Discussion and rationale for algorithm

This process has for the first time enabled the production of an algorithm (figure 1) to guide the management of TCA in the paediatric population and to provide a basis for the evaluation of outcomes and for identifying areas of further research into developing effective systems for the provision of optimal care. The algorithm provided in figure 1 bears similarity to existing published algorithms for the adult population, focusing on the rapid management of potentially reversible causes.7–9 12

Resuscitation algorithms are commonly used in emergency medicine, with clinicians trained in their use for the medical management of cardiac arrest in both adults and children. In high acuity, low frequency situations such as paediatric TCA, the provision of an algorithm ensures a standardised and structured approach, which can mitigate inevitable human factors stressors. This could be even more relevant in hospitals that are not designated major trauma centres (equivalent to level 1 trauma centres), where resuscitation is being coordinated by a team less familiar with managing severe trauma in children. Despite the regionalisation of trauma services, 50%–60% of severely injured children present initially to hospitals not designated as major trauma centres, as a result of either self-presentation, geographical location or the severity of their injuries.1 13

During the development meeting, it was agreed that paediatric TCA should be treated with the same principles across the paediatric age range (0–16 years). The definition of TCA is a patient sustaining trauma with no palpable central pulse and either agonal or absent spontaneous respirations.5 In clinical practice, it was agreed that the absence of signs of life, no palpable pulses or a lack of cardiac activity on ultrasound should prompt entry into the paediatric TCA algorithm. The lack of cardiac activity on ultrasound assumes that an appropriately trained and qualified operator is available to perform the procedure.9

Simultaneous life-saving interventions

In keeping with the 2016 updated APLS guidelines, control of external haemorrhage is included in initial life-saving interventions.6 Over the last decade, terrorist incidents in Western Europe have increased, bringing a pattern of injuries that have traditionally only been seen on the battlefield, including traumatic limb amputations and blast injuries.14 While not specific to the paediatric population, the indiscriminate nature of these attacks frequently results in children being affected.15 When applicable (such as following a traumatic amputation secondary to a blast injury), the control of external haemorrhage using tourniquets and haemostatic dressings is a simple intervention associated with increased survival.16 17

In keeping with adult TCA algorithms, consensus was reached regarding the initial management of paediatric TCA, with the rapid identification and simultaneous correction of hypoxia, hypovolaemia, tension pneumothorax and cardiac tamponade.8 9 18 This has been represented in the algorithm in box 1, which describes a bundle of potentially life-saving interventions that should be undertaken simultaneously by the resuscitating team. The intention is to provide one algorithm to guide management in all circumstances, but there may be occasions where not all of these interventions are appropriate, if a reversible cause can be excluded or if the situation is judged to be futile, guided by senior clinical decision makers. In the presence of a multidisciplinary trauma team, the interventions can be undertaken simultaneously, but this may be limited by the number and skills of the team.

Effective oxygenation and ventilation is a key principle of trauma resuscitation, and correcting hypoxia is essential in the reversal of hypoxic cardiac arrest.5 During the Delphi process, consensus was reached that the correction of hypoxia should be optimised where possible by using an endotracheal tube or supraglottic device placed by an appropriately skilled individual in either the prehospital or hospital environment.

Performing bilateral finger thoracostomies is recommended in adult TCA and has replaced needle thoracocentesis in the initial management of tension pneumothorax in the context of TCA.8 9 This topic was reviewed during the consensus development meeting, where it was strongly supported (95.0%) that bilateral thoracostomies should be performed instead of needle thoracocentesis in paediatric TCA.19 However, we acknowledge that needle thoracocentesis continues to be taught as the primary method of chest decompression on paediatric life support courses, and individuals may therefore elect to perform needle thoracocentesis ahead of thoracostomy.7

With severe haemorrhage implicated in the majority of reversible cases of paediatric TCA, the rapid identification and reversal of hypovolaemia is vital in the attempt to improve survival.1 Epidemiological studies in both the adult and paediatric population demonstrate that, within the UK, the majority of severe haemorrhage is within the thoracic cavity and is therefore non-compressible.1 4 Consensus was reached during the Delphi study that hypovolaemia should be corrected by the rapid restoration of blood volume using warmed whole blood. When blood is not immediately available, the temporary use of warmed crystalloid infusions was advised. As with the management of the critically unwell medical paediatric patient, early circulatory access, either via the intravenous or intraosseous route, is essential in the management of paediatric TCA.20 21

In the context of blunt trauma, the application of an appropriately sized pelvic binder (if not already done in the prehospital setting) is part of the management of non-compressible haemorrhage and reversal of hypovolaemia for lower girdle injuries.22

Cardiac tamponade following penetrating trauma is well described in the adult population, and survival following thoracotomy (within 10 min of cardiac arrest) in this group of patients is as high as 18%.23 In keeping with adult recommendations, the Delphi group reached consensus favouring thoracotomy for penetrating trauma to relieve possible cardiac tamponade. There was discussion about the role of thoracotomy in blunt trauma, as it can be used to relieve tamponade, contain pulmonary bleeding and to apply aortic compression for proximal control of haemorrhage below the diaphragm.24 25 However, the group failed to reach consensus for or against thoracotomy in blunt paediatric TCA, and it is therefore presented as an option for consideration, but without clear recommendation, within the algorithm. This remains a key area for future trauma registry work.

While cardiac chest compressions are recommended as the mainstay of basic life support for both adult and paediatric patients in medical cardiac arrest,26–28 in the TCA setting, cardiac chest compressions have been deprioritised in adults until potential reversible causes have been addressed.5 The consensus meeting achieved unanimous 100% agreement in the deprioritisation of chest compressions in both penetrating and blunt paediatric TCA. However, the group achieved consensus in supporting the delivery of chest compressions once interventions to address the main potentially reversible causes (hypoxia, tension pneumothorax, hypovolaemia and cardiac tamponade) have been achieved.

The use of vasopressors in the context of trauma to allow catch-up with blood products is an area of controversy in adult trauma practice, with currently little or no evidence for their use and one study demonstrating potential harm from their administration.29 30 The group failed to reach positive or negative consensus on the use of vasopressors (either by bolus or infusion) before return of spontaneous circulation (ROSC) in the context of any paediatric TCA (including paediatric TCA from suspected isolated traumatic brain injury (TBI)). We acknowledge that there may be a small cohort of paediatric patients in TCA where the use of vasopressors will be required, particularly in the context of neurogenic shock combined with hypovolaemia. After ROSC from paediatric TCA, the group failed to achieve consensus regarding the use of vasopressors except in the context of those patients with isolated TBI, in which case a blood pressure should be maintained at a level sufficient to provide neuroprotection but balancing this against the risk of destabilising other injuries (including clot formation).

The group supported the deprioritisation of defibrillation of a shockable rhythm in the setting of paediatric TCA while other reversible causes were addressed (see suggested algorithm). Once reversible causes have been addressed, the group supported defibrillation in such circumstances where a shockable rhythm is present.

The cessation of resuscitation attempts in children in TCA is challenging, and recognition of features suggesting futility is important in supporting such a decision. In adult medical cardiac arrest, end tidal carbon dioxide (ETCO₂) has been used to determine the futility of continued resuscitation.31 32 While we are unaware of similar studies in either the paediatric population or TCA cohort, the group agreed that the use of ETCO₂ may be useful in determining the futility of ongoing resuscitation. Reaching the end of the suggested algorithm without ROSC was also discussed as a marker of futility and a point at which further resuscitation efforts may be withdrawn.

The main limitation for this study is that the algorithm was by necessity based on consensus rather than robust clinical evidence. The lack of evidence suggests that future research is needed to answer some of these research questions. In the meantime, it is hoped that reaching consensus on at least some aspects of the recognition and management of patients in TCA will provide a useful framework on which clinicians might base their management.