Author: Kuo Downing-Reese
Treating pediatric cardiac arrest patients can be nerve wracking. Knowing that you are working on a child pulls on the heart strings. There’s also the knowledge that they are young and haven’t had the chance to really live their life yet. Plus, pre-hospital providers have limited experience dealing with pediatric patients. They only make up about 13% of all our calls and most are not seriously ill or injured1.
The old approach to pediatric cardiac arrest was “scoop and go.”2 However, data has shown that “scoop and go” often results in poorer neurological outcomes2.Studies have also found that arterial hyperoxia following resuscitation has been associated with higher mortality rates. In pediatric OHCA, post arrest patients had increased mortality rates when the patients presented with both hypocapnia and hypercapnia versus normocapnia1. Hyperoxemia did not seem to be associated with mortality rate.
There has been a big change in the care that we provide with the recommendation that all patients with an advanced airway be ventilated at a rate of one breath per every six seconds and continuous chest compressions4. It’s important to remember that pediatric out-of-hospital (OHCA) cardiac arrest is often caused by respiratory etiology rather than cardiac or even trauma2. Unfortunately, EMS provider’s training often lacks pediatric airway management, including endotracheal intubation (ETI). While ETI has been considered the gold standard in cardiac arrest patients, studies show that ALS providers only attempted pediatric intubation once every three years; rates were even less in rural settings or areas with low call volume3. This contributes to the low, first-time success rate for out-of-hospital ETI compared to in-hospital pediatric cardiac arrest patients1.While increased skills training on the pediatric airway should be a target for continuing education, the key is to focus on providing adequate ventilation and oxygenation. This is especially important because the most common etiology was respiratory in nature1. Perhaps our focus in pediatric OHCA patients should be monitoring for high-quality compressions with minimal interruptions and providing adequate ventilations and oxygenation. Doing this is useful for both a basic airway adjunct or advanced airway adjunct, and will help us as we, “strive for near perfection with basic airway management.” 1
Supporting the pediatric airway in OHCA should focus on three key elements: patient positioning, placement of equipment and providing supplemental oxygen3. The pediatric airway is very different than the adult airway. Infants and small children have a much larger head-to-body ratio due to occiput size3. Padding behind the shoulders should be utilized to appropriately position the patient for optimal airway positioning. Pediatric tongue size also tends to be larger and is more likely to create partial airway obstruction. Using appropriately sized oropharyngeal airways is essential to maintaining effective bag-mask ventilation3. Creating a proper seal is also critical. Remember, it is important to provide efficient oxygenation with ventilations. Respiratory rates need to be properly controlled to adequately provide oxygenation while avoiding hypocapnia or hypercapnia, which resulted in increased mortality3.
The large rush of adrenaline to treat the severely ill or injured pediatric patient can lead some pre-hospital providers to overly ventilate their patient. Barotrauma from over ventilation is a common complication with manual bag-mask ventilations. Another complication with bag-mask ventilation is aspiration of gastric contents. Both complications create higher mortality rates in OHCA pediatric patients where return of spontaneous circulation was achieved2. As advanced providers, the best approach is ETI. This will help secure the airway and all us to manage oxygenation and ventilation in the patient. However, successfully performing ETI, especially in the pediatric population, requires regular practice and training with a variety of pediatric airway manikins. Training and use of ETCO2 waveform capnography must also be utilized. This can help ensure proper tube placement, and it can be used with both basic airway and advanced airway management5.
Pediatric OHCA is not something we will treat often as first responders. We need to continuously undergo airway training, especially for pediatric patients, and practice as much as possible. When these calls do come in, we need to be focused on providing the best possible care: high-quality compressions, maintaining efficient oxygenation and ventilation, and avoiding the common complications associated with managing the pediatric airway.
- M. Puffenbarger M.D. (2017, Jan.10). It Takes A Village…: Pediatric Out Of Hospital Cardiac Arrest. Retrieved from http://www.naemsp-blog.com/emsmed/2017/1/10/it-takes-a-village-pediatric-out-of-hospital-cardiac-arrest?rq=it%20takes%20a%20village
- EMSWORLD (2009, Jan.1). Prehospital Pediatric Airway Management. Retrieved from https://emsworld.com/article/10320673/prehospital-pediatric-airway-management
- D. Castillo et al. (2012 Dec. 1). Hyperoxia, hypocapnia and hypercapnia as outcome factors after cardiac arrest in children [Abstract]. Resusciation, 83(12):1456-61.
- EMSWORLD (2018, Jan.2). The Pit Crew Model and Pediatric Cardiac Arrest. Retrieved from https://emsworld.com/article/219579/pit-crew-model-and-pediatric-cardiac-arrest
- Caffrey, S. & NEMSA. (2016, July 7). EMS leader’s 8-step guide to excellent pediatric care: Paramedic chiefs and EMS leaders can ensure pediatric patients receive the correct care with right preparation, equipment and training. Retrieved from https://www.ems1.com/ems-products/neonatal-pediatric/articles/105222048-EMS-leaders-8-step-guide-to-excellent-pediatric-care/