There are few positive terms associated with pediatric cardiac arrest. Terms like poor outcome, bleak, dismal, and ultimately futile pepper the literature, creating a context of despair any time the topic is approached. It’s no wonder pediatric out-of-hospital cardiac arrest (POHCA) patients are among our most traumatic. When an agency hits upon a formula that improves their measures across the board, it’s worthy of notice.

Children are not supposed to die, so when they do the event represents a level of dissonance that creates enormous collateral impact. POHCAs are not only life-enders, they also represent potential career-enders for the providers involved—the burden of a failure for an event they were unable to mitigate becomes theirs to carry for the remainder of their careers. POHCAs rend a jagged tear through the fabric of resiliency that is often difficult, and sometimes impossible, to repair.

Polk County Fire Rescue in Central Florida looked at its pediatric cardiac arrest survival rates, and while its system had demonstrated regular improvement in adult ROSC and survival rates, its pediatric rates prior to 2014 remained nil. Facing this high-acuity, low-frequency event (approximately 30 a year systemwide) with a significant stress and questionable competency components, leaders decided to focus on what could be changed from an operational level that might impact these numbers. Were providers doing something fundamentally wrong?

Scoop of Practice

The accepted practice in many areas of the country is rapid transport to the hospital, minimizing any delays and attempting any ALS resuscitation en route. Especially in regions with access to pediatric-specific capabilities, this seems a prudent application of the conventional practice of “scoop and run.”

In the history of prehospital care, two terms are often applied, scoop and run or stay and play. The scoop method represents the time-honored tradition of getting the sick and injured to the hospital with all possible speed, sometimes regardless of the quality of that transport or medical interventions provided in transit. It represents the idea that there is little that can be done in the field and “definitive care” can only be provided at the hospital.

As the reins loosened and providers gained more competence and access to education, this direction changed, and we entered the era of stay and play. Providers spent longer on scene, perfecting their freshman skill sets and attempting to fit more interventions into that brief but critical window of time. Then the argument became that EMS was spending too much time on scene, resulting in detrimental outcomes.

It has been difficult for EMS to walk the finely scripted line of just what “definitive care” really is. Arguments about the value of rapid transport in relation to local facility capabilities are important and a separate debate for another time.

There is a universal element of fear and denial when it comes to critically ill infants and children. The infrequency with which they present, along with the inherent emotional stress they create, creates the perfect storm of chaos on scene. By default, when faced with circumstances they cannot interpret or comfortably manage, responders will turn to the idea of “definitive care” (the hospital) to help them.

Thus, in their minds, the speed with which they can get the patient to the hospital where that care resides may be their best opportunity to improve the patient’s chance of survival. There is no clearer evidence of this than in POHCA cases.

However, even in the best rapid evacuation and transport scenario, there will be a risk of delayed critical early interventions and suboptimal compressions, with the resulting significant impact in survival rates.

When it came to POHCA in Polk County prior to 2014, they typically managed these cases with scoop and run: “Patients were managed in the traditional manner involving rapid evacuation to one of several appropriate receiving facilities while [crews attempted] ALS interventions after leaving the scene.”1

That left them with a 0% survival rate.

The Scene Reseen

What if they stayed and played?

Instead of immediate transport, what if the focus were shifted to improving competency and application of skills? Anatomic challenges, airway size, vascular access, and infrequent practice result in weak procedural memories for providers. The same pathophysiology that leads to POHCA supports the earliest interventions possible for the best response.

Polk County Fire Rescue reviewed its responses and came up with a new initiative that steered the paradigm to one that stays in place and focuses on supporting successful interventions done in conjunction with immediate high-quality CPR. In addition to the pit-crew approach, it focused on four other key skills.

Training and competency measures in definitive airway management were applied to ALS providers, with the target being immediate attempts at ETI or the i-gel supraglottic airway (within 5 minutes). Tightly controlled ventilation rates (one breath every 10 seconds) were instituted. Patent, rapid vascular access occurs via the intraosseous route versus waiting on intravenous attempts, and there’s a focus on early epinephrine dosing.

Drug dosing presents an enormous stressor when it comes to critically ill prehospital patients. Having to accurately calculate weight-based dosing while managing a POHCA increases the risk of errors and delays in administration. Length-based tapes have proven to be inaccurate, with a range of error that at best delays administration and at worst results in errors of omission (nonadministration) or commission (over-/underdosing).2

To alleviate this, Polk County Fire Rescue trained its personnel to use a proscribed “system one thinking” approach when it came to dosing, which was determined by the patient’s approximate age. To achieve this the service implemented the Handtevy system, which uses a hybridized combination of age-based methodology and a refined length-based tape for prearrival dosing. This, in conjunction with the age- and length-segregated equipment configuration offered by the Handtevy system, helped Polk leaders standardize their resources in an agency-specific manner, which allowed them to rapidly deploy with consistency and confidence.

Simplifying the treatment process to one they could do in an “ACLS mind-set,” without calculations, dramatically reduced the time to first epinephrine administration by well over 50% (from 16.6 to 7.65 minutes). Offloading a task like dose calculation removes a large obstacle in the flow of care and improves responder’s procedural (muscle) memory, which in turn reduces functional stress. POHCAs represent an arrest scenario where early epinephrine may be of the most benefit, and the ability to streamline its delivery with a method like the Handtevy system is a game-changer for provider confidence and dosing accuracy.

Conclusion

When faced with a task like saving a child, it is not uncommon for providers to have laser focus and operate within a silo of their own making—decreasing effective communication with each other and those around them. This also leads to increased stress, error risk, and long-term emotional impact on responders and patient families alike. Increased training on better interaction with team members, bystanders, and family gives crews the tools they need to communicate with confidence and provide reassurance where previously there may have been none.

The success of Polk County Fire Rescue’s initiative is remarkable (see the sidebar below). Its ROSC rate went from 5.3% to 30.4%. Neurologically intact survival also shot up, from 0% to 23.2%. By being willing to take a hard look at fundamental practices, Polk leaders were able to reduce delays by being willing to stay on scene. Even with the new approach, the average scene time only increased by approximately three minutes.

Three minutes bought them more than a dozen survivors. That’s a lot of children who get to stay and play.

References

1. Banerjee PR, Ganti L, Pepe PE, Singh A, Roka A, Vittone RA. Early On-Scene Management of Pediatric Out-of-Hospital Cardiac Arrest Can Result in Improved Chances for Neurologically-Intact Survival. Resuscitation, 2018; https://www.resuscitationjournal.com/article/S0300-9572(18)31080-3/abstract.

2. Waseem M, Chen J, Leber M, Giambrone A, Gerber L. A Reexamination of the Accuracy of the Broselow Tape as an Instrument for Weight Estimation. Pediatric Emergency Care, 2017 Jan 17.

Sidebar: What the Study Says

Emergency physicians Paul Banerjee, DO, Latha Ganti, MD, and Paul Pepe, MD, and EMS chief Raf Vittone, EMT-P, coauthors of the above article, were also part of the team that wrote up Polk County Fire Rescue’s change in approach for journal publication. Their article, “Early On-Scene Management of Pediatric Out-of-Hospital Cardiac Arrest Can Result in Improved Chances for Neurologically-Intact Survival,” appeared in Resuscitation.

Their study evaluated the frequency of neurologically intact survival among POHCA patients before and after the 2014 implementation of new on-scene resuscitation efforts that included methods to expedite protocols on-site and control positive-pressure ventilation. They compared survival to hospital discharge for the two years prior to the new strategy to the two years after. There were no significant differences among the patient groups in age, sex, etiology, presenting electrocardiograph, drug infusions, or bystander CPR, and their scenes times ultimately didn’t differ much (14.3 vs. 17.67 minutes).

Their findings: Survival “increased significantly upon implementation of the immediate on-scene management strategy and was sustained over the next two years (0.0% to 23%; p = 0.0013).” The improvement was associated with a shorter (though statistically indeterminate) mean time to epinephrine administration among resuscitated patients.

“Facilitating immediate on-scene management of POHCA,” the authors concluded, “can result in improvements in lifesaving. Although a historically controlled evaluation, the compelling appearance of neurologically intact survivors was immediate and sustained. Targeted training, more efficient, physiologically driven procedures, and trusted encouragement from supervisors likely played the most significant roles, and not necessarily extended scene times.”

Paul Banerjee, DO, is the medical director for Polk County Fire Rescue, the Polk County Sheriff s Office SWAT team, the Lake County Sheriff s Office, and Lake Technical College EMS program in Florida. He serves as associate medical director for Osceola Regional Medical Center and an associate professor of emergency medicine at the University of Central Florida School of Medicine.

Latha Ganti, MD, is a professor of emergency medicine and neurology at the University of Central Florida College of Medicine, as well as vice chair for research and academic affairs at the University of Central Florida/HCA emergency medicine residency program. She is associate medical director for Polk County Fire Rescue.

Paul E. Pepe, MD, MPH, is a professor of emergency medicine, internal medicine, surgery, pediatrics, public health, and the Riggs Family Chair in Emergency Medicine at the University of Texas Southwestern Medical Center (UTSW) in Dallas. He is the medical director for EMS and public safety, Dallas County, TX. Pepe is also the global coordinator for the Metropolitan EMS Medical Directors Coalition, AKA "Eagles." Reach him at paul.pepe@utsouthwestern.edu.

Raf A. Vittone, EMT-P, AS, is deputy chief of EMS for Polk County Fire Rescue and an adjunct instructor at Polk State College in Winter Haven, Fla.

Tracey Loscar, BA, NRP, FP-C, is the EMS Operations Chief at Matanuska-Susitna Borough Department of Emergency Services in Wasilla, Alaska. Her adventures started on the East Coast, where she spent 27 years serving as a paramedic, educator, and supervisor in Newark, NJ. She is a member of the EMS World editorial advisory board and currently the author of the popular "Midlife Medic" column. Contact her at taloscar@gmail.com or www.taloscar.com.