Letter re: Improving Outcomes and Resuscitation Strategies for Traumatic Cardiac Arrest in the Pediatric Population

We read with great interest the published article: “Traumatic Cardiac Arrest in Pediatric Patients: An Analysis of the National Trauma Database 2007-2016” by Faulkner et al. ¹ This article analyzed pediatric patients who presented with cardiac arrest and no signs of life and described outcomes. ¹ The study goal was to determine if extraordinary treatment measures should be implemented in certain cases to increase the chances of survival. ¹ We compliment the authors for investigating this important topic; however, we offer critiques with the goal to improve future studies and aid in critical trauma-related decisions for the pediatric population.

First, the authors recognize the National Trauma Database (NTDB) has a dedicated variable–no signs of life. ¹ Although the authors chose to disregard this variable due to a high number of patients reported with a perfect GCS. ¹ Instead the patient population included those reported with a zero for pulse and systolic blood pressure. ¹ Consequently, this raises many questions regarding the selection process for the patient population. The authors state that 7503 patients were included in the study, although the percentage of patients originally removed for missing the values of pulse or systolic blood pressure was not specified. ¹ Additionally, the authors did not mention the number of patients included in the initial search using the variable– no signs of life. This information would have provided readers with full disclosure of the amount of data eliminated from the study and if statistical amputations were performed or needed. It is important to mention that over 10% of cases reported to NTDB have incomplete patient data, specifically regarding admission vital signs, and an even larger percentage are lacking EMS vital signs. ² Thus utilizing the NTDB may have introduced additional biases and limited the reliability and validity of these findings.

Second, the authors could have considered utilizing a more validated and consistent database, namely the “American College of Surgeon Trauma Quality Improvement Program Participant User Profile” dataset (ACS-TQP-PUF). ³ For example, the ACS-TQP-PUF dataset may have provided more information on variables such as pre-hospital vs in-hospital thoracotomies, EMS response time, EMS scene time, the total number of EMS transport time from dispatch to hospital arrival in minutes, mode of transportation, and EMS vs on hospital arrival vital signs. These are crucial pieces of information to control for as they can significantly impact the outcomes of patients who present with no signs of life. ³

Third, it’s important to note that 18 year-old patients were included in this study. Although nearly every state recognizes 18 year-old patients as adults. This is particularly noteworthy as Table 1. Provides outcomes by 2 cohorts, “pediatric” (0-14) and “older teenager” (15-18). ¹ It would be interesting to see what percentage of “older teenager” patients were 18 to ensure interventions studied and/or recommended are appropriately targeted towards pediatric trauma populations.

Fourth, a subset analysis was performed for patients that underwent a thoracotomy. ¹ Although authors utilize descriptive statistics, ¹ an adjusted analysis controlling for variables such as the timing of thoracotomy, mechanism of injury: blunt vs penetrating trauma, location of the procedure, EMS transport time, type of transport, and level of trauma center, could have yielded the least biased and generalizable results.

Fifth, and most importantly, the authors state shortly after the results paragraph that thoracotomy in a small subset of patients may be beneficial. Although the authors fail to provide any detailed results about the 3% of pediatric patients that received a thoracotomy and survived. It’s unclear if the 3% survival rate significantly differs from pediatric populations that did not receive a thoracotomy. The authors’ statement that thoracotomy may be beneficial is in contrast to the conclusion by Prieto et al, which is mentioned in the study. ⁴ Prieto et al conclude that emergency department (ED) thoracotomy should not be utilized in pediatric populations that arrive at the ED without signs of life. ⁴ Therefore, we caution the conclusions readers may draw from this study without strong evidence to help support claims that thoracotomy may be beneficial in certain pediatric patients.

In conclusion, Faulkner et al. provide an important study regarding pediatric populations experiencing traumatic cardiac arrest. ¹ Despite our concerns, we congratulate the authors for contributing to an important area of research. We hope the study will spark future investigations that continue to investigate interventions aimed at improving outcomes for traumatic cardiac arrest in pediatric trauma patients.