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Shi D, McLaren C, Evans C. Neurological outcomes after traumatic cardiopulmonary arrest: a systematic review. Trauma Surg Acute Care Open 2021; 6:e000817. [PMID: 34796272 PMCID: PMC8573669 DOI: 10.1136/tsaco-2021-000817] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/10/2021] [Indexed: 12/26/2022] Open
Abstract
Background Despite appropriate care, most patients do not survive traumatic cardiac arrest, and many survivors suffer from permanent neurological disability. The prevalence of non-dismal neurological outcomes remains unclear. Objectives The aim of the current review is to summarize and assess the quality of reporting of the neurological outcomes in traumatic cardiac arrest survivors. Data sources A systematic review of Embase, Medline, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and ProQuest databases was performed from inception of the database to July 2020. Study eligibility criteria Observational cohort studies that reported neurological outcomes of patients surviving traumatic cardiac arrest were included. Participants and interventions Patients who were resuscitated following traumatic cardiac arrest. Study appraisal and synthesis methods The quality of the included studies was assessed using ROBINS-I (Risk of Bias in Non-Randomized Studies - of Interventions) for observational studies. Results From 4295 retrieved studies, 40 were included (n=23 644 patients). The survival rate was 9.2% (n=2168 patients). Neurological status was primarily assessed at discharge. Overall, 45.8% of the survivors had good or moderate neurological recovery, 29.0% had severe neurological disability or suffered a vegetative state, and 25.2% had missing neurological outcomes. Seventeen studies qualitatively described neurological outcomes based on patient disposition and 23 studies used standardized outcome scales. 28 studies had a serious risk of bias and 12 had moderate risk of bias. Limitations The existing literature is characterized by inadequate outcome reporting and a high risk of bias, which limit our ability to prognosticate in this patient population. Conclusions or implications of key findings Good and moderate neurological recoveries are frequently reported in patients who survive traumatic cardiac arrest. Prospective studies focused on quality of survivorship in traumatic arrest are urgently needed. Level of evidence Systematic review, level IV. PROSPERO registration number CRD42020198482.
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Affiliation(s)
- Daniel Shi
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Christie McLaren
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Chris Evans
- Emergency Medicine, Queen's University, Kingston, Ontario, Canada
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Carlisle EM, Bagwell CE. Ethical challenges with decisions to withhold or withdraw resuscitation in pediatric surgery. Semin Pediatr Surg 2021; 30:151096. [PMID: 34635284 DOI: 10.1016/j.sempedsurg.2021.151096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Providers often dispute the ethical equivalence of withholding and withdrawing care, despite theoretical frameworks that support equivalency. We highlight two cases, one where providers express concern with initiation of aggressive resuscitation and another where providers experience emotional distress from the decision to cease resuscitation. Both cases illustrate how the ethical challenges encountered can result in high levels of provider distress. Mitigation of this moral distress by team members will require an improved understanding of available evidence in the literature and active discussion by debriefing after a child dies. Medical staff and national organizations can help recognize that these patient events contribute to provider burnout and facilitate the design and support of programs to increase provider resiliency.
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Affiliation(s)
- Erica M Carlisle
- Department of Surgery, Division of Pediatric Surgery, University of Iowa Hospitals and Clinics, USA; Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, USA.
| | - Charles E Bagwell
- Department of Surgery, Division of Pediatric Surgery, Virginia Commonwealth University/Medical College of Virginia, USA
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Smith AD, Hudson J, Moore LJ, Scalea TM, Brenner ML. Resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporization of hemorrhage in adolescent trauma patients. J Pediatr Surg 2020; 55:2732-2735. [PMID: 32912618 DOI: 10.1016/j.jpedsurg.2020.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/06/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as an alternative technique for traumatic hemorrhage control in the adult population. The purpose of this study is to describe the details of REBOA placement in adolescent trauma patients. METHODS Patients 18 years of age or less who received REBOA for aortic occlusion (AO) from August 2013 to February 2017 at 2 urban tertiary care centers were included. RESULTS 7 adolescent trauma patients received REBOA by trauma surgeons for both blunt (n = 4) and penetrating mechanisms (n = 3); mean age was 17 + 1.5 years, mean admission lactate 13.0 + 4.85 mmol/L, and mean Hgb 10.7 + 2.7 g/dL. 3 patients received REBOA through a 12Fr sheath and 4 through a 7Fr sheath. AO occurred mostly at the distal thoracic aorta (Zone I) (85.7%) and also in the distal abdominal aorta (Zone III) (14.3%). 57% of patients were in arrest with ongoing CPR at the time of REBOA. In-hospital mortality was 57%; all of these patients were in arrest at the time of REBOA, had return of spontaneous circulation (ROSC), and survived to the operating room. No complications from REBOA were identified. CONCLUSION REBOA appears to be feasible for use in adolescents despite their smaller caliber vessels, even with use of a 12Fr sheath. REBOA results in improved physiology and can bridge adolescent trauma patients presenting in extremis to the operating room. TYPE OF STUDY Treatment/therapeutic study LEVEL OF EVIDENCE: Level IV.
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Affiliation(s)
- Alexis D Smith
- Children's Healthcare of Atlanta, Department of Pediatric Surgery, 5461 Meridian Mark Rd Suite 570, Atlanta, GA 30342.
| | - Jessica Hudson
- University of Texas Health Sciences Center at Houston, Department of Surgery, 6550 Fannin Street #583, Houston, TX 77030
| | - Laura J Moore
- University of Texas Health Sciences Center at Houston, Department of Surgery, 6550 Fannin Street #583, Houston, TX 77030
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, Department of Surgery, 22 South Greene Street, Baltimore, MD 21201
| | - Megan L Brenner
- University of California Riverside, Department of Surgery, 26520 Cactus Avenue Moreno Valley, CA 92555
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Monsieurs K, Nolan J, Bossaert L, Greif R, Maconochie I, Nikolaou N, Perkins G, Soar J, Truhlář A, Wyllie J, Zideman D. Kurzdarstellung. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0097-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Nikolaou NI, Perkins GD, Soar J, Truhlář A, Wyllie J, Zideman DA, Alfonzo A, Arntz HR, Askitopoulou H, Bellou A, Beygui F, Biarent D, Bingham R, Bierens JJ, Böttiger BW, Bossaert LL, Brattebø G, Brugger H, Bruinenberg J, Cariou A, Carli P, Cassan P, Castrén M, Chalkias AF, Conaghan P, Deakin CD, De Buck ED, Dunning J, De Vries W, Evans TR, Eich C, Gräsner JT, Greif R, Hafner CM, Handley AJ, Haywood KL, Hunyadi-Antičević S, Koster RW, Lippert A, Lockey DJ, Lockey AS, López-Herce J, Lott C, Maconochie IK, Mentzelopoulos SD, Meyran D, Monsieurs KG, Nikolaou NI, Nolan JP, Olasveengen T, Paal P, Pellis T, Perkins GD, Rajka T, Raffay VI, Ristagno G, Rodríguez-Núñez A, Roehr CC, Rüdiger M, Sandroni C, Schunder-Tatzber S, Singletary EM, Skrifvars MB, Smith GB, Smyth MA, Soar J, Thies KC, Trevisanuto D, Truhlář A, Vandekerckhove PG, de Voorde PV, Sunde K, Urlesberger B, Wenzel V, Wyllie J, Xanthos TT, Zideman DA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary. Resuscitation 2015; 95:1-80. [PMID: 26477410 DOI: 10.1016/j.resuscitation.2015.07.038] [Citation(s) in RCA: 568] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Koenraad G Monsieurs
- Emergency Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, Bristol, UK
| | | | - Robert Greif
- Department of Anaesthesiology and Pain Medicine, University Hospital Bern, Bern, Switzerland; University of Bern, Bern, Switzerland
| | - Ian K Maconochie
- Paediatric Emergency Medicine Department, Imperial College Healthcare NHS Trust and BRC Imperial NIHR, Imperial College, London, UK
| | | | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jonathan Wyllie
- Department of Neonatology, The James Cook University Hospital, Middlesbrough, UK
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Maconochie IK, Bingham R, Eich C, López-Herce J, Rodríguez-Núñez A, Rajka T, Van de Voorde P, Zideman DA, Biarent D, Monsieurs KG, Nolan JP. European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2015; 95:223-48. [DOI: 10.1016/j.resuscitation.2015.07.028] [Citation(s) in RCA: 217] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Wyrick DL, Dassinger MS, Bozeman AP, Porter A, Maxson RT. Hemodynamic variables predict outcome of emergency thoracotomy in the pediatric trauma population. J Pediatr Surg 2014; 49:1382-4. [PMID: 25148742 DOI: 10.1016/j.jpedsurg.2014.03.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 03/19/2014] [Accepted: 03/25/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Limited data exist regarding indications for resuscitative emergency thoracotomy (ETR) in the pediatric population. We attempt to define the presenting hemodynamic parameters that predict survival for pediatric patients undergoing ETR. METHODS We reviewed all pediatric patients (age <18years), entered into the National Trauma Data Bank from 2007 to 2010, who underwent ETR within one hour of ED arrival. Mechanism of injury and hemodynamics were analyzed using Chi squared and Wilcoxon tests. RESULTS 316 children (70 blunt, 240 penetrating) underwent ETR, 31% (98/316) survived to discharge. Less than 5% of patients survived when presenting SBP was ≤50mmHg or heart rate was ≤70bpm. For blunt injuries there were no survivors with a pulse ≤80bpm or SBP ≤60mmHg. When survivors were compared to nonsurvivors, blood pressure, pulse, and injury type were statistically significant when treated as independent variables and in a logistic regression model. CONCLUSIONS When ETR was performed for SBP ≤50mmHg or for heart rate ≤70bpm less than 5% of patients survived. There were no survivors of blunt trauma when SBP was ≤60mmHg or pulse was ≤80bpm. This review suggests that ETR may have limited benefit in these patients.
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Affiliation(s)
- Deidre L Wyrick
- Department of Pediatric Surgery, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR 72202, USA.
| | - Melvin S Dassinger
- Department of Pediatric Surgery, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR 72202, USA
| | - Andrew P Bozeman
- Department of Pediatric Surgery, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR 72202, USA
| | - Austin Porter
- Arkansas Department of Health, Little Rock, AR 72202, USA
| | - R Todd Maxson
- Department of Pediatric Surgery, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR 72202, USA
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Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Ann Emerg Med 2014; 63:504-15. [PMID: 24655460 DOI: 10.1016/j.annemergmed.2014.01.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This multiorganizational literature review was undertaken to provide an evidence base for determining whether or not recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care, because the evidence suggests that either death or a poor outcome is inevitable.
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Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Pediatrics 2014; 133:e1104-16. [PMID: 24685948 DOI: 10.1542/peds.2014-0176] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.
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McFadyen JG, Ramaiah R, Bhananker SM. Initial assessment and management of pediatric trauma patients. Int J Crit Illn Inj Sci 2012. [PMID: 23181205 PMCID: PMC3500003 DOI: 10.4103/2229-5151.100888] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Injury is the leading cause of death and disability in children. Each year, almost one in six children in the United States require emergency department (ED) care for the treatment of injuries, and more than 10,000 children die from injuries. Severely injured children need to be transported to a facility that is staffed 24/7 by personnel experienced in the management of children, and that has all the appropriate equipment to diagnose and manage injuries in children. Anatomical, physiological, and emotional differences between adults and children mean that children are not just scaled-down adults. Facilities receiving injured children need to be child and family friendly, in order to minimize the psychological impact of injury on the child and their family/carers. Early recognition and treatment of life-threatening airway obstruction, inadequate breathing, and intra-abdominal and intra-cranial hemorrhage significantly increases survival rate after major trauma. The initial assessment and management of the injured child follows the same ATLS® sequence as adults: primary survey and resuscitation, followed by secondary survey. A well-organized trauma team has a leader who designates roles to team members and facilitates clear, unambiguous communication between team members. The team leader stands where he/she can observe the entire team and monitor the “bigger picture.” Working together as a cohesive team, the members perform the primary survey in just a few minutes. Life-threatening conditions are dealt with as soon as they are identified. Necessary imaging studies are obtained early. Constant reassessment ensures that any deterioration in the child's condition is picked up immediately. The secondary survey identifies other injuries, such as intra-abdominal injuries and long-bone fractures, which can result in significant hemorrhage. The relief of pain is an important part of the treatment of an injured child.
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Affiliation(s)
- J Grant McFadyen
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
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