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Should EMS Terminate on Scene? Protocols for Pediatric Patients
COVID-19 and national media coverage brought increased attention to EMS termination of resuscitation protocols, though these protocols have been widely used for some time—among adult patients at least. Decades of research have identified clear criteria for determining when resuscitation continued efforts are ineffective.
Collectively, these criteria have been deemed the Universal Termination of Resuscitation (TOR) Guidelines. These guidelines suggest that resuscitation may be discontinued if after at least four 2-minute intervals of cardiopulmonary resuscitation, three criteria are met:
- The arrest was not witnessed by emergency medical services
- There has been no return of spontaneous circulation
- No shocks were delivered
TOR protocols, however, are not commonly in place for pediatric patients. In 2019, the Maryland Institute of EMS Systems developed a set of pediatric TOR (pTOR) criteria based on review of existing research and engagement of community stakeholders.
These criteria include specific recommendations based on whether the cardiac arrest was the result of a medical or trauma-related condition.
| Medical pTOR criteria | Trauma pTOR criteria | |
| Age | <18 years | <15 years |
| CPR cycles | Two 15-minute cycles | Two 5-minute cycles |
| Medications | At least 3 doses of epinephrine | At least 1 dose of epinephrine |
| Cardiac rhythm | Asystole | Asystole |
| End-tidal CO2 | Terminal sustained <15 mmHg | Terminal sustained <15 mmHg |
| Additional considerations | Adequate safety/emotional support |
Adequate safety/emotional support |
In a recently published study, researchers used ESO’s Data Collaborative to evaluate how pTOR criteria perform in a real-world collection of EMS records from 2,000 agencies across the country. Out of more than 8 million EMS encounters, there were 70,709 emergency (9-1-1) responses involving cardiac arrests overall. After applying inclusion and exclusion criteria, the final sample looked at 1,595 pediatric patients (0-17 years old) with out-of-hospital cardiac arrest.
Eighty-eight percent of patients had a cardiac arrest with medical etiology, and the remaining 12% experienced cardiac arrest as the result of a traumatic injury. In total, the algorithm worked well. Out of the 1,595 patients, the algorithm misclassified 5 patients who experienced ROSC as eligible for pTOR consideration. Interestingly, most of the misclassified patients were victims of drowning. Because of this finding, the research recommends identifying special considerations for drowning patients for future pTOR guidelines.
Discontinuing resuscitation efforts for a pediatric patient on scene is a delicate situation, but when continued efforts will most certainly be futile, there is value in considering termination on scene and allowing an intimate space for survivors to begin the grieving process.
While the evidence supporting use of an ethical framework for pTOR in EMS is growing, pTOR protocols should be developed and implemented under close guidance of the EMS medical director.
In addition, community stakeholders should be aware of the protocols to avoid misinformation. Finally, EMS clinicians must be confident in applying the pTOR criteria and prepared to deliver death notifications following termination of resuscitation. Failure to provide such education can lead to burnout and be harmful for clinician mental well-being. While the implementation approach must consider these factors and others, there is encouraging evidence supporting use of pediatric resuscitation protocols to guide care that is clinically sound, is respectful of the patient, family, and EMS clinicians, and is firmly rooted in ethical principles.
Key points:
- 88% of cardiac arrests were medical and the remaining 12% were trauma related.
- In patients with medical etiologies meeting TOR criteria, only one had a return of spontaneous circulation.
- In patients with trauma etiologies, 93% (50/54) were correctly classified as being eligible for termination of resuscitation on scene.
- In total, the three out of five patients meeting TOR criteria who had a return of spontaneous circulation were drowning victims.
- Special considerations should be given when making a TOR decision for drowning victims.
Remle Crowe, PhD, NREMT, is director of clinical and operational research for ESO.
Comments
Even though the outcome is often predictable, I am hesitant to terminate resuscitative efforts on a pediatric patient because mom and dad need to know ALL efforts were made for their child.
—Todd Richard