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Seesink J, van der Wielen W, Dos Reis Miranda D, Moors XJ. Successful prehospital ECMO in drowning resuscitation after prolonged submersion. Resusc Plus 2024; 19:100685. [PMID: 38957704 PMCID: PMC11217753 DOI: 10.1016/j.resplu.2024.100685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 05/23/2024] [Accepted: 05/27/2024] [Indexed: 07/04/2024] Open
Abstract
An 18-year-old drowning victim was successfully resuscitated using prehospital veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Despite 24 min of submersion in water with a surface temperature of 15 °C, the patient was cannulated on-scene and transported to a trauma center. After ICU admission on VA-ECMO, he was decannulated and extubated by day 5. He was transferred to a peripheral hospital on day 6 and discharged home after 3.5 weeks with favorable neurological outcome of a Cerebral Performance Categories (CPC) score of 1 out of 5. This case underscores the potential of prehospital ECMO in drowning cases within a well-equipped emergency response system.
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Affiliation(s)
- Jeroen Seesink
- Department of Anaesthesiology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | | | - Dinis Dos Reis Miranda
- Helicopter Emergency Medical Services, Trauma Centre Zuid-West Nederland, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
- Department of Intensive Care, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Xavier J.R. Moors
- Department of Anaesthesiology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
- Helicopter Emergency Medical Services, Trauma Centre Zuid-West Nederland, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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Scaife JH, Hewes HA, Iantorno SE, Clinker CE, Fenton SJ, Skarda DE, Kastenberg ZJ, Swendiman RA, Russell KW. Optimizing patient selection for ECMO after pediatric hypothermic cardiac arrest. Injury 2024:111731. [PMID: 39048398 DOI: 10.1016/j.injury.2024.111731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 06/12/2024] [Accepted: 07/14/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND In 2004, our level 1 regional pediatric trauma center created a protocol to activate ECMO for children with suspected hypothermic cardiac arrest based on inclusion criteria: serum potassium ≤9, submersion <90 min, and core body temperature <30 °C. In 2017, Pasquier et al. developed a model to help predict the survival of adults after hypothermic cardiac arrest (HOPE score) that has not been validated in children. We sought to apply this score to our pediatric patient population to determine if it can optimize our patient selection. METHODS This was a retrospective review of all patients cannulated onto VA ECMO for hypothermic cardiac arrest between 2004 and 2022. We used abstracted data points to calculate the HOPE score for our patient population, both with and without presumed asphyxia. RESULTS Over 19 years, 18 patients were cannulated for suspected hypothermic arrest, with three survivors (17 %). The HOPE score survival prediction ranged from 1 to 86 % with presumed asphyxia and 6-98 % without presumed asphyxia. Survivor HOPE scores ranged from 9 to 86 % with presumed asphyxia and 42-98 % without presumed asphyxia. Non-survivors' scores ranged 1-29 % with asphyxia and 6-57 % without asphyxia. A cutoff of >5 % predicted survival with asphyxia for ECMO could have decreased our cannulations by half without missing survivors. CONCLUSION ECMO can be a lifesaving measure for specific children after hypothermic arrest. However, identifying the patients that will benefit from this resource-intensive intervention remains difficult. HOPE score utilization may decrease the rate of futile cannulation in children, but multi-centered research is needed in the pediatric population.
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Affiliation(s)
- Jack H Scaife
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Hilary A Hewes
- Department of Pediatric Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Stephanie E Iantorno
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Christopher E Clinker
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Stephen J Fenton
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - David E Skarda
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Zachary J Kastenberg
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Robert A Swendiman
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Katie W Russell
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
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Santos-Folgar M, Fernández-Méndez F, Otero-Agra M, Barcala-Furelos R, Rodríguez-Núñez A. Is It Feasible to Perform Infant CPR during Transfer on a Stretcher until Cannulation for Extracorporeal CPR? A Randomization Simulation Study. CHILDREN (BASEL, SWITZERLAND) 2024; 11:865. [PMID: 39062314 PMCID: PMC11276386 DOI: 10.3390/children11070865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) improves infant survival outcomes after cardiac arrest. If not feasible at the place of arrest, victims must be transported to a suitable room to perform ECMO while effective, sustained resuscitation maneuvers are performed. The objective of this simulation study was to compare the quality of resuscitation maneuvers on an infant manikin during simulated transfer on a stretcher (stretcher test) within a hospital versus standard stationary resuscitation maneuvers (control test). METHODS A total of 26 nursing students participated in a randomized crossover study. In pairs, the rescuers performed two 2 min tests, consisting of five rescue breaths followed by cycles of 15 compressions and two breaths. The analysis focused on CPR variables (chest compression and ventilation), CPR quality, the rate of perceived exertion and the distance covered. RESULTS No differences were observed in the chest compression quality variable (82 ± 10% versus 84 ± 11%, p = 0.15). However, significantly worse values were observed in the test for ventilation quality on the stretcher (18 ± 14%) compared to the control test (28 ± 21%), with a value of p = 0.030. Therefore, the overall CPR quality was worse in the stretcher test (50 ± 9%) than in the control test (56 ± 13%) (p = 0.025). CONCLUSIONS Infant CPR performed by nursing students while walking alongside a moving stretcher is possible. However, in this model, the global CPR quality is less due to the low ventilation quality.
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Affiliation(s)
- Myriam Santos-Folgar
- REMOSS Research Group, Faculty of Education and Sport Sciences, Universidade de Vigo, 36005 Pontevedra, Spain
- School of Nursing, Universidade de Vigo, 36001 Pontevedra, Spain
- Department of Obstetrics, Complexo Hospitalario of Pontevedra, Sergas, 36001 Pontevedra, Spain
| | - Felipe Fernández-Méndez
- REMOSS Research Group, Faculty of Education and Sport Sciences, Universidade de Vigo, 36005 Pontevedra, Spain
- School of Nursing, Universidade de Vigo, 36001 Pontevedra, Spain
- CLINURSID Research Group, Psychiatry Radiology Public Health Nursing and Medicine Department, Universidade de Santiago de Compostela, 15705 Galicia, Spain
| | - Martín Otero-Agra
- REMOSS Research Group, Faculty of Education and Sport Sciences, Universidade de Vigo, 36005 Pontevedra, Spain
- School of Nursing, Universidade de Vigo, 36001 Pontevedra, Spain
| | - Roberto Barcala-Furelos
- REMOSS Research Group, Faculty of Education and Sport Sciences, Universidade de Vigo, 36005 Pontevedra, Spain
- CLINURSID Research Group, Psychiatry Radiology Public Health Nursing and Medicine Department, Universidade de Santiago de Compostela, 15705 Galicia, Spain
- Simulation and Intensive Care Unit of Santiago (SICRUS) Research Group, Health Research Institute of Santiago, University Hospital of Santiago de Compostela—CHUS, 15706 Santiago de Compostela, Spain
- Collaborative Research Network Orientated to Health Results (RICORS), Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Antonio Rodríguez-Núñez
- CLINURSID Research Group, Psychiatry Radiology Public Health Nursing and Medicine Department, Universidade de Santiago de Compostela, 15705 Galicia, Spain
- Simulation and Intensive Care Unit of Santiago (SICRUS) Research Group, Health Research Institute of Santiago, University Hospital of Santiago de Compostela—CHUS, 15706 Santiago de Compostela, Spain
- Collaborative Research Network Orientated to Health Results (RICORS), Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Faculty of Nursing, Universidade de Santiago de Compostela, 15705 Santiago de Compostela, Spain
- Paediatric Critical Intermediate and Palliative Care Section, Hospital Clínico Universitario de Santiago de Compostela, Sergas, 15706 Santiago de Compostela, Spain
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Bilodeau KS, Gray KE, McMullan DM. Extracorporeal cardiopulmonary resuscitation outcomes for children with out-of-hospital and emergency department cardiac arrest. Am J Emerg Med 2024; 81:35-39. [PMID: 38657347 DOI: 10.1016/j.ajem.2024.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 02/29/2024] [Accepted: 03/31/2024] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVE Data suggest extracorporeal cardiopulmonary resuscitation (ECPR) improves survival in adult patients with refractory cardiac arrest; however, ECPR outcomes in pediatric patients with out-of-hospital cardiac arrest (OHCA) is lacking. The primary aim of this study was to characterize pediatric patients who experience OHCA or cardiac arrest in the ED (EDCA). The secondary aim was to examine associations of cardiac arrest and location of ECPR cannulation with mortality. METHODS We performed a retrospective analysis of the Extracorporeal Life Support Organization registry. We included pediatric patients (age > 28 days to <18 years) who received ECPR for refractory OHCA or EDCA between 2010 and 2019. Patient, cardiac arrest, and ECPR cannulation characteristics were summarized. We examined associations of location of cardiac arrest and ECPR cannulation with in-hospital mortality using multivariable logistic regression. RESULTS We analyzed data from 140 pediatric patients. 66 patients (47%) experienced OHCA and 74 patients (53%) experienced EDCA. Overall survival to hospital discharge was 31% (20% OHCA survival vs. 41% EDCA survival, p = 0.008). In adjusted analyses, OHCA was associated with 3.9 times greater odds of mortality (95% confidence interval [CI] 1.61, 9.81) when compared to compared to EDCA. The location of ECPR cannulation was not associated with mortality (odds ratio 1.8, 95% CI 0.75, 4.3). CONCLUSIONS The use of ECPR for pediatric patients with refractory OHCA is associated with poor survival compared to patients with EDCA. Location of ECPR cannulation does not appear to be associated with mortality.
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Affiliation(s)
- Kyle S Bilodeau
- University of Washington, Department of General Surgery, Seattle, WA, United States of America
| | - Kristen E Gray
- VA Puget Sound Health Care System, Health Services Research and Development, Seattle, WA, United States of America; University of Washington, Department of Health Systems and Population Health, Seattle, WA, United States of America
| | - D Michael McMullan
- Seattle Children's Hospital, Division of Cardiac Surgery, Seattle, WA, United States of America.
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Mommers L, Slagt C, RN FC, van der Crabben R, Moors X, Dos Reis Miranda D. Feasibility of HEMS performed prehospital extracorporeal-cardiopulmonary resuscitation in paediatric cardiac arrests; two case reports. Scand J Trauma Resusc Emerg Med 2023; 31:49. [PMID: 37726847 PMCID: PMC10510161 DOI: 10.1186/s13049-023-01119-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/10/2023] [Indexed: 09/21/2023] Open
Abstract
INTRODUCTION A broad range of pathophysiologic conditions can lead to cardiopulmonary arrest in children. Some of these children suffer from refractory cardiac arrest, not responding to basic and advanced life support. Extracorporeal-Cardiopulmonary Resuscitation (E-CPR) might be a life-saving option for this group. Currently this therapy is only performed in-hospital, often necessitating long transport times, thereby negatively impacting eligibility and chances of survival. We present the first two cases of prehospital E-CPR in children performed by regular Helicopter Emergency Medical Services (HEMS). CASE PRESENTATIONS The first patient was a previously healthy 7 year old boy who was feeling unwell for a couple of days due to influenza. His course deteriorated into a witnessed collapse. Direct bystander CPR and subsequent ambulance advanced life support was unsuccessful in establishing a perfusing rhythm. While doing chest compressions, the patient was seen moving both his arms and making spontaneous breathing efforts. Echocardiography however revealed a severe left ventricular impairment (near standstill). The second patient was a 15 year old girl, known with bronchial asthma and poor medication compliance. She suffered yet another asthmatic attack, so severe that she progressed into cardiac arrest in front of the attending ambulance and HEMS crews. Despite maximum bronchodilator therapy, intubation and the exclusion of tension pneumothoraxes and dynamic hyperinflation, no cardiac output was achieved. INTERVENTION After consultation with the nearest paediatric E-CPR facilities, both patients were on-scene cannulated by regular HEMS. The femoral artery and vein were cannulated (15-17Fr and 21Fr respectively) under direct ultrasound guidance using an out-of-plane Seldinger approach. Extracorporeal Life Support flow of 2.1 and 3.8 l/min was established in 20 and 16 min respectively (including preparation and cannulation). Both patients were transported uneventfully to the nearest paediatric intensive care with spontaneous breathing efforts and reactive pupils during transport. CONCLUSION This case-series shows that a properly trained regular HEMS crew of only two health care professionals (doctor and flight nurse) can establish E-CPR on-scene in (older) children. Ambulance transport with ongoing CPR is challenging, even more so in children since transportation times tend to be longer compared to adults and automatic chest compression devices are often unsuitable and/or unapproved for children. Prehospital cannulation of susceptible E-CPR candidates has the potential to reduce low-flow time and offer E-CPR therapy to a wider group of children suffering refractory cardiac arrest.
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Affiliation(s)
- Lars Mommers
- Department of Anaesthesiology and Pain Medicine, Maastricht University Medical Centre, P.Debyelaan 25, Maastricht, 6229 HX The Netherlands
- Helicopter Emergency Medical Service Lifeliner 3 Radboudumc, Geert Grooteplein 10, Nijmegen, 6525 GA The Netherlands
| | - Cornelis Slagt
- Helicopter Emergency Medical Service Lifeliner 3 Radboudumc, Geert Grooteplein 10, Nijmegen, 6525 GA The Netherlands
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Geert Grooteplein 10, Nijmegen, 6525 GA The Netherlands
| | - Freek Coumou RN
- Helicopter Emergency Medical Service Lifeliner 3 Radboudumc, Geert Grooteplein 10, Nijmegen, 6525 GA The Netherlands
| | - Ruben van der Crabben
- Department of Anaesthesiology, Erasmus University Medical Centre, Dr. Molewaterplein 40, Rotterdam, 3015 GD The Netherlands
- Helicopter Emergency Medical Service Lifeliner 2, Dr. Molewaterplein 40, Rotterdam, 3015 GD The Netherlands
| | - Xavier Moors
- Department of Anaesthesiology, Erasmus University Medical Centre, Dr. Molewaterplein 40, Rotterdam, 3015 GD The Netherlands
- Helicopter Emergency Medical Service Lifeliner 2, Dr. Molewaterplein 40, Rotterdam, 3015 GD The Netherlands
| | - Dinis Dos Reis Miranda
- Helicopter Emergency Medical Service Lifeliner 2, Dr. Molewaterplein 40, Rotterdam, 3015 GD The Netherlands
- Department of Adult Intensive Care, Erasmus University Medical Centre, Dr. Molewaterplein 40, Rotterdam, 3015 GD The Netherlands
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Singer D. Pediatric Hypothermia: An Ambiguous Issue. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:11484. [PMID: 34769999 PMCID: PMC8583576 DOI: 10.3390/ijerph182111484] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/17/2021] [Accepted: 10/19/2021] [Indexed: 02/06/2023]
Abstract
Hypothermia in pediatrics is mainly about small body size. The key thermal factor here is the large surface-to-volume ratio. Although small mammals, including human infants and children, are adapted to higher heat losses through their elevated metabolic rate and thermogenic capacity, they are still at risk of hypothermia because of a small regulatory range and an impending metabolic exhaustion. However, some small mammalian species (hibernators) use reduced metabolic rates and lowered body temperatures as adaptations to impaired energy supply. Similar to nature, hypothermia has contradictory effects in clinical pediatrics as well: In neonates, it is a serious risk factor affecting respiratory adaptation in term and developmental outcome in preterm infants. On the other hand, it is an important self-protective response to neonatal hypoxia and an evidence-based treatment option for asphyxiated babies. In children, hypothermia first enabled the surgical repair of congenital heart defects and promotes favorable outcome after ice water drowning. Yet, it is also a major threat in various prehospital and clinical settings and has no proven therapeutic benefit in pediatric critical care. All in all, pediatric hypothermia is an ambiguous issue whose harmful or beneficial effects strongly depend on the particular circumstances.
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Affiliation(s)
- Dominique Singer
- Division of Neonatology and Pediatric Critical Care Medicine, University Medical Center Eppendorf, 20246 Hamburg, Germany
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