Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none applicable
The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: none applicable
CoSTR Citation
Tiwari L, Scholefield B, Kleinman M, , Nadkarni V, Wang SG, Ross C, de Caen A, Acworth J, on behalf of the International Liaison Committee on Resuscitation Pediatric Life Support Task Force. Reversible causes of pediatric cardiac arrest - Pulmonary Embolism - Paediatric Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Paediatric Advanced Life Support Task Force, 2024 October xxxxx. Available from: http://ilcor.org
Methodological Preamble and Link to Published Systematic Review
The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review (Tiwari, 2024, PROSPERO CRD42024560884) with involvement of clinical content experts. Additional evidence was sought and considered by the Pediatric Life Support (PLS) Task Force, including literature published after the completion of the systematic review, and is described in the Justifications and Evidence to Decision Framework Highlights section of this CoSTR.
Systematic Review
Webmaster to insert the Systematic Review citation and link to Pubmed using this format when it is available if published
Tiwari et al. Reversible causes of pediatric cardiac arrest - Pulmonary Embolism - (in preparation)
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Infants and children (excluding newborn children) who are in cardiac arrest due to confirmed or suspected pulmonary embolism in any setting
Intervention: Any specific alteration in the treatment algorithm (eg. fibrinolysis, embolectomy, thrombectomy, with or without extracorporeal cardiopulmonary resuscitation (ECPR))
Comparison: Compared with standard cardiopulmonary resuscitation
Outcomes: Any clinical outcome including but not limited to:
- Survival to hospital discharge with good neurologic outcome
- Survival to hospital discharge
- Survival to hospital admission
- Return of circulation (ROC)
The PLS TF prefers outcomes defined in the P-COSCA publication.(1)
Study Design: Randomized controlled trials (RCTs), non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) and case series with a minimum of 5 number of cases are eligible for inclusion. Unpublished studies (e.g., conference abstracts, and trial protocols) and animal studies are excluded.
All relevant publications in any language are included as long as there is an English abstract.
Timeframe: All years. The last search was performed on 15 May 2024.
PROSPERO Registration: CRD42024560884
Consensus on Science
In this systemic review, we could not identify any pediatric randomized controlled trial (RCT), nonrandomized trials or observational studies directly comparing standard cardiopulmonary resuscitation/ cardiac arrest algorithms with any specific alteration in the treatment algorithm (eg. fibrinolysis, embolectomy, thrombectomy, with or without extracorporeal cardiopulmonary resuscitation ECPR) in managing cardiac arrest due to confirmed or suspected pulmonary embolism (PE).
Two small institutional case series described a total of 10 infants and children where individual or combined interventions (fibrinolysis, embolectomy, thrombectomy, with or without ECPR) were used in addition to standard cardiac arrest algorithms for cardiac arrest associated with confirmed or suspected pulmonary embolism. The number of patients reported and nature of the data presented precluded any meaningful statistical comparison of these supplemental interventions to standard cardiac arrest care when assessing any patient outcomes.
One single institution case series identified PE as the cause of in-hospital cardiac arrest (IHCA) in 5 (6.3%) of 79 children who received at least 5 minutes of CPR for an IHCA. They were treated with thrombolysis (IV tissue plasminogen activator) in addition to standard CPR; four of five patients were successfully resuscitated and survived to hospital discharge. Three patients had intact neurological outcome and one with baseline PCPC score of 4 (developmental delay with autism) deteriorated to a score of 5.(2)
A retrospective cohort study of pediatric PE outcomes and risk factors from two Canadian paediatric hospitals reported 170 children aged 18 years or younger with massive and sub massive pulmonary embolism, 5 of whom suffered cardiac arrest. Patients were treated with individual or combined interventions (embolectomy, thrombolysis, and catheter-directed thrombolysis with or without extra corporeal membrane oxygenation (ECMO) during or after cardiac arrest for PE in addition to the standard cardiac arrest algorithm. Five cases achieved ROSC and four survived to hospital discharge.(3)
Treatment Recommendations
There is insufficient evidence to make a treatment recommendation for or against the use of any specific alteration to the cardiac arrest algorithm for pediatric cardiac arrest due to suspected or confirmed pulmonary embolism.
Justification and Evidence to Decision Framework Highlights
This question has not been previously evaluated by the PLS task force. ILCOR Treatment Recommendations for adults are in place (unchanged since 2015) and suggest administering fibrinolytic drugs for cardiac arrest when PE is the suspected cause of cardiac arrest (weak recommendation, very low-certainty evidence). The treatment recommendation suggests the use of fibrinolytic drugs or surgical embolectomy or percutaneous mechanical thrombectomy for cardiac arrest when PE is the known cause of cardiac arrest.(4,5)
The PLS task force acknowledges an absence of good quality pediatric evidence.
The task force considered additional data that did not meet the SR inclusion criteria. A single centre retrospective study of 33 pediatric patients with massive and sub massive PE reported 4 patients that suffered cardiac arrest. One patient died despite standard cardiac arrest care, while 1 of 3 additionally treated with one of or a combination of systemic fibrinolysis, catheter directed fibrinolysis, Embolectomy or ECMO survived.(6)
The task force also identified 15 pediatric case reports that did not meet the SR inclusion criteria. Four patients were treated as per standard cardiac arrest algorithm, none of whom survived. Eleven patients were treated with alterations to the algorithm (Fibrinolysis, Embolectomy, ECMO), 7 of whom survived to hospital discharge.
Link to EtD: PLS 4160 10 Et D Reversible causes of pediatric cardiac arrest PE
Knowledge Gaps
Identification of PE as an underlying cause of cardiac arrest in children
Studies on use of fibrinolysis, embolectomy, thrombectomy with or without extracorporeal cardiopulmonary resuscitation in patients under 18 years who experienced an in-hospital cardiac arrest due to apparent or confirmed pulmonary embolism
References
1. Topjian AA, Scholefield BR, Pinto NP, Fink EL, Buysse CMP, Haywood K, et al. P-COSCA (Pediatric Core Outcome Set for Cardiac Arrest) in Children: An Advisory Statement From the International Liaison Committee on Resuscitation. Resuscitation. 2021 May;162:351–64.
2. Morgan RW, Stinson HR, Wolfe H, Lindell RB, Topjian AA, Nadkarni VM, et al. Pediatric In-Hospital Cardiac Arrest Secondary to Acute Pulmonary Embolism. Crit Care Med. 2018 Mar;46(3):e229–34.
3. Pelland-Marcotte MC, Tucker C, Klaassen A, Avila ML, Amid A, Amiri N, et al. Outcomes and risk factors of massive and submassive pulmonary embolism in children: a retrospective cohort study. Lancet Haematol. 2019 Mar;6(3):e144–53.
4. Soar J, Berg KM, Andersen LW, Böttiger BW, Cacciola S, Callaway CW, et al. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2020 Nov;156:A80–119.
5. Soar J, Callaway CW, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, et al. Part 4: Advanced life support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2015 Oct;95:e71-120.
6. Ross CE, Shih JA, Kleinman ME, Donnino MW. Pediatric Massive and Submassive Pulmonary Embolism: A Single-Center Experience. Hosp Pediatr. 2020 Mar;10(3):272–6.