Patient Characteristics and Emergency Department Factors Associated with Survival After Sudden Cardiac Arrest in Children and Young Adults: A Cross-Sectional Analysis of a Nationally Representative Sample, 2006-2013

Association Between Emergency Medical Services Intervention Volume and Out-of-Hospital Cardiac Arrest Survival: A Propensity Score Matching Analysis

BACKGROUND

Out of hospital cardiac arrest (OHCA) survival rates are very low. An association between institutional OHCA case volume and patient outcomes has been documented. However, whether this applies to prehospital emergency medicine services (EMS) is unknown.

OBJECTIVES

To investigate the association between the volume of interventions by mobile intensive care units (MICU) and outcomes of patients experiencing an OHCA.

METHODS

A retrospective cohort study including adult patients with OHCA managed by medical EMS in five French centers between 2013 and 2020. Two groups were defined depending on the overall annual numbers of MICU interventions: low and high-volume MICU. Primary endpoint was 30-day survival. Secondary endpoints were prehospital return of spontaneous circulation (ROSC), ROSC at hospital admission and favorable neurological outcome. Patients were matched 1:1 using a propensity score. Conditional logistic regression was then used.

RESULTS

2,014 adult patients (69% male, median age 68 [57-79] years) were analyzed, 50.5% (n = 1,017) were managed by low-volume MICU and 49.5% (n = 997) by high-volume MICU. Survival on day 30 was 3.6% in the low-volume group compared to 5.1% in the high-volume group. There was no significant association between MICU volume of intervention and survival on day 30 (OR = 0.92, 95%CI [0.55;1.53]), prehospital ROSC (OR = 1.01[0.78;1.3]), ROSC at hospital admission (OR = 0.92 [0.69;1.21]), or favorable neurologic prognosis on day 30 (OR = 0.92 [0.53;1.62]).

Mortality after cardiac arrest in children less than 2 years: relevant factors

BACKGROUND

There are only scant studies of predicting outcomes of pediatric resuscitation due to lack of population-based data. This study aimed to determine variable factors that may impact the survival of resuscitated children aged under 24 months.

METHODS

This is a retrospective study of 66 children under 24 months. Cardiopulmonary resuscitation (CPR) with pediatric advanced life support guideline was performed uniformly for all children. Linear regression analysis with variable factors was conducted to determine impacts on mortality.

RESULT

Factors with statistically significant increases in mortality were the number of administered epinephrine (p value < 0.001), total CPR duration (p value < 0.001), in-hospital CPR duration of out-hospital cardiac arrest (p value < 0.001), and changes in cardiac rhythm (p value < 0.040). However, there is no statistically significant association between patient outcomes and remaining factors such as age, sex, underlying disease, etiology, time between last normal to CPR, initial CPR location, initial cardiac rhythm, venous access time, or inotropic usage.

CONCLUSION

More than 10 times of epinephrine administration and CPR duration longer than 30 minutes were associated with a higher mortality rate, while each epinephrine administration and prolonged CPR time increased mortality.

IMPACT STATEMENT

This study analyzed various factors influencing mortality after cardiac arrest in patients under 24 months. Increased number of administered epinephrine and prolonged cardiopulmonary resuscitation duration do not increase survival rate in patients under 24 months. In patients with electrocardiogram rhythm changes during CPR, mortality increased when the rhythm changed into asystole in comparison to no changes occurring in the rhythm.

Sudden cardiac death in the young: An update for NPs

NPs can identify risk for sudden cardiac death in children during physical exams to prevent tragedy. The updated American Academy of Pediatrics 2021 policy statement on this issue provides guidance on using a combination of elements to determine and manage risk, including the organization's own 4-question screening tool, the American Heart Association 14-Element Preparticipation Cardiovascular Screening of Young Competitive Athletes, personal history, family history, physical exam, ECG, and cardiology referral as indicated.

Classic Presentation of Catecholaminergic Polymorphic Ventricular Tachycardia: A Case Report

Syncope is a common reason for children and adolescents to seek care in the emergency department. Often syncopal episodes are benign and most commonly due to a vasovagal event. Occasionally an underlying cardiac arrhythmia is responsible. We present a case report of a 17-year-old male who collapsed during an emotional event and went into cardiac arrest. Emergency department evaluation including imaging, laboratory studies, and EKG indicated the cause of cardiac arrest was likely a primary cardiac arrhythmia. An initial clinical diagnosis of catecholaminergic polymorphic ventricular tachycardia (CPVT) was made based on symptom onset during an emotional event, family history of sudden cardiac death, patient age, past episodes of chest pain and palpitations, absence of structural heart defect, and lack of EKG changes after the return of spontaneous circulation (ROSC). The diagnosis was later confirmed with genetic testing. The patient was started on a beta-blocker and a subcutaneous implantable cardioverter-defibrillator (S-ICD, Boston Scientific, Marlborough, MA) was placed. Given the rarity of this condition, this diagnosis is often missed, which contributes to increased mortality rates. In children and young adults presenting with syncope without clear etiology in the presence of high-risk features, further evaluation should be performed including referral to cardiology to rule out chronic cardiac arrhythmias.

Association between Hospital volume of cardiopulmonary resuscitation for in-hospital cardiac arrest and survival to Hospital discharge

BACKGROUND

Prior studies have shown that hospital case volume is not associated with survival in patients with out-of-hospital cardiac arrest (OHCA). However, how case volume impact on survival for in-hospital cardiac arrest (IHCA) is unknown.

METHODS

We queried the National Inpatient Sample (NIS) in the U.S. 2005-2011 to identify cases in which in-hospital CPR was performed for IHCA. Restricted cubic spine was used to evaluate the association between hospital annual CPR volume and survival to hospital discharge.

RESULTS

Across more than 1000 hospitals in NIS, we identified 125,082 cases (mean age 67, 45% female) of IHCA for which CPR was performed over the study period. Median [Q1, Q3] case volume was 60 [34, 99]. Compared to those in the 1 st quartile of case volume, hospitals in the 4th quartile tends to have younger patients (mean = 66 vs 68 yrs), higher comorbidities (median Elixhauser score = 4 vs 3), and in low income areas (37 vs 30%). Overall, 23% of the patients survived to hospital discharge. There was a non-linear association between CPR volume and survival: a non-significant trend towards better survival was observed with increasing annual CPR volume that reached a plateau at 51-55 cases per year, after which survival began to drop and became significantly lower after 75 cases per year (p for non-linearity<0.001). Compared to those in first quartile of case volume, hospitals in 4^th quartile had higher length of stay (median = 8 vs 10 days, respectively) and higher rate of non-routine home discharge (64% vs 67%) among those who survived.

CONCLUSION

Unlike OHCA, low CPR volume is an indicator of good performing hospitals and increasing CPR case volume does not translate to improve survival for IHCA.

Relationship between institutional case volume and one-month survival among cases of paediatric out-of-hospital cardiac arrest

AIM

To evaluate volume-outcome relationship in paediatric out-of-hospital cardiac arrest (OHCA).

METHODS

This post hoc analysis of the SOS-KANTO 2012 study included data of paediatric OHCA patients <18 years old who were transported to the 53 emergency hospitals in the Kanto region of Japan between January 2012 and March 2013. Based on the paediatric OHCA case volume, the higher one-third of institutions (more than 10 paediatric OHCA cases during the study period) were defined as high-volume centres, the middle one-third institutions (6-10 cases) were defined as middle-volume centres and the lower one-third of institutions (less than 6 cases) were defined as low-volume centres. The primary outcome measurement was survival at 1 month after cardiac arrest. Multivariate logistic regression analysis for 1-month survival and paediatric OHCA case volume were performed after adjusting for multiple propensity scores. To estimate the multiple propensity score, we fitted a multinomial logistic regression model, which fell into one of the three groups as patient demographics and prehospital factors.

RESULTS

Among the eligible 282 children, 112, 82 and 88 patients were transported to the low-volume (36 institutions), middle-volume (11 institutions) and high-volume (6 institutions) centres, respectively. Transport to a high-volume centre was significantly associated with a better 1-month survival after adjusting for multiple propensity score (adjusted odds ratio, 2.55; 95% confidence interval, 1.05-6.17).

CONCLUSION

There may be a relationship between institutional case volume and survival outcomes in paediatric OHCA.