapid and reasonable substitute – especially since evidence from simulation trials indicates that it improves team dynamics and ease of resuscitation. ² This author suggests placing the tape on the bed prior to the patient’s arrival so the first thing called out can be a weight and color (e.g. “8kg, Red on Broselow”).  Taking this further, part of pediatric EMS readiness there should include some form of weight estimation; EMS providers must appreciate that relaying this information to the hospital is critical so medications and resuscitative equipment and medications can be ready to go prior to arrival.

Establish Access

If you can establish IV access, consider yourself lucky –this can be difficult in a small kid undergoing CPR.  If available, an interosseous line is rapid and reliable, but should be properly secured as they tend to move and dislodge during CPR. ³ Once access is established, epinephrine can be given per ACLS/PALS recommendations; remember that ET tube medications have variable absorption and should be a last resort only if IV or IO access is unavailable.

Obtain a Point of Care Glucose

Quick and easy- just check it off the list low glucose can be a very unusual but potentially reversible cause of cardiac arrest.

Gather Your Resources & Assign Someone to Stay with the Family

Pediatric codes are all-hands-on deck events. In addition to ED physicians and nurses, having social work and pediatrics or pediatric critical care teams present can be invaluable.  Additionally, the family must be kept informed about what’s going on.  While there is ample literature to support having the family in the room for adult resuscitation, there is an absence of pediatric literature and a wide variety of opinions among providers. The limited literature supports offering the parents the option to be in the room and witness the resuscitation, and/or designating someone to stay with them and explain the resuscitation process. ⁴

The 3 Minute Goals: The Airway Plus

Establish a Secure Airway

Although the adage is “ABCs”, if the child has appropriate chest rise with bag mask ventilation there are other priorities prior to placing an ET tube.  Before attempting an airway ensure appropriately sized equipment. An entire podcast on managing a pediatric airway can be found here (https://pemgems.com/450-2/).  If you are unable to place an ET tube- consider placing an LMA for the duration of resuscitation and then move to re-attempt intubation if you achieve ROSC.

Check a Temperature

If these kids have a prolonged downtime, they can be hypothermic and require rewarming.

Obtain a Focused Medical History

Emphasis on focused.  The question is: Is there something in the child’s medical history or presentation that would lead to a reversible cause of cardiac arrest (e.g. renal disease and hyperkalemia).

The 5 Minute Goals: The Arc of Resuscitation

Establish Priorities for the Team

At this point there is not much to the PALS algorithm other than continued epinephrine every 3-5 minutes and high-quality, uninterrupted, CPR.  Be sure to consider all possible reversible causes and using adjuncts like POCUS to check for a pericardial effusion or pneumothorax.  Keep in mind the overwhelming number of these children will not have an immediately reversible cause found.

Check in with the family

At this time, it’s important to let them know what has been done, i.e. we secured an airway and have a route to give medications.  It is also important to let the family know the next priorities for the resuscitation which include using everything possible to restart the heart.  As discussed in the intro, the prognosis is often not good and giving the family a warning shot such as “we are going to try for 10 more minutes to restart the heart and if we are unable, we will have to stop.”

ROSC or Termination of Resuscitation

PALS is a temporizing measure with only two possible outcomes.  The first is the child has return of circulation with a perfusing rhythm.  In this case, the best thing for the patient is high quality post arrest care:

• Maintain normothermia (of note: therapeutic hypothermia was not found to be beneficial in post arrest care)⁵
• Evaluate for and correct any electrolyte abnormalities or severe acidosis
• Place an OG tube for gastric decompression (a distended stomach from bag mask ventilation can hinder mechanical ventilation)
• Consider a peripheral vasopressor such as epinephrine as children post arrest can be very tenuous and prone to rearrest.
• Arrange for admission to a pediatric intensive care unit
• Update the family – as noted many times, the neurologic outcome even with ROSC is still quite poor.

Termination of Resuscitation

This can be an extremely difficult decision to make and relies on many factors both medical (such as the clinical status of the actual patient) and non-medical (such staff and physician comfort level with termination.)⁶ Eventually, there comes a point when resuscitative efforts become futile and only prolong the suffering of the patient; at this point efforts must be terminated.  Finding precise recommendations for time is difficult for a single prognostic factor or time of resuscitative efforts is difficult as most societies do not give a hard and fast guideline. In this author’s experience 30 minutes of high quality ACLS without ROSC should prompt strong consideration for termination. It should also be noted that high dose epinephrine- even as a last-ditch effort- is not recommended. ⁷

Post Incident Stress Debriefing

While pediatric cardiac arrests are thankfully rare, their shock waves can seem incalculable.  Several studies have outlined the mental health toll that these events can have on everyone involved.  There is an appreciable increase in issues among providers including mental health concerns among providers such as PTSD, burn out, or even leaving the profession all together.   While the effects can in no way be completely mitigated, one strategy is to have a stress debriefing after the event- ideally in the same shift. ⁸ Consider all the ED and hospital staff involved – including EMS – and allow for an open discussion of both medical facts of the case as well as feelings and emotions surrounding the event.

Take Home Points

• Have a plan for pediatric resuscitation; making timed goals can help you stay organized.
• Get an accurate weight or length-based resuscitation color at the beginning of the resuscitation.
• Consider termination after 30 minutes of high-quality ACLS and PALS care.
• If possible, have a post incident stress debriefing and include all personnel involved.

References

1. Kämäräinen A. Out-of-hospital cardiac arrests in children. J Emerg Trauma Shock. 2010;3(3):273-276. doi:10.4103/0974-2700.66531
2. Agarwal S, Swanson S, Murphy A, Yaeger K, Sharek P, Halamek LP. Comparing the utility of a standard pediatric resuscitation cart with a pediatric resuscitation cart based on the Broselow tape: a randomized, controlled, crossover trial involving simulated resuscitation scenarios. Pediatrics. 2005 Sep;116(3):e326-33. doi: 10.1542/peds.2005-0320. Epub 2005 Aug 1. PMID: 16061568.
3. Horton MA, Beamer C. Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients. Pediatr Emerg Care. 2008 Jun;24(6):347-50. doi: 10.1097/PEC.0b013e318177a6fe. PMID: 18562874.
4. Dainty KN, Atkins DL, Breckwoldt J, et al. International Liaison Committee on Resuscitation’s (ILCOR) Pediatric; Neonatal Life Support Task Force; Education, Implementation and Teams Task Force. Family presence during resuscitation in paediatric and neonatal cardiac arrest: A systematic review. Resuscitation. 2021 May;162:20-34. doi: 10.1016/j.resuscitation.2021.01.017. Epub 2021 Feb 9. PMID: 33577966.
5. Moler FW, Silverstein FS, Holubkov R, et al. THAPCA Trial Investigators. Therapeutic hypothermia after out-of-hospital cardiac arrest in children. N Engl J Med. 2015 May 14;372(20):1898-908. doi: 10.1056/NEJMoa1411480. Epub 2015 Apr 25. PMID: 25913022; PMCID: PMC4470472.
6. Campwala RT, Schmidt AR, Chang TP, Nager AL. Factors influencing termination of resuscitation in children: a qualitative analysis. Int J Emerg Med. 2020 Mar 14;13(1):12. doi: 10.1186/s12245-020-0263-6. PMID: 32171233; PMCID: PMC7071657.
7. Perondi MB, Reis AG, Paiva EF, Nadkarni VM, Berg RA. A comparison of high-dose and standard-dose epinephrine in children with cardiac arrest. N Engl J Med. 2004 Apr 22;350(17):1722-30. doi: 10.1056/NEJMoa032440. PMID: 15102998.
8. Nocera M, Merritt C. Pediatric Critical Event Debriefing in Emergency Medicine Training: An Opportunity for Educational Improvement. AEM Educ Train. 2017;1(3):208-214. Published 2017 May 4. doi:10.1002/aet2.10031