Maxilla and zygoma injuries

Cite this article as:
Jessie Lynch. Maxilla and zygoma injuries, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21700

A 2-year-old child called Lucy is brought to your ED by ambulance. She was the right-sided rear seat passenger in a high-speed head-on road traffic collision. The driver of the other car died on impact. She was restrained in a car seat, however, the seatbelt holding the car seat in place had broken and the car seat was thrown forward. She had a 4-minute episode of loss of consciousness. She had a GCS of 14/15 on arrival, she was maintaining her airway and she was haemodynamically stable. She had significant swelling, bruising, and superficial abrasions to the right side of her face, and her right eye was swollen shut.

Facial injuries in children are relatively common. The most common facial injuries encountered in a paediatric population are dental trauma, oral trauma and facial lacerations. Facial fractures, however, are exceedingly rare in this population, with an incidence of <15% in those under the age of 16 years, and only 0.87% – 1% in those under the age of 5 years.

There are a number of factors which make children less prone to facial fractures. These include:

  • Retruded position of the midface relative to the skull
  • Structural stability increased by the presence of tooth buds within maxilla and mandible and lack of sinus pneumatisation
  • A thick layer of adipose tissue coverage
  • More elastic bones and flexible suture lines
  • High level of adult supervision

These factors also make children more prone to greenstick and minimally displaced fractures as opposed to comminuted or complex fractures. These factors become less significant as the child grows older.

History

Common causes of facial fractures include falls, road traffic collisions, sports-related injuries and, less commonly, interpersonal violence. 2.3% of victims of non-accidental injury have facial fractures and the possibility of this should always be taken into account.

Examination

The presence of a midfacial fracture in a child implies that a significant velocity impact has occurred. 40% of children with a midfacial fracture have an associated skull fracture, and associated cervical spine injury is also common. The primary survey should be undertaken following APLS protocols, with particular attention paid to cervical spine immobilisation and airway management. A detailed craniomaxillofacial examination should be performed as part of the secondary survey, after initial stabilisation.

Image from Wikimedia

Fractures of different parts of the face will lead to different clinical signs.

Zygomatic arch and zygomaticomaxillary complex (ZMC) 

The zygomaticomaxillary complex (ZMC) is made up of four parts:

  • lateral orbital wall
  • zygomatic-maxillary junction
  • zygomatic arch
  • orbital floor

An approach to the assessment of ZMC fractures includes:

  • Inspect the orbit. There may be periorbital swelling or ecchymosis, enophthalmos, subconjunctival haemorrhage and diplopia (due to extraocular muscle dysfunction). The orbital examination should also include visual acuity, visual fields and extraocular muscle function.
  • Palpate the facial bones. There may be a palpable depression or step in the infraorbital rim or zygomatic arch as well as tenderness or widening of the frontozygomatic suture.
  • Oral assessment. There may be trismus (lock jaw) and bruising and tenderness of the upper buccal sulcus.
  • Infraorbital nerve assessment, documenting any paraesthesia.

Maxilla

Maxillary fractures are classified according to the Le Fort classification system*

  1. Le Fort I: A horizontal fracture through the floor of maxillary sinuses with the teeth contained within the detached fragment. Only palate moves.
  2. Le Fort II: A fracture which can be one-sided or bilateral fracture through the maxilla extending into the floor of the orbit, the nasal cavity and hard palate. This results in a pyramidal shaped fracture.
  3. Le Fort III: A fracture through the orbits in which the entire maxilla and one or more facial bones, the entire midface, becomes separated from the base of the skull. This is called craniofacial disjunction.

*Rene Le Fort was a French physician at the turn of the 20th century. He discovered that the midface tended to fracture in three different ways when traumatising cadavers in quite gruesome, but scientifically important, ways.

Clinical signs of Le Fort fractures are much the same signs as for ZMC and zygomatic arch fractures but signs are, for the most part, bilateral. Facial asymmetry, flattening or elongation may be evident in older children.

Management

Manage pain with non-pharmacologic and pharmacological measures. Oral and intravenous analgesia may be required but avoid intranasal analgesia in case of fracture.

Investigations

Facial bone x-rays may give you some valuable information, but the caveat is that they can be difficult to interpret in children. If you have a high clinical suspicion of a facial bone fracture, a CT scan is the imaging modality of choice and can be argued to be the cornerstone of investigation for facial bone fractures in children.

A chest x-ray may be indicated to exclude aspiration of foreign bodies or dental fragments.

Specific treatment

All fractures should be discussed with the local maxillofacial service and/or ophthalmology if orbital involvement is present. A formal ophthalmological review should be carried out as early as is feasible in children with any suspected midfacial fracture.

Most greenstick or minimally displaced fractures can be managed conservatively with soft diet, advice not to blow nose or hold nose closed while sneezing, antibiotic prophylaxis and a nasal decongestant.

There is no clear consensus on the best choice of antibiotic for facial fractures, and there is much variety among papers. The most commonly used would appear to be co-amoxiclav, cefuroxime, and clindamycin in penicillin-allergic patients.

Surgical intervention range from an intraoral approach for minimally displaced zygoma fractures to open reduction and internal fixation for comminuted fractures.

Potential complications, including mal/non-union, are less common in paediatric patients than in adults.

The do not miss bits

  • Reduced or lost vision, severe eye pain or proptosis of the globe are all features of retro-orbital haemorrhage, an ophthalmological emergency which requires immediate surgical intervention to avoid permanent blindness.
  • Although facial fractures are rare in children they have the potential to cause significant disruption to future growth, function & cosmesis and thus it is vital that they are recognised.
  • It takes significant velocity to cause a facial fracture in a child, and examination & investigations must be thorough to identify any other potential injuries. Consideration should be given to the possibility of non-accidental injury when assessing a child with a facial fracture.

Lucy’s CT brain & c-spine showed no significant abnormalities. CT facial bones showed a minimally displaced fracture of the frontal process of the right zygoma. She was reviewed by ophthalmology & maxillofacial specialists & was treated conservatively with oral antibiotics with a soft diet until her fracture had healed.

Selected references

Alcalá-Galiano A,  Arribas-García IJ,  Martín-Pérez MA, et al. Paediatric Facial Fractures: Children Are Not Just Small Adults. RadioGraphics. 2008; 28:441-461

Kumaraswamy SV, Madan N, Keerthi R, Singh DS. Paediatric injuries in maxillofacial trauma: a 5 year study. J Maxillofac Oral Surg. 2009; 8(2):150-153

Braun TL, Xue AS, Maricevich RS. Differences in the Management of Paediatric Facial Trauma. Semin Plast Surg. 2017;31:118-122

Cole P, Kaufman Y, Hollier LH. Managing the Pediatric Facial Fracture. Craniomaxillofac Trauma Reconstruction. 2009;2:77-84

Kidd AJ, Beattie TF, Campbell-Hewson G. Facial injury patterns in a UK paediatric population aged under 13 years. Emergency Medicine Journal. 2010;27:603-606

Mundinger GS, Borsuk DE, Okhah Z, et al. Antibiotics and facial fractures: evidence-based recommendations compared with experience-based practice. Craniomaxillofac Trauma Reconstr. 2015;8(1):64–78

The Royal Children’s Hospital Melbourne.The Paediatric Trauma Manual. Maxillofacial Injury. https://www.rch.org.au/trauma-service/manual/maxillofacial-injury/

Top Tips for Play & Distraction

Cite this article as:
Ana Waddington. Top Tips for Play & Distraction, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29018

Next up in our DFTB Top Tips series is a set of helpful ideas for improving play & helping distract your patients from painful procedures. A special thanks to Janie Saunders for helping share her wisdom from many years working as a play specialist.

  1. Play is a tool that opens doors and is a universal language.
  2. Always address the child or young person first (not their parents). Treat them as the individuals that they are.
  3. Do not lie – Say what you are going to do. Do it.
  4. Every age needs distraction no matter how old!
  5. A smile is always good. Consider how you can show children your calmness and gentleness. If they trust you, it will be easier to examine them and perform procedures.
  6. Remember that no one is ever too big to be scared.
  7. Consider play specialists for bereavement talks
  8. Take your time to talk to them.
  9. If something doesn’t work – try something else! Keep trying; it really makes a difference
  10. Toys are your friend – there are plenty of different toys to choose from – bubbles, talking, iPads, noisy books, lighting up toys, cause and effect toys, books, finding games, sensory toys, cards, and ‘Where’s Wally’ and ‘I Spy’ books.

What are some of your top tips for play and distraction? Feel free to share them in the comments below!

For your convenience or as a handy reminder for your workplace, the top tips are highlighted in an A4 poster below (infographic design by Kat Priddis @kls_kat & Grace Leo @gracie_leo):

Picture of house

Hospital in the Home

Cite this article as:
Jo Lawrence. Hospital in the Home, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.28959

Elise is about to have her 8th birthday and has planned a small party at home with her family and two best friends.  Elise also has acute lymphoblastic leukaemia and is in the middle of chemotherapy treatment.  Her next dose of methotrexate is due the day after her birthday but requires pre-hydration the day before….

Thomas is in year 3 and loves playing foursquare at lunch with his friends. He also has CF and requires regular tune-ups of 2 weeks IV antibiotics and physiotherapy…..

MaryKate is an 8 month old and the youngest of 5 children.  She has poor oral feeding due to a complex medical background and requires nasogastric top-ups. Her parents have been told that she could wean from the tube if she participated in an intensive multidisciplinary program but are reluctant to attend hospital due to the significant disruption on family routine…..  

Is there a way Elise could enjoy her birthday at home, Thomas stay active at school and MaryKate receive the treatment she needs without significant family disruption?

What is Hospital in the Home?

Hospital in the Home (HITH) refers to hospital level care provided in the home environment. 

As we look at managing our growing population with a fixed number of hospital beds this is one area of healthcare that is set to boom!  

When admitted to HITH, clinicians visit the home and provide the acute care interventions required in 1-2 visits per day.  The advantages of this model of care on hospital flow and access are readily apparent.  Less obvious, although equally critical, are the substantial benefits for the family and patient.  Being treated in a safe place surrounded by familiar faces eases the stress and anxiety experienced by the child. Cost-savings for families obviously include not having to fork out for travel and hospital parking, but the real cost-savings occur for families because both parents no longer have to take carers leave – one for the hospitalized child, the other for the siblings. On average, HITH ends up being one-third of the cost of hospitalization for families1. In addition, HITH avoids disruption to family routines and unwanted separation.

So what can Hospital in the Home do?

Pretty much anything!  As long as the patient is clinically stable (not heading for ICU) and can have their care needs delivered in up to 2 visits per day, then it can be done.  

Traditionally Hospital in the Home models have centred around IV antibiotics and little else, but that has dramatically changed over the past few years. 

Here are some of the common things that paediatric HITHs are currently doing2:

  • Diabetes education
  • Eczema dressings
  • Subcutaneous infusions
  • Chemotherapy
  • Pre and post-hydration for chemotherapy
  • TPN hook ons and hook offs
  • Wound dressings
  • NG feed support
  • Cardiac monitoring
  • CF tunes ups
  • Physiotherapy 
  • IV antibiotics 

Baseline criteria regarding distance from hospital and safety of home environment exist but solutions exist for almost situations.

Although most centres service a certain distance from hospital, care can often be outsourced for children who live more rurally.  The care continues to be managed by the tertiary hospital but provided by local care teams – a superb option.

In cases where a barrier exists for staff to enter the home, creative solutions can be found by meeting children at school, in parks or family member’s homes.  

What has changed with Covid-19?

Whilst paediatric hospitals in general saw a fall in patient presentations, HITH referrals have sky-rocketed.  Doctors and families have experienced renewed interest in moving vulnerable patients out of hospital walls and away from the potential of cross-infection.  Stricter visitor restrictions meant hospitalisation had an even greater impact on family life and the driver to manage care at home wherever possible has grown.

Most of this growth has been through increasing the proportion of eligible children referred rather than creating new pathways.  A couple of children have been admitted for observation of Covid-19 infection, but these cases have been few and far between.

However, as with every area of healthcare delivery, the biggest changes for HITH have been moving with the technology.  Education visits, medical and nursing reviews and physiotherapy have all been converted to telehealth where safe to do so.

Vaccination for influenza was offered to all patients admitted to HITH and was accepted by 70% of eligible patients.  65% of these were being vaccinated for the first time against flu3.  In an environment where routine vaccinations have been falling4, this is a powerful demonstration of the opportunities that exist within HITH.

Infants with bronchiolitis have been managed through HITH before5 but the care pathway has never stuck due to barriers accessing cylinders on the same day and clinician confidence.  A new model has been rolled out overcoming these barriers through utilising oxygen concentrators and remote monitoring.

With time, our use of remote monitoring and ability to feed vital signs directly into the Electronic Medical Record, will allow massive expansion of HITH services.   Predictive modelling from large EMR datasets will allow more accurate prediction of which children are likely to be safely transferred to the home environment.  Realtime data and predictive modelling will enhance clinician and family confidence and enable us to fully realise the benefits of HITH to hospitals and families.  

So what about our friends Elise, Thomas and MaryKate….

Elise is able to receive her pre-hydration at home on her birthday.  She celebrates her birthday in her parent’s bed with her sister beside her, both building her new lego sets.  Her best friends visit and her mother prepares a special meal and bakes a special cake.  She is able to go to bed that night, knowing the HITH nurses will visit every day over the following week to administer her chemotherapy and post-hydration and she has avoided another week in hospital.

The HITH nurses visit Thomas daily before school to connect his longline to a Baxter antibiotic infusion. Before and after school he performs physiotherapy via telehealth.  At school, he wears his antibiotic in a backpack and can continue to play 4 square at lunch.

MaryKate is visited by the HITH dietitian and speech therapy who provide feeding advice and a regime that fits around the family routine. They can see where MaryKate sits for meals and how her meals are prepared first hand and are able to offer some helpful suggestions. The team are also able to visit MaryKate at her daycare and ensure her routine is consistent. In between visits, MaryKate is reviewed via telehealth by the allied health team.  She makes significant oral progress and by the end of 2 weeks, her tube is no longer required.

Curiosity is the wick: Ross Fisher at DFTB19

Cite this article as:
Team DFTB. Curiosity is the wick: Ross Fisher at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22124
This final talk from DFTB19 is something else. So sit down, pour yourself a cup of hot cocoa and listen to the mellifluous tones of Mr. Ross Fisher*.
* Ross will read your children bedtime stories if you ask him very nicely.
This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.
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Top Tips for Paediatric Cardiology

Cite this article as:
Ana Waddington. Top Tips for Paediatric Cardiology, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.28999

Here is our next fabulous little treasure trove of tips on Paediatric Cardiology from Helen Ormrod and Anna Mcquorquodale…

  1. In SVT – use a 3 way tap because the adenosine half life is so small that even if you use a bio-connector, the medication will get lost and you don’t want to be giving more adenosine than you need to.
  2. When performing Pre and Post ductal sats, use the right hand and right leg – as a rule of thumb, looking for a gradient of more than 5 (95% vs 90%). We do this because we are worried about any cardiac lesion that is affecting systemic circulation such as cortication of the aorta
  3. Four limb BP is only useful within the first 3-4 months of life because of the conditions that we are looking for. The gradient has to be 20 or more. Don’t worry if there is a tiny discrepancy.
  4. When following up a patient with a known congenital heart disease, try and find out through their letter or consultant where they are with their surgery. If they now have an anatomically normal heart, we don’t need to be as concerned about their cardiac disease. For example, a PDA ligation 3 years ago.
  5. It’s important to be aware that CHD kids, especially post repair, are more likely to have arrhythmias (even if they have reached a stage where their heart is structurally normal). Arrhythmias that can be quite benign in general kids can have a significantly more detrimental effect on those with CHD (even if repaired).
  6. Fluids are part of a delicate balance. These patients need to remain hydrated in order to help their cardiac function but for the same reason they should not be overloaded. Strict input and output balances are required.
    • If the patient has a cardiac shunt (BT Shunt etc) and are dehydrated, this is a life threatening emergency and can become a cardiac arrest very quickly. Move to resus!
  7. If a child has an uncorrected TOFF and have come in with pyrexia or discomfort need to be managed in HDU bay as they can become sick very quickly. Apply cardiac monitoring and saturation.
  8. If a cardiac baby is septic, there is no reason not to give treatment as they need it to help their cardiac function.

What are some of your top tips? Feel free to share them in the comments below!

For your convenience, the top tips are summarised in an A4 poster format (infographic design by Kat Priddis @kls_kat & Grace Leo @gracie_leo):

Post ROSC care

Cite this article as:
Costas Kanaris. Post ROSC care, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29109

Or some pointers on clinical management following the successful return of spontaneous circulation in children. 

It’s 5:40 am at Bubblesville ED. The red phone rings. The paramedic crew informs you that they are five minutes away with a 7 kg, 6-month-old, previously thriving, baby boy called Tarquin. He has had a witnessed out of hospital cardiac arrest at home and there was no prodromal illness according to the family. He choked during a breastfeed, turned blue, and stopped breathing. He had 5 minutes of CPR by the parents by the time the ambulance arrived and had ROSC by the paramedic team after a further 8 minutes. The rhythm strip was consistent with a PEA arrest. They are hand-ventilating him through an LMA.

This is his capillary gas on arrival in the ED
  1. What are your clinical priorities?
  2. What clinical problems do you anticipate in the immediate post-arrest phase?
  3. Who do you call for help?
  4. What do you do with the family whilst you’re managing the patient?
  5. What investigations do you need?

A systematic, collaborative, well-led approach to advanced paediatric life support can maximize the chances of the clinical team achieving a return of spontaneous circulation in a child that has arrested. We’ve seen the drill be before. We can go through our algorithms expertly and the 5-H’s and 5-T’s roll off the tongue, even under duress. The return of a pulse is heralded as the “hallelujah moment”, almost as if the patient is now healthy and safe and all we have to do is wait for the paediatric critical care retrieval team to arrive.

Whilst traditional APLS teachings are vital for the dissemination of knowledge and it’s application in everyday clinical life, their main focus is on the initial phase of achieving a pulse with very little attention placed on the all-important post-resuscitation phase.  This part of care is crucial, not only if we are to minimize secondary brain injury to the child but also to improve the chances of permanent returns of spontaneous circulation. Good short and long term outcomes rely heavily on how well we manage the post-resuscitation stage. 

There are four phases of cardiac arrest:-

Phase one: Prevention. This is the pre-arrest phase. Child safety and injury prevention strategies are in place to recognize deterioration. Adequate monitoring by using early warning systems and a pro-active approach to management is likely to contribute to avoiding an arrest.

Phase two: No flow arrest. This is a period of cardiac arrest prior to us commencing CPR. Our aim here is to minimize the time it takes to start life support. It is key that we involve the cardiac arrest team quickly, we start chest compressions early, and that we do not delay defibrillation if this is needed. 

Phase three: Low flow resuscitation. This phase describes when CPR is in progress. The aim is to achieve high-quality CPR in order to allow adequate coronary and cerebellar perfusion. Maintaining good ventilation and oxygenation whilst avoiding aggressive over-ventilation is paramount. It is during this phase that we systematically approach and threaten the reversible causes of cardiac arrest. 

Phase four: This is the post-resuscitation phase after ROSC has been achieved. Our aim here is to optimize coronary and cerebral perfusion. Neuroprotection and treatment of arrhythmias as well as treatment of post-cardiac arrest syndrome come under this phase. 

Adult v paediatric arrest: What’s the difference?

Out of hospital cardiac arrests in children >16 years of age are relatively rare – reported at 8-20/100000/ year. The incidence is only comparable to that of the adult population, estimated at 70/100000/year. The incidence of in-hospital paediatric arrests is much higher, with a nearly one-hundred-fold increase, compared to the out-of-hospital incidence for the <16’s. 

Survival, and especially a “good” survival from a neurological perspective still remain poor. Out of hospital survival rates are estimated to be 5 – 12%. Only 0.3 to 4% of those that survive have no long-term neurological insult.

Children have cardiac arrests due to severe respiratory insult or circulatory collapse, in the main. Either can lead to a respiratory arrest coupled with hypoxia, which then results in a cardiac arrest. The overwhelming majority of cardiac arrests present with a non-shockable rhythm.  It is also worth noting that almost half of the paediatric population that have a cardiac arrest have other chronic comorbidities such as respiratory conditions e.g. asthma, congenital cardiac disorders, or neurodisability. 

In the adult population, cardiac arrest is more likely due to long-term comorbidities such as ischaemic heart disease. This contributes to the development of an acute myocardial insult and (usually) a shockable rhythm. Understanding the difference in pathology leading to a cardiac arrest between adults and children is vital. Reversing the cause of the respiratory compromise can make the impalpable pulse palpable, allowing us to perfuse our patient once again. 

The recommended CPR ratio of 15:2 for children aims to provide adequate ventilation for oxygenation as well as satisfactory cardiac compressions to maintain sufficient perfusion of the coronary and cerebral circulation. Adult studies looking at compression-only CPR in patients with VF arrest have shown that success in achieving ROSC is due to pre-existing pre-arrest aortic blood oxygen and pulmonary oxygen stores.  As a mere 14% of cardiac arrests are due to a shockable rhythm, combining ventilation and compressions is vital. 

What is the Post Cardiac Arrest Syndrome (PCAS)? 

PCAS describes the period in which our patients are at the highest risk of developing ventricular arrhythmias and reperfusion injuries after ROSC. This is secondary to prolonged ischaemia then reperfusion of vital organs, primarily the myocardium and central nervous system. Its systemic effects are not dissimilar to those encountered in severe sepsis. There are four stages to PCAS:

  • Immediate post-arrest – First 20 minutes. 
  • Early post-arrest – 20 minutes to 6-12 hours. 
  • Intermediate phase – 6-12 hours up to 72 hours.
  • Recovery phase – From 72h onwards. 

Neuroprotection

Even high-quality closed-chest CPR can only achieve 50% of normal cerebral blood flow at best. It is not a secret that the brain does not tolerate hypoxia or ischaemia, the effects on both of these processes are exponential during a cardiac arrest, the longer the downtime, the worse the neurological hit

The pathophysiological cascade for neurodegeneration following cardiac arrest is complex and multi-factorial. Following a hypoxic or ischaemic period the brain develops cerebral oedema and cerebral hyperaemia. There is impaired cerebral vascular reactivity and like any other organ trying to reperfuse, the post-ischaemic biochemical cascade is activated. All these factors contribute to a secondary brain injury. Of course, the duration of hypoxia will in large part dictate how severe the primary brain injury is and whether the patient is likely to survive or not. Brain injury can manifest as myoclonus, stroke, seizures, coma, or brain death. 

We can minimize the extent of secondary brain injury with simple proactive, neuroprotective measures:

  • Strict normothermia
  • Aggressive seizure prophylaxis
  • Avoiding hypoxia and hyperoxia
  • Tight circulatory monitoring and support
  • Patient position
  • Eucapnia and normoventilation
  • Vigilant glucose monitoring
  • Frequent neurological assessment, especially before the administration of anaesthetic agents and paralysis

Strict normothermia

Therapeutic hypothermia following a cardiac arrest during the intermediate phase (after VF in adults), as well as newborns with birth asphyxia, has shown some correlation with better neurological outcomes and reduced neurodisability.  Similarly, there is strong evidence linking core temperature above 38° with worse neurological outcomes in patients following cardiac arrest. There is a wide variation in practice in relation to therapeutic hypothermia.  Mild hypothermia after paediatric cardiac arrest is in the policy of some PICU’s. Patients are cooled to 33-34°C for 1 – 2 days and are then gradually rewarmed. Paralysis can be used as an adjunct to stop shivering. Temperatures below 32°C should be avoided as they are associated with worse survival, immunosuppression, arrhythmias, coagulopathies, and infections.  The decision to “cool” must be made early and in conjunction with your critical care transport team. You have many tools at your disposal to achieve this such as cold IV fluids, cooling blankets, and catheters. 

What is, and should be, more aggressively targeted is strict normothermia (temperatures between 36-37°C), and depending on local practice hypothermia can be targeted to 33-36°C. Avoidance of pyrexia is crucial. Fever can result in an increased metabolic demand of the brain. This contributes to more ischemic injury and more infarcts as the threshold for ischemia in the injured brain is lower than that of the normal brain. The brain can no longer auto-regulate the mismatch between cerebral blood flow and metabolic demand.

Aggressive seizure prophylaxis

Seizures after paediatric cardiac arrest can occur in up to 47% of cases. 35% of these can lead to refractory status epilepticus.  Whilst CFAM/EEG monitoring is unlikely to be available in your local PED, it is important to have a low threshold to administer a long-acting anti-epileptic or a continuous infusion of a short-acting medicine to prevent/avoid this from happening. Ideally, a continuous infusion of midazolam +/- levetiracetam (less arrhythmogenic than phenytoin but both will work) and standard national guidelines should be followed. 

Clues as to whether a patient is still fitting include:

  • Unexpected changes in the pupillary size (beware of the child that had atropine on induction with the “fixed dilated pupils”).
  • Sudden changes in BP or heart rate.  

If you have given a paralytic for intubation, do not fall into the trap of thinking that the patient is not seizing, only an EEG or CFAM can tell you that. It is better to err on the side of caution.

Avoiding hypoxia and hyperoxia

Avoiding hypoxia and hyperoxia are also key components in minimizing secondary brain injury.  Whilst hypoxia will further exacerbate secondary brain injury, hyperoxia  (PaO2 > 40 kPa) is also be associated with worse survival due to oxygen free-radical formation that can inactivate intracellular enzymes, damage DNA, and destroy lipid membranes. It is reasonable to have high concentration oxygen therapy during the low-flow resuscitation and early post-resuscitation phases (as the commonest causes are respiratory). In the subsequent phases, we should target oxygen saturations between 94 and 96% and be proactive in how we reduce the FiO2 whilst avoiding hypoxia. There is a caveat in cases of severe anaemia or carbon monoxide poisoning. Then it is clinically appropriate for the highest concentration of oxygen to be administered.

Tight circulatory monitoring and support

Inotropic support may also be needed early. A degree of myocardial dysfunction/stunning is expected following CPR. To ensure adequate cerebral perfusion we need to target an age-specific, physiologically normal blood pressure. Both hypo and hypertension can exacerbate secondary brain injury. Because of this, monitoring the blood pressure through an arterial line is preferred. If the local set-up or skillset does not allow for arterial line placement, especially in smaller children, having non invasive blood pressure on 1-2 minute cycles can be a useful proxy.  

The paediatric myocardium is much more resilient than its adult counterpart.  If the arrest is not secondary to congenital heart disease the paediatric heart can regain normal function within 12-24 hours.  During the first 20 minutes following ROSC poor cardiac function is due to profound systemic vasoconstriction and cellular acidosis. We can support the myocardium by supplying adequate fluid resuscitation, targeting normal (age-appropriate) blood pressure and inotropic support. Point of care ultrasound, CVP monitoring, or assessing for hepatomegaly/rales if there is no access to the former, can help us prevent fluid overload

Inotrope choice is usually made with the help of the critical care team and depends on the balance between the need for inotropy and vasoconstriction.  Adrenaline is preferred for inotropy, noradrenaline for vasoconstriction.  Be aware that severe acidosis can cause catecholamine resistance, so giving some bicarbonate if the pH <7 may help your inotropes work better. Routine administration of bicarbonate has not been shown to improve clinical outcomes. There are some special circumstances in which we should consider its use such as cases of hyperkalaemia or hypermagnesaemia and arrests due to tricyclic antidepressant overdose. 

Patient position

The patient position that can achieve optimum cerebral perfusion is with the patient semi-sat up at a 30-45 degree angle.

Eucapnia and normoventilation

Avoidance of hypercapnia or hypocapnia is important in preventing secondary brain injury. It is, therefore, recommended that eucapnia is achieved by targeting a PaCO2 between 4.5 and 5.5 kPa. Hyperventilation can cause hypoxia and increase intracranial pressure due to hyperaemia, it can also cause further cerebral ischemia. As the intrathoracic pressures increase, cardiac venous return is impaired. Since the myocardium is already injured this can have catastrophic effects causing the BP to plummet and subsequently impair cerebral perfusion.

Vigilant glucose monitoring 

Following ROSC, children are also at risk of developing hypoglycemia (glucose <3 mmol/L). There is good evidence to suggest that hypoglycaemia negatively impacts neurological outcome and cause hypoglycaemic seizures, especially in the younger ages. Vigilant glucose monitoring and correction as per APLS guidelines is important. If regular dextrose boluses are needed, consider a continuous glucose infusion. If the patient mounts an adequate stress response, they may become hyperglycaemic.  There is no evidence to suggest that aggressive glucose control with insulin in the non-diabetic patient is beneficial; wait with watchful deliberation and the glucose will usually return to normal levels with no intervention.

Frequent neurological assessment

It is important to frequently assess neurological status frequently after ROSC as this can help us prognosticate. Take the time to do a very quick assessment ideally before the administration of anaesthetic agents and paralysis. Document clearly pupillary size/reactivity, GCS (and its break down) and any respiratory effort or gasping. 

Adjunctive investigations

Following ROSC a number of investigations will be needed to guide diagnosis and therapy. Routine bloods such as renal function, electrolytes, liver function tests, full blood count, and clotting are a basic standard. In cases of lactaemia and/or severe metabolic acidosis ammonia and toxicology is useful. Arterial blood sampling is invaluable to allow quick correction of any electrolyte abnormalities and help titrate ventilation settings and (in part) guide inotropic support. Arterial samples will also help uncover any exposure to carbon monoxide, especially in burns cases. 

From an imaging perspective, a chest X-ray is vital in ascertaining tube positioning and lung pathology as well as cardiac contours in case a congenital or acquired heart disease is suspected. Head CT is obviously useful in cases in keeping with traumatic arrest and NAI but timing of the CT and whether it should take place pre-departure to PICU or after depends largely on local trauma network protocols so should ideally be discussed with the regional trauma team lead and paediatric critical care transport team. 

Children that die or arrest unexpectedly in the UK are subject to a sudden unexpected death in infancy investigation (SUDI) so the appropriate referrals need to be made to the child protection team, police and social care. It is important to clarify that even near-miss cases merit triggering the same SUDI process to ensure that any NAI cases don’t slip through the net. 

Transport pearls

After ROSC the patients will need stabilisation and transfer to PICU for on-going management. Depending on the geographical location of your hospital and the availability of a critical care retrieval service you may have to transfer the patient yourselves or look after them until he/she is retrieved by transport team. A good transport and adequate neuroprotection can be achieved by applying these simple pearls: 

  1. Aggressive temperature monitoring and control between 33°C and 37°C.
  2. Monitor for seizures and pre-empt with long-acting antiepileptic accordingly.
  3. Correct electrolytes and hypoglycaemia and monitor frequently.
  4. Nurse the patient a 45° degree angle.
  5. Aim for a higher end of normal BP and use inotropes to achieve this. If you can’t insert an arterial line, have the NIVBP cycle every couple of minutes. 
  6. In cases of trauma, blood products should be used for volume. In an atraumatic arrest, balanced solution boluses are less harmful than 0.9% saline; don’t forget that you are still likely to need blood products. 
  7. Aim for a pCO2 of 4.5-5.5 kPa; use your continuous EtCO2 monitor to titrate ventilation. 
  8. Vigilant and through history/examination to rule out NAI. Free up a member of the team to do a thorough history from the family, always suspect NAI until proven otherwise especially in children under 6 months. 
  9. Know your anaesthetic drug side-effects (atropine dilates pupils for example so impairs our ability to monitor for seizures). Primum non nocere. 
  10. Intraosseous access can be used instead of a central line, have a low threshold to insert one and do it early.
  11. Have a member of the team check-in with the family every 10-15 minutes to explain what is happening, this is a bad day at work for you but probably the worst day of their lives. 

Conclusion

Achieving ROSC is an important step to give our patients a shot at survival. In some cases, achieving ROSC can only give us enough time to prognosticate and understand that survival is not possible. In some other cases ROSC can be the stepping-stone for a good, meaningful survival with a good quality of life. To achieve that, we must be able to apply good quality post–ROSC care and aggressive, pre-emptive neuroprotection. Learn the PCAS disease process to beat the PCAS disease process.  The APLS algorithm has become the bread and butter of anyone that is involved in paediatric care. Understanding and applying the principles of post-cardiac arrest syndrome is equally vital in improving survival outcomes for our patients. Learn the pearls, use them, teach them and I guarantee that it will make a difference.