Pediatric out-of-hospital cardiopulmonary resuscitation by helicopter emergency medical service, does it has added value compared to regular emergency medical service?
Pediatric out‑of‑hospital cardiopulmonary resuscitation by helicopter emergency medical service, does it has added value compared to regular emergency medical service?
X. R. J. Moors 0 1 2
K. Rijs 0 1 2
D. Den Hartog 0 1 2
R. J. Stolker 0 1 2
0 Department of Surgery-Traumatology, Erasmus University Medical Center , Rotterdam , The Netherlands
1 HEMS, Erasmus University Medical Center , Rotterdam , The Netherlands
2 Department of Pediatric Anesthesiology, Erasmus MC, University Medical Center Rotterdam-Sophia Children's Hospital , P.O. Box 2060, 3015 CN Rotterdam , The Netherlands
3 X. R. J. Moors
Purpose To determine the outcome of out-of-hospital (OOH) cardiopulmonary resuscitation (CPR) and the advanced life support (ALS) procedures provided in pediatrics by the Rotterdam Helicopter Emergency Medical Service (HEMS) Methods Retrospective evaluation of all pediatric (0-17 years) OOH cardiopulmonary arrests within a 6-year period and attended by the Rotterdam HEMS team. Results There were 201 OOH CPRs from October 2008 until October 2014. Endotracheal intubation was performed in 164 cases and done by HEMS in 104 patients (63%), intraosseous/intravenous cannulation 43/27 times, and additional medication given by HEMS in 70 patients (35%). The overall survival rate for OOH CPR was 15%, but in trauma was low. Twenty-seven of the 29 pediatric patients who survived until discharge are neurological well. Although the Dutch nationwide ambulance protocol states intubation, intravenous, or intraosseal excess and medication, in many patients, only HEMS provided additional ALS care. Conclusion The HEMS brings essential medical expertise in the field not provided by regular emergency medical Vol.:(011233456789)
service. HEMS provide a significant quantity of
procedures, obviously needed by the OOH CPR of a pediatric
The Helicopter Emergency Medical Service (HEMS) was
introduced in The Netherlands in 1995, enabling the
delivery of a medical team to the scene in addition to the
regular ambulance service. A HEMS team consists of a
physician (board-certified anesthesiologist or trauma surgeon), a
specialized nurse [Paramedic or Registered Nurse from the
Emergency Department (ED)] and a helicopter pilot.
The Emergency Medical Service (EMS) protocol in The
Netherlands is a nationwide protocol with precise
description of procedures to follow, but the ambulance crew is
limited in expertise and experience in vitally compromised
]. When HEMS became operational, EMS
frequently secondary asked for assistance in stabilizing vitally
compromised children. After a few years, it became
protocol to activate HEMS primarily in vitally compromised
children. Prehospital data concerning pediatric EMS and/
or pediatric HEMS in The Netherlands are lacking and it
is difficult to extrapolate research done in other countries
due to the differences in their HEMS and EMS
organizations and HEMS dispatch criteria. Previous studies show a
low survival rate in pediatric out-of hospital cardio
pulmonary resuscitation (OOH CPR) [
]. This study was done
to assess the survival rate and outcome in OOH CPR in
pediatric patients treated by the Rotterdam HEMS. It is
difficult to measure the expertise that leads to additional care
provided by HEMS. To do so, we wanted to evaluate the
medical interventions done either by the HEMS or by the
EMS and to examine how often the HEMS provided this
additional medical care, which was or could not be
provided by the EMS.
We performed a retrospective analysis of a database in
which every patient treated by Rotterdam HEMS is
registered. Only patients under the age of 18 on the day of the
emergency call were included in the period October first
2008 until October first 2014. We selected all consecutive
patients who underwent OOH CPR.
We considered an OOH cardio pulmonary arrest when
EMS and/or HEMS objectified the indication of OOH CPR
by clinical assessment, because it is difficult for a
non-professional to assess if an arterial pulse is present in a
pediatric patient [
]. The Pediatric Basic Life Support (PBLS)
guidelines also advise PBLS providers when in doubt to
start CPR. This study included pediatric patients by PBLS
providers (police or fire brigade) only when an automatic
external defibrillator (AED) gave a shock, this to avoid
pediatric patients with poor circulation but with cardiac
Patients primarily treated in other hospitals and then
transferred to our hospital were excluded.
After identifying all pediatric OOH CPR cases, we
analyzed all ALS procedures, done by EMS and/or HEMS
and the outcome of every case. We divided the groups in
trauma, drowning, CPR at birth and non-trauma. The
nontrauma group includes patients who do not fit in one of
the other groups, for example, septic patients or patients
with cardiomyopathy, etc. The unknown group consists of
patients, due to missing data, and we did not know which
group they belonged to.
Our primary outcome parameters were survival and
success rate of ALS procedures, such as intubation, venous
access, and intraosseal access. Secondary predictors were
cause of OOH CPR and first rhythm.
A total of 201 pediatric OOH CPRs were selected in the
database (Table 1).
Nine patients (4%) were lost to follow up and we could
not assess if they survived and were discharged from
hospital. Out of the 192 subjects, 29 patients survived to
discharge from hospital (15%). Two of them suffered from
severe neurological disability. In eight patients, there was
no registration of the indication of OOH CPR, due to
missing data (one hospital refused to give data).
Mean age is 5.0 years with a range 0–16.9 years. The
first rhythm related to survival until discharge from
hospital is shown in Table 2. In the survivor group, all
pediatric patients showed return of spontaneous circulation
(ROSC) before leaving the incident scene to hospital.
HEMS performed intubation in 104 patients, 79
intubations were done by EMS alone and eight by EMS
under direct supervision by an HEMS physician.
Unsuccessful primary intubations by EMS without
supervision occurred in 40 of 79 intubations (51%). In 27 of the
40 unsuccessful intubations, EMS tried to intubate, but
failed, another seven tubes were placed
intraesophageally, four intrabronchially, and one neurotrauma
pediatric patient was intubated after ROSC without additional
medication. The overall success rate by EMS was 57
versus 99% for HEMS. Only one intubation done by HEMS
failed, because the patient could not be intubated due to
rigor mortis, and the team feels responsibility to the
parents to carry on for psychosocial reasons.
Intravenous access was successfully achieved in 76
patients, 27 by HEMS versus 41 by EMS (8 unknown).
Intraosseal access was achieved in 139 patients, 43 by
HEMS versus 33 by EMS (63 Unknown). Intraosseal
dislocation (first attempt successful in bone marrow then
dislocated) was found in four patients and extraosseal
placement in 14 patients (not in bone marrow), all done
ALS procedures in the survivor group are shown in
Table 3. HEMS did the majority of these procedures.
Failures by EMS were extubation by accident (1),
intrabronchial intubation (1), leakage due to too small tube
size (1), tube intraesophageal (2), and failed intubation
[tried to intubate but not succeeded (3)]. In the
survivor group, 15 pediatric patients received medication by
HEMS not mentioned in the nationwide EMS protocol,
such as sedation, relaxation, antibiotics, and medication
to regulate blood pressure.
Pediatric out‑of‑hospital cardiopulmonary resuscitation by helicopter emergency medical…
We found a 15% survival rate in OOH CPR of children.
Studies in other countries [
] show lower survival rates
(2.1–11%). A possible explanation is the group of
lowrisk OOH CPR at birth. The Netherlands has a high
number of planned birth delivery at home. In the 90s, 35% of
pregnant women had a planned delivery at home. In 2012,
still, 20% of pregnant women had a planned delivery at
home. Although delivery at home is decreasing, a
significant number of pregnant women choose to deliver at home
rather than a (planned) delivery in hospital. In other
countries, the vast majority of women have planned birth in
hospital rather than at home. To compare this study to others,
taking out the OOH CPR at birth, the overall survival rate
would be 13% instead of 15%. When HEMS became
operational, EMS frequently secondary asked for assistance in
stabilizing vitally compromised children. After a few years,
it became protocol to activate HEMS primarily in vitally
compromised children and over the years HEMS gained
more and more experience. Nowadays, 21% of all calls are
concerning pediatric patients. That could also be an
explanation why the survival rate from the early years has gone
up to 13%.
In our study, EMS performed less ALS procedures than
HEMS. Maybe, EMS would have done more ALS
procedures if HEMS took more time to get on scene or was
not available. However, in a large number of cases, HEMS
arrived later at the scene, but EMS only provided BLS care;
in cases, they also should have performed ALS procedures.
HEMS did the majority (73%) of ALS procedures in the
survivor group of 29 patients. Especially the patients who
were intubated not correctly or had a non-working
intraosseous access, HEMS could have altered the outcome by
emergency correction of the endotracheal tube and/or
intraosseous cannulation (Table 3). In addition, intubation done
by an HEMS physician was more successful than by an
EMS paramedic. Members of HEMS have more training,
experience and exposure. Successful intubation in children
seems to be a difficult task for EMS paramedics [
1, 9, 10
Bag-mask ventilation is to be preferred to a failed
intubation effort, even if bag-mask ventilation is suboptimal [
Pediatric airway skills decay quickly after training because
of the low-call volume, and endotracheal intubation skills
drop off more significantly than bag-mask ventilation skills
]. HEMS had to perform an emergency correction of
the tracheal tube in 11 patients (14%). In the opinion of the
authors, this is an unacceptable rate. Because of the high
rate of unsuccessful intubations, EMS in The Netherlands
should not intubate children.
It is difficult to measure long-term neurological
outcome in (very) young children. Only few of them had
a prior admission to hospital, which make it difficult
to objectively assess a small neurological deficit. Two
pediatric patients were obviously severely neurological
impaired and scored severe disability based on a
modified Pediatric Cerebral Performance Category Scale [
After the incident, they remained in a wheelchair and are
not able to perform normal activities of daily living. The
other 27 survivors are scored in the category normal or
no change from baseline or mild disability. There is no
previous scoring so it is difficult to set a baseline, but
most of the children in this group score conform other
children of their age.
All survivors in our study had ROSC before transport to
hospital. This could mean that there is time to set up a good
BLS and ALS rather than “scoop and run” to hospital.
Prior to our study and prior to 1997 (the start of
Rotterdam HEMS), there are no studies available with only
EMS and OOH CPR in pediatric patients performed in
The Netherlands with outcome known to the authors.
Another finding was that HEMS delivered additional
medication, not stated in national EMS protocol to 70
patients. Most of the medication was given after ROSC, for
instance, medication to regulate blood pressure (and thus
cerebral blood perfusion), sedation, or antibiotics in sepsis.
The retrospective design of this study may be
considered as a limitation. In addition, in nine (4%) patients,
there were missing data and we could not assess if they
lived up to discharge from hospital.
After reviewing all pediatric out-of-hospital
cardio pulmonary resuscitations (OOH CPRs), 29 patients
(15%) survived until discharge. The Helicopter
Emergency Medical Service (HEMS), especially the younger
the patients, performed the majority of the advanced life
support (ALS) skills, such as intubation, intraosseous,
and/or intravenous access, and had less failures than in
procedures performed by Emergency Medical Service.
Therefore, we conclude that Helicopter Emergency
Medical Service brings essential skills and expertise to
the scene of out-of-hospital cardio pulmonary
resuscitation in pediatric patients.
Acknowledgements The authors would like to thank their
colleagues at Rotterdam HEMS for collecting data for the database,
which made it possible to extract data for this research.
Compliance with ethical standards
Conflict of interest None.
No external funding was received for this study.
Ethics approval The Medical Ethical Committee of the Erasmus
University Medical Center (MEC-2015-428) approved this study.
Open Access This article is distributed under the terms of the
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creativecommons.org/licenses/by/4.0/), which permits unrestricted
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link to the Creative Commons license, and indicate if changes were
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