Resuscitation Today Spring 2016 by Media Publishing Company

Volume 3 No. 1

Spring 2016

Resuscitation Today A Resource for all involved in the Teaching and Practice of Resuscitation Supported by CPRO

Waveform EtC02 thatâ&#x20AC;&#x2122;s perfect for emergency grab bags & 2015 ALS capnography compliance All Patient use Adult/Paediatric Infant/Neonate

Multi-Application Intubated & Non intubated Effectiveness of CPR, ROSC...

Comprehensive Alarms Configurable alarms, Apnoea Blocked airway, Battery status

High Performance NDIR Accurate Infrared NDIR Efficacy of proof of intubation

In this issue

details on page 3

Education - Saving lives with Education Evidence - Outcome after resuscitation beyond 30 minutes

EMMA Capnograph

Evidence - Outcomes of Basic Versus Advanced Life Support for Out-of-Hospital Medical Emergencies

www.medacx.co.uk

Waveform EtC02 - Respiratory rate - Alarms

medical

CONTENTS

CONTENTS 5

EDITORS COMMENT

EDUCATION

EVIDENCE

Resuscitation Today This issue edited by: Alan Batt c/o Media Publishing Company Media House 48 High Street SWANLEY, Kent BR8 8BQ ADVERTISING & CIRCULATION: Media Publishing Company Media House, 48 High Street SWANLEY, Kent, BR8 8BQ Tel: 01322 660434 Fax: 01322 666539 E: info@mediapublishingcompany.com www.MediaPublishingCompany.com

COVER STORY EMMA Capnograph - portable waveform capnography from MEDACX EMMA Capnograph second generation following the huge success of EMMA Capnometer introduced by MEDACX in 2006. With over 10 years of proven application experience EMMA Capnograph builds on its reputation, now with its waveform display and breath by breath EtC02 and Respiratory Rate values plus a ‘pulsing heart’, it’s the first choice in many hospitals, ambulance and emergency organisations in the United Kingdom, Europe and around the world. October 2015: European Resuscitation Council issued NEW 2015 ALS Guidelines1, with particular emphasis on the use of waveform capnography to confirm and continually monitor tracheal tube placement, quality of CPR and to provide an early indication of return of spontaneous circulation [ROSC]. EMMA Capnograph provides compliance to ALS guidelines and more… with clear and precise EtC02 waveform display together with EtC02 and Respiratory rate values opens up its use for both intubated and non-intubated and use on Adult/ Paediatric through to Infant/Neonate patients. Confirming efficacy of endotracheal tube placement; providing early recognition of ROSC, instant feedback of effectiveness of CPR, indication of Hypercapnia & Hypocapnia states. It is ideal for patient transfer and can be used with bags and face masks.

Contact information: MEDACX Limited, Frederick House, 58 Station Road, Hayling Island, Hampshire, PO11 0EL, United Kingdom. Tel: +44 (0) 2392 469737 Fax: + 44 (0) 2392 469639 Email: info@medacx.co.uk Website: www.medacx.co.uk References: 1European Resuscitation Council [ERC] - ERC Guidelines 2015

COPYRIGHT: Media Publishing Company Media House 48 High Street SWANLEY, Kent, BR8 8BQ PUBLISHERS STATEMENT: The views and opinions expressed in this issue are not necessarily those of the Publisher, the Editors or Media Publishing Company. Next Issue Autumn 2016 Subscription Information – Spring 2016 Resuscitation Today is a bi-annual publication published in the months of March and September. The subscription rates are as follows:UK: Individuals - £12.00 inc. postage Commercial Organisations - £30.00 inc. postage Rest of the World: Individuals - £60.00 inc. postage Commercial Organisations - £72.00 inc. postage We are also able to process your subscriptions via most major credit cards. Please ask for details. Cheques should be made payable to MEDIA PUBLISHING. Designed in the UK by Hansell Design

RESUSCITATION TODAY - SPRING 2016

You can find more information about the MEDACX capnography range at: www.medacx.co.uk/products/capnography [also see Outside back cover of this edition].

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EDITORS COMMENT

EDITORS COMMENT Strengthening the links How many of us have considered the issue of patient safety in the context of resuscitation? For instance, the intervals of hands off time during a resuscitation attempt (pre-, peri- and post shock pauses) may not be recorded, but these have a serious impact on morbidity and mortality. Any interruption in chest compressions greater than 10 seconds compromises myocardial function and thus should be considered an adverse event.

Medication administration errors are also all too common in healthcare, and studies have shown they are more common in stressful situations. Given the high-stakes nature of resuscitation, it shouldn’t be surprising that medication errors are another risk to patient safety. Effective teamwork and communication are other essential components in reducing the risk to patients. How can we design for improvement in these areas? Measures such as resuscitation data review and cognitive offloading through the use of checklists, improving team choreography and implementing components of high-performance resuscitation have all been proven to improve performance. All services should consider where they can not only improve the quality of care delivered during resuscitation attempts, but also where potential enhancements to patient safety can be identified. A structured approach to improving care in these types of situations has the potential to change the performance of an entire system, and ultimately the outcomes for patients. The focus should be on strengthening, where possible, each individual link of the chain of survival. An example of one such approach is the OneLife project of the National Ambulance Service (NAS) in Ireland. Spearheaded by the Medical Directorate of NAS, the OneLife quality improvement project is focused on increasing cardiac arrest survival through a process of improving standards and increasing transparency. It aims to achieve this through increasing community interaction and public education, enhancing call-taking and dispatch capacity, improving clinical capability at scene and refining the audit and research processes. It is an initiative that deserves to be applauded, and we look forward to seeing improved outcomes published over the coming years. If your service is not currently doing so, consider implementing a structured approach to improving care and safety during resuscitation attempts. Remember, a chain is only as strong as its weakest link… Until next time,

Alan Batt Editor

RESUSCITATION TODAY - SPRING 2016

“All services should consider where they can not only improve the quality of care delivered during resuscitation attempts, but also where potential enhancements to patient safety can be identified.”

Unless the service in question utilises CPR feedback and performs individual case review of every cardiac arrest, this adverse event may never be identified, and many paramedics may not think to self-report this type of event as a patient safety issue. Would you? Does your service review every cardiac arrest case for identification of improvements?

EDUCATION

IMPROVING CARDIAC ARREST CARE IN IRELAND Author: David Hennelly AP MSc, Clinical Development Manager, National Ambulance Service, Ireland

The National Ambulance Service (NAS) serves a population of almost 4.6 million people in the Republic of Ireland, the service responds to over 300,000 ambulance calls each year. The NAS employs over 1,600 staff across 100 locations and has a fleet of approximately 500 vehicles. Emergency Medical Services attempt resuscitation on just under 2000 Out of Hospital Cardiac Arrest (OHCA) cases each year.

Over the past two years the National Ambulance service has engaged with both the country’s leading resuscitation experts and our international counterparts in a collaborative project focused on developing and expanding the National Ambulance Services response to out of hospital cardiac arrest. The One Life Project not only represents our commitment to improve standards of care it also represents our commitment to measure and publicly report on clinical outcomes of patients.

The implementation strategy is broken into four strategic pillars:

NAS community interac0on and public educa0on Build community resilience by developing complementary models of OHCA response and expand Community First Responder (CFR) and Public Access DeﬁbrillaBon (PAD) schemes. Expand the NaBonal Ambulance Services role in public health promoBon and educaBon.

Na0onal Emergency Opera0ons Centre call taking and dispatch Reﬁne call taking, resource allocaBon and dispatcher assisted CPR of OHCA cases by the NaBonal Emergency OperaBons Centre (NEOC) and promote the vital role they play in outcomes of the OHCA paBent. RESUSCITATION TODAY - SPRING 2016

High quality care delivered by Emergency Medical Services at the scene of an OHCA Enhance the quality of care delivered by Emergency Medical Services at the scene and culBvate a coordinated approach to Return 0f Spontaneous CirculaBon (ROSC) Care.

High quality data management, audit and research processes Reﬁne the process and quality of data management, clinical audit and research for OHCA and improve feedback to all stakeholders.

EDUCATION NAS community interaction and public education The National Ambulance Service continues to support and grow its Community First Responder (CFR) network and currently has in excess of 140 linked CFR Schemes. The role of the One Life Project has been to support the growth of CFR groups linked to the NAS and to seek out complementary methods of community response, such as; increasing Public Access Defibrillator (PAD) registration, activation of off duty NAS practitioners, activation of other healthcare professionals and responders and exploring the evolving arena of social media responders. We have had an excellent response from our medical colleagues in General Practice. In conjunction with University College Dublin MERIT program we have now almost 100 General Practitioners across the country linked to the NAS to receive text alert to OHCA cases in close proximity to their workplace. This area also focuses on the interaction and education of the public, from growing support for schools CPR programs in association with the Irish Heart Foundation to a significant increase in our services promotion of the chain of survival via our social media outlets on Twitter and Facebook: https://twitter.com/ambulancenas https://www.facebook. com/NationalAmbulanceService

Life threatening calls, such as a cardiac or respiratory arrest takes precedence over all other calls. The closest available resource is immediately dispatched, such as a NAS Emergency Ambulance, NAS Rapid Response Vehicle, NAS Intermediate Care Vehicles, or a local Community First Responder (CFR) group or doctor. For a suspected cardiac arrest the NAS Call Taker will instruct the person making the call, how to perform CPR and how to use an automated external defibrillator (AED) where available to the person.

National Emergency Operations Centre call taking and dispatch

The NEOC is continually striving to enhance the role they play in each OHCA, focusing on key areas of impact such as, early recognition of the cardiac arrest patient, increasing bystander CPR

When an emergency ambulance call is received, the Call Taker within the National Emergency Operations Centre (NEOC) uses a medical priority dispatch system (MPDS) to triage the call to determine the clinical priority and the appropriate response required. A coded response system is used, based on international best practice.

rates and rapid activation of multiple responders. This has been achieved through ongoing education and performance review and investment in the newest software support MPDS v13.0 which incorporates a Fast Track to â&#x20AC;&#x153;hands-on-chestâ&#x20AC;? for suspected OHCA cases.

RESUSCITATION TODAY - SPRING 2016

EDUCATION This continued focus on improving outcomes from cardiac arrest has seen a continued rise in bystander CPR rates from 60% in 2012 to 71% in 2014.

High quality care delivered by Emergency Medical Services at the scene of an OHCA The One Life Project has developed a comprehensive position paper on the optimal scene management of an out of hospital cardiac arrest which will be released early in 2016 in line with clinical practice guideline updates on the 2015 ILCOR guidelines. The document and supporting material focuses on the best evidence in resuscitation care outlining the principles of high performance resuscitation and human factors management, the objective of which is to improve the quality and dignity of care delivered by NAS practitioners at the scene. and data processing; with collaboration from OHCAR the NAS can now This process includes a renewed emphasis on resuscitation training in

track each OHCA event from inception to conclusion and has significantly

2016 where NAS Education and Competency Assurance Teams (ECAT)

reduced the data processing required and allowed greater emphasis on

will be introducing the principles high-performance resuscitation into

Validation of the data and feedback to the appropriate stakeholders.

each OHCA. This includes a well-planned, well-rehearsed and often choreographed approach to caring for the victim of sudden cardiac

In November 2015 the NAS Medical Directorate introduced quarterly

arrest with an increased focus on using a team approach; human

OHCA Infographics to highlight the important work NAS practitioners

factors training and the use of pre determine roles and checklists during

are carrying out in each of their own areas. The One Life Project will

resuscitation at the scene. This quality improvement process is running concurrently with a significant investment by the NAS in a single monitor /defibrillator solution for the entire service (Physio Control LIFEPAK® 15) and an increase in the number of mechanical compression devices (LUCAS 2). This investment is providing our service with the opportunity to standardise the equipment used during each resuscitation and a greater opportunity to capture data at the scene and analyse our performance via CODE-STAT™ 9.0 data review software. The One Life Project has also introduced post return of spontaneous circulation (ROSC) checklists, optimising the care of the post ROSC patient. This incorporates the principle outlined in the 2015 ILCOR guidelines, including optimising oxygenation, ventilation, haemodynamic and neurologic status and targeting those STEMI patients who require direct admission to primary percutaneous coronary intervention.

RESUSCITATION TODAY - SPRING 2016

High quality data management, audit and research processes Ireland is one of only three European countries with a single National OHCA Registry. Since inception in 2007, OHCAR has grown from a regional register in the North West to a nationwide Out of Hospital Cardiac Arrest register in 2012, incorporating OHCA data from statutory and voluntary services across Ireland. One of the early innovations of the One Life Project was the identification of the issues surrounding Out Of Hospital Cardiac Arrest Registry (OHCAR) data collection and processing. To that point there had been no single approach to the collation of OHCAR data from each region within the NAS. The One Life Project has developed and instituted a national process of data collection, regional collation

continue to work with OHCAR to maximise the data collection and processing in line with future technological advances. The benefits to patients and their families remain the overarching focus of the One Life Project. Our services goal is to treat effectively as many people in cardiac arrest as possible so that they are neurologically intact and ready to resume their role within their family and society. Since the introduction of this quality improvement initiative we have seen a steady rise in the percentage ROSC at ED rates, from 24% in 2014 to 42% at the end of 2015, this is down to the consistent professional effort by our front line call takers, dispatchers and practitioners. By working together, the implementation of this project will improve patient outcomes for each cardiac arrest call and dramatically increase our chances of saving that ‘One Life’.

EDUCATION

SAVING LIVES WITH EDUCATION Jenny Jones, (RN) Resuscitation officer Jenny has been evaluating the recognition of sick patients courses

My role is to ensure the technical accuracy of the clinical findings, to

that she taught in the UK and explains how she hopes to transfer

teach some of the sessions, and of course to make the learning fun and

these skills into her new Resus Officer role in Abu Dhabi

entertaining. ISimulate is a tool that I can use on anybody in the role play, 2 iPads connected by wifi that allows me to use one iPad to adjust the physiological parameters on the other, I like the device as i can

A review of ALERT™ The ALERT™ course incorporates interactive seminars, practical demonstrations and role–play clinical scenarios during which the candidates are encouraged to reflect on their actions and to consider “What would I do next?” An ALERT™ course manual, for pre–course reading, is provided to all attendees.

attach the bp cuff, ECG, and sats probe to a volunteer student and then control the physiological deterioration of the student as they role play the scenario. The look of surprise I get as the simulated patient begins to deteriorate is hysterical. Even the so called patient is not expecting to have the altered physiology that we create. The purpose of the ALERT™ course is that it supports earlier referral to intensive care and reduces the likelihood of avoidable in hospital deaths. Our focus is to look at the decision making and improvements in multi professional team working, communication and complaint reduction. It is a fantastic course for teaching and introducing many of the recognition factors associated with cardiac arrest.

Originally developed in 1999 by Professor Gary Smith, and colleagues at Portsmouth Hospitals NHS Trust, ALERT™ is a multi-professional course to train staff in recognising patient deterioration and act appropriately

Transferring ALERT into Middle East.

in treating the acutely unwell. The course is usually delivered as a oneday interactive seminar built around practical patient-based scenarios.

After 6 months of working in Abu Dhabi I feel that I have a huge

The day is supported by a comprehensive reference manual and slide

challenge on my hands, the major difference between here and the UK

presentation.

are the cultural differences that I encounter in the hospital settings.

ALERT™ uses a structured and prioritised system of patient assessment

We have a truly global workforce, Arabic doctors, European doctors

and management to enable a pre-emptive approach to critical illness. It

and many from the USA, we have nurses from Philippines and India

instructs staff in the recognition of impending clinical deterioration, the

and a complete cultural melting pot, which combined with medical

management of disordered physiology and other aspects of the delivery

hierarchies makes the ALERT course a perfect tool for this area.

of acute care. ‘Culture can kill’ is a philosophy that we have recently adopted, and our current attempts to standardise care here in the UAE is

tool to re-create the physiology associated with the clinical scenarios,

being met with huge success. The role of resuscitation officer is

and we base our course on recognising the physiological parameters,

becoming common in the region, and I am aware of many of the

history taking and elements of human factors that create failures in

original CPRO members now supporting resuscitation education

patients care.

out here in the desert.

As a resus officer I love the course, it has I feel provided definite

Resuscitation is really starting to become popular in the region,

improvements in patient care, because it is suitable for interdisciplinary

with both the ERC programmes and those from the AHA becoming

teams, nurses, and doctors at all levels focussing upon prevention of

popular and indeed mandatory for some healthcare delivery.

cardiac arrest. Staff are often trained before they come here to the UAE with so Originally we used the course without a great deal of technology, just

many different levels in performance and competence. Ongoing

slides and projectors, but now we have started to use a few more

healthcare demand is high, and we are I feel that we are busier

props, we have a faculty of consultants from ITU, cardiology, respiratory

than the UK with so many co morbidities prevalent amongst the

medicine and the a Emergency Dept, but we also have many senior

locals and workers, the opportunity for resuscitation officers to

nurses who share our passion for recognising sick patients,

make a difference is incredible.

RESUSCITATION TODAY - SPRING 2016

During the courses I have attended my role is to use the iSimulate ALSI

EDUCATION I will be introducing ALERT into the hospital group for which I work, after

The course is delivered as a one day programme providing a clear

the Ramadan period, we are also setting up local resuscitation officer

framework of knowledge and skills for healthcare support staff to

networks with the teams in Qatar, and Oman who have both invested

promote early identification of patients whose condition is deteriorating.

significantly in their healthcare worker education.

It also outlines specific competencies that will contribute to the effective management of patients at risk to contribute to the provision of high

ALERT™ has now run successfully since the beginning of 2000 and has

quality nursing care. The day is supported by a comprehensive

been delivered in over 100 centres in the UK and overseas. The course is:

workbook that includes action planning to provide a clear link to practice and other learning activities, a teaching manual, and slide presentations.

• a blended, flexible, learning programme • a track record of delivery over the past 10 years

Learning activities included in the course are varied to meet the learning needs of the candidate group and include:

• multi-disciplinary • recognised by several medical royal colleges • supported by optional assessments and issuing of formal certificates • simple to organise and deliver with no special equipment needed

• Quizzes • Group work • Discussion • Questions and answers

To become an Alert centre please see below: Contact details ALERT™ Course Headquarters 2nd Floor QuAD Centre

• Patient scenarios • Decision making and role play • Workbook • Competency assessment in practice

Portsmouth Hospitals NHS Trust Queen Alexandra Hospital Cosham Portsmouth PO6 3LY United Kingdom

Aims of AWARE™ are to:

Tel: +44 (0)23 9228 6306 Fax: +44 (0)23 9228 6326 Email: alert.course@porthosp.nhs.uk Website: www.alert-course.com

• Explore the role and responsibility of HCAs in recognising and responding to changes in patients condition • Develop underpinning knowledge and skills to enable effective

AWARE™ Another programme I loved to teach is the AWARE course, which

performance when observing and monitoring patients • Support completion of competency to verify achievement in practice • Support learning in a variety of clinical areas

is aimed at those who are most often the ones recording clinical observations - the Healthcare support staff, over the years, I have met

Objectives of AWARE™ are to:

many Healthcare support care workers who instantly could spot the sick patient, but may not know exactly why!

• Demonstrate understanding of principles and correct technique when monitoring physiological observations

The AWARE™ course was developed in 2009 by members of the nursing and midwifery education team at Portsmouth Hospitals NHS Trust, AWARE™ is a developmental programme for healthcare support staff to improve recognition and response to deteriorating patients. It responds to an increasing focus on the role of Healthcare Support Staff RESUSCITATION TODAY - SPRING 2016

in development of competent performance. It also links to changes in workforce demographics and the need to work more effectively in enhancing patient safety and promoting high quality care and was informed by key evidence from National Patient Safety Agency (2007), National Confidential Enquiry into Patient Outcomes and Death (2005,

• Recognise and respond effectively to physiological signs that indicate adverse changes in patients condition • Discuss use of track and trigger systems and the importance of accurate record keeping • Explore strategies for effective communication and reporting of results • Recognise key emergency equipment and provide appropriate support in emergency situations

2009, 2010 & 2011), NICE Clinical Guideline 50 (2007) and Royal College of Physicians. (2012).

Feedback and evaluation from candidates demonstrates that the AWARE™ course: • “increases awareness of the responsibilities of our roles” • provides meaning to tasks performed in practice • improves confidence and competence • provides a better understanding of the need for assistance

EDUCATION • improves awareness of good communication • improves awareness of good documentation The ALERT and AWARE are in my opinion definitely helping to transform healthcare provision, and support the ongoing introduction of the NeWS score within the UK. My challenge and that of the other Resus officers out here in the Middle East is to transfer our learning from the UK and contextualise it for local delivery.

Recognition of and response to acute illness in adults in hospital. Manchester: National Institute for Health and Care Excellence. Royal College of Physicians. (2012). National Early Warning Score (NEWS): Standardising the assessment of acute illness severity in the NHS. Report of a working party. London: Royal

College of Physicians.

Find us at

Key References National Patient Safety Agency. (2007). PSO/5Safer care for the acutely ill patient: learning from serious incidents. London: National Patient Safety Agency. National Confidential Enquiry into Patient Outcomes and Death. (2005). An Acute Problem. London: National Confidential Enquiry into Patient Outcomes and Death.

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National Confidential Enquiry into Patient Outcomes and Death. (2009). Deaths in Acute Hospitals: Caring to the End? London: National Confidential Enquiry into Patient Outcomes and Death.

National Confidential Enquiry Patient Outcomes and Death. (2011). Knowing the Risk. A Review of Peri-Operative Care of Surgical Patients. London: National Confidential Enquiry into Patient Outcomes and Death. NICE Clinical Guideline 50. (2007). Acutely ill patients in hospital.

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National Confidential Enquiry Patient Outcomes and Death. (2010). An Age Old Problem A Review of the Care Received by Elderly Patients Undergoing Surgery. London: National Confidential Enquiry into Patient Outcomes and Death.

EDUCATION

WHEN BABIES DIE Jessica Morton, Student Paramedic, Nurse Every fibre of our paramedic, nurse or doctor self yearns to help,

10 minutes from delivery may account for the entire time it took to

prevent, assist or relieve the pain, suffering, injury and illness of

make an emergency call, be dispatched, and reach the scene in some

our patients. It goes against our very being when we cannot do

circumstances.

those things, where the only thing we can attempt to do, is comfort while we straighten our shoulders and swallow extra hard to remain

The legal standpoint of the paramedics’ rights and responsibilities in

focused.

relation to the non-initiation of resuscitation of the severely premature infant (SPI) was discussed on Twitter. Below is a sample of some of the

Death is a part of our job. We attune ourselves to the reality of this and

contributions made (unedited – for original tweets please visit

our personal resilience is what gets us up for work the next day and the

http://prehospitalresearch.eu/?p=3988)

day after. Professionalism & fortitude is what enables us to leave one patient who has died, or is about to and walk into another with the ability to give the positive and proficient care they need. But what about when babies die? When babies die and we are just too late….Or they are far too early?

• No guideline to help guide decisions in prem resus but i taught around >24 is potentially viable from internal edu • Definitely tough decision. I’ve never seen a solid guideline on it. • Treat as you find it. Setting a strict cut off may be exclusionary - have had 22/40 transported. -ve outcome eventually.

This sadly is the reality too. Some babies will never make it to the emergency or maternity department alive and likewise, some babies will never go home. In Australia, for every 135 live births, one baby is stillborn, equalling approximately 2000 stillbirths a year. Miscarriage is deemed the birth of a baby less than 20 week’s gestation with no signs of life. Intrauterine foetal death (IUFD) is the birth of a baby over 20 week’s gestation also with no signs of life. To determine if it is the case of a stillbirth; alongside normal assessment algorithms the paramedic can check for cord pulsation, reflex movements, colour or gasps. If none of these are present, the baby is stillborn. Current guidelines suggest to not attempt resuscitation of the foetus (or I prefer baby), that is 23 weeks or less gestation, less than 400grams or is already macerated. Foetal maceration can be described as the “process of tissue degeneration which begins to occur as soon as an undelivered infant dies.” (Pauli, 1995) It occurs in stages when the earliest sign within a few hours of death is the appearance of peeling skin. Observing and documenting the stage of maceration can be useful for estimating the RESUSCITATION TODAY - SPRING 2016

time of death and will contribute to giving the parents closure.

• Agree 20weeks is beyond the cusp. More harm to family and pt. Support mum. • In South African government sector: 900gram baby won’t be intubated / ventilated by any hospital. What are your thoughts? What are your guidelines? It seems it is not written into many CPGs that a paramedic is within their rights and ethical responsibilities to withhold resuscitation of a severely premature infant. Even in a fully equipped and specialised neonatal intensive care unit (NICU), the ethics of withdrawing or not initiating treatment remain controversial. An interesting case detailed in the article below by Sanders et al. (2012) is the story of EMS attending a mum who delivered her SPI at around 24-25 weeks into the toilet. On arrival, EMS were directed by the woman’s partner to care for her first and leave the baby. Once they were allowed to assess the infant, they found it to be cool and cyanotic and had been submerged for approximately 20 minutes. They deemed that the baby was not viable. There was no documentation of any examination and the baby was placed in a plastic bag for transport to the hospital. On arrival at the ED 30-40 minutes after the

The out of hospital arena is one of uncertainty. Paramedics will unlikely

delivery, medical staff found the baby to be bradycardic and apnoeic.

have access to hospital records and the mum for whatever reason

Resuscitation occurred and the baby was intubated.

may not know how pregnant she is. It leaves prehospital providers in a difficult situation when needing to decide if the baby is viable for

The baby sadly had a rough journey of sepsis, metabolic acidosis and

resuscitation. Paramedics do not carry the equipment to weigh a baby

an ICH. After seven days, the decision was made to make the baby

and estimation of only a few hundred grams cannot be an accurate or

comfortable and it quickly died after it was extubated. You can read the

ethical method as even 100grams may make all the difference to the

article for yourself and form opinions on the treatment given and not

potential survival of the infant.

given based on facts: http://informahealthcare.com/doi/abs/10.3109/10 903127.2011.616258

A literature review by Harrington et al. (2007) suggests that the outcome of resuscitation of a baby with an APGAR of zero at 10 minutes was

Resuscitating a 23 week plus infant and the process and management

very poor and that it predominantly lead to later mortality or moderate

of withholding treatment from a 0-23 week infant is a vastly different one.

to severe disability and morbidity. It should be kept in mind that the

It is difficult in that we are trained to help and resuscitate.

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EDUCATION We are not trained to stand back and watch a baby take a few futile breaths before dying and not act. We of course are never emotionally prepared for the process of handing a distraught and exhausted mum a lifeless baby.

Moving on It is ok to ask the ED or neonatal team for follow up at the next opportunity to seek feedback, or see what answers were discovered. It is ok to be human and let the family see and know that you are not a

What can we do when we can’t do anything?

robot. I say this as someone who has been with countless families as or immediately after their loved one has died.

When you do this, language & terminology is important. Be respectful,

It is ok to cry. I admit, I am not a crier. I internalise things or get agitated.

but clear on the information to avoid misunderstanding and further

I get a pit in my stomach. But you can cry, you can get angry, you

distress. “I am sorry, your baby has died” makes this clear. Ms. Trish

should be human! Talk to those who were there with you. Talk to your

Wilson (midwife, nurse & counsellor) presented at the Paramedics

workmates or your work counselling service. Maybe even write a

Australasia International conference neonatal resuscitation workshop in

blog. I hope if and when you find yourself in this position, the pearls of

2014. Trish advises the best way that paramedics can start helping the

information that I have shared from others will help you better help the

mother and partner to cope with the situation is by “normalising” it.

family, the baby and yourself.

Do not appear to be walking “eggshells” around the mum or by handling the baby in any other way than you would normally.

This article originally appeared in its original format as a blog post at http://prehospitalresearch.eu/?p=3988 under a Creative Commons

The immediate practical management of the stillborn infant should

Licence.

include: • Retrieving the baby and drying off as normal (some babies may be born into the toilet etc.) • Clamp and cut the umbilical cord. (Keep the placenta and document the condition and appearance)

References Crowe, L. (2014). Swearing your way out of a crisis. Available at http:// lifeinthefastlane.com/swearing-way-crisis/. [Accessed 12 Feb. 2016].

• Wrap the baby just as you would with any other.

Harrington, D., Redman, C., Moulden, M. and Greenwood, C. (2007). The

• Hold, treat and talk to the baby as you would any other live baby.

systematic review of the literature and hospital-based cohort. American

• All mums and babies require transport to hospital • Reassure the mum and others present that there is nothing they could have done to prevent this. Explain that the baby has died some time ago or is too small to survive and there is nothing that can be done. • Support mum and dad, and encourage them to hold the baby.

long-term outcome in surviving infants with Apgar zero at 10 minutes: a Journal of Obstetrics and Gynecology, 196(5), pp.463.e1-463.e5. Sanders, W., Fringer, R. and Swor, R. (2012). Management of an Extremely Premature Infant in the Out-of-Hospital Environment. Prehospital Emergency Care, 16(2), pp.303-307. Pauli R (1995). Maceration and the Timing of Intrauterine Death. [online] Available at: http://www2.marshfieldclinic.org/wissp/wisspers/jan95001. htm [Accessed 12 Feb. 2016].

Minimising Trauma “Obstetric emergencies can’t always be prevented, however PTSD doesn’t have to be consequence”. Trish says there are three parts to this: RESUSCITATION TODAY - SPRING 2016

1. Safety: Help the parents to feel safe both physically and emotionally and provide reassurance. 2. Mastery: Provide information. Be honest. Answer questions directly. 3. Control: Where possible, give the parents choices and options. These are the things we can do when we feel useless. Be honest with the parents, if you cannot answer a question, it is ok to say so and that someone at the hospital will be able to help. Encourage mum or dad to hold the baby on the way instead of placing the baby in a plastic bag or wrapped up and transported separately. This may indicate that something is wrong with the baby or cause further distress to the parents.

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USE OF ADVANCED PRACTICE PARAMEDICS IN EMS SYSTEM DESIGN Michael J Christie NRP, LP, APP Clinical Educator, National Ambulance LLC, Abu Dhabi, UAE In Seattle/King County Washington, the Portland Metropolitan

While the use of standard paramedic interventions make an impact on

Area in Oregon, and Clark County Nevada during the past ten

patient’s suffering ventricular fibrillation arrest, only through application

years, there has been an ever increasing rate of neurologically

of advanced techniques can the patient in PEA arrest have an equal

intact survival from cardiac arrest, functionally intact recovery from

chance at survival, by the application of a modified approach to the PEA

trauma, and functionally intact recovery from myocardial infarction

patient, rapid intervention is possible to improve lives saved (2a).

and cerebral vascular accidents. With all three system being among the world’s top performing EMS systems, and Seattle/King

In the current lexicon of trauma, Damage Control Resuscitation (DCR)

County Medic One system taking firm hold as the top performing

has been the standard of care since 2008 in the military medical

EMS system in the world today with cardiac arrest neurologically-

systems worldwide for the 3-8% of trauma patients on the edge of

intact survival exceeding 50% in 2013.

physiologic exhaustion and cardiac arrest; but only through application of advanced techniques (3a-3f), can these patients experience the

Numerous national reports have acknowledged the need to improve

dramatic recovery rates (approaching 7%3b in traumatic arrest and 80%

the quality of hospital and pre-hospital care for high- risk patients and

in multisystem trauma) shown in high performance EMS systems within

reduce preventable deaths in England each year (6a). The emergency

South Africa and the United States. The addition of blood products for

medical system in the United States delivers 20% lower mortality rates

specific trauma patients allows the advanced practice paramedic to

than the UK for trauma patients and double the neurologically intact

again increase survival (3g, 3h), when coupled with ultrasound identification

survival for cardiac arrest patients.

of specific traumatic injuries, the advanced practice paramedic will be able to reduce some injury fatality rates by as much as 50% (5a- 5c).

For systems to match the results of the highest performing EMS systems in the world, the first step must be a unique, close, and

Through the use of advanced techniques and treatment protocols, the

intimate integration of clinical governance, education, and operations

advanced practice provider will be able to improve outcomes secondary

management, because only through acknowledgement of the equal

to myocardial infarction in a dramatic fashion, through advanced practice

footing of medical direction and operations can an EMS system be

protocols and direct admission to PCI processes established between the

successful. It is entirely possible to move toward a high fidelity, high

cardiology PCI staff and the small cohort of advanced practice paramedics,

performance, and high impact model with the implementation of a

the time of event to PCI intervention can be under 90 minutes (1e).

tiered response system acknowledging a small group of paramedics functioning at an advanced practice level with less emphasis on “every

The application of advanced practice paramedics with advanced airway

vehicle has a paramedic” model, which does not allow for the level of

capability can improve airway management success and improve

clinical experience necessary to build a reservoir of knowledge and

patient outcomes (4a-g).

experience in the paramedic provider. Fiscal impacts to the EMS system are negligible for implementation of

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It is probable that a small cadre of medical director approved and

this model program, if the model for advanced practice utilized by a

clinically mentored advanced practice paramedics staffing “paramedic

number of locations is utilized in this circumstance:

units with transport capability” can provide a high frequency of critical patient care encounters to augment or supersede the care being

Personnel must apply for the available positions and attend a training/

provided by ambulance-based BLS and ALS EMS providers. This cadre,

selection academy on their own time. The Medical Director appoints

with appropriate dispatch perimeters, will also provide those advanced

a single supervising educator for the program, this individual works

interventions that must be done “right now” or the patient will perish.

directly with the advanced personnel as the medical director’s designee and intimately with operations to develop an effective team of personnel

As discussed during the International science symposium (1a-1d), full

while guiding and assessing their education and clinical competencies

application of the immediate post cardiac arrest algorithm, advanced

in the classroom and field. The supervising training officer selects field

preparation steps for PCI, and direct PCI admission can improve

training officers at a ratio of 10:1 for the advanced practice personnel,

cardiac arrest survival from 27% to 43%. This level of intervention

these FTO personnel work as shift personnel, but report to the Medical

combined with rapid defibrillation and CPR from first in units and the

Director and Supervising Educator.

general public (through increased public response with the use of PulsePoint) would result in an increased neurologically intact cardiac

Fiscal impacts to the healthcare system can exceed $2,000,000 per

arrest survival rate.

patient who is converted from a disabled state to a fully functional

EVIDENCE state by the application of these techniques. In the United States, the CDC estimates that in 2000 the medical costs and indirect costs (lost productivity) of TBI in United States totaled $60 billion, with extended care for comatose patients exceeded $1,000 USD/day. The Markov model estimated rehabilitation costs of $1.4 million and nursing home cost of $4.8 million per long term maintenance patient care; and the American Heart Association estimated significant savings in their “Cost and Outcome of Mechanical Ventilation for Life-Threatening Stroke” consensus statement for patients whose functionality could be improved rather than long term care being required. This process also applies to the post cardiac arrest and trauma patient populations.

Conclusion: As the George Washington School of Public Health, The Health System Nova Scotia, the AMR Reach and Treat Program, and Ambulance Victoria have identified, the use of prehospital advanced practice staff can have a significant impact on the EMS system in three ways: Responding to and resolving critical medical emergencies that require an experienced paramedic to mitigate and/or perform advanced procedures and diagnostics. Secondly, redirecting patients not in need of emergency department care from the emergency department system to alternative destinations. And finally, reducing readmission through targeted follow up with re-admission risk patients (CHF, brittle diabetics, pediatric asthma, etc…) using advanced diagnostics and in home treatment. Through the implementation of an advanced practice paramedic model, integrating clinical education, medical direction, and operational re-design, EMS systems have the opportunity to reduce healthcare costs, system fatigue, and increase the numbers of neurologically intact survivors.

Evidence References: 1. Improving Post Cardiac Arrest Survival and ACS: a. Implementation of complete field post cardiac arrest care and direct admission to PCI resulted in an adjusted unpaired analysis of 27.4% neurologically survival without immediate PCI verses 43.7% neurologically intact survival with PCI (Immediate PCI after Cardiac Arrest is associated with short and long term outcome; Guillaume Geri, Florence Dumas, etAl; Original Research Presented November 16, 2014 at AHA/ILCOR Science Meeting, Chicago, Illinois, USA)

c. Overall, optimizing advanced and systemic implementation is the action most likely to result in widespread improvement in survival after OHCA (Implementation Strategies for Improving Survival After Out-of-Hospital Cardiac Arrest in the United States; Robert W. Neumar, et Al; Circulation; 2011; 123: 2898-2910) d. If Out Of Hospital Cardiac Arrest (OOHCA) associated with STEMI, field providers should bypass nearest hospitals and go directly to a cardiac receiving hospital so patients can receive angiography

e. Hospital door-to-balloon time for those patients averaged 47 minutes and only 87 minutes from when the 9-1-1 call was answered until the patient received a PCI. (Paramedics Activate Cath Lab for STEMI Patients in Some Areas; JEMS, June 25, 2007) f. A STEMI system allowing EMS to transport patients directly to a primary PCI center was associated with a significant reduction in mortality (Reduction in Mortality as a Result of Direct Transport From the Field to a Receiving Center for Primary Percutaneous Coronary Intervention; Michel R. Le May, MD, et Al; Journal of the American College of Cardiology Vol. 60, No. 14, 2012) 2. Improving Cardiac Arrest Survival a. A modified approach to PEA focuses on “cause-specific” interventions utilizing two simple tools: ECG and Bedside Ultrasound (US) (Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity. Littmann L, Bustin D, Haley M. A; Med Princ Pract 2014; 23:1-6) b. In CARES, survival was higher among OHCA receiving ETI than those receiving SGA (McMullan J, Gerecht R, Bonomo J, et al. Airway management and out-of-hospital cardiac arrest outcome in the CARES registry. Resuscitation. 2014;85(5):617–622. doi:10.1016/j. resuscitation.2014.02.007) c. “In out-of-hospital urban and rural settings, patients intubated during resuscitation had a better survival rate than patients who were not intubated, whereas in an in-hospital setting, patients who required intubation during CPR had a worse survival rate. A recent study found that delayed endotracheal intubation combined with passive oxygen delivery and minimally interrupted chest compressions was associated with improved neurologically intact survival after out-ofhospital cardiac arrest in patients with adult witnessed VF/pulseless VT” (2010 CPR/ECC Science Guidelines, Part 8.1, Advanced Airways) d. The presence of an intensive care paramedic had a significant effect on survival (OR = 1.43, 95% CI = 1.02 to 1.99). (Impact of advanced cardiac life support-skilled paramedics on survival from out-of-hospital cardiac arrest in a statewide emergency medical service; John Woodall, Molly McCarthy and Vivienne Tippett, Emerg Med J. Feb 2007; 24(2): 134–138) 3. Improving Trauma Survival a. The natural extension and development of DCS has been damage control resuscitation. DCR is a structured, mobile intervention that can be delivered to a critically ill patient in any location. Basic principles include arresting hemorrhage; restoring blood volume; and correcting coagulopathy, acidosis and hypothermia (Damage control resuscitation: history, theory and technique; Chad G. Ball, MD, MSc; Can J Surg. Feb 2014; 57(1): 55–60) b. 6.6% of the patients survived with a CNR. Our data allow us to state beyond any doubt that advanced life support should be initiated in TCA patients regardless of the initial rhythm, especially in children and those with VF or PEA as the initial rhythm. (Traumatic cardiac arrest: should advanced life support be initiated?; Leis CC1, Hernández CC, Blanco MJ, Paterna PC, Hernández Rde E, Torres EC; J Trauma Acute Care Surg. 2013 Feb;74(2):634-8) c. Contrasted patients kept at a MAP of 65 verses those kept at a MAP of 50; Patients in the low MAP group: Had lower transfusion requirements, Developed coagulopathy less frequently, Had a lower 24-hour mortality (Hypotensive Resuscitation Strategy Reduces Transfusion Requirements And Coagulopathy In Trauma Patients With Hemorrhagic Shock; Morrison CA. J Trauma 2011; 70:652-663) d. Targeted pre-hospital ventilation is associated with lower mortality after severe TBI (The impact of prehospital ventilation on outcome after severe traumatic brain injury; Warner KJ, Cuschieri J, Copass MK, Jurkovich GJ, Bulger EM; J Trauma. 2007 Jun;62(6):1330-6)

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b. Few systems worldwide have achieved the benchmark time of less than 90 minutes from emergency medical services (EMS) contact to balloon inflation (E2B) for patients sustaining ST-segment elevation myocardial infarction (STEMI) (Paramedic contact to balloon in less than 90 minutes: a successful strategy for st-segment elevation myocardial infarction bypass to primary percutaneous coronary intervention in a Canadian emergency medical system. Cheskes S, Turner L, Foggett R, Huiskamp M, Popov D, Thomson S, Sage G, Watson R, Verbeek R.; Prehosp Emerg Care. 2011 OctDec;15(4):490-8)

within 90 minutes (Regional Systems of Care for OOHCA: A Policy Statement from the AHA, Circulation Feb 9, 2010)

e. Aeromedical crews appear to appropriately select major trauma victims to undergo field needle thoracostomy and tube

EVIDENCE thoracostomy. A low incidence of complications and a small but significant group of unexpected survivors support continued use of this procedure by aeromedical personnel. (The safety and efficacy of prehospital needle and tube thoracostomy by aeromedical personnel; Davis DP, Pettit K, Rom CD, Poste JC, Sise MJ, Hoyt DB, Vilke GM; Prehosp Emerg Care. 2005 Apr-Jun;9(2):191-7) f. Found that advanced scope paramedics could safely provide ALS care in a backcountry environment. This care improved patient comfort during long extrication and allowed for life-saving interventions such as advanced airway management, at the patient’s side preventing loss of life. (Advanced life support in the wilderness: 5-year experience of the Reach and Treat team; Terri A. Schmidt; Carol S. Federiuk; Andrew Zechnich; Markus Forsythe; Michael Christie; Christopher Andrews; Wilderness and Environmental Medicine. 1996;7(3):208-215.) g. Similar to the data published from the ongoing war, improved early outcomes are associated with placing blood products prehospital, allowing earlier infusion of life-saving products to critically injured patients. (Prehospital Transfusion of Plasma and Red Blood Cells in Trauma Patients; John B. Holcomb, Daryn P. Donathan, et Al; Prehospital Emergency Care, June 16, 2014) h. It is feasible and practical to provide prehospital trauma teams with pRBCs for use in the field. Use of pRBCs in the prehospital setting is associated with similar rates of pRBC wastage to that reported in emergency departments. (The feasibility of civilian prehospital trauma teams carrying and administering packed red blood cells; Daniel Bodnar, et Al; Emerg Med J 2014;31:93-95) 4. Airway Management at the ESP Level: a. In this population-based cohort of out-of-hospital cardiac arrest, RSI was used in 15% of patients and associated with a better prognosis than intubation attempted without paralytics. Because this subset with a favorable prognosis may not be readily intubated in systems without paralytics, these findings could help to explain the adverse relationship between intubation and survival observed in prior studies. (Use of rapid sequence intubation predicts improved survival among patients intubated after out-of-hospital cardiac arrest; Kwok, et Al; Resuscitation. 2013 Oct;84(10):1353-8) b. In adults with severe TBI, pre-hospital rapid sequence intubation by paramedics increases the rate of favorable neurologic outcome at 6 months compared with intubation in the hospital. (Prehospital Rapid Sequence Intubation Improves Functional Outcome for Patients With Severe Traumatic Brain Injury; Stephen A. Bernard MD, Vina Nguyen BSc, Peter Cameron MD, et Al; Annals of Surgery Volume 252, Number 6, December 2010) c. Seattle Medic One’s first-pass success rate for oral endotracheal intubation is 75%; its overall success rate is 98.4%. (Prehospital Management of the Difficult Airway: A Prospective Cohort Study; Keir J. Warner, BS, Sam R. Sharar, MD, Michael K. Copass, MD, Eileen M. Bulger, MD; Journal of Emergency Medicine, Volume 36, Issue 3, Pages 257–265, April 2009) RESUSCITATION TODAY - SPRING 2016

d. Although rarely performed, cricothyroidomy can be a life-saving procedure. Evidence from model lung studies shows that the surgical method provides effective ventilation independent of the degree of upper airway restriction, whereas the efficacy of initial ventilation via a cannula reduces as an inverse function of increasing upper airway restriction, and becomes totally inadequate within 60 s if a low pressure (15 l.min−1) self-assembled ventilation system is used (Needle vs surgical cricothyroidomy: a short cut to effective ventilation; I. Scrase and M. Woollard; Anaesthesia; Volume 61, Issue 10, pages 962–974, October 2006) e. Surgical cricothyrotomy appeared to be a preferable method for establishing a definitive airway over the percutaneous method (A laboratory comparison of emergency percutaneous and surgical cricothyrotomy by prehospital personnel; Keane MF, Brinsfield KH, Dyer KS, Roy S, White D; Prehosp Emerg Care. 2004 OctDec;8(4):424-6.) f. In this study, only 1.1% of patients required a surgical airway. We

attribute this low rate to the use of paralytic agents. The availability of paralytic agents also allows expansion of the indications for prehospital airway control. (An analysis of advanced prehospital airway management; Bulger EM1, Copass MK, et Al; J Emerg Med. 2002 Aug;23(2):183-9.) g. Paramedics successfully intubated 95.5% (1,582) of all patients receiving Succinylcholine; 94% (1,045) of trauma patients and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative advanced methods, such as SGA or surgical cricothyroidomy. (Prehospital use of Succinylcholine: a 20-year review; Wayne MA, Friedland E.; Emergency Medical Services, Bellingham/Whatcom County, Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.) 5. Ultrasound Application for Patient Improvement: a. Pre-hospital ultrasound when applied by an proficient examiner using a goal-directed, time sensitive protocol is feasible, does not delay patient management and provides diagnostic and therapeutic benefit. Further studies are warranted to identify the exact indications and role of pre-hospital sonography. (Portable ultrasound in prehospital emergencies: a feasibility study; M. Busch, et Al; Acta Anaesthesiologica Scandinavica, Volume 50, Issue 6, pages 754–758, July 2006) b. Prehospital emergency ultrasound has many clinical applications that would reduce morbidity and improve outcomes of patients with life-threatening emergency conditions. This imaging modality improves diagnostic accuracy and provides crucial information to prehospital providers to guide management and help triage patients to appropriate destinations (Prehospital Emergency Ultrasound: A Review of Current Clinical Applications, Challenges, and Future Implications; Mazen J. El Sayed and Elie Zaghrini; Department of Emergency Medicine, Beirut Medical Center, Beirut, Lebanon; Emergency Medicine International, 2013 c. Logistic regression revealed that ABD CT was independently associated with more than a 70% higher risk of mortality. (OR, 1.71; 95% CI 1.2-2.2, p <0.001) (Over reliance of CT imaging in patients with severe abdominal injury: Is the delay worth the risk?; Neal MD. J Trauma 2011; 70:278-284) 6. System Design: a. Critiquing Critical Care Paramedics, Geoff Hughes, doi: 10.1136/ emj.2011.114918, Emerg Med J 2011 28: 642 b. Advanced Practice Paramedic: Community Para Medicine and Mobile Healthcare; George Washington University School of Public Health and Health Services; https://smhs.gwu.edu/urgentmatters/ sites/urgentmatters/files/AdvancedPracticePresentation.pdf c. Advanced Practice Paramedics, Wake County EMS, http://www. wakegov.com/ems/about/staff/Pages/advancedpracticeparamedics. aspx d. Prehospital Advanced Life Support: Benefits in Trauma. Jacobs, Et Al; Journal of Trauma-Injury Infection & Critical Care: January 1984 e. An analysis of advanced prehospital airway management; Eileen M Bulger, MD, Michael K Copass, MD, Et Al; The Journal of Emergency Medicine, Volume 23, Issue 2, August 2002, Pages 183–189 Disclaimer The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of their employers or organizations. Keywords – paramedic, education, advanced practice, EMS Address for correspondence: mchristie@nationalambulance.ae Author: Michael J. Christie is an Advanced Practice Paramedic with over 30 years of experience across the USA, Asia-Pacific and Middle East regions, with experience in advanced practice, critical care, SAR and military medicine. He currently works as a Clinical Educator with National Ambulance LLC in Abu Dhabi, UAE.

Evidence based EVIDENCE airway management in emergency medicine and resuscitation

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OUTCOME AFTER RESUSCITATION BEYOND 30 MINUTES IN DROWNED CHILDREN WITH CARDIAC ARREST AND HYPOTHERMIA: DUTCH NATIONWIDE RETROSPECTIVE COHORT STUDY Abstract

Introduction

Objectives To evaluate the outcome of drowned children with cardiac arrest and hypothermia, and to determine distinct criteria for termination of cardiopulmonary resuscitation in drowned children with hypothermia and absence of spontaneous circulation.

Drowning is the primary cause of accidental death in children aged 2-5 throughout the world, with a death rate of three per 100 000 per year in developed countries.1 2 In children who do not need any resuscitation or who recovered promptly after basic life support, the neurological prognosis is usually excellent.3 4 The prognosis is much worse in children who did not resuscitate with basic life support.5 6 7 8

Design Nationwide retrospective cohort study. Setting Emergency departments and paediatric intensive care units of the eight university medical centres in the Netherlands. Participants Children aged up to 16 with cardiac arrest and hypothermia after drowning, who presented at emergency departments and/or were admitted to intensive care. Main outcome measure Survival and neurological outcome one year after the drowning incident. Poor outcome was defined as death or survival in a vegetative state or with severe neurological disability (paediatric cerebral performance category (PCPC) ≥4).

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Results From 1993 to 2012, 160 children presented with cardiac arrest and hypothermia after drowning. In 98 (61%) of these children resuscitation was performed for more than 30 minutes (98/160, median duration 60 minutes), of whom 87 (89%) died (95% confidence interval 83% to 95%; 87/98). Eleven of the 98 children survived (11%, 5% to 17%), but all had a PCPC score ≥4. In the 62 (39%) children who did not require prolonged resuscitation, 17 (27%, 16% to 38%) survived with a PCPC score ≤3 after one year: 10 (6%) had a good neurological outcome (score 1), five (3%) had mild neurological disability (score 2), and two (1%) had moderate neurological disability (score 3). From the original 160 children, only 44 were alive at one year with any outcome. Conclusions Drowned children in whom return of spontaneous circulation is not achieved within 30 minutes of advanced life support have an extremely poor outcome. Good neurological outcome is more likely when spontaneous circulation returns within 30 minutes of advanced life support, especially when the drowning incident occurs in winter. These findings question the therapeutic value of resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia.

Cardiac arrest in drowned children is often associated with hypothermia.9 In such children, guidelines advocate continuation of resuscitation beyond 30 minutes.10 11 The rationale is that hypothermia is a potentially reversible cause of cardiac arrest and that hypothermia could exert a protective effect on the brain by slowing its metabolism.11 12 13 14 Current practice is to continue resuscitation until a core body temperature of 32-34°C has been achieved.12 This is based on an extensive list of case reports on people with good neurological recovery after prolonged resuscitation for cardiac arrest with hypothermia after drowning, recently reviewed by Tipton and colleagues.15 These case reports almost invariably concerned drowning in cold (≤6°C) or icy water.15 Drowning in ice water could induce rapid cooling, both because of the large temperature gradient and, in the case of hypothermia, induced muscle rigidity and areflexia because of the relative absence of struggle and panic.16 It has been suggested that rapid cooling in cold or icy water can exert some protection against anoxia.16 17 Hypothermia might not only reflect rapid cooling in cold water, however, but also prolonged submersion in warmer water.4 Hypothermia in patients on arrival at the emergency department has usually been a sign of poor outcome.18 There are, however, no epidemiological data on the relation between water temperature and neurological outcome in children who have drowned with cardiac arrest and hypothermia. We evaluated the outcome of drowned children with cardiac arrest and hypothermia and determined distinct criteria for termination of cardiopulmonary resuscitation in drowned children with hypothermia without spontaneous return of circulation.

Methods Background and setting There is an abundance of open water in the Netherlands. Many houses are built near to ponds, ditches, or canals. A temperate maritime climate

EVIDENCE prevails, with mean air temperatures of 3.5°C in winter, 9.5°C in spring,

defibrillation. Data collected at the emergency department included

10.6°C in autumn, and 17.0°C in summer and water temperatures

initial core body temperature, score on Glasgow coma scale, the use of

ranging from 0-8°C in winter, 6-18°C in spring and autumn, and 15-28°C

bag and mask ventilation, intubation, duration of chest compressions,

in summer.19 20

number of doses of adrenaline, use of extracorporeal life support for cardiac arrest, and return of spontaneous circulation or death.

The Dutch emergency medical service has a legally enforced arrival time

Data collected at the paediatric intensive care unit included death or

of less than 15 minutes for medical emergencies. All ambulance teams

discharge, the cause of death, and, if applicable, the withdrawal of

consist of a nurse trained in paediatric basic and advanced life support

life sustaining treatment. Final disposition was dead or alive at one

and allowed to perform intubation and administration of adrenaline

year after the drowning incident, and, if alive, the neurological status

(epinephrine) in children and a driver trained in paediatric basic life

according to the paediatric cerebral performance category score

support. In cases of a cardiac arrest, a second emergency medical

(PCPC).23

team is always called on, and, since 1999, this second team is often the helicopter emergency medical service with a physician on board.

Definitions

Prehospital treatment is provided by emergency medical service nurses

The minimum and maximum durations of submersion were taken from

according to Dutch national ambulance protocols. These protocols are in accordance with the guidelines of the European Resuscitation Council. The national ambulance protocols instruct that all children with cardiac arrest and hypothermia should be transported, under continuous cardiopulmonary resuscitation, to a hospital with facilities for extracorporeal life support. The physicians of the helicopter emergency

the medical records and were based on estimations by the caretaker(s) of the child at the time of incident. Cardiac arrest was defined as the necessity for chest compressions on arrival of the emergency medical service or and/or helicopter emergency medical service. The start point of the resuscitation time was marked by the initiation of chest compressions by the emergency services and the total duration of

medical service and the emergency department treat according to

resuscitation included prehospital and in hospital advanced life support

the guidelines of the Dutch Resuscitation Council and the European

but excluded bystander cardiopulmonary resuscitation. Prolonged

Resuscitation Council. All children with return of spontaneous circulation

resuscitation was defined as more than 30 minutes of total resuscitation.

after prolonged resuscitation, whether primarily presented at the

This cut off was chosen because the mean attempted resuscitation time

emergency department of a general hospital or a university medical

in many studies concerning resuscitation in children with out of hospital

centre, are transferred to a paediatric intensive care unit in one of the

cardiac arrest averaged 30 minutes.24 We defined spring as the period

eight university medical centres.

between 1 March and 31 May, summer between 1 June and 31 August,

Patients

autumn between 1 September and 30 November, and winter between 1 December and 29 February.

We retrospectively identified eligible patients by using the ICD-9

Initial cardiac arrest rhythm was the first rhythm visible after connection

(international classification of diseases, ninth edition) code for drowning

of the patient to the electrocardiograph of the emergency medical

(994.1). For those aged 16 and under, their demographical and clinical

services. Initial temperature was defined as the first body temperature

data were entered in the database when they were admitted at the

measured within one hour after arrival at the emergency department and

emergency department, the general paediatric ward, or the paediatric

concerned measurements of rectal or oesophageal temperature with a

intensive care unit of one of the eight university medical centres from 1 January 1993 to 1 January 2012. Children who presented at the emergency department of a general hospital and transferred to the

low reading thermometer. The initial blood gas analysis was measured within two hours after arrival at the emergency department. The term extracorporeal life support was used to indicate both extracorporeal

paediatric intensive care unit were included in this database.

circulation and extracorporeal membrane oxygenation. In the paediatric

Inclusion and exclusion criteria

lead to withdrawal of further intensive treatment. The severity of the

(excluding heated outdoor swimming pools) and an initial core body temperature below 34°C. Drowning outside was an inclusion criterion so we could use season as a proxy for water temperature. As concurrent traumatic injuries could possibly influence outcome, we excluded children who drowned in a traffic or boating incident.

Variables

brain damage was assessed by clinical neurological examination, cerebral magnetic resonance imaging and/or electroencephalography, and/or sensory evoked potentials. The combined results could lead to a decision to withdraw further intensive treatment. The paediatric cerebral performance category scale (PCPC)23 was used to qualify neurological outcome. This scale rates the neurological outcome by cognitive impairment in six categories: good neurological performance, mild neurological disability, moderate neurological disability, severe neurological disability, coma or vegetative state, and brain death.23 A good outcome was characterised by a PCPC score ≤3 at one year after the incident. Although it can be debated whether patients with a score

The data collection was based on the Utstein style variables for uniform

of 3, who will require assistance in daily activities, really have a good

reporting of data from drowning.22 Data collected at the arrival of the

outcome, we chose this conservative cut off point to be able to classify

emergency medical service included initial cardiac arrest rhythm,

extremely poor outcome beyond discussion. We therefore defined poor

the use of bag and mask ventilation, intubation, duration of chest

outcome as death or survival with severe neurological disability at one

compressions, and number of doses of adrenaline and attempts at

year after the incident (score ≥4).

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We included children with cardiac arrest after drowning outside

intensive care unit a diagnosis of severe neurological damage could

EVIDENCE

Continuous data are presented as medians and interquartile range. Dichotomous and categorical data are presented as proportions, percentages of total, and 95% confidence intervals. We used Fisher’s exact test for categorical data and Mann-Whitney U test for continuous data. P<0.05 was considered significant. The odds ratios are presented with 95%

RESEARCH

confidence interval. We used IBM SPSS statistics version 22 for the analyses.

Results

RESEARCH

Description of study population From 1993 to 2012, 784 children were identified by the ICD-9 code for drowning. Two of the eight university medical centres were unable to identify children who died at the emergency department. Medical between 1 September and 30 November, and winter records were available forbetween 753 children. Seventeen children were 1 December and 29 February. Initialwere cardiac arrest rhythm the first rhythm vismisclassified, thus 736 children retained in the was database, of whom ible after connection of the patient to the electrocardio207 (28%) experienced cardiac arrest requiring advanced life support. graph of the emergency medical services. Initial Of these 207 children, 47temperature (47/207, 23%) were excluded present was defined as the firstfrom bodythe temperature study: 25 had an initial body temperature of ≥34°C, 14 were in measured within one hour after arrivalinvolved at the emerand concerned a vehicle or boat incident,gency and department eight drowned indoors. measurements of rec-

tal or oesophageal temperature with a low reading thermometer. The initial blood gas analysis was meaWe concentrated on the 160 children a cardiac sured withinwho two experienced hours after arrival at thearrest emergency department. Thewhich term extracorporeal life support was with hypothermia after drowning outside, was not associated with a used to indicate both extracorporeal circulation and motor vehicle or boat incident. Figure 1 shows the flow of the 160 included extracorporeal membrane oxygenation. In the paediatchildren from the emergency department and their subsequent ric intensive care onwards unit a diagnosis of severe neurological to had withdrawal of cardiac further intensive clinical outcome. Of these damage children,could 104 lead (65%) ongoing treatment. The severity of children the brain arrest on arrival at the emergency department. All 98 in damage whom was assessed by clinical neurological examination, cerebral return of spontaneous circulation was not achieved within 30 minutes magnetic resonance imaging and/or electroencephareceived prolonged resuscitation. thesesensory 98 children, 23potentials. children died lography,Ofand/or evoked The combinedThe results could children, lead to aindecision to withdraw in the emergency department. 137 other whom return of further intensive treatment. The paediatric cerebral spontaneous circulation was achieved, were admitted to the paediatric performance category scale (PCPC)23 was used to qualintensive care unit (137/160, whereoutcome. 79 died This (79/137; 95% ify86%), neurological scale58%, rates the neurologoutcome by cognitive impairment six categories: confidence interval 50% toical 66%); 30 had a diagnosis of brainin death (30/79; performance, mild neurological dis38%, 27% to 49%) and 27 good had aneurological diagnosis of severe neurological damage ability, moderate neurological disability, severe neuro(27/79; 34%, 24% to 44%),logical the 22disability, others died of cardiac arrest, acute coma or vegetative state, and brain respiratory distress syndrome, or23 multi-organ failure 28%, 18% A good outcome was(22/79; characterised by ato PCPC death. score ≤ 3the at one after the incident. Although it can 38%). In the original 160 children, totalyear mortality rate after cardiac arrest be debated whether patients with a score of 3, who will with hypothermia was 73% (66% to 80%; n=116). Ten children remained in require assistance in daily activities, really have a good a vegetative state (10/160;outcome, 6%, 2% to 17 had severe neurological we10%), chose and this conservative cut off point to be to classify beyond discusdamage (17/160; 11%, 6%able to 16%). Oneextremely year afterpoor theoutcome drowning accident sion. of We≤3therefore poor 17 children had a PCPC score (17/160;defined 11%, 6% tooutcome 16%). as death or

RESUSCITATION TODAY - SPRING 2016

Fig 1 Patient flow and clinical outcome of children who drowned with cardiac arrest and hypothermia after presentation at emergency department. Final outcome was one year after drowning incident and categorised with paediatric cerebral performance categories (PCPC). Death, vegetative state, and severe disability were categorised as poor outcome. ROSC=return of spontaneous circulation, PICU=paediatric intensive care unit. Figure 2 shows that most incidents of drowning in children with cardiac arrest and hypothermia occurred in summer. Tables 1, 2, and 3 describe the basic characteristics of the children and the parameters correlated to outcome.Winter Spring Summer Autumn Winter 30

No of children No of children

Statistical analyses

25 Winter Spring RESEARCH Summer Autumn Winter 30 20 25 survival with 15 severe neurological disability at one year after the20 incident (score ≥ 4). 10 statistical analyses 15 Continuous data are presented as medians and inter5 quartile range. Dichotomous and categorical data are 10 as proportions, percentages of total, and presented 0 95% confidence We used Janintervals. Feb Mar Apr Fisher’s May Junexact JultestAug Sep Oct Nov Dec 5 for categorical data and Mann-Whitney U test for Month of drowning continuous data. P < 0.05 was considered significant. The odds0ratios are presented with 95% confidence Jan Feb MarofApr May Jun Aug Sepwith Oct cardiac Nov Dec Fig 2 | Distribution children whoJuldrowned interval. We used IBM SPSS statistics version 22 for the analyses. Month of drowning arrest and hypothermia by month and season

Prolonge Prolonge children Prolonge 95% confi Prolonged not goodw children tion confi beyo 95% 3%)good (fig 3i not prolonge tion beyon after(fig one 3%) 3) The maxi prolonged comeone was after tation wa The maxim (89%, 83 come was or with tation was Table 83% 4 sh (89%, tion to or with du se port was Table 4 sh oneto surv tion dur underwe port was p extracorp one survi

results Fig of children who drowned with cardiac arrest and Fig22Distribution | Distribution of children who drowned with cardiac Description of study population arrest and by hypothermia by month and season hypothermia month and season From 1993 to 2012, 784 children were identified by the ICD-9 code for drowning. Two of the eight university table 1 | Characteristics of 160 children medical centres were unable to identify children who who drowned with diedcardiac at the emergency department. Medical Data recordsare presented as arrest and hypothermia. were available for 753 children. Seventeen children number (percentage) unless stated otherwise. were misclassified, thus 736 children were children retained in who drowned with table 1 | Characteristics of 160 the database, of whom 207 (28%) experienced cardiac Characteristic Data underwen cardiac arrest and hypothermia. Data are presented as arrest requiring advanced life support. Of these 207 season Boys 117 (73) extracorp number (percentage) unless stated otherwise. children, 47 (47/207, 23%) were excluded from the presMedian (IQR) age (years) 2 (1–3) Season c ent study: 25 had an initial body temperature of ≥ 34°C, Characteristic Data 14 were involved inof a vehicle or boat incident, and eight Distribution age (years): dren who season Boys indoors. 117 (73) drowned 0 2 (1) outcome We concentrated on (years) the 160 children who experiMedian (IQR) age 2 (1–3) Season co 52 (33) enced a1cardiac arrest with hypothermia after drown(5/17,who 29% Distribution of age (years): dren ing outside, which was not associated with a motor 2 40 (25) 8% (4% 2 (1) vehicle0or boat incident. Figure 1 shows the flow of the outcome 3 29 (18) 160 included children from the emergency department This 29% seas 1 52 (33) (5/17, 4 and their subsequent clinical outcome. Of 16 (10) onwards 2 40 (25) underwe 8% (4% t these children, 104 (65%) had ongoing cardiac arrest 5 6 (4) 3 at the emergency department. All 98 chil29 (18) five child on arrival This seas 6–10 10 (6) dren in 4 whom return of spontaneous circulation was 16 (10) come com underwen 11–16 within 30 minutes received prolonged 5 (3) not achieved 5 6 (4) Cardiac arrest with hypothermia after drowning, presented at emergency department (n=160) in other resuscitation. Of these children, 23 children died in Body of water (n98 = 156): five childs 6–10 department. The 137 other children, in 10 (6) the emergency ROSC No ROSC (10% to 3 Ditch 75 (47) come com whom11–16 return of spontaneous circulation was 5 (3) Admitted to PICU (n=137; 86%) Died (n=23; 14%) median Garden 39 (24) achieved, were pond admitted to the paediatric intensive in other se Body of water (n = 156): care unit (137/160, 86%), where 79 died (79/137; 58%, of subme Swimming pool 14 (9) (10% to 3 Ditch 75 (47) Transferred to nursing ward (n=58; 36%) Died (n=79; 49%) 95% confidence interval 50% to 66%); 30 had a diagRiver 12 (8) seasons median e nosis of brain death Garden pond(30/79; 38%, 27% to 49%) and 27 39 (24) Lake of severe neurological damage (27/79; 9 (6) significan had a diagnosis of subme Swimming pool 14 (9) Discharged from hospital (n=46; 29%) Died (n=12; 8%) 34%, 24% Seato 44%), the 22 others died of cardiac arrest, 4 (3) than in o( River 12 (8) seasons acute respiratory distress syndrome, or multi-organ Other 3 (2) failureLake (22/79; 28%, 18% to 38%). In the original 160 9 (6) Follow-up 1 year after drowning Died (n=2; 1%) significan Season: incident (n=44; 28%) children, the total mortality rate after cardiac arrest initial Sea 4 (3) than in ca ot with hypothermia Summer was 73% (66% to 80%; n = 116). Ten 75 (47) We were a Other 3 (2) children remained in a vegetative state (10/160; 6%, PCPC = 1, good PCPC = 2, mild PCPC = 3, PCPC = 4, severe PCPC = 5, Spring/autumn 68 (43) 2% Season: to 10%), and 17 had severe neurological damage rhythm f neurological neurological moderate neurological vegetative state initial car 17 (11) outcome disability neurological disability (n=10; 6%) (17/160;Winter 11%, 6% to 16%). One year after the drowning Summer 75 (47) (n=10; 6%) (n=5; 3%) disability (n=17; 11%) children accident 17 children had a PCPC score of ≤3 (17/160; We were a IQR = interquartile range. (n=2; 1%) Spring/autumn 68 (43) 11%, 6% to 16%). children rhythm fr Figure 2 shows that most incidents of drowning in Winter 17 (11) Fig 1 | Patient flow and clinical outcome of children who drowned with cardiac arrest and children children with cardiac arrest and hypothermia occurred hypothermia after presentation at emergency department. Final outcome was one year IQR = interquartile range. in summer. Tables 1, 2, and 3 describe the basic characafter drowning incident and categorised with paediatric cerebral performance categories children teristics ofwith the children parameters correlated (PCPC). Death, vegetative state, and severe disability were categorised poor outcome. correlated table 2 | Keyasparameters good and andthe poor outcome in 160 children who drowned with card rOsC = return of spontaneous circulation, PiCu = paediatric intensive care unit to outcome.

odds ratio are for having good outcome

Other Season: Summer Spring/autumn Winter

3 (2)

initial cardiac arrest rhythm We were able to retrieve data on the initial cardiac arrest rhythm from the medical records in 118 of the 160 children (74%). Asystole was diagnosed in nearly all children (101/118, 86%), followed by bradycardia

75 (47) 68 (43) 17 (11)

EVIDENCE

IQR = interquartile range.

table 2 | Key parameters correlated with good and poor outcome in 160 children who drowned with cardiac arrest and hypothermia. univariate analysis odds ratio are for having good outcome no of children

Number of children 160 Total duration of advanced life support (minutes): ≤ 30 62 (39%) > 30 98 (61%) Season: Winter 17 (11%) Other seasons 143 (89%) Initial cardiac arrest rhythm: No of children with data 118 Asystole 101 (86%) Bradycardia 15 (13%) Ventricular fibrillation 2 (2%)

no (%, 95% Ci) with good outcome

no (%, 95% Ci) with poor outcome

Or (95% Ci)

P value

17 (11, 6 to 15)

143 (89, 85 to 94)

—

17 (27, 16 to 39) 0 (0, 0 to 3)

45 (73, 61 to 84) 98 (100, 97 to 100)

—

< 0.001

5 (29, 8 to 51) 12 (8, 4 to 13)

12 (71, 49 to 92) 131 (92, 87 to 96)

4.55 (1.37 to 15.09)

0.008

14 8 (8, 3 to 13) 6 (40, 15 to 65) 0 (0, 0 to 66)

104 93 (92, 87 to 97) 9 (60, 35 to 85) 2 (100, 34 to 100)

— 0.13 (0.04 to 0.46)

— 0.001

RESEARCH

—

4 doi: 10.1136/bmj.h418 | BMJ 2015;350:h418 | the bmj table 3 | additional parameters in 160 children who drowned with cardiac arrest and hypothermia at drowning scene, at arrival of emergency medical service, and at arrival at emergency department, categorised by outcome. number of children stated when fewer than total (160). univariate analysis odds ratio are for having good outcome

No of children Drowning event Median estimated duration of submersion (IQR): Minimal (min) Maximal (min) Basic life support at scene: Performed Delayed: No delay ≤ 10 min > 10 min emergency medical service Bag and mask ventilation Endotracheal intubation Adrenaline Defibrillation emergency department Ongoing ALS at ED Median (IQR) initial core body temperature (°C) Median (IQR) initial GCS Initial blood gas analysis: Median (IQR) pH Median (IQR) negative BE (mmol/l) Median (IQR) pCO2 (kPa) Median (IQR) total duration of ALS (min) Median (IQR) total doses of adrenaline Extracorporeal life support

total

no (%, 95% Ci) or median (iQr) with good outcome

no (%, 95% Ci) or median (iQr) with poor outcome

Or (95% Ci)

P value

160

17 (11%, 6 to 15)

143 (89%, 85 to 94)

—

13 (10–20), n = 130 20 (15–40), n = 105

9 (5–10), n = 14 13 (9–19), n = 12

15 (10–24), n = 116 20 (15–43), n = 93

0.85 (0.75 to 0.96)* 0.89 (0.82 to 0.98)*

0.009 0.02

124/134 (93%)

16 (94, 83 to 100)

108/117 (92, 87 to 97)

—

0.79

100/124 (81%) 20/124 (16%) 4/124 (3%)

14/16 (88, 71 to 100) 2/16 (13, 0 to 29) 0/16 (0, 0 to 17)

86/108 (80, 72 to 87) 18/108 (17, 10 to 24) 4/108 (4, 0 to 7)

—

0.46

159/159 (100%) 133/153 (87%) 124/139 (89%) 18/120 (15%)

17 (100, 84 to 100) 11 (65, 42 to 87) 9/15 (60, 35 to 85) 0/14 (0, 0 to 19)

142/142 (100, 98 to 100) 122/136 (90, 85 to 95) 115/124 (93, 88 to 97) 18/106 (17, 10 to 24)

— 0.25 (0.08 to 0.83) 0.12 (0.03 to 0.40) —

— 0.02 0.01 0.13

104 (65%) 29.8 (28.0–31.9) 3 (3–3)

1 (1, 0 to 3) 29.0 (26.3–31.0) 4 (3–5)

103 (99, 97 to 100) 29.8 (28.0–32.0) 3 (3–3)

0.02 (0.00 to 0.19) — 0.19 (0.09 to 0.43)†

< 0.001 0.39 < 0.001

6.74 (6.53–6.90), n = 135 28 (23–31), n = 106 8.1 (4.8–14.0), n = 126 45 (20–75) 3 (2–6), n = 88 12 (8%)

6.90 (6.80–7.00), n = 13 22 (18–24), n = 11 7.6 (4.2–8.5), n = 11 10 (5–15) 1 (0–3), n = 13 0 (0, 0 to 22)

6.70 (6.50–6.87), n = 122 28 (24–32), n = 95 8.1 (4.9–15.0), n = 115 50 (30–80) 4 (2–7), n = 75 12 (100, 78 to 100)

0.56 (0.39 to 0.81)‡ 0.80 (0.69 to 0.92) — 0.82 (0.74 to 0.92)* 0.65 (0.47 to 0.89)§ —

< 0.001 < 0.001 0.08 < 0.001 0.01 < 0.001

(15/118, 13%) and ventricular fibrillation (2/118, 2%). duration of submersion was not precisely known in Bradycardia correlated strongly with good outcome: six most cases. The typical history of most incidents was a of the 15 children with bradycardia had good outcome sudden realisation of the child’s absence, followed by versus eight of the 101 children with asystole (40% an immediate search by the caretaker. Though the duraProlonged resuscitation was performed in 98 of interval the 160 children of prolonged was extremely poor: 87 ofwell the known, 98 children tion of the search was reasonably it was (95% confidence 15% to 65%) v 8% (3% to 13%); resuscitation unknown how long child had been out of odds ratio 7.8 (2.2 27.3), P = 0.001). with a cardiac arrest and hypothermia (61%, 95%toconfidence interval died (89%, 83%usually to 95%), and 11 survived in athe vegetative state or with sight.damage The median minimum and maximum 54% to 69%). The outcome was not good in any of the children who severe neurological (11%,estimated 5% to 17%). Table 4 shows the Duration of submersion, doses of adrenaline, durations of submersion correlated negatively with outunderwent resuscitation beyond 30 minutes (0% with good outcome, characteristics of the children in relation to duration of resuscitation. and blood gas abnormalities come (Table 3). The longest estimated duration of sub0% to 3%) (fig 3). Seventeen of the children who did not require Extracorporeal life support was performed in 12 children, of whom In only 3% of the cases (5/160) was the drowning mersion with good outcome was 25 minutes. Fig 6 prolonged resuscitation survived with a witnessed PCPC scoreby≤3an after oneand yearconsequently 11 died and survived a vegetative state. Thus, no estimated child who subincident adult, the one shows the in relation between maximum (17/62 good outcome; 27%, 16% to 38%). The maximum duration underwent prolonged with or without extracorporeal life mersionresuscitation, duration and outcome. of resuscitation with good outcome40was 25 minutes. The outcome support, had a good Theoutcome. median total number of doses of adrenaline Good outcome administered was negatively associated with outcome Poor outcome (Table 3). The median initial pH and the base excess 30 were significantly lower in children with poor outcome (table 3). All children were manually or mechanically 20 ventilated at the time of the initial blood gas measureNo of children

Prolonged resuscitation

RESUSCITATION TODAY - SPRING 2016

IQR = interquartile range, ALS = advanced life support, ED = emergency department, GCS = Glasgow coma scale score, BE = base excess. *Per 1 min increase. †Per 1 decrease. ‡Per 0.1 decrease. §Per dose.

rival at emergency department, categorised by outcome. number of children stated when fewer than total (160). univariate analysis having good outcome

EVIDENCE RESEARCH160

total

no (%, 95% Ci) or median (iQr) with good outcome

no (%, 95% Ci) or median (iQr) with poor outcome

Or (95% Ci)

P value

17 (11%, 6 to 15)

143 (89%, 85 to 94)

—

9 (5–10), n = 14

15 (10–24), n = 116

0.85 (0.75 to 0.96)*

0.009

uration of submersion (IQR): 13 (10–20), n = 130

scene:

table 4 | Characteristics of 160 children who drowned with cardiac arrest and hypothermia at drowning scene, at arrival of emergency medical service, 20 (15–40), n = 105 categorised 13 (9–19), n = 12of advanced life 20 (15–43), n =number 93 0.89stated (0.82when to 0.98)* 0.02 and at arrival at emergency department, by duration support (als). of children fewer than totals. univariate analysis odds ratio are for having good outcome

124/134 (93%)

no 95% median (iQr) 16(%, (94, 83Ci) toor100) with als ≤ 30 minutes

no (%, 95% Ci)87 or to median 108/117 (92, 97) (iQr) — with als > 30 minutes

Or (95% Ci)

0.79

P value

No of children 62 (39, 31 to 46) 98 (61, 54 to 69) — — 100/124 (81%) 14/16 (88, 71 to 100) 86/108 (80, 72 to 87) — 0.46 Drowning event 20/124 (16%) 2/16 (13, 0 to 29) 18/108 (17, 10 to 24) Season: 4/124 (3%) 0 to 17) 4/108 (4,to0 92) to 7) Winter 50/16 (29, 8(0, to 51) 12 (71, 49 — 0.41 Other seasons 57 (40, 32 to 48) 86 (60, 52 to 68) l service Median estimated submersion duration (IQR): ation 159/159 (100%) 17 (100, 84 to 100) 142/142 (100, 98 to 100) — — Minimal (min) 10 (5–15), n = 50 15 (10–30), n = 80 1.08 (1.03 to 1.23)* < 0.01 tion 133/153 (87%) 11 (65, 42 to 87) 122/136 (90, 85 to 95) 0.25 (0.08 to 0.83) 0.02 Maximal (min) 15 (10–22), n = 41 28 (15–45), n = 64 1.04 (1.01 to 1.07)* < 0.01 124/139at(89%) 9/15(93, (60,8635toto 85) 115/124 (93, 8898) to 97) 0.12—(0.03 to 0.40) 0.01 1.0 Basic life support performed scene 52/56 100) 72/78 (92, 86 to 0/14 (0, 0 to 19) 18/106 (17, 10 to 24) — 0.13 emergency medical18/120 service(15%) Initial cardiac arrest rhythm: ment Asystole 351 (35, 66 (65, to to 75)100) 0.07 104 (65%) (1, 025toto3)44) 103 (99,5697 0.02— (0.00 to 0.19) < 0.001 Bradycardia 9 (60, 35 to 85) 6 (40, 15 to 65) core body temperature (°C) 29.8 (28.0–31.9) 29.0 (26.3–31.0) 29.8 (28.0–32.0) — 0.39 Ventricular fibrillation 2 (100, 22 to 100) 0 (0, 0 to 78) — — GCS 3 (3–3) 4 (3–5) 3 (3–3) 0.19 (0.09 to 0.43)† < 0.001 Endotracheal intubation 49/59 (83, 73 to 93) 84/93 (90, 84 to 96) — 0.21 lysis: Adrenaline 42/54 (78, 67 to 89) 82/85 (96, 93 to 100) 7.81 (2.09 to 29.20) < 0.01 Defibrillation 6/51 (12, 3 to 21) 12/69(6.50–6.87), (17, 8 to 26) n = 122 0.45 6.74 (6.53–6.90), n = 135 6.90 (6.80–7.00), n = 13 6.70 0.56— (0.39 to 0.81)‡ < 0.001 emergency department ative BE (mmol/l) 28 (23–31), n = 106 22 (18–24), n = 11 28 (24–32), n = 95 0.80 (0.69 to 0.92) < 0.001 Ongoing ALS at ED 12 (19, 10 to 29) 92 (94, 89 to 99) — — 8.1 (4.8–14.0), n = 126 7.6 (4.2–8.5), n = 11 8.1 (4.9–15.0), n = 115 — 0.08 2 (kPa) Median (IQR) initial core body temperature (°C) 30.4 (28.9–32.2) 29.0 (27.0–31.7) 1.16 (1.03 to 1.31)† < 0.01 uration of ALSInitial (min)blood gas analysis: 45 (20–75) 10 (5–15) 50 (30–80) 0.82 (0.74 to 0.92)* < 0.001 oses of adrenaline 1 (0–3), n = 13n = 53 46.58 (2–7), n = 75 n = 82 0.651.74 (0.47 0.01 < 0.01 Median (IQR) pH 3 (2–6), n = 88 6.86 (6.75–6.97), (6.47–6.81), (1.41to to0.89)§ 2.16)‡ Median (IQR) negative BE (mmol/L) 26 = 47 28(100, (25–33), < 0.01 upport 12 (8%) 0 (21–29), (0, 0 ton22) 12 78n59 to 100) — 1.13 (1.05 to 1.22)§ < 0.001 (4.3–8.6),coma n = 50scale score, BE = base 10.9 (6.2–17.0), 1.22 (1.13 to 1.34)¶ < 0.01 Median (IQR) pCO 2 (kPa) ge, ALS = advanced life support, ED = emergency department, GCS6.1 = Glasgow excess. n = 76 Median (IQR) total duration of ALS (min) 15 (10–25) 60 (45–90) — — Median (IQR) total doses of adrenaline 2 (1–3), n = 45 6 (4–8), n = 43 1.82 (1.41 to 2.34) < 0.01 Extracorporeal life support 0 (0, 0 to 5) 12 (12, 6 to 19) — — Outcome Death 29 (47%, 34 to 59) 87 (89%, 83 to 95) 9.00 (4.04 to 20.06) < 0.01 Vegetative state (PCPC 5) 5 (8%, 1 to 15) 5 (5%, 1 to 9) — 0.51 submersion was not precisely in (15/118, 13%) ventricular fibrillation 2%). duration Severe damage (PCPCand 4) 11 (18%, 8(2/118, to 27) 6 (6%, 1of to 11) 0.30 (0.11 to 0.87) known0.03 Mild-moderate damage (PCPC 2–3) strongly with 7good (11%, 3outcome: to 19) (0%, 0 toThe 3) (0.81 toincidents 0.97) < 0.01 typical history0.89 of most was a Bradycardia correlated six most0cases. No damage (PCPC 1) 10 (16%, 7 to 25) 0 (0%, 0 to 3) 0.84 (0.75 to 0.94) < 0.01

of the 15 children with bradycardia had good outcome

sudden realisation of the child’s absence, followed by

IQR = interquartile range, ED = emergency department, BE = base excess, PCPC = paediatric cerebral performance category. versus eight of the 101 children with asystole (40% an immediate search by the caretaker. Though the dura*Per 1 min increase. †Per 1°C decrease (95% confidence interval 15% to 65%) v 8% (3% to 13%); tion of the search was reasonably well known, it was ‡Per 0.1 decrease §Per 1 mmol decrease. usually unknown how long the child had been out of odds ratio 7.8 (2.2 to 27.3), P = 0.001). ¶Per 1 kPa increase.

0 24 0

Fig 4 | Proportion of children with good outcometoof100%) cardiacv 12/57, 21% (10% to 32%); odds ratio 4.8 (2.9 to 7.9), childrenestimated after drowning. Theand cohort included all chilarrest and hypothermia after drowning according to season P=0.01). The median minimum maximum durations Duration of advanced life support (mins) treatment changes (as proxy for water temperature) dren who had been admitted after drowning to of submersion were not different for winter and other seasonsone (fig of

Percentage of children

No of children

RESUSCITATION TODAY - SPRING 2016

sight. The median estimated minimum and maximum Duration of submersion, doses of adrenaline, durations of submersion correlated negatively with outthe main outcomes. The percentage of children with 3). discussion and blood gas abnormalities come (Table The longest estimated duration of subgood (5/160) outcome in the the first five years of the mersion study period of key findings In only 3% of the cases was drowning withimplication good outcome was 25 minutes. Fig 6 was comparable with the percentage in the last five In children with cardiac arrest and hypothermia after incident witnessed by an adult, and consequently the shows the relation between maximum estimated subyears (7/51, 14% (95% confidence interval 4% to 23%) drowning the necessity for resuscitation for more than mersion duration and outcome. 30 minutes did not result in good outcome in any child: v 5/30, 17% (3% to 30%), P = 0.75). The median total number doses of adrenaline Season 40 89% of children diedofand 11% survived in a vegetative 60 Good outcome administered was negatively associated with outcome state or with severe neurological damage. The study P=0.013 Poor outcome used a nationwide database over the period 1993–2012. 50 Season3). correlated strongly with outcome (fig 4). Children who (Table The median initial pH and the base excess 30 Mosthad children drowned during spring, summer, drowned in winter a significantly better outcome than those or were significantly lower in children with poor outcome 40 autumn and had a much poorer outcome than those who drowned in other seasons (5/17, 29% (95% confidence interval (table 3). All children were manually or mechanically 30 who drowned in winter. These results strongly question 20 8% to 51%) v 12/143, 8% (4% to 13%); odds ratio (1.4 to 15.1), ventilated at the of thevalue initialofblood gas4.6 measurethe time therapeutic prolonged resuscitation in 20 P=0.013). This seasonal effect was also evident in children who ment, while some children were being resuscitated drowned children withstill cardiac arrest and hypothermia. underwent resuscitation for less than 30 minutes: all five children 10 10 and others already had return of spontaneous circulawho drowned strengths in winter had good outcome compared with 12 of anda weaknesses tion. The lowest pH associated with good a outcome 0 Winter Other seasons the 57 childrenTowho in this other (5/5, 100% ourdrowned knowledge is seasons the largest study that(55% has eval0 was 6.75. uated outcome of cardiac arrest with hypothermia in Fig 3 | Outcome in drowned children with cardiac arrest and

6 hypothermia according to duration of advanced life support Fig 3 Outcome in drowned children with cardiac arrest and

hypothermia according to duration of advanced life support

350:h418 | doi: 10.1136/bmj.h418

We subanalysis determine 5). performed The initial corea body temperaturetowas significantlywhether lower in doi: 10.1136/bmj.h418 | BMJ 2015;350:h418 | the bmj changes in treatment during the study children who drowned in winter than in other period seasonsaffected (difference 3.7°C, P<0.001; fig 5).

P=0.013

50 40 30 20

Maximum est

discussion 30 of key findings implication In children with cardiac arrest and hypothermia after 0 drowning the necessity for resuscitation for more than 40did not result in good outcome in any child: 30 minutes P<0.001 89% of children died and 11% survived in a vegetative Initial cardiac arrest rhythm state or with 30 severe neurological damage. The study used a nationwide database over period We were able to retrieve data on the initialthe cardiac arrest1993–2012. rhythm from the Most children drowned during spring, summer, or medical records in 118 of the 160 children (74%). Asystole was diagnosed 20 autumn and had a much poorer outcome than those in nearly all children (101/118, 86%), followed by bradycardia (15/118, 13%) who in winter. These strongly question anddrowned ventricular fibrillation (2/118, 2%).results Bradycardia correlated strongly with 10 the therapeutic value prolonged resuscitation in good outcome: six of the 15 of children with bradycardia had good outcome versus eight of the 101 children with asystole confidence interval drowned children with cardiac arrest (40% and (95% hypothermia.

EVIDENCE Fig 7 | Pro

Initial core body tmperature (˚C)

Percentage of children

the main outcomes. The percentage of children with good outcome in the first five years of the study period was comparable with the percentage in the last five years (7/51, 14% (95% confidence interval 4% to 23%) v 5/30, 17% (3% to 30%), P = 0.75).

0 v 8% (3% to 13%); odds ratio 7.8 (2.2 to 27.3), P=0.001). 15% to 65%) Winter Other seasons

10 0

Winter

Other seasons

Fig 4 | Proportion of children with good outcome of cardiac

Fig 4 Proportion of children with good outcomeaccording of cardiac to arrest and arrest and hypothermia after drowning season hypothermia after drowning according to season (as proxy for water (as proxy for water temperature)

strengths and weaknesses Fig 5 | estimated minimum and maximum durations of ToDuration our knowledge this is the largestdoses study that has evalof submersion, of adrenaline, submersion and initial core body temperature in drowned uated outcome of cardiac arrest with hypothermia in to and blood abnormalities children withgas cardiac arrest and hypothermia according children after drowning. The cohort included all chilseason (as proxy for water temperature) dren who admitted after drowning one of by In only 3% had of thebeen cases (5/160) was the drowning incidentto witnessed

RESEARCH

anthe adult, and Dutch consequently the duration of submersion not precisely eight university medical centreswas in 1993–2012.

temperature)

doi:cases. 10.1136/bmj.h418 | BMJof2015;350:h418 the absudden mj all known in most The typical history most incidents In the Netherlands it is common practice to |was transfer

caretaker. Though the duration of the search was reasonably well known, it

sive care unit. It therefore seems unlikely that we

P=0.85

100

wasChild usually unknown long thehypothermia child had been outdrowning of sight. The median with cardiachow arrest and after missed any children with a good outcome after proestimated minimum and maximum durations of submersion correlated

longed resuscitation. Theoretically it is possible that we

negatively30with outcome (table 3). The longestlife estimated duration of of adequate advanced missed minutes children who showed suchsupport a rapid and full submersion with good outcome was 25 minutes. Figure 6 shows the

recovery after a cardiac arrest with hypothermia that

relation between maximum estimated submersion duration and outcome. of spontaneous transfer toReturn intensive care wascirculation? not indicated; this seems

No of children

180

P=0.65

150 120

Exceptional circumstances?*

Move to paediatric Good outcome intensive care unit Poor outcome

Yes

Stop 10resuscitation

Continue resuscitation, preferably extracorporeal life support

90 12 0 15 0 18 0

Estimated maximum duration of submersion (mins)

Fig Fig 7 | Proposed decision tree for continuation of 6 | estimated maximum duration of submersion and resuscitation 30children minutes insubmersion children Fig 6 Estimated maximum duration with of andcardiac outcome outcome inbeyond drowned cardiacwith arrest and in arrest andchildren hypothermia (corearrest bodyand temperature < 34°C) drowned with cardiac hypothermia. hypothermia after drowning outside in temperate climate

0 40

P<0.001

resuscitat arrest and after drow

improbab categorie missed— and in w and thos two of th less, this ings; incl an even m As this emergenc extrapol resources stances w does not with less cal servic Our stu ological l ing we m an under however, The fact t (such as p tion of p outcome observed more acc temperat small bod Instead, w ture. As mate, “se parts of t peratures help with Finally,

The10.1136/bmj.h418 median total number of doses of adrenaline administered was the bmj | BMJ 2015;350:h418 | doi:

20 10

Winter

Other seasons

Fig 5 | estimated minimum and maximum durations of submersion and initial core body temperature in drowned children with cardiac and hypothermia to Fig 5 Estimated minimumarrest and maximum durations according of submersion season water temperature) and initial (as coreproxy bodyfor temperature in drowned children with cardiac arrest and hypothermia according to season (as proxy for water

the eight Dutch university medical centres in 1993–2012. temperature).

In the Netherlands it is common practice to transfer all mechanically ventilated children to a paediatric intensive care unit. It therefore seems unlikely that we missed any children with a good outcome after pro-

negatively associated with outcome (table 3). The median pH and improbable after prolonged resuscitation. Twoinitial other the base excess were significantly lower in children with poor outcome categories of children who drowned could have been (table 3). All childrenthose were manually or mechanically ventilated at the missed—namely, presented at a general hospital time of the initial blood gas measurement, while some children were and in whom spontaneous circulation never returned still being resuscitated and others already had return of spontaneous and those who died in the emergency department of circulation. The lowest pH associated with good a outcome was 6.75. two of the eight university medical centres. Nevertheless, this would not have undermined the main findTreatment changes ings; inclusion of these children would have resulted in an even more unfavourable outcome. We performed a subanalysis to determine whether changes in treatment As this study pertains to a setting with excellent during the study period affected the main outcomes. The percentage of emergency medical services, it might not be possible to children with good outcome in the first five years of the study period was extrapolate the results to settings with limited comparable with the percentage in the last five years (7/51, 14% (95% resources. The prognosis in circumconfidence intervalextremely 4% to 23%) vpoor 5/30, 17% (3% to 30%), P=0.75). stances with excellent healthcare provisions, however, does not offer much hope for the prognosis in areas with less developed or less available emergency medical services.

RESUSCITATION TODAY - SPRING 2016

Initial core body tmperature (˚C)

Yes

*Exceptional circumstances include: 5 Motor vehicle or boat incident with possible air bubble inside Immersion before submersion Winter season Rapidly moving water 0 or ventricular fibrillation at start of advanced life support Bradycardia Bradycardia or ventricular fibrillation after 30 minutes of advanced life support

5 10

Maximum estimated duration of submersion (mins)

Minimum estimated duration of submersion (mins)

realisation of the child’s absence, followed by to an immediate search by the mechanically ventilated children a paediatric inten-

120

Winter se Rapidly m Bradycard Bradycard support

EVIDENCE Discussion

during the 19 year period of our study. Despite these changes, the

Implication of key findings

study period was comparable with that in the last five years.

In children with cardiac arrest and hypothermia after drowning the necessity for resuscitation for more than 30 minutes did not result in good outcome in any child: 89% of children died and 11% survived in a vegetative state or with severe neurological damage. The study used a nationwide database over the period 1993-2012. Most children drowned during spring, summer, or autumn and had a much poorer outcome than those who drowned in winter. These results strongly question the therapeutic value of prolonged resuscitation in drowned children with cardiac arrest and hypothermia.

Strengths and weaknesses

percentage of children with good outcome in the first five years of the

Comparison with other studies In children with cardiac arrest after drowning, neurologically intact survival varies from 0% to 40%.8 25 26 27 28 The most recent study reported a neurologically favourable outcome in only 4.4% of children.8 The percentage in that study could have been because of the low rate of bystander cardiopulmonary resuscitation, in contrast with our study, and the fact that the emergency medical services were not allowed to perform advanced life support in children.8 29 In the Netherlands both the emergency medical services and helicopter emergency medical service are adequately trained and certified in paediatric advanced life support. Prolonged resuscitation has been advocated in patients with cardiac

To our knowledge this is the largest study that has evaluated outcome

arrest and hypothermia.10 30 Its importance has been well established for

of cardiac arrest with hypothermia in children after drowning. The

patients with accidental hypothermic cardiac arrest without asphyxia.12

cohort included all children who had been admitted after drowning to

13 31 32

one of the eight Dutch university medical centres in 1993-2012. In the

hypothermia has been identified as the most predictive factor for

Netherlands it is common practice to transfer all mechanically ventilated

death.33 This urges the need for prognostic factors that could help

children to a paediatric intensive care unit. It therefore seems unlikely

to identify children who might benefit from prolonged resuscitation.

that we missed any children with a good outcome after prolonged

In our study, however, we found no beneficial effect from prolonged

resuscitation. Theoretically it is possible that we missed children who

resuscitation in any child. The high percentage of return of spontaneous

showed such a rapid and full recovery after a cardiac arrest with

circulation after prolonged resuscitation suggests that in children

hypothermia that transfer to intensive care was not indicated; this

the hypoxic heart is capable of restoring function, but the extremely

seems improbable after prolonged resuscitation. Two other categories

poor outcome suggests that the brain has already sustained severe

of children who drowned could have been missed – namely, those

damage.29 Drowning in icy or cold water might be associated with good

presented at a general hospital and in whom spontaneous circulation

neurological outcome.15 Despite the fact that none of the 12 children

never returned and those who died in the emergency department of

who received prolonged resuscitation after drowning in winter had good

two of the eight university medical centres. Nevertheless, this would not

outcome, the 95% confidence interval for this group, based on such a

have undermined the main findings; inclusion of these children would

small sample, extends to a survival rate of 22%. We cannot, therefore,

have resulted in an even more unfavourable outcome.

exclude a beneficial effect of prolonged resuscitation in a substantial

In contrast, an asphyxia-related cause of cardiac arrest with

fraction of children who drown in winter. As most childhood drowning As this study pertains to a setting with excellent emergency medical

incidents occur in non-icy water,4 7 34 the observation that prolonged

services, it might not be possible to extrapolate the results to settings

resuscitation was futile in children with cardiac arrest and hypothermia

with limited resources. The extremely poor prognosis in circumstances

after drowning in other seasons is important. Slow body cooling in

with excellent healthcare provisions, however, does not offer much

warmer water could explain this poor outcome.31 An initial core body

hope for the prognosis in areas with less developed or less available

temperature of less than 34°C would probably indicate a longer duration

emergency medical services.

of submersion when the water temperature is higher. Accordingly, moderate to severe hypothermia after drowning in seasons other than

RESUSCITATION TODAY - SPRING 2016

Our study is retrospective, with the inherent methodological limitations.

winter probably reflects a long duration of submersion associated with

By using the ICD-9 code for drowning we might not have identified all

severe asphyxia.35 Duration of submersion is the predominant factor in

children. Because an underlying cause is rare in drowning in children,

determining outcome of drowning.4 18 36 Theoretically, the influence of

however, the risk of misclassification seems limited. The fact that most

the season of drowning on the outcome in the present study could be

children drowned in stagnant water (such as ponds and most ditches)

related to differences in duration of submersion. The median estimated

might raise the question of possible contamination influencing the

durations of submersion, however, were not different for winter and the

final outcome. Sepsis or meningitis, however, was not observed in

other seasons. Importantly, the accuracy of the estimations of duration

this cohort. Although it would have been more accurate to correlate

was limited because of the lack of witnesses. Thus, there might be an

outcome with exact water temperature, temperatures were not available

additional impact of a neuroprotective effect of rapid body cooling after

for the small bodies of water in which most children drowned. Instead,

drowning in ice cold water.12 15 31 Previous studies have not established

we used season as a proxy for water temperature. As we carried out this

the influence of water temperature on outcome.4 18 36 These studies

study in a temperate climate, “season” cannot be simply extrapolated

included people who recovered spontaneously or after basic life

to other parts of the world. The indicated range of water temperatures

support after drowning, and therefore the results are difficult to compare

during the Dutch seasons, however, could help with translating our

because our cohort consisted solely of children with cardiac arrest

findings to other climates. Finally, guidelines for the treatment of

who required advanced life support. Our findings seem in accordance

paediatric cardiac arrest and cardiac arrest with hypothermia changed

with anoxia by another mechanism—namely, avalanches. People in

RESEARCH EVIDENCE Minimum estimated duration of submersion (mins)

avalanches 120with cardiac arrest caused by hypothermia have a good

P=0.85 with cardiac arrest prognosis compared with people in avalanches caused 100 by asphyxia and subsequent hypothermia.37

Child with cardiac arrest and hypothermia after drowning 30 minutes of adequate advanced life support

Our study shows that survival with good neurological outcome is

60children who experience cardiac arrest with hypothermia unlikely for after drowning in seasons other than winter, and who remain in asystole

after 30 minutes of adequate advanced life support.

Previously reported risk factors for poor outcome after drowning

0 include duration of submersion,5

9 18 38

asystole at the initial

Maximum estimated duration of submersion (mins)

39 assessment 180 by the emergency medical services, number of

40 and Glasgow coma score P=0.65 5 7 41 42 150 at the emergency department. The number of doses of

doses of adrenaline,7 initial pH,7

adrenaline, the initial pH, and the coma score were associated

120

with outcome, but all could be regarded as indicators of prolonged resuscitation. 90 Asystole as the initial cardiac arrest rhythm correlated significantly with poor outcome. The duration of submersion could

be estimated in only 75% of the children, and this information was often not30 available in the emergency department. Compared with other studies, we found no correlation between sex and age and outcome. 7039 40

Initial core body tmperature (˚C)

Importance of study

P<0.001

resuscitation in children with cardiac arrest and hypothermia after 10 11 drowning.20 We propose a decision tree to be used in children

experiencing cardiac arrest with hypothermia after drowning outside in a temperate climate (fig 7). The current data provide support for 10 a strategy to refrain from continuation of resuscitation beyond 30 minutes in children with an initial core body temperature <34°C after

0 Winter Other drowning in seasons other than winter and asystole as seasons the initial

cardiac arrest rhythm. It is important to emphasise, however, that this

Fig 5 | estimated minimum and maximum durations of submersion and initial core body temperature in drowned preceded asphyxia or in whom hypothermia occurred rapidly. Such children with cardiac arrest and hypothermia according to exceptional circumstances couldtemperature) be drowning in a motor vehicle or season (as proxy for water strategy is not advocated in children in whom hypothermia possibly

boat incident with a possible air bubble inside,15 being immersed

before drowning,43 or drowning in rapidly moving water.44 Our study

No of children

Unanswered questions and future research Good outcome

Given that only 12 children in our study underwent prolonged

Poor outcome

resuscitation or extracorporeal life support after drowning in winter, 15

future research should focus on the effect of prolonged resuscitation and/or extracorporeal life support on the outcome in children with cardiac arrest and hypothermia after drowning in ice cold water.

5 0

Exceptional circumstances?* No Stop resuscitation

Yes Move to paediatric intensive care unit Yes Continue resuscitation, preferably extracorporeal life support

*Exceptional circumstances include: Motor vehicle or boat incident with possible air bubble inside Immersion before submersion Winter season Rapidly moving water Bradycardia or ventricular fibrillation at start of advanced life support Bradycardia or ventricular fibrillation after 30 minutes of advanced life support

Fig 7 | Proposed decision tree for continuation of resuscitation beyond 30 minutes in children with cardiac 30 minutes in children with cardiac arrest and hypothermia (core body arrest and hypothermia (core body temperature < 34°C) temperature <34°C) after drowning outside in temperate climate after drowning outside in temperate climate

Conclusions

improbable after prolonged resuscitation. Two other

categories of children who drowned have Children with cardiac arrest with hypothermia aftercould drowning havebeen an

extremely poor outcomethose if return of spontaneous not missed—namely, presented at acirculation generalishospital

achieved 30 spontaneous minutes of advanced life support.never Good neurological and in within whom circulation returned outcome is more likelydied whenin return spontaneous circulation occursof and those who theofemergency department within 30 minutes, especially when the drowning occurs in winter.

two of the eight university medical centres. Nevertheless, this would not have undermined the main findresuscitation beyond 30 minutes in drowned children with cardiac arrest ings; inclusion of these children would have resulted in and hypothermia. an even more unfavourable outcome. As this study pertains to a setting with excellent What is already known on this topic emergency medical services, it might not be possible to extrapolate theoften results to cardiac settings limited • Drowned children experience arrest with with hypothermia, resources. The extremely poor prognosis in circumfor which prolonged resuscitation has been advocated stances with excellent healthcare provisions, however, • Outcome of cardiac arrest with hypothermia in children after does not offer much hope for the prognosis in areas drowning is poor, although several case reports describe with less developed or less available emergency medineurological outcome after prolonged resuscitation or calgood services. extracorporeal life support Our study is retrospective, with the inherent methodological limitations. By using the ICD-9 code for drown• Several variables correlate with outcome, but so far lack sensitivity ingtowe might not have identified all children. Because determine important treatment decisions in the emergency an department, underlying cause is rare intodrowning in children, such as whether or not continue resuscitation however, riskorofto misclassification beyond 30the minutes start extracorporeal life seems support limited. The fact that most children drowned in stagnant water (such as ponds and adds most ditches) might raise the quesWhat this study tion of possible contamination influencing the final outcome. Sepsis or meningitis, however, was not • Survival with good overall performance or with mild to moderate overall disability in 11% of children cardiac arrest and observed in thisoccurred cohort. Although it with would have been hypothermia whoto required advanced life support more accurate correlate outcome with exact water temperature, temperatures were not available for the small bodies of water in which most children drowned. Instead, we used season as a proxy for water temperature. As we carried out this study in a temperate cliThe findings of this cohort study question the therapeutic value of

RESUSCITATION TODAY - SPRING 2016

the eight Dutch university medical centres in 1993–2012. In the Netherlands it is common practice to transfer all excluded children involved in motor vehicle or boat incidents and mechanically ventilated children to a paediatric intendid not identify any child with immersion before drowning or who sive care unit. It therefore seems unlikely that we drowned in rapidly moving water. Therefore for children who drown in missed anyexceptional children circumstances with a goodthese outcome prowinter or under data do after not support longed resuscitation. Theoretically it is possible that a change in the present recommendation—namely, to continue we missed children who isshowed such a rapid andlifefull resuscitation until the patient rewarmed, with extracorporeal recovery after12a13cardiac arrest with hypothermia that support if feasible. transfer to intensive care was not indicated; this seems does not provide data for these exceptional circumstances as we

Fig 7 Proposed decision tree for continuation of resuscitation beyond

Our findings challenge the current recommendation for prolonged

Return of spontaneous circulation?

EVIDENCE • Resuscitation beyond 30 minutes was performed in more than half

This is an Open Access article distributed in accordance with the

of the children in cardiac arrest with hypothermia after drowning, but

Creative Commons Attribution Non Commercial (CC BY-NC 4.0)

did not result in a good outcome in any child

license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different

• Cardiac arrest with hypothermia after drowning in spring, summer, or autumn was associated with poor outcome compared with

terms, provided the original work is properly cited and the use is noncommercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

drowning in winter • The data from this large nationwide cohort question the therapeutic value of resuscitation beyond 30 minutes in children with cardiac arrest and

References 1.

World Health Organization. Factsheet on drowning. www.who.int/ mediacentre/factsheets/fs347/en/index.html.

Centers for Disease Control and Prevention (CDC). Drowning— United States, 2005-2009. MMWR Morb Mortal Wkly Rep2012;61:344-7.

Venema AM, Groothoff JW, Bierens JJ. The role of bystanders during rescue and resuscitation of drowning victims. Resuscitation2010;81:434-9.

Suominen P, Baillie C, Korpela R, Rautanen S, Ranta S, Olkkola KT. Impact of age, submersion time and water temperature on outcome in near-drowning. Resuscitation2002;52:247-54.

Quan L, Kinder D. Pediatric submersions: prehospital predictors of outcome. Pediatrics1992;90:909-13.

Bohn DJ, Biggar WD, Smith CR, Conn AW, Barker GA. Influence of hypothermia, barbiturate therapy, and intracranial pressure monitoring on morbidity and mortality after near-drowning. Crit Care Med1986;14:529-34.

Graf WD, Cummings P, Quan L, Brutocao D. Predicting outcome in pediatric submersion victims. Ann Emerg Med1995;26:312-9.

Nitta M, Kitamura T, Iwami T, Nadkarni VM, Berg RA, Topjian AA, et al. Out-of-hospital cardiac arrest due to drowning among children and adults from the Utstein Osaka Project. Resuscitation2013;84:1568-73.

Salomez F, Vincent JL. Drowning: a review of epidemiology, pathophysiology, treatment and prevention. Resuscitation2004;63:261-8.

hypothermia after drowning, especially in seasons other than winter

Notes Cite this as: BMJ 2015;350:h418

Footnotes • We thank the physicians of the paediatric intensive care units participating in the Stichting Kinder Intensive Care. The participating units were the university medical centres of Amsterdam (AMC, J B M van Woensel and A P Bos, and VUMC, D G Markhorst and F B Plötz), Leiden (LUMC, N A M van Dam and B J Gesink), Nijmegen (Radboud MC, C Neeleman and L G F M van ‘t Hek), Maastricht (MMC, D A van Waardenburg and G D Vos), Rotterdam (Erasmus MC, M de Hoog and D Tibboel), and Utrecht (UMCU, N J G Jansen and A J van Vught). We thank N M Turner, medical director of the Dutch Foundation for the Emergency Medical Care of Children, for his help with the English language. • Contributors: JKK, JJB, and MJA contributed to the study design. JKK and S A van der Linden and J R Prins (medical students at University of Groningen) collected the data. All authors contributed to the analysis, drafting of the manuscript, and approved the final version. All authors had full access to all of the data and can take responsibility for the integrity of the data and the accuracy of the data analysis. JKK is guarantor. • Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and RESUSCITATION TODAY - SPRING 2016

declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. • Ethical approval: Not required. • Data sharing: The relevant anonymised patient level data are available on reasonable request from JK. • Transparency declaration: JKK affirms that the manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

10. Soar J, Perkins GD, Abbas G, Alfonzo A, Barelli A, Bierens JJ, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution.Resuscitation2010;81:1400-33. 11. Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Drowning. N Engl J Med2012;366:2102-10. 12. Brown DJ, Brugger H, Boyd J, Paal P. Accidental hypothermia. N Engl J Med2012;367:1930-8. 13. Corneli HM. Accidental hypothermia. Pediatr Emerg Care2012;28:475-82. 14. Topjian AA, Berg RA, Bierens JJ, Branche CM, Clark RS, Friberg H, et al. Brain resuscitation in the drowning victim.Neurocrit Care2012;17:441-67. 15. Tipton MJ, Golden FS. A proposed decision-making guide for the search, rescue and resuscitation of submersion (head under) victims based on expert opinion. Resuscitation2011;82:819-24. 16. Orlowski JP. Drowning, near-drowning, and ice-water submersions. Pediatr Clin North Am1987;34:75-92.

EVIDENCE 17. Orlowski JP. Drowning, near-drowning, and ice-water drowning. JAMA1988;260:390-1. 18. Suominen PK, Korpela RE, Silfvast TG, Olkkola KT. Does water temperature affect outcome of nearly drowned children. Resuscitation1997;35:111-5. 19. Royal Netherlands Meteorological Institute. Climate scenarios. www.knmi.nl/klimaatscenarios/knmi06/gegevens/ temperatuur/#Inhoud_3. 20. Dutch Ministry of Infrastructure and the Environment. Database on the qualities of the Dutch surface water.Error! Hyperlink reference not valid. http://live.waterbase.nl. 21. Dutch Government. Laws and regulations. www.wetten.overheid. nl/BWBR0032159/HoofdstukIII/2/Artikel7. 22. Idris AH, Berg RA, Bierens J, Bossaert L, Branche CM, Gabrielli A, et al. Recommended guidelines for uniform reporting of data from drowning: the “Utstein style”. Resuscitation2003;59:45-57. 23. Fiser DH. Assessing the outcome of pediatric intensive care. J Pediatr1992;121:68-74. 24. American College of Surgeons Committee on Trauma, American College of Emergency Physicians Pediatric Emergency Medicine Committee, National Association of EMS Physicians, American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Ann Emerg Med2014;63:504-15. 25. Atkins DL, Everson-Stewart S, Sears GK, Daya M, Osmond MH, Warden CR, et al. Epidemiology and outcomes from out-ofhospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest.Circulation2009;119:1484-91. 26. Donoghue AJ, Nadkarni V, Berg RA, Osmond MH, Wells G, Nesbitt L, et al. Out-of-hospital pediatric cardiac arrest: an epidemiologic review and assessment of current knowledge. Ann Emerg Med2005;46:512-22.

34. Lee LK, Mao C, Thompson KM. Demographic factors and their association with outcomes in pediatric submersion injury. Acad Emerg Med2006;13:308-13. 35. Veenhuizen L, Haasnoot K, van Vught AJ, Bierens JJ, Thunnissen BT, Gemke RJ. Submersion in children; the role of hypothermia and development of adult respiratory distress syndrome. Ned Tijdschr Geneeskd1994;138:906-10. 36. Quan L, Mack CD, Schiff MA. Association of water temperature and submersion duration and drowning outcome. Resuscitation2014;85:790-4. 37. Brugger H, Durrer B, Adler-Kastner L, Falk M, Tschirky F. Field management of avalanche victims.Resuscitation2001;51:7-15. 38. Kyriacou DN, Arcinue EL, Peek C, Kraus JF. Effect of immediate resuscitation on children with submersion injury. Pediatrics1994;94:137-42. 39. Eich C, Brauer A, Timmermann A, Schwarz SK, Russo SG, Neubert K, et al. Outcome of 12 drowned children with attempted resuscitation on cardiopulmonary bypass: an analysis of variables based on the “Utstein Style for Drowning”. Resuscitation2007;75:42-52. 40. Orlowski JP. Prognostic factors in pediatric cases of drowning and near-drowning. JACEP1979;8:176-9. 41. Layon AJ, Modell JH. Drowning: update 2009. Anesthesiology2009;110:1390-401. 42. Bierens JJ, van der Velde EA, van Berkel M, van Zanten JJ. Submersion in The Netherlands: prognostic indicators and results of resuscitation. Ann Emerg Med1990;19:1390-5. 43. Tipton M, Golden F, Morgan P. Drowning: guidelines extant, evidence-based risk for rescuers?Resuscitation2013;84:e31-2. 44. Eich C, Brauer A, Kettler D. Recovery of a hypothermic drowned child after resuscitation with cardiopulmonary bypass followed by prolonged extracorporeal membrane oxygenation. Resuscitation2005;67:145-8.

27. Kuisma M, Suominen P, Korpela R. Paediatric out-ofhospital cardiac arrests—epidemiology and outcome. Resuscitation1995;30:141-50. 28. Sirbaugh PE, Pepe PE, Shook JE, Kimball KT, Goldman MJ, Ward MA, et al. A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest. Ann Emerg Med1999;33:174-84.

30. Bierens JJ, Knape JT, Gelissen HP. Drowning. Curr Opin Crit Care2002;8:578-86. 31. Giesbrecht GG. Cold stress, near drowning and accidental hypothermia: a review. Aviat Space Environ Med2000;71:733-52. 32. Wanscher M, Agersnap L, Ravn J, Yndgaard S, Nielsen JF, Danielsen ER, et al. Outcome of accidental hypothermia with or without circulatory arrest: experience from the Danish Praesto Fjord boating accident.Resuscitation2012;83:1078-84. 33. Ruttmann E, Weissenbacher A, Ulmer H, Muller L, Hofer D, Kilo J, et al. Prolonged extracorporeal membrane oxygenation-assisted support provides improved survival in hypothermic patients with cardiocirculatory arrest. J Thorac Cardiovasc Surg2007;134:594600.

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29. Bierens JJ, Warner DS. Drowning resuscitation requires another state of mind. Resuscitation2013;84:1467-9.

EVIDENCE

OUTCOMES OF BASIC VERSUS ADVANCED LIFE SUPPORT FOR OUT-OF-HOSPITAL MEDICAL EMERGENCIES Journal Club Appraisal: Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Ann Intern Med. 2015 Oct 13.

Abstract Background: Most Medicare patients seeking emergency medical

Primary Funding Source: National Science Foundation, Agency for

transport are treated by ambulance providers trained in advanced life

Healthcare Research and Quality, and National Institutes of Health.

support (ALS). Evidence supporting the superiority of ALS over basic life support (BLS) is limited, but some studies suggest ALS may harm patients. Objective: To compare outcomes after ALS and BLS in out-of-hospital medical emergencies. Design: Observational study with adjustment for propensity score weights and instrumental variable analyses based on county-level variations in ALS use. Setting: Traditional Medicare. Patients: 20% random sample of Medicare beneficiaries from nonrural counties between 2006 and 2011 with major trauma, stroke, acute myocardial infarction (AMI), or respiratory failure. Measurements: Neurologic functioning and survival to 30 days, 90 days, 1 year, and 2 years. Results: Except in cases of AMI, patients showed superior unadjusted outcomes with BLS despite being older and having more comorbidities. In propensity score analyses, survival to 90 days among patients with trauma, stroke, and respiratory failure was higher with BLS than ALS (6.1 percentage points [95% CI, 5.4 to 6.8 percentage points] for trauma; 7.0 percentage points [CI, 6.2 to 7.7 percentage points] for stroke; and RESUSCITATION TODAY - SPRING 2016

Analysis: 1. Did the study address a clearly focused issue? Yes…in a way. 2. Was the cohort recruited in an acceptable way? No. Only Medicare beneficiaries from non-rural counties were studied. The authors chose a “random” 20% sample of Medicare fee-for-service beneficiaries who lived in non-rural counties, who were transported to hospital for trauma, stroke, AMI or respiratory failure. These additional exclusion criteria alone mean that the sample could not be random, introducing selection bias, reducing the internal valiity, and therefore the reliability of the results, of the study. (An internally valid trial is one which has accounted for and reduced all potential sources of bias and error, thus ensuring reliability of results.) Patients were selected and analysed based on ICD-9 codes in the Medicare database, and no clinical or direct observation data was utilised. This is a considerable methodological flaw. Of note is that patients were studied from January 2006 to October 2011. Changes to clinical practices, international guidelines and evidence-based interventions throughout this period cannot be controlled for.

3.7 percentage points [CI, 2.5 to 4.8 percentage points] for respiratory failure). Patients with AMI did not exhibit differences in survival at 30

Medicare provides health insurance for Americans aged 65 and older

days but had better survival at 90 days with ALS (1.0 percentage point

who have worked and paid into the system. It also provides health

[CI, 0.1 to 1.9 percentage points]). Neurologic functioning favored

insurance to younger people with disabilities, end stage renal disease

BLS for all diagnoses. Results from instrumental variable analyses

and amyotrophic lateral sclerosis. While they attempted to control for the

were broadly consistent with propensity score analyses for trauma

effects of patient age within their sample, it doesn’t account for the fact

and stroke, showed no survival differences between BLS and ALS for

that the sample contains an age-related bias. This reduces the external

respiratory failure, and showed better survival at all time points with BLS

validity of the results from this study. (An externally valid trial is one in

than ALS for patients with AMI.

which the results can be generalised to the “real world”.)

Limitation: Only Medicare beneficiaries from nonrural counties were

3. Were the exposure and outcome accurately measured to

studied.

minimise bias?

Conclusion: Advanced life support is associated with substantially

The conclusions of this paper are based on a billing code for BLS or

higher mortality for several acute medical emergencies than BLS.

ALS care. The authors claim that it is possible that ALS providers billed

EVIDENCE for ALS care after initial assessment of the patient even though the

• Of note is that BLS transports were more likely from a skilled

patient may have required only BLS level care possible, but unless they

nursing facility, while ALS transports were more likely from a

can support this with some evidence, then it’s merely an allegation

home residence. Early recognition and intervention by other

against ALS providers.

healthcare providers in the skilled nursing facility may affect the results of the BLS arm.

Because they relied on generic billing categories (BLS v ALS), there’s no way for the authors, or readers to distinguish between the exact

7. How precise are the results?

interventions performed by crews at scene or en-route. Calls billed as ALS may have been treated by BLS crews or first responders for an unknown period of time prior to the arrival of advanced life support crews. No direct observations of patients took place in this study. Any conclusions drawn from these results must be tempered with regard

• This is a retrospective, observational study, which can only demonstrate a correlative relationship. • It is a ‘registry type’ study, however, it did not utilise any clinical data or observation of patients.

to the lack of internal validity inherent to this type of study design. This is a retrospective, observational study, which can only demonstrate a correlative relationship. It did not utilise any clinical data or observation

• Twenty percent sample therefore small chance of inadequate sample sizing.

of patients. Remember that no statistical analysis can establish a cause and effect relationship using retrospective data.

• For example, in the stroke population studied (119,989) only 19,985 received BLS billed care.

4. Have the authors identified all confounding factors? Have they taken account of the confounding factors in the design and/or analysis? The authors address several confounding factors in the text. The authors had no way of directly assessing the quality of care for

• In the AMI population (114,469) only 14,434 received BLS billed care. • In the respiratory failure population (82,530) only 9,502 received BLS billed care.

emergency patients that was not susceptible to potential confounding by characteristics of ambulance services. No direct observations of patients took place in this study.

• Only non-rural patients were studied. The benefits of BLS treatment and rapid transport to a nearby trauma centre in urban settings is obvious. However, not all patients have access to

5. Was the follow up of subjects complete enough? Was it long

timely BLS (or ALS) response, or live near a trauma centre.

enough? • We suggest ALS ambulances generally carry sicker patients. There was no follow up with patients. This was a retrospective observational review of billing data, not clinical data. The sample only

8. Should you believe the results?

included patients with hospital Medicare claims. Patients who refused transport, or died at scene could not be accounted for.

The paper raises some interesting questions, but changes to care or policy should not be made based on this study’s results.

6. What are the results of this study? 9. Can the results be applied to the local population? • Much of the difference in trauma survival between ALS and BLS was explained by higher mortality among ALS patients in the days

No. This study is based on uniquely US-centric data (Medicare

immediately after trauma. At 1 year and 2 years, survival was higher

billing). Medicare patients are aged 65 and older, are younger

with BLS but not statistically significantly.

with disabilities, end stage renal disease or amyotrophic lateral population studied were also based in non-rural settings.

was explained by higher mortality among ALS patients in the days immediately after stroke. There was no statistically significant

10. Do the results of this study fit with other available evidence?

difference in neurologic functioning between BLS and ALS patients in instrumental variable analysis.

The evidence of better outcomes in BLS or ALS systems is poorly understood, and poorly researched. Studies with poor methodology

• AMI – Survival to 30 days did not statistically significantly differ between ALS and BLS in propensity score analysis. Neurologic

such as this one do little to advance our understanding of this issue.

performance did not statistically differ between BLS and ALS patients in instrumental variable analysis. • Respiratory failure – no statistically significant survival differences

11. What are the implications of this study for practice? There should be none. A retrospective, observational study does

between ALS and BLS. Early survival gains among patients receiving

not provide sufficiently robust evidence to recommend changes to

BLS narrowed with time.

clinical practice or policy decision making.

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