Kids and Strokes Are they little adults after all?

If you are an EMS provider and want to ruffle some feathers simply tell your local easy going pediatric specialist “kids are just little adults,” and then sit back and watch them boil up with anger. For years I was that guy. Having trained at 2 large academic children’s hospitals it was ingrained in me that kids are kids, and absolutely NOT just little adults. That was the gospel and it’s what I believed for a decade. That is until I joined the world of EMS and everything became clearer. From the pre-hospital perspective kids may be little adults after all!

Resuscitation
A quick side-by-side comparison of ACLS and PALS reveals algorithms that are nearly identical. Asystole and PEA need high quality CPR plus epinephrine whereas ventricular fibrillation requires an additional drug and electricity. The only differences in treatment relate to equipment sizes and drug dosing. Remove the math from that equation and you are left with two documents that are near mirror images. While the etiologies may differ, the primary concern of EMS providers and adult trained emergency medicine physicians is recognition and treatment.

Pediatric Stroke
The terms “pediatric” and “stroke’” intuitively feel wrong together and seem to not even belong in the same sentence. Mention a pediatric case of cerebral ischemia to your colleague and chances are they will look at you with a surprised look. A recent abstract presented at the International Stroke Conference in San Diego, CA sheds some light on the pediatric brain attack. Investigators firmly concluded that pediatric strokes present the same as in adults and should be treated the same by caregivers and EMS providers. Dare I say again that kids are just little adults! Yes, and as the picture becomes more clear it appears that the biggest delay in treatment is caused by lack of awareness by parents, EMS and emergency departments around the country.

This breakthrough research presented by Mark MacKay, MD enforces the fact that infants and children have strokes that present similarly to adults: sudden weakness or numbness of the face, arm or leg; sudden difficulty speaking, seeing or walking; dizziness; or sudden onset of headache. Seizures are also common in pediatric stroke, although more so in infants than in any other age group. Surprisingly, however, parents did not associate these warning signs with stroke. This data provides the first clues as to why, historically, children have had such a long delay to diagnosis; in most cases up to 35 hours. Conversely, the same symptoms in an adult would more than likely lead to a “call for help,” and this is thought to be a direct result of the powerful educational campaign (F.A.S.T) by the American Heart Association (AHA) aimed towards the general public.

F.A.S.T is the AHA’s comprehensive campaign that instructs the layperson to detect a stroke without the need to speak to them, for obvious reasons. The focus is on the body language of a stroke victim while also emphasizing the importance of time. What better campaign to also use on the segment of the population who can’t speak to begin with, small children. Again, we’ve circled back to this concept of “kids are just little adults.” It’s a concept that makes perfect sense, again, to the right audience, specifically parents, EMS personnel and adult ED physicians.

In the aforementioned study most of the parents of children with strokes thought that the symptoms were serious yet only about a half called 9-1-1. Of further interest, only 36% of parents considered the possibility of a stroke while 21% had a wait and see attitude or called a relative prior to taking emergency action.

Pediatric Risk Factors
While stroke can occur in otherwise well children with no prior medical history, the pre-hospital provider should be aware of the at risk groups. Infants and children with cardiac disease are at high risk for a CVA, with the etiology dependent mainly on the specific cardiac issue. One specific example of stroke due to a cardiac etiology is that of a patent foramen ovale (PFO). The foramen ovale is a small hole located in the atrial septum of the unborn fetus. At birth this hole should close once circulation converts from right to left, to left to right. If this hole does not close a chance exists for a clot to cross the septum (right to left) during times when there is increased pressure in the chest; straining during a bowel movement, coughing or sneezing, to name a few. The prevalence of PFO is reported to be 25% in the general population. If a young patient has a stroke without known risk factors, studies show that the likelihood of PFO being the etiology climbs to 48%. As a clinical pearl, patients with a PFO are at high risk from air embolism when small air bubbles enter the circulation via improperly handled IV tubing. While a relatively large volume of air (5-8 ml/kg body wt) can be tolerated in the RV and pulmonary artery, as little as 0.5 ml of air can be lethal when entered into the left side of circulation. Well known New England Patriots linebacker Tedy Bruschi, at the age of 31, was reported to have suffered a stroke secondary to a PFO in 2005 (Bleacher Report online).
                                                                          
                              PFO schematic                                                                                  Tedy Bruschi

                       
Sickle Cell Disease (SCD) patients should also be considered high risk for brain attack. EMS providers must pay close attention to the neurologic exam in these children as often times the findings may be subtle. Patients and parents are not likely to state weakness as their chief complaint leaving the health care provider as the only safety net.

Other common risk factors for stroke in children are diseases of the arteries, acute or chronic head and neck disorders, abnormal blood clotting and infection. Preliminary results of the VIPS (vascular effects of infection in pediatric stroke) study, presented at the 2014 International Stroke Conference, showed that recent infection conferred increased risk of childhood AIS. Routine vaccinations appeared to be protective in that same study. Investigators reported an odds ratio of 47 for stroke cases reporting an infection within a week of development of symptoms.

Time Delay a Major Hurdle
For adults IV rtPA is a time sensitive intervention and therefore is a major quality measure for high quality stroke systems of care. Door to needle times are reported by all stroke centers and can lead to significant improvement in morbidity and mortality. Time is brain and the AHA has educated the public as well as well as health care providers to move as quickly as possible. The same thing needs to happen for the pediatric population. Although IV rtPA is not licensed for use in children, many pediatric hospitals have protocols that allow for off-label use. A prospective trial is underway in order to determine the safety and most appropriate dose for pediatric patients. The major hurdle, however, is that most pediatric stroke patients are not diagnosed as such for hours past the 4-hour threshold required for IV rtPA use. Four different studies showed that the average time to stroke diagnosis in children was approximately 24 hours. Such delays make treatment success improbable while raising the likelihood of long term morbidity. Stroke remains one of the top ten cause of death in children and over 50% of pediatric stroke victims suffer long term disability. The time is now to begin to educate parents and providers alike that stroke is not just a disease of elderly people. It knows no boundaries and must be taken seriously. In order to improve outcomes, education should be focused on the following three areas:
1. Parental Awareness
2. Pre-hospital Awareness
3. ED physician Awareness

Destination Determination
Like adults with stroke, pediatric patients benefit the most when treated at pediatric centers with the full compliment of specialties required to treat the disease. The list is lengthy and includes the following specialties: Emergency department, neurology, pharmacy, respiratory therapy, radiology, neurosurgery, interventional radiology, cardiology, anesthesiology and critical care. Transport directly to these facilities is beneficial yet may not be feasible due to the paucity of such institutions. Receiving hospitals should prepare themselves for these patients and transfer them to a predetermined pediatric stroke center. It is not uncommon for a center with a higher volume of pediatric stroke patients to be more liberal with off label treatment protocols such as IV rtPA and endovascular clot removal. The decision to use these modalities is typically institutional, and transfer decisions should have these issues in mind in order to maximize outcomes. Treatment for pediatric stroke care varies considerably and is likely to be different at every hospital in this country. EMS agencies have the opportunity to push for enhanced pediatric stroke care by meeting with local hospital partners and discussing pediatric stroke care. Hospital specific pediatric stroke protocols greatly enhance the care received by patients and should be mandatory for those centers claiming to be pediatric stroke centers. The arrival of a pediatric stroke patient to that hospital should trigger multiple events via overhead alert and group paging. Mobilization of personnel should mirror that of the adult stroke patient.

The Age-Old Question
To complicate matters even further, many EMS agencies and hospitals differ in their definition of “child.” Some hospitals will label a child a medical patient up until their 18th birthday, yet for trauma the cutoff changes 16 years of age. So the adult trauma surgeons will have privileges to treat a 17-year-old stabbing victim, yet that same adolescent with symptoms of a stroke will be turned away because “he’s not an adult, and we can’t treat him here!” EMS personnel are often confused by these arbitrary cutoffs and often struggle with destination decisions, particularly when stroke is suspected. PALS guidelines clearly reflect that children can be treated as adults once they demonstrate signs of puberty (axillary hair in males or breast development in females. Technically then, the 17-year-old pubertal adolescent should be treated by EMS as an adult, transported to an adult stroke facility and treated as such by the physicians. Unfortunately, this seemingly straightforward case becomes a complicated mess with the patient at the receiving end of substandard care due to significant time delays or unnecessary transfers.

The Road Ahead
A major emphasis must be placed on public awareness of pediatric stroke. The AHA must include pediatric stroke in the same campaign as for adults. Parents of at-risk children must be educated by their physicians and subspecialists about the signs and symptoms of pediatric stroke. EMS personnel need to keep pediatric stroke high on their list of potential problems, specifically in high-risk children and also in those who present with classic stroke symptoms. The concept that “kids don’t get strokes” should be revised to “kids absolutely get strokes,” and did I mention that kids are just little adults! Next, ED physicians must be given the same awareness education and should immediately consider transfer to a pediatric center that is a stroke center in practice, not just in name. Pediatric centers with stroke protocols typically are not shy about advertising it since the investment is quite significant. Furthermore, EMS departments should insist on high quality pediatric stroke care for their patients and should divert suspected cases to hospitals that have implemented a stroke system of care.

So Are Kids Really Just Little Adults?
After over a decade in practice as a pediatric emergency physician and 5 years as an EMS medical director I have concluded that the following 2 groups should treat kids like little adults: EMS and adult ED physicians. To these groups there is no benefit in viewing the “smaller” population as any different than their larger counterparts. I feel strongly that the idiosyncrasies of pediatric care should be left to the pediatric subspecialists. To those groups, kids should be viewed as completely different than adults. They should be adept as teasing out particular etiologies and tailoring treatment to their patient’s specific needs. The initial triage and treatment of the critical pediatric patient by EMS and adult ED physicians should be straightforward and consistent and should focus on rapid stabilization and transfer to a pediatric center with demonstrable outcomes.

Original Article Appeared in the Carolina Fire Rescue Journal (Fall 2014)