Chief William Cebulskie MSMEd, NRP - Pediatric Termination of Resuscitation (3/15/24)

All right, everybody, let's get started. Happy Friday everybody. It's March 15, 2024 and we have a very special guest today. William Cyboulski is from the Penn State area. He's from Pleasant Gap Fire Company, the EMS chief there. He will be going to medical school. He's applying very shortly. But the great story about William is that he met Doug Kupas, which many of you know. And Doug said, hey, there's this ESO research forum, the pcrf. Why don't you go there? And he did. And next thing you know he found himself surrounded by a bunch of other smart people. And the next thing you know, he's winning the best pediatric abstract of the namsp, which he's now a member of. So this is the exact pathway where if you're watching this and you're in a leadership position, you ought to be finding people like William and saying, hey, you're a smart guy, smart girl. You come on up and then you bring them and you actually like up their career tremendously. So kudos to Doug Koopas and also to William for making that happen. So without any further ado, William, thank you so much for joining us. It's a very stressful topic for most people, pediatric termination resuscitation. So if you want to share your screen, then take it away, my friend. Thanks for joining.

Like Dr. Antevy said, my name is William, I'm from the the Penn State area and I'm also very excited to have one of the co researchers on this project, Danielle Dechesre. She is the associate medical director from Orange County, Florida and she is here. So she's going to help with answering some questions as well. She's been nothing but phenomenal in helping with this project. But again, right not the the easiest subject matter for some people, you know, termination of resuscitation in children. And it took us a little bit to even get to this topic idea. We wanted to definitely do something pediatric focused with and especially with resuscitation. But we finally got it down to this and it actually yielded some really interesting results for the future of care for children.

And I have no disclosures to make.

So the background on this project, it started with us realizing that, you know, pre hospital termination of resuscitation protocols are used across the United States in adults very widely and they've become very common and well adapted.

Now furthering that on a little bit, we also took into consideration that that EMS care for pre hospital cardiac arrest has significantly increased and oftentimes mirrors exactly what care is going to be provided to those patients in a hospital or in an emergency department.

We've also come to the conclusion that termination of resuscitation protocols have demonstrated much success in reducing futile transports. But more importantly, they have also led to an enhancement of on scene care for patients in cardiac arrest, because we're not rushing and moving to get them into an ambulance and driving down a bumpy road. So it is prioritized that on scene care, high quality resuscitation, there are some also, you know, benefits that include, you know, reducing false senses of hope for the family or loved ones whenever a patient gets to the point in which their resuscitation is futile. It also reduces the risk associated with emergency transport of patients who are likely not to survive. But with all of that, there's a lot of research that supports the use of termination of resuscitation pre hospital in adults. But there was really limited data that existed for the exact same thing in the pediatric population. So that is kind of the background of our project.

So our overall objective was to evaluate the rate of EMS transport of patients in cardiac arrest who met pediatric termination of resuscitation criteria. Now some of you may ask, you know, where did that resuscitation criteria come from? And we're going to get into that.

So our methods began. We did a retrospective analysis using the 2022 ESO Data Collaborative. And the data was all analyzed using descriptive statistics and our primary outcome was EMS transport. So when we were working on this, we identified 911 EMS responses for all patients aged 0 to 17 years that were in cardiac arrest prior to EMS arrival and in which resuscitation was attempted by EMS. We excluded drownings, EMS witnessed cardiac arrests and cases that there was no documented ECG readings or end tidal capnography.

So continuing on with the method methods, we use the Maryland pediatric termination of resuscitation criteria. So in case some of you don't know, the state of Maryland does have a protocol that is in place and being used now for termination of resuscitation in pediatric patients. This was all previously validated criteria, so we felt very comfortable using it. And that was the Harris et al paper and it was published in 2021.

So it is broken down based on etiology of the cardiac arrest. So there was medical and trauma. So in the medical group, these patients had to meet 152 minute, or sorry, 152 minute cycles of CPR, one dose of epinephrine, they had to have asystole or non shockable rhythm and an end tidal CO2 of less than 15 in order to be considered for field termination. The trauma group is similar, but a little different with the CPR cycles. So in the trauma etiology group, the EMS had to complete five 2 minute cycles of CPR. The patient also had to have a non shockable rhythm or BNA systole and their end tidal CO2 had to be less than 15.

So what we did for the approximation of CPR is we used an on scene time of greater than 30 minutes and then an on scene time of greater than 10 minutes for the trauma arrest. And although it's not completely perfect, that was what we use as our proxy to just approximate the CPR cycles and time requirement that these patients would have had to meet.

So here we have a little bit of a breakdown of our how we got to our sample size. So we started with over 100,000 adult and child cardiac arrests. We excluded all of those that had a missing age or that were older than 18. So that left us with children 18 or younger and with just about 3,400 included there. Then we excluded those that had no resuscitation attempted. And then furthering on, we excluded any patients that had a transfer of care at some point or that refused against medical advice. So we were a little confused how there were some that refused medical advice with the, the whole cardiac arrest situation. But there were a couple, so we excluded them. We then further on, and we excluded drownings. And a lot of people were kind of curious as to why we excluded drowning patients. And this was just based on some of the research that we looked at that showed that patients that had a cardiac arrest due to drowning had a higher probability of survival. So we didn't want that to skew the data. So we excluded pediatric drownings. We then excluded those that had no ECG recorded and then no end tidal CO2 recorded, which left us with a total sample size of 1,278 patients. We did think that it was kind of interesting that we had to exclude nearly 1,000 pediatric arrests because there was no title CO2 documented for their care.

So then to kind of break it down by etiology, the cardiac arrest, a majority of those in our sample had a medical etiology 87%. And then the rest were trauma, which left us with about 13% of our overall sample.

So getting into our results a little bit. So like I just said, we had a lot more patients that experienced a medical etiology arrest. So whenever we started to look at our results, we also thought that that was a little interesting given the, the Higher rates of trauma arrests, which I'm going to get into in older children. So but looking here, 87% of the patients included in the sample were transported by EMS. So 1,110 were still transported. 27% of the patients transported had documented return of spontaneous circulation. So after that we looked only 9% of medical etiology arrests met the pediatric termination of resuscitation criteria that we used to complete this analysis. When we looked at the trauma side, 34% of the traumatic arrests met the pediatric termination of resuscitation criteria.

Sorry, had a little technical difficulty there. But furthering on with our results, of those that were meeting the pediatric termination of resuscitation criteria for medical etiology cardiac arrest, 34% were transported. And of those meeting the PTOR criteria for traumatic etiology cardiac arrest, 73% were transported by EMS.

So of the patients that were transported by EMS without ROSC during the EMS encounter, just over 809% of the medical etiology cardiac arrest met the 30 minute minimum on scene time for termination eligibility. When we looked at the trauma side, 58% of the traumatic etiology arrests met the 10 minute minimum seeing time for termination of eligibility.

And of course we did have several limitations with our study, including retrospective review and we had the inability to consider conditions on scene that would have inhibited EMS clinicians from safely performing pediatric termination of resuscitation. We understand that the, the data doesn't show those emotional and potentially, you know, safety concerns on scene. So in conclusion, one in three patients meeting medical etiology pediatric termination of resuscitation criteria and nearly three out of four patients meeting the traumatic etiology PTOR criteria were still transported by ems. In the medical etiology cardiac arrest, most patients without any ROSC were transported by EMS prior to meeting seeing time or CPR cycle requirements to even have them considered for termination of resuscitation eligibility. So in identifying that, we can see that it's suggestive that we're still using a scoop and run or a load and go approach to pediatric cardiac arrest management in the pre hospital setting. So with that we may be able to consider that these practices may reduce high quality resuscitation attempts on scene. And we've seen from other research that the prioritization of on scene management and stabilization of patients in cardiac arrest has led to better outcomes.

And that is all that I have now and I'm going to open it up for questions and go from there.

William? Amazing. And first of all, if you want to tell folks, just to make sure I have it. Right. This is this one, the best pediatric presentation at namsp.

Correct.

Awesome. Wonderful. And the follow ups I have are the following. The Maryland TOR criteria which you had mentioned. They, I believe found in their paper that the items, the children that they were missing were the drownings. And that's why you actually remove drownings from your criteria. Correct?

Correct.

So did you have the ability and I guess it's a retrospective review, so it wasn't easy to do.

To actually find out why people are practicing medicine this way. This is obviously a problem that we all know that we have.

I've tried to get my folks at least spend the time on scene. Whether they transport or not is a whole nother ball of wax. Right. What I've tried to do is get people just to actually do the work on scene. And then.

Very few, if any, would actually terminate, at least in South Florida. When you look at our CARES data and we all know this is a problem, even for adults, our termination rate is 4%. Whereas the United States, if you look at cares data, it's 40%. So we are having.