CAPS Paper
Assessment of termination of trauma resuscitation guidelines: are children small adults?

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Abstract

Background

Guidelines for termination of resuscitation in prehospital traumatic cardiopulmonary arrest (TCPA) have recently been published for adults. Clinical criteria for termination of care include absent pulse, unorganized electrocardiogram (ECG), fixed pupils (all at the scene), and cardiopulmonary resuscitation (CPR) greater than 15 minutes. The goal of this study was to evaluate these guidelines in a pediatric trauma population.

Methods

Pediatric trauma patients with documented arrest were included in the study. Data assessed were duration of CPR, ECG rhythm, pulse assessment, pupil response, transport times, and standard injury criteria (eg, mechanism of injury). Survivors were compared to nonsurvivors using descriptive statistics, χ2, and Pearson correlation.

Results

Between 2000 and 2009, 30 patients were identified as having had a TCPA. Of the 30 with a prehospital TCPA, there were 9 females and 21 males (0.2-18 years old). The average (SD) injury severity score was 35.4 (20.6). Twenty-four patients (80%) did not survive. Severe traumatic brain injury was associated with nonsurvivors in 78%. One-way analysis of variances demonstrated that CPR greater than 15 minutes (P = .011) and fixed pupils (P = .022) were significant variables to distinguish between survivors and nonsurvivors, whereas ECG rhythm (P = .34) and absent pulse (P = .056) did not, 42 ± 28 minutes for nonsurvivors and 7 ± 3 minutes for survivors.

Conclusion

Criteria for termination of resuscitation correctly predicted 100% of those who died when all the criteria were met. More importantly, no survivors would have had resuscitation stopped. Duration of CPR seems to be a strong predictor of mortality in this study.

Section snippets

Methods

This study was approved by the University of Michigan's institutional review board. It is a retrospective design with trauma patients aged 0 to 19 years with prehospital TCPA. The University of Michigan CS Mott Children's Hospital is an American College of Surgeons verified level I pediatric trauma center. It is a 287-bed teaching hospital and a level 1 pediatric trauma center located in Ann Arbor, MI. It serves the city of Ann Arbor in Washtenaw County. It is a tertiary referral center for the

Results

Between 2000 and 2009, 30 patients were identified as having had a prehospital TCPA from EMS sheets and hospital and trauma registry records.(Fig. 1) There were 9 females and 21 males (0.2-18 years old). The average (SD) injury severity score was 35.4 (20.6). The mechanisms of injury are shown in Fig. 2. Twenty-four (80%) did not survive. Severe traumatic brain injury was associated with nonsurvivors in 78%. The complete clinical criteria (CPR >15 minutes, nonreactive pupils, absent pulse,

Discussion

In December 2008, the World Heath Organization released the “World Report on Child Injury Prevention” that established injury as the number 1 pediatric public health problem in the world [12]. Every day worldwide, 2000 families suffer a loss of a child to an unintentional injury. To combat this problem, several countries have developed trauma programs to reduce morbidity and mortality. These include regionalization of trauma care, trauma centers, specific training (eg, Advanced trauma life

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Presented at the 41st Annual Meeting of the Canadian Association of Paediatric Surgeons, Halifax, Nova Scotia, Canada, October 1-3, 2009

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