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Efficacy of cardiopulmonary resuscitation in pulseless paediatric trauma patients
Resuscitation 36 (1998) 9 – 13
Efficacy of cardiopulmonary resuscitation in pulseless paediatric trauma patients P. Suominen a,*, J. Ra¨sa¨nen b, A. Kivioja c a Department of Anaesthesia, Helsinki Uni6ersity Central Hospital, Haartmaninkatu 4, FIN-00290 Helsinki, Finland Hospital for Children and Adolescents, Paediatric Anaesthesia, Uni6ersity of Helsinki, Stenba¨ckinkatu 9, FIN-00290 Helsinki, Finland c Department of Orthopaedics and Traumatology, Helsinki Uni6ersity Central Hospital, Haartmaninkatu 4, FIN-00290 Helsinki, Finland b
Received 15 August 1997; received in revised form 18 August 1997; accepted 7 November 1997
Abstract Background: A study was designed to determine which paediatric trauma patients with no detectable vital signs are likely to benefit from cardiopulmonary resuscitation (CPR). Methods: A 10-year retrospective study of all pulseless patients under 16 years of age with trauma in whom CPR was initiated in a prehospital or in-hospital setting in Southern Finland. Results: Forty-one patients, 25 male and 16 female, were included in this study. The mean age was 7.8 years (range 0.1 – 15.9 years). Twenty three patients had blunt injuries and three patients had penetrating injuries. The mean Injury Severity Score was 51 (range 25 –75). In 15 patients, the arrest was secondary to smoke inhalation, strangulation or electric shock. Resuscitation was initiated at the scene or en route in 28 patients and in 13 patients at the hospital. Five patients received open-chest CPR and 36 patients closed-chest CPR. Spontaneous circulation was restored in four patients with open-chest CPR and in six patients with closed-chest CPR. Two patients had intact survival and one patient survived with moderate disability. The mechanism of traumatic cardiac arrest, initial cardiac rhythm or location of arrest did not seem to affect outcome of CPR. Conclusions: The overall survival rate of paediatric patients with cardiac arrest secondary to trauma is poor. Trauma patients in whom cardiac arrest is caused by respiratory arrest or by thoracoabdominal trauma in the hospital setting may have a chance of survival if a spontaneous circulation is rapidly restored with effective resuscitative measures. © 1998 Elsevier Science Ireland Ltd. Keywords: Paediatric; CPR; Trauma and cardiac arrest
1. Introduction Beyond the first year of life, trauma is the leading cause of prehospital cardiac arrest in paediatric patients [1,2]. Over 50% of all paediatric trauma deaths occur at the scene and 77% of victims die within the first 6 h [3]. The effectiveness of paediatric trauma care has been evaluated with the preventable death rate [4]. However, it is not known how often and under what conditions Abbre6iations: EMS, emergency medical systems; ALS, advanced life support; BLS, basic life support; CPR, cardiopulmonary resuscitation; OC-CPR, open-chest cardiopulmonary resuscitation; ISS, injury severity score; ROSC, restoration of spontaneous circulation. * Corresponding author. Tel.: + 358 9 4712540; fax: +358 9 4714017.
paediatric trauma patients with cardiac arrest could still be salvageable. Earlier studies have demonstrated that the value of resuscitation in patients with blunt trauma is limited [5,6], even though emergency thoracotomy and open-chest cardiopulmonary resuscitation (OC-CPR) have been shown useful in patients with penetrating torso trauma [7]. Few data are available on the efficacy of cardiopulmonary resuscitation (CPR) in pulseless paediatric patients with cardiac arrest secondary to smoke inhalation, electrocution and strangulation. The purpose of this study was to determine, which of the paediatric trauma patients who present with no detectable vital signs, are likely to benefit from CPR, and whether or not the location of the arrest has any effect on survival.
0300-9572/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 3 0 0 - 9 5 7 2 ( 9 7 ) 0 0 0 8 8 - 9
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P. Suominen et al. / Resuscitation 36 (1998) 9–13
2. Patients and methods We included in the study all trauma patients under 16 years of age with no detectable vital signs in whom CPR was initiated in prehospital or in-hospital setting in the Province of Uusimaa. The original study sample included 347 trauma patients who required intensive care at the Helsinki University Central Hospital or who had autopsies at the Forensic Department of the University of Helsinki between January 1, 1985 and December 31, 1994 [3]. Injuries due to drowning, airway obstruction due to foreign bodies and intoxication (with the exception of smoke inhalation), were excluded [3]. Helsinki University Central Hospital is the tertiary trauma center of the Province of Uusimaa, to which all paediatric trauma patients requiring intensive care (including all successfully resuscitated patients) are referred. Altogether there were 121 pulseless trauma patients, but 80 (66.1%) patients were excluded because no CPR was initiated. The sophistication of the local emergency medical system (EMS) is variable according to the local geography. Outside Helsinki, the local EMS units were trained in basic life support (BLS) procedures and to all patients are taken to the nearest regional hospital or health center, where physicians started advanced life support (ALS). Two physician-staffed prehospital emergency care units operated 24 h a day in the study area. The city of Helsinki is served by a land-based unit, and the surrounding area by a helicopter team since 1992. The physicians providing these services are anaesthetists or other experienced ALS-trained physicians. Previously reported mean call to arrival times comparing BLS with ALS units were 9.0 versus 12.4 min in Helsinki, and 10.3 versus 23.1 min in the peripheral areas of Uusimaa province [1,8]. Cardiorespiratory arrest was defined as loss of consciousness, and absence of spontaneous ventilation and palpable pulses in major arteries. The first responding EMS unit initiated BLS in trauma patients with cardiac arrest unless obvious clinical signs of death, such as rigor mortis, postmortem lividity or mutilating unsurvivable trauma were detected. Resuscitation was either continued at the scene by a physician, or the patient was transported with ongoing CPR to the nearest hospital. In-hospital CPR was consistent with the current guidelines issued by the American Heart Association [9]. Open-chest CPR was not routinely used in our trauma system. An autopsy was conducted in all patients, in whom CPR was unsuccessful. The neurological status of the survivors was evaluated retrospectively from the hospital records using the Pediatric Overall Performance Category Scale [10] either at the time of discharge or 1 year after discharge if the category on discharge was other than good.
Records covering events prior to hospital admission, treatment at the hospital, and autopsy findings were reviewed to obtain information concerning patient demography, mechanism of injury, time and place of the arrest, initial cardiac rhythm, prehospital and hospital procedures, and outcome. Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) [11] were calculated for patients with blunt or penetrating trauma from data based on the first 24 h of hospitalisation, or from autopsy findings.
3. Results A total of 41 patients, 25 male and 16 female, fulfilled the inclusion criteria. The mean age was 7.8 years (range 0.1–15.9 years). The mechanisms of traumatic cardiac arrest are shown in Table 1. Blunt trauma was caused by a road traffic accident except in one case. All three patients with penetrating trauma had a stab injury. The mean Injury Severity Score of the patients with blunt and penetrating injuries was 51 (range 25– 75). Most of the patients arrested at the scene (Table 1). The initial cardiac rhythm was asystole in 60% of the patients in whom the initial rhythm was recorded (Table 1). The mean duration of CPR was 39 min (range 5–120 min). None of the 15 patients, who were transported with ongoing resuscitation to hospital survived.
Table 1 Characteristics and outcome of paediatric patients with traumatic cardiac arrest Total (n =41)
Circulation restored (n = 10)
Survival (n = 3)
Mechanism of injury Blunt Penetrating Other Strangulation Smoke inhalation Electrocution
23 3 15 8 5 2
8 1
2
1
1
Location of arrest Scene En route Emergency room Operating theater Psychiatric ward Intensive care unit Radiology suite
27 1 5 5 1 1 1
3 1
1
5 1
1 1
Initial cardiac rhythm Asystole PEA VF Bradycardia Not available
21 6 4 4 6
1
1
3 2 4
1 1
P. Suominen et al. / Resuscitation 36 (1998) 9–13 Table 2 Restoration of spontaneous circulation (ROSC) and outcome of resuscitation
Closed-chest CPR Open-chest CPR
Total
ROSC
Survival
36 5
6 4
2 1
Five of the 41 patients underwent emergency thoracotomy and received OC-CPR; spontaneous circulation was restored in four patients. One unsuccessful emergency thoracotomy was performed at the scene for a pulseless teenager with a stab injury of the heart and liver. The other four emergency thoracotomies were done in the operating theatre (Table 2). Five of the ten patients in whom spontaneous circulation returned, died within 24 h and two other patients within 5 days (Table 1). The mechanism of traumatic cardiac arrest, initial cardiac rhythm or location of arrest appeared not to affect outcome of CPR (Table 1). Open-chest CPR was associated with a higher primary success rate than closed-chest CPR, but the number of survivors was not significantly higher. Two patients survived intact, one had self-inflicted trauma by hanging and the other had haemorrhagic shock. The former had early and effective resuscitation initiated by nurses at the psychiatric institution and continued by a physician-staffed emergency care unit. The duration of CPR was 8 min. The latter arrested after massive bleeding from a spleen laceration in the operating theatre of a local hospital. The haemorrhage was rapidly controlled and OC-CPR was performed for a short period. One patient, who survived with moderate disability was run over by a tram and was trapped beneath it. This patient had cerebral contusion and fractures of the vertebral column and extremities; her airway was obstructed because of her head position. Spontaneous circulation was restored within 17 min of the accident after 5 min resuscitation.
4. Discussion This study shows that the overall survival rate of paediatric trauma patients with cardiac arrest remains low regardless of the mechanism of traumatic cardiac arrest, initial cardiac rhythm or the location of arrest. Cardiac arrest in children with trauma is due to severe bleeding or to hypoxia progressing over time. Hypoxia results in combined respiratory and metabolic acidosis, and the anoxic injury to the brain and other vital organs may be too severe to permit recovery [12]. The increased physiological reserve of the child allows the maintenance of nearly normal vital signs even in the presence of severe hypovolaemia, which complicates the
11
evaluation of the need for fluid resuscitation [13]. Thus hypotension is a late sign of shock in children. Hypotension can also be due to severe closed head injury. The presence of severe hypotension, defined as a systolic blood pressure of 50 mmHg or less, among paediatric trauma patients may indicate just as dismal an outcome as cardiac arrest [6]. On the other hand, apneic trauma patients with demonstrable pulses in the ER have been shown to have an outstanding survival [14]. Experimental data in animals show that closed-chest CPR produces very low levels of cerebral and myocardial blood flow—of the order of 3–9% of prearrest perfusion [15]. When closed-chest CPR was prolonged in infant piglets beyond 20 min, aortic pressure, cerebral and myocardial blood flow declined to near-zero values; with a continuous infusion of epinephrine, a higher perfusion pressure were maintained somewhat longer [16]. Open-chest CPR has been shown experimentally to produce a cerebral blood flow greater than 66% of the prearrest value, which can be maintained for up to 60 min [17]. However, OC-CPR has been shown experimentally to improve survival only if it is performed within 15–20 min after cardiac arrest [18]. In the study by Durham [7], patients with penetrating thoracoabdominal trauma had a chance of survival if the duration of prehospital CPR before an emergency thoracotomy was less than 9 min in intubated patients and less than 4 min in non-intubated. In an earlier study [1] of paediatric prehospital cardiac arrest with all aetiologies, a duration of CPR less than 15 min was the only factor associated with favorable outcome in a multivariate analysis. It has also been shown that the outcome of prolonged CPR in a normothermic paediatric patient, who does not respond quickly with restoration of spontaneous circulation, is death or severe disability [2]. In patients with blunt trauma emergency thoracotomy and OC-CPR have not been shown to be successful [5–7,19,20] and therefore emergency thoracotomy has not been recommended for patients with blunt trauma or asystole on arrival in the emergency room [5,7,19,20]. In an earlier study, which included patient of all ages with thoracoabdominal injuries, emergency thoracotomy resulted in survival rates of 15% and 7% for stab and gunshot wounds, respectively [7]. In the present study spontaneous circulation was restored in all the patients, who arrested in the emergency room or operating theatre and who received OC-CPR. One of these patients survived intact and three patients died. The one patient who received OC-CPR at the scene, did not survive. In the present and in earlier studies [5,6], the mean ISS values has varied from 33 to 53 in pediatric trauma patients with cardiac arrest. Thus ISS appears not to be a predictor of survival in patients who already have
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P. Suominen et al. / Resuscitation 36 (1998) 9–13
developed cardiac arrest. However, a low value for ISS in a deceased trauma patient may indicate that the patient could have been salvageable with early access to help from an optimally functioning EMS/Trauma system [4]. There are limited data available on the efficacy of CPR in paediatric patients, who have arrested because of smoke inhalation, strangulation or electrocution. Carbon monoxide is the most frequent cause of immediate fire deaths. Carbon monoxide levels at a fire may reach 10%, which can elevate the blood carboxyhemoglobin level to a fatal level within 1 min [21]. Cyanide is often also a component of smoke and has similar toxic cerebral and cardiovascular effects to carbon monoxide [21]. Strangulation causes hypoxic-ischaemic injury to the central nervous system [22]. In an electrical injury, AC and low voltage are associated with ventricular fibrillation, whereas highvoltage electric shocks provoke asystole. Respiratory arrest is usually a combined effect of tetanic paralysis of the respiratory muscles and damage to the respiratory center in the brain stem [23]. The chance of survival for an electric shock victim may be greater than for other causes of cardiac arrest [24]. In the present study, there was no successful resuscitation for patients with smoke inhalation or electrocution; this may be partly due to the small number of patients and time delay from the accident to the initiation of CPR. This study is limited by its retrospective nature and by the relatively small number of patients despite the 10-year study period. This reflects the extremely low incidence of traumatic cardiac arrest in Southern Finland. The large catchment area of the trauma center and the heterogeneous level EMS run sheets and hospital records made determination of time data and initial cardiac rhythm in some cases impossible. In conclusion although the prognosis of pulseless paediatric trauma patients is poor, a short period of closed-chest CPR should be initiated. A 20 min period of ALS is indicated in patients with witnessed arrest, because of the possibility that arrest resulted from airway obstruction and not from the trauma itself. A patent airway, preferably by endotracheal intubation, and proper ventilation should therefore be given utmost priority in the treatment of these patients. Patients with thoracoabdominal injuries who have in-hospital cardiac arrest may benefit from OC-CPR and immediate control of bleeding.
Acknowledgements This study was supported by the Laerdal Foundation for Acute Medicine and the Foundation for Orthopaedical and Traumatological Research in Finland. The authors would like to thank the staff from the archives
of Forensic Department of the University of Helsinki, To¨o¨lo¨ Hospital and Hospital for Children and Adolescents of Helsinki University Central Hospital for their valuable assistance in obtaining the patients’ records.
References [1] Suominen P, Korpela R, Kuisma M, Silfvast T, Olkkola KT. Paediatric cardiac arrest and resuscitation provided by physician staffed emergency care units. Acta Anest Scand 1997;41:260–5. [2] Hickey RW, Cohen DM, Strasbaugh S, Dietrich AM. Pediatric patients requiring CPR in the prehospital setting. Ann Emerg Med 1995;25:495 – 501. [3] Suominen P, Kivioja A, O8 hman J, Korpela R, Rintala R, Olkkola KT. Severe and fatal childhood trauma. Injury (in press). [4] Dykes EH, Spence LJ, Young JG, Bohn DJ, Filler RM, Wesson DE. Preventable pediatric trauma deaths in a metropolitan region. J Ped Surg 1989;24:107 – 11. [5] Sheikh A, Brogan T. Outcome and cost of open- and closedchest cardiopulmonary resuscitation in pediatric cardiac arrests. Pediatrics 1994;93:392 – 8. [6] Hazinski MF, Chahine AA, Holcomb GW III, Morris JA. Outcome of cardiovascular collapse in pediatric blunt trauma. Ann Emerg Med 1994;23:1229 – 35. [7] Durham LA III, Richardson RJ, Wall MJ, Pepe PE, Mattox KL. Emergency center thoracotomy: Impact of prehospital resuscitation. J Trauma 1992;32:775 – 9. [8] Suominen P, Silfvast T, Korpela R, Erosuo J. Pediatric prehospital care provided by a physician-staffed emergency medical helicopter unit in Finland. Pediatric Emerg Care 1996;12:169– 72. [9] American Heart Association; Emergency Cardiac Care Committee and Subcommittees. Guidelines for cardiopulmonary resuscitation and emergency care. J Am Med Assoc 1992; 268:2171 – 302. [10] AHA Medical/Scientific Statement. Recommended guidelines for uniform reporting of pediatric advanced life support: The pediatric Utstein style. Circulation 1995;7:2006 – 2020. [11] Association for the Advancement of Automotive Medicine. The Abbreviated Injury Scale 1990 Revision. Des Plaines, IL: AAAM, 1990. [12] Chameides L. CPR challenges in pediatrics. Ann Emerg Med 1993;22:388 – 92. [13] American College of Surgeons: Pediatric trauma. In: Advanced Trauma Life Support Course for Physicians, Student Manual. ed. 3. Chicago, IL: ACS, 1995:261 – 281. [14] Schoenfeld PS, Baker DM. Management of cardiopulmonary and trauma resuscitation in the pediatric emergency department. Pediatrics 1993;91:726 – 9. [15] Lucy JM, Ross BK, O’Quin RJ, et al. Regional blood flow during cardiopulmonary resuscitation in dogs using simultaneous and non-simultaneous compression and ventilation. Circulation 1983;67:258 – 65. [16] Schleien CL, Dean MJ, Koehler RC, et al. Effect of epinephrine on cerebral and myocardial perfusion in an infant animal preparation of cardiopulmonary resuscitation. Circulation 1986; 73:809 – 17. [17] Stadjuhar K, Safar P, Steinberg R, et al. Cerebral Blood flow (CBF) and other benefits from wider use of open-chest cardiopulmonary resuscitation. Crit Care Med 1983;11:226. [18] Sanders AB, Kern KB, Atlas M, Bragg S, Ewy GA. Importance of the duration of inadequate coronary perfusion pressure on resuscitation from cardiac arrest. J Am Coll Cardiol 1985;6:113– 8
P. Suominen et al. / Resuscitation 36 (1998) 9–13 [19] Beaver BL, Colombani PM, Buck JR, Dudgeon DL, Bohrer LS, Haller JA. Efficacy of emergency room thoracotomy in pediatric trauma. J Ped Surg 1987;22:19–23. [20] Powell RW, Gill AL, Jurkovich GJ, Ramenofsky ML. Resuscitative thoracotomy in children and adolescents. Amer Surg 1988;54:188 – 91. [21] Ellenhorn MJ, Barceloux DG, editors. Medical Toxicology. New York: Elsevier Science, 1987.
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[22] Sabo RA, Hanigan WC, Flessner K, Rose J, Aaland M. Strangulation injuries in children. Part 1. Clinical analysis. J Trauma 1996;40:68 – 72. [23] Leibovici D, Shemer J, Shapira SC. Electrical injuries: current concepts. Injury 1995;26:623 – 7. [24] Fontarosa PB. Electrical shock and lightning stroke. Ann Emerg Med 1993;22:378 – 87.
Efficacy of cardiopulmonary resuscitation in pulseless paediatric trauma patients P. Suominen a,*, J. Ra¨sa¨nen b, A. Kivioja c a Department of Anaesthesia, Helsinki Uni6ersity Central Hospital, Haartmaninkatu 4, FIN-00290 Helsinki, Finland Hospital for Children and Adolescents, Paediatric Anaesthesia, Uni6ersity of Helsinki, Stenba¨ckinkatu 9, FIN-00290 Helsinki, Finland c Department of Orthopaedics and Traumatology, Helsinki Uni6ersity Central Hospital, Haartmaninkatu 4, FIN-00290 Helsinki, Finland b
Received 15 August 1997; received in revised form 18 August 1997; accepted 7 November 1997
Abstract Background: A study was designed to determine which paediatric trauma patients with no detectable vital signs are likely to benefit from cardiopulmonary resuscitation (CPR). Methods: A 10-year retrospective study of all pulseless patients under 16 years of age with trauma in whom CPR was initiated in a prehospital or in-hospital setting in Southern Finland. Results: Forty-one patients, 25 male and 16 female, were included in this study. The mean age was 7.8 years (range 0.1 – 15.9 years). Twenty three patients had blunt injuries and three patients had penetrating injuries. The mean Injury Severity Score was 51 (range 25 –75). In 15 patients, the arrest was secondary to smoke inhalation, strangulation or electric shock. Resuscitation was initiated at the scene or en route in 28 patients and in 13 patients at the hospital. Five patients received open-chest CPR and 36 patients closed-chest CPR. Spontaneous circulation was restored in four patients with open-chest CPR and in six patients with closed-chest CPR. Two patients had intact survival and one patient survived with moderate disability. The mechanism of traumatic cardiac arrest, initial cardiac rhythm or location of arrest did not seem to affect outcome of CPR. Conclusions: The overall survival rate of paediatric patients with cardiac arrest secondary to trauma is poor. Trauma patients in whom cardiac arrest is caused by respiratory arrest or by thoracoabdominal trauma in the hospital setting may have a chance of survival if a spontaneous circulation is rapidly restored with effective resuscitative measures. © 1998 Elsevier Science Ireland Ltd. Keywords: Paediatric; CPR; Trauma and cardiac arrest
1. Introduction Beyond the first year of life, trauma is the leading cause of prehospital cardiac arrest in paediatric patients [1,2]. Over 50% of all paediatric trauma deaths occur at the scene and 77% of victims die within the first 6 h [3]. The effectiveness of paediatric trauma care has been evaluated with the preventable death rate [4]. However, it is not known how often and under what conditions Abbre6iations: EMS, emergency medical systems; ALS, advanced life support; BLS, basic life support; CPR, cardiopulmonary resuscitation; OC-CPR, open-chest cardiopulmonary resuscitation; ISS, injury severity score; ROSC, restoration of spontaneous circulation. * Corresponding author. Tel.: + 358 9 4712540; fax: +358 9 4714017.
paediatric trauma patients with cardiac arrest could still be salvageable. Earlier studies have demonstrated that the value of resuscitation in patients with blunt trauma is limited [5,6], even though emergency thoracotomy and open-chest cardiopulmonary resuscitation (OC-CPR) have been shown useful in patients with penetrating torso trauma [7]. Few data are available on the efficacy of cardiopulmonary resuscitation (CPR) in pulseless paediatric patients with cardiac arrest secondary to smoke inhalation, electrocution and strangulation. The purpose of this study was to determine, which of the paediatric trauma patients who present with no detectable vital signs, are likely to benefit from CPR, and whether or not the location of the arrest has any effect on survival.
0300-9572/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 3 0 0 - 9 5 7 2 ( 9 7 ) 0 0 0 8 8 - 9
10
P. Suominen et al. / Resuscitation 36 (1998) 9–13
2. Patients and methods We included in the study all trauma patients under 16 years of age with no detectable vital signs in whom CPR was initiated in prehospital or in-hospital setting in the Province of Uusimaa. The original study sample included 347 trauma patients who required intensive care at the Helsinki University Central Hospital or who had autopsies at the Forensic Department of the University of Helsinki between January 1, 1985 and December 31, 1994 [3]. Injuries due to drowning, airway obstruction due to foreign bodies and intoxication (with the exception of smoke inhalation), were excluded [3]. Helsinki University Central Hospital is the tertiary trauma center of the Province of Uusimaa, to which all paediatric trauma patients requiring intensive care (including all successfully resuscitated patients) are referred. Altogether there were 121 pulseless trauma patients, but 80 (66.1%) patients were excluded because no CPR was initiated. The sophistication of the local emergency medical system (EMS) is variable according to the local geography. Outside Helsinki, the local EMS units were trained in basic life support (BLS) procedures and to all patients are taken to the nearest regional hospital or health center, where physicians started advanced life support (ALS). Two physician-staffed prehospital emergency care units operated 24 h a day in the study area. The city of Helsinki is served by a land-based unit, and the surrounding area by a helicopter team since 1992. The physicians providing these services are anaesthetists or other experienced ALS-trained physicians. Previously reported mean call to arrival times comparing BLS with ALS units were 9.0 versus 12.4 min in Helsinki, and 10.3 versus 23.1 min in the peripheral areas of Uusimaa province [1,8]. Cardiorespiratory arrest was defined as loss of consciousness, and absence of spontaneous ventilation and palpable pulses in major arteries. The first responding EMS unit initiated BLS in trauma patients with cardiac arrest unless obvious clinical signs of death, such as rigor mortis, postmortem lividity or mutilating unsurvivable trauma were detected. Resuscitation was either continued at the scene by a physician, or the patient was transported with ongoing CPR to the nearest hospital. In-hospital CPR was consistent with the current guidelines issued by the American Heart Association [9]. Open-chest CPR was not routinely used in our trauma system. An autopsy was conducted in all patients, in whom CPR was unsuccessful. The neurological status of the survivors was evaluated retrospectively from the hospital records using the Pediatric Overall Performance Category Scale [10] either at the time of discharge or 1 year after discharge if the category on discharge was other than good.
Records covering events prior to hospital admission, treatment at the hospital, and autopsy findings were reviewed to obtain information concerning patient demography, mechanism of injury, time and place of the arrest, initial cardiac rhythm, prehospital and hospital procedures, and outcome. Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) [11] were calculated for patients with blunt or penetrating trauma from data based on the first 24 h of hospitalisation, or from autopsy findings.
3. Results A total of 41 patients, 25 male and 16 female, fulfilled the inclusion criteria. The mean age was 7.8 years (range 0.1–15.9 years). The mechanisms of traumatic cardiac arrest are shown in Table 1. Blunt trauma was caused by a road traffic accident except in one case. All three patients with penetrating trauma had a stab injury. The mean Injury Severity Score of the patients with blunt and penetrating injuries was 51 (range 25– 75). Most of the patients arrested at the scene (Table 1). The initial cardiac rhythm was asystole in 60% of the patients in whom the initial rhythm was recorded (Table 1). The mean duration of CPR was 39 min (range 5–120 min). None of the 15 patients, who were transported with ongoing resuscitation to hospital survived.
Table 1 Characteristics and outcome of paediatric patients with traumatic cardiac arrest Total (n =41)
Circulation restored (n = 10)
Survival (n = 3)
Mechanism of injury Blunt Penetrating Other Strangulation Smoke inhalation Electrocution
23 3 15 8 5 2
8 1
2
1
1
Location of arrest Scene En route Emergency room Operating theater Psychiatric ward Intensive care unit Radiology suite
27 1 5 5 1 1 1
3 1
1
5 1
1 1
Initial cardiac rhythm Asystole PEA VF Bradycardia Not available
21 6 4 4 6
1
1
3 2 4
1 1
P. Suominen et al. / Resuscitation 36 (1998) 9–13 Table 2 Restoration of spontaneous circulation (ROSC) and outcome of resuscitation
Closed-chest CPR Open-chest CPR
Total
ROSC
Survival
36 5
6 4
2 1
Five of the 41 patients underwent emergency thoracotomy and received OC-CPR; spontaneous circulation was restored in four patients. One unsuccessful emergency thoracotomy was performed at the scene for a pulseless teenager with a stab injury of the heart and liver. The other four emergency thoracotomies were done in the operating theatre (Table 2). Five of the ten patients in whom spontaneous circulation returned, died within 24 h and two other patients within 5 days (Table 1). The mechanism of traumatic cardiac arrest, initial cardiac rhythm or location of arrest appeared not to affect outcome of CPR (Table 1). Open-chest CPR was associated with a higher primary success rate than closed-chest CPR, but the number of survivors was not significantly higher. Two patients survived intact, one had self-inflicted trauma by hanging and the other had haemorrhagic shock. The former had early and effective resuscitation initiated by nurses at the psychiatric institution and continued by a physician-staffed emergency care unit. The duration of CPR was 8 min. The latter arrested after massive bleeding from a spleen laceration in the operating theatre of a local hospital. The haemorrhage was rapidly controlled and OC-CPR was performed for a short period. One patient, who survived with moderate disability was run over by a tram and was trapped beneath it. This patient had cerebral contusion and fractures of the vertebral column and extremities; her airway was obstructed because of her head position. Spontaneous circulation was restored within 17 min of the accident after 5 min resuscitation.
4. Discussion This study shows that the overall survival rate of paediatric trauma patients with cardiac arrest remains low regardless of the mechanism of traumatic cardiac arrest, initial cardiac rhythm or the location of arrest. Cardiac arrest in children with trauma is due to severe bleeding or to hypoxia progressing over time. Hypoxia results in combined respiratory and metabolic acidosis, and the anoxic injury to the brain and other vital organs may be too severe to permit recovery [12]. The increased physiological reserve of the child allows the maintenance of nearly normal vital signs even in the presence of severe hypovolaemia, which complicates the
11
evaluation of the need for fluid resuscitation [13]. Thus hypotension is a late sign of shock in children. Hypotension can also be due to severe closed head injury. The presence of severe hypotension, defined as a systolic blood pressure of 50 mmHg or less, among paediatric trauma patients may indicate just as dismal an outcome as cardiac arrest [6]. On the other hand, apneic trauma patients with demonstrable pulses in the ER have been shown to have an outstanding survival [14]. Experimental data in animals show that closed-chest CPR produces very low levels of cerebral and myocardial blood flow—of the order of 3–9% of prearrest perfusion [15]. When closed-chest CPR was prolonged in infant piglets beyond 20 min, aortic pressure, cerebral and myocardial blood flow declined to near-zero values; with a continuous infusion of epinephrine, a higher perfusion pressure were maintained somewhat longer [16]. Open-chest CPR has been shown experimentally to produce a cerebral blood flow greater than 66% of the prearrest value, which can be maintained for up to 60 min [17]. However, OC-CPR has been shown experimentally to improve survival only if it is performed within 15–20 min after cardiac arrest [18]. In the study by Durham [7], patients with penetrating thoracoabdominal trauma had a chance of survival if the duration of prehospital CPR before an emergency thoracotomy was less than 9 min in intubated patients and less than 4 min in non-intubated. In an earlier study [1] of paediatric prehospital cardiac arrest with all aetiologies, a duration of CPR less than 15 min was the only factor associated with favorable outcome in a multivariate analysis. It has also been shown that the outcome of prolonged CPR in a normothermic paediatric patient, who does not respond quickly with restoration of spontaneous circulation, is death or severe disability [2]. In patients with blunt trauma emergency thoracotomy and OC-CPR have not been shown to be successful [5–7,19,20] and therefore emergency thoracotomy has not been recommended for patients with blunt trauma or asystole on arrival in the emergency room [5,7,19,20]. In an earlier study, which included patient of all ages with thoracoabdominal injuries, emergency thoracotomy resulted in survival rates of 15% and 7% for stab and gunshot wounds, respectively [7]. In the present study spontaneous circulation was restored in all the patients, who arrested in the emergency room or operating theatre and who received OC-CPR. One of these patients survived intact and three patients died. The one patient who received OC-CPR at the scene, did not survive. In the present and in earlier studies [5,6], the mean ISS values has varied from 33 to 53 in pediatric trauma patients with cardiac arrest. Thus ISS appears not to be a predictor of survival in patients who already have
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developed cardiac arrest. However, a low value for ISS in a deceased trauma patient may indicate that the patient could have been salvageable with early access to help from an optimally functioning EMS/Trauma system [4]. There are limited data available on the efficacy of CPR in paediatric patients, who have arrested because of smoke inhalation, strangulation or electrocution. Carbon monoxide is the most frequent cause of immediate fire deaths. Carbon monoxide levels at a fire may reach 10%, which can elevate the blood carboxyhemoglobin level to a fatal level within 1 min [21]. Cyanide is often also a component of smoke and has similar toxic cerebral and cardiovascular effects to carbon monoxide [21]. Strangulation causes hypoxic-ischaemic injury to the central nervous system [22]. In an electrical injury, AC and low voltage are associated with ventricular fibrillation, whereas highvoltage electric shocks provoke asystole. Respiratory arrest is usually a combined effect of tetanic paralysis of the respiratory muscles and damage to the respiratory center in the brain stem [23]. The chance of survival for an electric shock victim may be greater than for other causes of cardiac arrest [24]. In the present study, there was no successful resuscitation for patients with smoke inhalation or electrocution; this may be partly due to the small number of patients and time delay from the accident to the initiation of CPR. This study is limited by its retrospective nature and by the relatively small number of patients despite the 10-year study period. This reflects the extremely low incidence of traumatic cardiac arrest in Southern Finland. The large catchment area of the trauma center and the heterogeneous level EMS run sheets and hospital records made determination of time data and initial cardiac rhythm in some cases impossible. In conclusion although the prognosis of pulseless paediatric trauma patients is poor, a short period of closed-chest CPR should be initiated. A 20 min period of ALS is indicated in patients with witnessed arrest, because of the possibility that arrest resulted from airway obstruction and not from the trauma itself. A patent airway, preferably by endotracheal intubation, and proper ventilation should therefore be given utmost priority in the treatment of these patients. Patients with thoracoabdominal injuries who have in-hospital cardiac arrest may benefit from OC-CPR and immediate control of bleeding.
Acknowledgements This study was supported by the Laerdal Foundation for Acute Medicine and the Foundation for Orthopaedical and Traumatological Research in Finland. The authors would like to thank the staff from the archives
of Forensic Department of the University of Helsinki, To¨o¨lo¨ Hospital and Hospital for Children and Adolescents of Helsinki University Central Hospital for their valuable assistance in obtaining the patients’ records.
References [1] Suominen P, Korpela R, Kuisma M, Silfvast T, Olkkola KT. Paediatric cardiac arrest and resuscitation provided by physician staffed emergency care units. Acta Anest Scand 1997;41:260–5. [2] Hickey RW, Cohen DM, Strasbaugh S, Dietrich AM. Pediatric patients requiring CPR in the prehospital setting. Ann Emerg Med 1995;25:495 – 501. [3] Suominen P, Kivioja A, O8 hman J, Korpela R, Rintala R, Olkkola KT. Severe and fatal childhood trauma. Injury (in press). [4] Dykes EH, Spence LJ, Young JG, Bohn DJ, Filler RM, Wesson DE. Preventable pediatric trauma deaths in a metropolitan region. J Ped Surg 1989;24:107 – 11. [5] Sheikh A, Brogan T. Outcome and cost of open- and closedchest cardiopulmonary resuscitation in pediatric cardiac arrests. Pediatrics 1994;93:392 – 8. [6] Hazinski MF, Chahine AA, Holcomb GW III, Morris JA. Outcome of cardiovascular collapse in pediatric blunt trauma. Ann Emerg Med 1994;23:1229 – 35. [7] Durham LA III, Richardson RJ, Wall MJ, Pepe PE, Mattox KL. Emergency center thoracotomy: Impact of prehospital resuscitation. J Trauma 1992;32:775 – 9. [8] Suominen P, Silfvast T, Korpela R, Erosuo J. Pediatric prehospital care provided by a physician-staffed emergency medical helicopter unit in Finland. Pediatric Emerg Care 1996;12:169– 72. [9] American Heart Association; Emergency Cardiac Care Committee and Subcommittees. Guidelines for cardiopulmonary resuscitation and emergency care. J Am Med Assoc 1992; 268:2171 – 302. [10] AHA Medical/Scientific Statement. Recommended guidelines for uniform reporting of pediatric advanced life support: The pediatric Utstein style. Circulation 1995;7:2006 – 2020. [11] Association for the Advancement of Automotive Medicine. The Abbreviated Injury Scale 1990 Revision. Des Plaines, IL: AAAM, 1990. [12] Chameides L. CPR challenges in pediatrics. Ann Emerg Med 1993;22:388 – 92. [13] American College of Surgeons: Pediatric trauma. In: Advanced Trauma Life Support Course for Physicians, Student Manual. ed. 3. Chicago, IL: ACS, 1995:261 – 281. [14] Schoenfeld PS, Baker DM. Management of cardiopulmonary and trauma resuscitation in the pediatric emergency department. Pediatrics 1993;91:726 – 9. [15] Lucy JM, Ross BK, O’Quin RJ, et al. Regional blood flow during cardiopulmonary resuscitation in dogs using simultaneous and non-simultaneous compression and ventilation. Circulation 1983;67:258 – 65. [16] Schleien CL, Dean MJ, Koehler RC, et al. Effect of epinephrine on cerebral and myocardial perfusion in an infant animal preparation of cardiopulmonary resuscitation. Circulation 1986; 73:809 – 17. [17] Stadjuhar K, Safar P, Steinberg R, et al. Cerebral Blood flow (CBF) and other benefits from wider use of open-chest cardiopulmonary resuscitation. Crit Care Med 1983;11:226. [18] Sanders AB, Kern KB, Atlas M, Bragg S, Ewy GA. Importance of the duration of inadequate coronary perfusion pressure on resuscitation from cardiac arrest. J Am Coll Cardiol 1985;6:113– 8
P. Suominen et al. / Resuscitation 36 (1998) 9–13 [19] Beaver BL, Colombani PM, Buck JR, Dudgeon DL, Bohrer LS, Haller JA. Efficacy of emergency room thoracotomy in pediatric trauma. J Ped Surg 1987;22:19–23. [20] Powell RW, Gill AL, Jurkovich GJ, Ramenofsky ML. Resuscitative thoracotomy in children and adolescents. Amer Surg 1988;54:188 – 91. [21] Ellenhorn MJ, Barceloux DG, editors. Medical Toxicology. New York: Elsevier Science, 1987.
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[22] Sabo RA, Hanigan WC, Flessner K, Rose J, Aaland M. Strangulation injuries in children. Part 1. Clinical analysis. J Trauma 1996;40:68 – 72. [23] Leibovici D, Shemer J, Shapira SC. Electrical injuries: current concepts. Injury 1995;26:623 – 7. [24] Fontarosa PB. Electrical shock and lightning stroke. Ann Emerg Med 1993;22:378 – 87.