A quick side-by-side comparison of Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) reveals algorithms that are nearly identical.
A quick side-by-side comparison of Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) reveals algorithms that are nearly identical. Asystole and Pulseless Electrical Activity (PEA) need high quality CPR plus epinephrine whereas ventricular fibrillation requires an additional drug and electricity. The only differences in treatment relate to equipment sizes and drug dosing. Remove the math from that equation and you are left with two documents that are near mirror images. While the etiologies may differ, the primary concern of EMS providers and adult trained emergency medicine physicians is recognition and treatment.
The terms “pediatric” and “stroke” intuitively feel wrong together and seem to not even belong in the same sentence. Mention a pediatric case of cerebral ischemia to your colleague and chances are they will look at you with a surprised look. A recent abstract presented at the International Stroke Conference in San Diego sheds some light on the pediatric brain attack. Investigators firmly concluded that pediatric strokes present the same as in adults and should be treated the same by caregivers and EMS providers. Dare I say again that kids are just little adults? Yes, and as the picture becomes more clear it appears that the biggest delay in treatment is caused by lack of awareness by parents, EMS and emergency departments around the country.
This breakthrough research presented by Mark MacKay, MD enforces the fact that infants and children have strokes that present similarly to adults: sudden weakness or numbness of the face, arm or leg, sudden difficulty speaking, seeing or walking, dizziness or sudden onset of headache. Seizures are also common in pediatric stroke, although more so in infants than in any other age group. Surprisingly, however, parents do not associate these warning signs with stroke1. This data provides the first clues as to why, historically, children have had such a long delay to diagnosis, in most cases up to 35 hours2. Conversely, the same symptoms in an adult would more than likely lead to a “call for help,” and this is thought to be a direct result of the powerful educational campaign (F.A.S.T) by the American Heart Association (AHA) aimed towards the general public.
F.A.S.T is the AHA’s comprehensive campaign that instructs the layperson to detect a stroke without the need to speak to them, for obvious reasons. The focus is on the body language of a stroke victim while also emphasizing the importance of time. What better campaign to also use on the segment of the population who can’t speak to begin with, small children? Again, we’ve circled back to this concept of “kids are just little adults.” It’s a concept that makes perfect sense, again - to the right audience, specifically parents, EMS personnel and adult emergency department (ED) physicians.
In the aforementioned study most of the parents of children with strokes thought that the symptoms were serious yet only about a half called 911. Of further interest, only 36 percent of parents considered the possibility of a stroke while 21 percent had a wait and see attitude or called a relative prior to taking emergency action1.
Pediatric Risk Factors
While stroke can occur in otherwise well children with no prior medical history, the pre-hospital provider should be aware of the at risk groups. Infants and children with cardiac disease are at high risk for a CVA (stroke), with the etiology dependent mainly on the specific cardiac issue. One specific example of stroke due to a cardiac etiology is that of a patent foramen ovale (PFO). The foramen ovale is a small hole located in the atrial septum of the unborn fetus. At birth this hole should close once circulation converts from right to left, to left to right. If this hole does not close a chance exists for a clot to cross the septum (right to left) during times when there is increased pressure in the chest, straining during a bowel movement, coughing or sneezing, to name a few. The prevalence of PFO is reported to be 25 percent in the general population. If a young patient has a stroke without known risk factors, studies show that the likelihood of PFO being the etiology climbs to 48 percent3. As a clinical pearl, patients with a PFO are at high risk from air embolism when small air bubbles enter the circulation via improperly handled IV tubing. While a relatively large volume of air (5-8 ml/kg body weight) can be tolerated in the RV and pulmonary artery, as little as 0.5 ml of air can be lethal when entered into the left side of circulation4,5. Well known New England Patriots linebacker TedyBruschi, 31, was reported to have suffered a stroke secondary to a PFO6.
Sickle Cell Disease (SCD) patients should also be considered high risk for brain attack. EMS providers must pay close attention to the neurologic exam in these children as often times the findings may be subtle. Patients and parents are not likely to state weakness as their chief complaint, leaving the health care provider as the only safety net.
Other common risk factors for stroke in children are diseases of the arteries, acute or chronic head and neck disorders, abnormal blood clotting and infection. Preliminary results of the VIPS (vascular effects of infection in pediatric stroke) study, presented at the 2014 International Stroke Conference, showed that recent infection conferred increased risk of childhood acute ischemic stroke (AIS). Routine vaccinations appeared to be protective in that same study7. Investigators reported an odds ratio of 47 for stroke cases reporting an infection within a week of development of symptoms.
Time Delay a Major Hurdle
For adults IV rtPA is a time sensitive intervention and therefore is a major quality measure for high quality stroke systems of care. Door to needle times are reported by all stroke centers and can lead to significant improvement in morbidity and mortality. Time is brain and the AHA has educated the public as well as health care providers to move as quickly as possible. The same thing needs to happen for the pediatric population. Although IV rtPA is not licensed for use in children, many pediatric hospitals have protocols that allow for off-label use. A prospective trial is underway in order to determine the safety and most appropriate dose for pediatric patients. The major hurdle, however, is that most pediatric stroke patients are not diagnosed as such for hours past the four-hour threshold required for IV rtPA use. Four different studies showed that the average time to stroke diagnosis in children was approximately 24 hours. Such delays make treatment success improbable while raising the likelihood of long term morbidity. Stroke remains one of the top 10 causes of death in children and over 50 percent of pediatric stroke victims suffer long term disability. The time is now to begin to educate parents and providers alike that stroke is not just a disease of elderly people. It knows no boundaries and must be taken seriously. In order to improve outcomes, education should be focused on the following three areas:
- Parental awareness
- Pre-hospital awareness
- ED physician awareness
Like adults with stroke, pediatric patients benefit the most when treated at pediatric centers with the full compliment of specialties required to treat the disease. The list is lengthy and includes the following specialties: Emergency department, neurology, pharmacy, respiratory therapy, radiology, neurosurgery, interventional radiology, cardiology, anesthesiology and critical care. Transport directly to these facilities is beneficial yet may not be feasible due to the scarcity of such institutions. Receiving hospitals should prepare for these patients and transfer them to a predetermined pediatric stroke center. It is not uncommon for a center with a higher volume of pediatric stroke patients to be more liberal with off label treatment protocols such as IV rtPA and endovascular clot removal. The decision to use these modalities is typically institutional, and transfer decisions should have these issues in mind in order to maximize outcomes. Treatment for pediatric stroke care varies considerably and is likely to be different at every hospital in this country. EMS agencies have the opportunity to push for enhanced pediatric stroke care by meeting with local hospital partners and discussing pediatric stroke care. Hospital specific pediatric stroke protocols greatly enhance the care received by patients and should be mandatory for those centers claiming to be pediatric stroke centers. The arrival of a pediatric stroke patient to that hospital should trigger multiple events via overhead alert and group paging. Mobilization of personnel should mirror that of the adult stroke patient.
FAST is an acronym used as a mnemonic to help detect and enhance responsiveness to stroke victim needs. The acronym stands for Facial drooping, Arm weakness, Speech difficulties and Time.
- Facial drooping: A section of the face, usually only on one side, that is drooping and hard to move
- Arm weakness: The inability to raise one’s arm fully
- Speech difficulties: An inability or difficulty to understand or produce speech
- Time: Time is of the essence when having a stroke, and an immediate call to emergency services or trip to the hospital is recommended
The Age-Old Question
To complicate matters even further, many EMS agencies and hospitals differ in their definition of “child.” Some hospitals will label a child a medical patient up until their 18th birthday, yet for trauma the cutoff changes at 16 years of age. So the adult trauma surgeons will have privileges to treat a 17-year-old stabbing victim, yet that same adolescent with symptoms of a stroke will be turned away because “he’s not an adult, and we can’t treat him here!” EMS personnel are often confused by these arbitrary cutoffs and struggle with destination decisions, particularly when stroke is suspected. PALS guidelines clearly reflect that children can be treated as adults once they demonstrate signs of puberty (axillary hair in males or breast development in females8. Technically then, the 17-year-old pubertal adolescent should be treated by EMS as an adult, transported to an adult stroke facility and treated as such by the physicians. Unfortunately, this seemingly straightforward case becomes a complicated mess with the patient at the receiving end of substandard care due to significant time delays or unnecessary transfers.
The Road Ahead
A major emphasis must be placed on public awareness of pediatric stroke. The AHA must include pediatric stroke in the same campaign as for adults. Physicians and sub-specialists must educate parents of at-risk children about the signs and symptoms of pediatric stroke. EMS personnel need to keep pediatric stroke high on their list of potential problems, specifically in high-risk children and also in those who present with classic stroke symptoms. The concept that “kids don’t get strokes” should be revised to “kids absolutely get strokes,” and did I mention that kids are just little adults? Next, ED physicians must be given the same awareness education and should immediately consider transfer to a pediatric center that is a stroke center in practice, not just in name. Pediatric centers with stroke protocols typically are not shy about advertising it since the investment is quite significant. Furthermore, EMS departments should insist on high quality pediatric stroke care for their patients and should divert suspected cases to hospitals that have implemented a stroke system of care.
Are Kids Really Just Little Adults?
After over a decade in practice as a pediatric emergency physician and five years as an EMS medical director I have concluded that the following two groups should treat kids like little adults: EMS and adult ED physicians. To these groups there is no benefit in viewing the “smaller” population as any different than their larger counterparts. I feel strongly that the idiosyncrasies of pediatric care should be left to the pediatric sub-specialists. To those groups, kids should be viewed as completely different than adults. They should be adept at teasing out particular etiologies and tailoring treatment to their patient’s specific needs. The initial triage and treatment of the critical pediatric patient by EMS and adult ED physicians should be straightforward and consistent and should focus on rapid stabilization and transfer to a pediatric center with demonstrable outcomes.
- MacKay, M. More awareness, fast response key to combating stroke in children. American Stroke Association Meeting Report: Abstract: 41. Feb 2014.
- Gabis LV et al. Time lag to diagnosis of stroke in children. Pediatrics. 2002 Nov;110(5):924-8.
- Alsheikh-Ali, A. Patent foramen ovale in cryptogenic stroke, incidental or pathogenic?Stroke. 2009; 40: 2349-2355
- Orebaugh SL. Venous air embolism: clinical and experimental considerations. Crit Care Med. 1992;20:1169–77.
- Olmedilla L, Garutti I, Pérez-Pe’a J, Sanz J, Teigell E, Avellanal M. Fatal paradoxical air embolism during liver transplantation. Br J Anaesth. 2000;84:112–4.
- Unknown Author. TedyBruschi: After Tragedy, a Chance to Make History. http://bleacherreport.com
- Hills, NK.Infection, Vaccination, and Childhood Stroke: Preliminary Results of the Vascular Effects of Infection in Pediatric Stroke (VIPS) Study. American Stroke Association Meeting Report: Abstract: 39. Feb 2014.
- Berg, MD et al. 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science. Circulation. 2010; 122: S862-S875
Peter Antevy is an 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 Program and 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.