If you have experienced this type of call, you can easily understand that the combined emotional energy of the provider, parent and child is a recipe for substandard care, both on scene and en-route to the hospital.
The first question you should ask yourself is how comfortable are you staying on scene to treat an adult cardiac arrest patient? Instinctively, most pre-hospital providers say they feel very comfortable with this scenario and there is a growing trend towards staying on scene until either ROSC (return of spontaneous circulation) is achieved or until termination of resuscitation is determined.1 Several leading EMS agencies have implemented protocols with a 20 to 25 minute mandate for on-scene resuscitation. Progressive departments, such as Wake County EMS, consider 40 minutes to be appropriate for select patients. This evolution in adult care has led to significant improvements in outcomes, specifically with noted increases in neurologically intact survival.2 Staying on scene for adult arrests has become common practice and with the pit-crew approach to CPR, teams feel comfortable in their roles, and their urge to rush a non-ROSC patient to the hospital has subsided.
Does that scenario change when dealing with a pediatric patient on scene? Should it change? Consider a three-year-old patient in cardiac arrest due to a drowning. Imagine the tones going off at the station and dispatch informing you of an unconscious child without a pulse with CPR in progress. You have a six-minute response time to a private residence where a pool party was being held, and suddenly they seem like the longest 360 seconds of your life. Numerous thoughts are racing through your mind yet the overwhelming emotion is trepidation and fear. Stop for a moment to try and understand where that feeling originates in order to begin to unlock the mystery of the pediatric code. Some healthcare providers say that there is just too much anxiety on scene to stay and treat, or that emergency department physicians want the patients at the hospital as soon as possible. Others claim that it’s just easier to work in the back of the truck instead of pool side or in the house. The dichotomy between adult and pediatric resuscitative care is not hidden or secretive, it’s quite obvious but at the same time conveniently and surprisingly tolerated.
The algorithm for ventricular fibrillation, PEA and asystole are strikingly similar for adult and pediatric patients yet the aforementioned differences are palpable yet remain unchanged. In the early 90s, one of the most richly performed population studies on out-of-hospital pediatric cardiac arrest was completed to address the demography, epidemiology, management and outcome.3 Lead authors Paul Sirbaugh MD and Paul Pepe MD collected data on 300 pediatric arrests over a three year period. Seventy-one percent (213/300) of the arrests were not related to injury or drowning. Of these children, ROSC was obtained in 10 percent (22/213) with only one neurologically intact survivor (0.46%). Eighty-seven of the 300 out of hospital pediatric arrests were related to injury and submersion and ROSC was obtained in 12.6 percent of these patients. However, this group did not yield even one neurologically intact survivor.
Interestingly, the authors report in the same paper that 65 children had drowned and received bystander CPR. Forty-one of these children were breathing and had a pulse upon EMS arrival, and all 41 survived to hospital discharge. This clear message is not difficult to understand and underscores the significant importance of early BLS intervention. Highly trained providers in drowning management will frequently be first on scene with a simple BVM (not attached to oxygen) and begin rescue breathing along with rapid initiation of CPR. The Brazilians are most famous for their aggressive on scene management of drowning victims along Copacabana Beach and demonstrated a 30 percent reduction in drowning deaths from 1979 to 2003 (Abstract, World Conference on Drowning 2007).
So why do pre-hospital providers remain on scene for an adult arrest yet prefer “diesel fuel” for a pediatric arrest? The sequence for the adult arrest is very standard and a typical protocol, along with the pit crew approach leaves little doubt in the mind of the resuscitator. There are EMS systems who have prioritized even the smallest detail of on-scene resuscitation, even predetermining who will clear the furniture once the in-house “code room” has been designated. It is a coordinated standard of care that leaves very little to the imagination. The overall perception of this ACLS provider is of Clark Kent turning into Superman and the confidence is palpable. The family can sense it and often doesn’t even question why “it’s been 30 minutes and you’re still in my living room.” These are medics who own the room, own the algorithm, and have eyes that shout ,“We got this!” The reward for the patient, the system, and the community are higher ROSC rates, shorter times to reperfusion and significantly improved rates of neurologically intact survival.
Turn now to the sequence of the pediatric arrest; again let’s use the three-year old drowning. Think to yourself quickly what the volume (ml) of epinephrine 1:10,000 IV /IO would be for this child? How about the volume (ml) of amiodarone, calcium chloride or sodium bicarbonate? Now, while you are considering those questions you must simultaneously select the correct size of equipment, and your anxiety escalates even further. Now the image of the paramedic exiting the ambulance is less superhero and more the visage of a scared cat. If there is one thing that paramedics and emergency department physicians really hate, it’s the appearance of incompetence. This perception of inappropriate care is the equivalent of a horse stumbling out of the gate. An awful start, and contact with the patient still hasn’t occurred.
The stage is now set and all eyes are on you. Unfortunately, the “I got this” look has left the building as your sympathetic surge is now at its peak. As the perfect storm begins to form you are forced to reveal your insecurity by pulling out a measuring device in front of mom, dad and the seemingly endless number of bystanders. The tool you are using has the drugs listed as milligrams instead of milliliters and therefore math calculations are now required. Try for instance to quickly calculate the volume of adenosine, calcium chloride, sodium bicarbonate, fentanyl and D25 for a three-year old. Now try it using a calculator during a code simulation. Both are cumbersome, if not impossible.
To add icing on the cake, the astute provider will recognize that their medical protocols have noticeable differences when compared to the dosing recommendations printed on the length-based tape. The drugs, corresponding doses and routes mandated by the medical director are discordant to the tune of up to 50 percent in a study of over 40 EMS agencies in Florida (abstract pending). Furthermore several medication dosages are listed at three to 10 times higher than the EMS protocol dose (midazolam, fentanyl and epinephrine 1:1000) often due to the differing indications (induction, RSI and resuscitation respectively) required predominantly in the hospital setting.
Numerous peer-reviewed studies have been published detailing the pervasive problem of medication overdoses in the pediatric population. In 1999 the Institute of Medicine (IOM) published a landmark paper, “To Err is Human,” which concluded that nearly 100,000 fatal errors occur yearly in U.S. hospitals. That number was readjusted and in September 2013 was reported to be upwards of 400,000 (“Journal of Patient Safety”). These numbers do not include the non-fatal errors that lead to patient harm, a number that is estimated to be 10 times the death rate. Further studies have shown that the risk of an adverse event in the pediatric population is three times higher than their adult counterparts.4
The next dilemma in the provision of high quality pediatric care is medication administration. This is the step that is often never spoken of and rarely trained on. Take for example a four-month-old infant in cardiac arrest. The typical epinephrine 1:10,000 IV dose is 0.6 ml (0.06 mg) and should be provided using a one ml syringe. However, because the epinephrine is packaged in a 10 ml pre-filled syringe it must be transferred from one syringe to another. This task is difficult for those who haven’t practiced the procedure, and fumbling through it while the mother and father are watching doesn’t typically lead to a warm and fuzzy feeling.
Another excellent example of the pediatric medication administration dilemma is dextrose. A neonate should receive D10W while a three year old should get D25W. Most agencies carry D50W and therefore must dilute the 50 ml pre-filled syringe down to the desired concentration. This task requires multiple steps and is very difficult for most providers. Dr. Lara Rappaport (Denver Health) demonstrated this in a study presented at the 2014 NAEMSP assembly.
The success rate for dextrose administration was only 31.8 percent using the currently accepted length based tape.5 The authors also found that procedural errors were most common, occurring in 30.8 percent of scenarios. Frequent types of procedural errors included pushing the wrong dose (16.1%), and using the tape incorrectly (9.9%). Cognitive errors occurred in 38.2 percent of scenarios where providers used the currently accepted length based tape.6
The picture is becoming clear as these important details come to the forefront. If a paramedic is asked how many times they will allow themselves to feel this way before they are convinced they never want to be exposed again, the answer is a resounding “Once!” These human factors play a large part into the split second decisions that EMS providers must make on a daily basis. Unless these factors are mitigated, either through training or alternative mechanisms, the pediatric patient will continue to receive substandard pre-hospital care in comparison to the adult population.
The first insight into how to fix this problem comes from academic pediatric institutions. Ask most pediatric emergency medicine physicians how they estimate the weight of a pediatric patient and a majority will respond with “using age.” PEM physicians, being as proud as a paramedic when it comes to perception of skill, often refuse to use a measuring tool in front of the family. They also understand clearly that most medications have a large therapeutic window and decimal point accuracy is often unnecessary. Take for example EpiPen Jr®which consists of 0.15 mg of epinephrine. The package insert instructs parents to use the injectable on children between the ages of one to eight years old. The PEM physician’s ultimate goal is to provide rapid high quality care while avoiding the 10-fold overdose and is less concerned about fraction precision dosing. Age-based resuscitation provides that vehicle.
The Age-Old Question
If using age to determine weight mitigates the psychological forces during a pediatric resuscitation, can it be used safely in children? In 1988, the first Broselow tape paper was published in the Annals of Emergency Medicine (17:6). In that paper, Drs. Lubitz and Seidel stated that up until that time “most methods currently used to estimate body weight in children are based on age.” The American Academy of Pediatrics still recommends a formula for age-based resuscitation (APLS formula) yet the AHA’s PALS 2010 guidelines favors length based resuscitation even though several studies have called the practice to question.
In 2007, the American Academy of Pediatrics committee on Pediatric Emergency Medicine stated, “although helpful, the Broselow tape is not ideal.” Then in 2013 Dr. Young published a paper in the “American Journal of Emergency Medicine” describing an age based technique and concluded it was an acceptable alternative to the Broselow method for weight estimation in children aged one to nine years. The “finger counting” method he described also outperformed the traditional APLS formula in that same study.7
Our research confirms this finding in an abstract that will be presented in October at ACEP (Chicago, IL). We compared an age-based technique (Handtevy) against a CDC database (2,456 children) and evaluated performance against the Broselow length based tape. The Handtevy age-based system performed statistically better (p < 0.05) for underweight, normal weight, and obese children. With the Handtevy system, age is used to directly determine the volume (ml) of the eight most critically used drugs in pediatric resuscitation. It allows the pre-hospital providers to enter onto the scene with the doses predetermined.
Take for example the three-year-old drowning victim. Using the Handtevy method the provider quickly determines that the epinephrine 1:10,000 IV/IO dose is 1.5 ml. Now the psychological barriers to the pulseless child have been removed and the algorithm can proceed as it would for the adult code. The entry onto the scene is seamless and the family’s perception is that the right people are taking care of their child.
EMS agencies using this method have embraced this concept and have now turned their focus to medication administration, with specific attention to syringe size, transfer techniques and dilution methods. These techniques are critical for the first phase of resuscitation or with any critical patient requiring multiple medications. The Handtevy pediatric box is utilized throughout the call and uses the hybrid mechanism (age and/or length) described above. Each box is customized to the agency’s protocols and individualized medication books and equipment pouches are organized and stocked accordingly.
Age based pediatric resuscitation mitigates the critical barriers pervasive with length based methodology. The preponderance of the evidence in past and recent literature suggests that it may be time to pivot towards a new paradigm. The most striking data that should be used for a call to action are the out of hospital pediatric cardiac arrest survival numbers. Since 1980 the survival has remained at six percent (three percent infants and nine percent children and adolescents) as reported in part 14 of the PALS 2010 guideline.8 Adult resuscitation, on the other hand, has matured significantly over the past three decades with dramatic improvements in ROSC rates and neurologic survival. It is time to begin to swing the pendulum in the other direction.
We can conclude that out of hospital adult and pediatric resuscitation algorithms differ very little yet there are clear issues (psychological/cognitive/mechanical) that lead to highly variable on scene management strategies. Mitigation of these issues can create an equal playing field and ultimately lead to improved outcomes.
Pediatric arrest patients deserve the same opportunity to walk out of the hospital and to that end we must mandate on-scene resuscitation for at least two minutes (one round of CPR) before moving off scene. Proficient and confident teams will remain on scene until ROSC is achieved, similar to the expectation in the adult scenario, while others may consider staying on scene within the confines of the ambulance. While this may be a culture change that will be difficult to obtain, consideration of age-based resuscitation will facilitate the transition. Attention to outcomes must be the number one priority and department champions on every level are required for such a change to occur.
- 1. Salt Lake City “Pit Crew Approach” to Cardiac Arrest Proves Successful
- MICHAEL MCFALL, The Salt Lake Tribune | Tuesday, February 4, 2014
- McNally B Out-of-hospital cardiac arrest surveillance --- Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005--December 31, 2010. MMWR Surveill Summ. 2011 Jul 29;60(8):1-19.
- Sirbaugh PE, et. al, A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest. Ann Emerg Med. 1999 Feb;33(2):174-84.
- The Joint Commission. (April 11, 2008). Sentinel event alert, Issue 39: Preventing pediatric medication errors. The Joint Commission.
- Rappaport, L et. al, Comparison of Two Length Based Tape Systems for Pediatric Resuscitation. (Abstract) Prehospital Emergency Care 2014;18:125
- Adelgais, K et. al, Errors in Pediatric Prehospital Simulation Scenarios. E-PAS2014:1450.2, Platform Session: Quality Improvement: Better Process of Care (PAS, Vancouver)
- Young TP, et al, Finger counting: an alternative method for estimating pediatric weights, Am J Emerg Med (2013), http://doi.org/10.1016/j.ajem.2013.11.034
- Kleinman et al. Part 14: Pediatric Advanced Life Support 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S876-S908
Peter Antevy is EMS Medical Director: Davie Fire Rescue, South West Ranches Fire Rescue, American Ambulance Services. He is an EMS Associate Medical Director: Coral Springs Fire Rescue, Plantation Fire Rescue, Seminole Tribe Fire Rescue, Margate Fire Rescue, Sunrise Fire Rescue and Miramar Fire Rescue. Antevy serves as Medical Director: Broward College EMS Programand is Pediatric Emergency Medicine Physician: Joe Dimaggio Childrens Hospital. He is founder and Chief Medical Officer: Pediatric Emergency Standards, Inc. Antevy is Associate Professor of Pediatrics: Florida Atlantic University School of Medicine.