Out-of-hospital cardiac arrests in children and adolescents: Incidences, outcomes, and household socioeconomic status

Out-of-hospital cardiac arrest in children in Norway: A national cohort study, 2016-2021

Aim

Children constitute an important and distinct subgroup of out-of-hospital cardiac arrest (OHCA) patients. This population-based cohort study aims to establish current age-specific population incidence, precipitating causes, circumstances, and outcome of paediatric OHCA, to guide a focused approach to prevention and intervention to improve outcomes.

Methods

Data from the national Norwegian Cardiac Arrest Registry was extracted for the six-year period 2016-21 for persons aged <18 years. We present descriptive statistics for the population, resuscitation events, presumed causes, treatment, and outcomes, alongside age-specific incidence and total paediatric mortality rates.

Results

Three hundred and eight children were included. The incidence of OHCA was 4.6 per 100 000 child-years and markedly higher in children <1 year at 20.9 child-years. Leading causes were choking, cardiac and respiratory disease, and sudden infant death syndrome. Overall, 21% survived to 30 days and 18% to one year.

Conclusion

A registry-based approach enabled this study to delineate the characteristics and trajectories of OHCA events in a national cohort of children. Precipitating causes of paediatric OHCA are diverse compared to adults. Infants aged <1 year are at particularly high risk. Mortality is high, albeit lower than for adults in Norway. A rational community approach to prevention and treatment may focus on general infant care, immediate first aid by caretakers, and identification of vulnerable children by primary health providers. Cardiac arrest registries are a key source of knowledge essential for quality improvement and research into cardiac arrest in childhood.

Mediators of the Association Between Socioeconomic Status and Survival After Out-of-Hospital Cardiac Arrest: A Systematic Review

Low socioeconomic status (SES) is associated with poor outcomes after out-of-hospital cardiac arrest (OHCA). Patient characteristics, care processes, and other contextual factors may mediate the association between SES and survival after OHCA. Interventions that target these mediating factors may reduce disparities in OHCA outcomes across the socioeconomic spectrum. This systematic review identified and quantified mediators of the SES-survival after OHCA association. Electronic databases (MEDLINE, Embase, PubMed, Web of Science) and grey literature sources were searched from inception to July or August 2023. Observational studies of OHCA patients that conducted mediation analyses to evaluate potential mediators of the association between SES (defined by income, education, occupation, or a composite index) and survival outcomes were included. A total of 10 studies were included in this review. Income (n = 9), education (n = 4), occupation (n = 1), and composite indices (n = 1) were used to define SES. The proportion of OHCA cases that had bystander involvement, presented with an initial shockable rhythm, and survived to hospital discharge or 30 days increased with higher SES. Common mediators of the SES-survival association that were evaluated included initial rhythm (n = 6), emergency medical services response time (n = 5), and bystander cardiopulmonary resuscitation (n = 4). Initial rhythm was the most important mediator of this association, with a median percent excess risk explained of 37.4% (range 28.6%-40.0%; n = 5; 1 study reported no mediation) and mediation proportion of 41.8% (n = 1). To mitigate socioeconomic disparities in outcomes after OHCA, interventions should target potentially modifiable mediators, such as initial rhythm, which may involve improving bystander awareness of OHCA and the need for prompt resuscitation.

Differences in Pathophysiology and Treatment Efficacy Based on Heterogeneous Out-of-Hospital Cardiac Arrest

Out-of-hospital cardiac arrest (OHCA) is heterogeneous in terms of etiology and severity. Owing to this heterogeneity, differences in outcome and treatment efficacy have been reported from case to case; however, few reviews have focused on the heterogeneity of OHCA. We conducted a literature review to identify differences in the prognosis and treatment efficacy in terms of CA-related waveforms (shockable or non-shockable), age (adult or pediatric), and post-CA syndrome severity and to determine the preferred treatment for patients with OHCA to improve outcomes.

Outcomes of Cardiopulmonary Resuscitation in the Pediatric Intensive Care of a Tertiary Center

Understanding the factors affecting survival and modifying the preventable factors may improve patient outcomes following cardiopulmonary resuscitation (CPR). The aim of this study was to assess the prevalence and outcomes of cardiac arrest and CPR events in a tertiary pediatric intensive care unit (PICU). Outcomes of interest were the return of spontaneous circulation (ROSC) lasting more than 20 minutes, survival for 24 hours post-CPR, and survival to hospital discharge. We analyzed data from the PICU CPR registry from January 1, 2011 to January 1, 2018. All patients who underwent at least 2 minutes of CPR in the PICU were included. CPR was administered in 65 PICU instances, with a prevalence of 1.85%. The mean patient age was 32.7 months. ROSC occurred in 38 (58.5%) patients, 30 (46.2%) achieved 24-hour survival, and 21 (32.3%) survived to hospital discharge. Younger age ( p  < 0.018), respiratory cause ( p  < 0.001), bradycardia ( p  < 0.018), and short duration of CPR ( p  < 0.001) were associated with better outcomes, while sodium bicarbonate, norepinephrine, and vasopressin were associated with worse outcome ( p  < 0.009). The off-hour CPR had no impact on the outcome. The patients' cumulative predicted survival declined by an average of 8.7% for an additional 1 minute duration of CPR ( p  = 0.001). The study concludes that the duration of CPR, therefore, remains one of the crucial factors determining CPR outcomes and needs to be considered in parallel with the guideline emphasis on CPR quality. The lower survival rate post-ROSC needs careful consideration during parental counseling. Better anticipation and prevention of CPR remain ongoing challenges.

Epidemiology of pediatric out-of-hospital cardiac arrest compared with adults

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is associated with ∼90% mortality rate. In the pediatric population, this would equate to a large number of years of life lost, posing a heavy medical and economic burden to society.

OBJECTIVE

The purpose of this study was to outline the characteristics and causes of pediatric OHCA (pOHCA) and associations with survival until discharge in patients enrolled in the End Unexplained Cardiac Death Registry.

METHODS

A prospective statewide multisource registry identified all pOHCAs cases in patients aged 1-18 years in Victoria, Australia (population 6.5 million), from April 2019 to April 2021. Cases were adjudicated using ambulance, hospital, and forensic records; clinic assessments; and interviews of survivors and family members.

RESULTS

The analysis included 106 cases after adjudication (62, 58.5% male), 45 (42.5%) of which were due to cardiac causes of OHCA, with unascertained (n = 33 [31.1%]) being the most common cardiac cause reported. Respiratory events (n = 28 [26.4%]) were the most common noncardiac cause of pOHCA. Noncardiac causes were more likely to present with asystole or pulseless electrical activity (P = .007). The overall survival to hospital discharge rate was 11.3% and associated with increasing age, witnessed cardiac arrest, and initial ventricular arrhythmias (P < .05).

CONCLUSION

The incidence of pOHCA in the study population was 3.69 per 100,000 child-years. In contrast to young adults with OHCA, the most common etiology was noncardiac in pediatric patients. Prognostic factors associated with survival to discharge included increasing age, witnessed arrest, and initial ventricular arrhythmias. Rates of cardiopulmonary resuscitation and defibrillation were suboptimal.

Sociodemographic factors associated with paediatric out-of-hospital cardiac arrest: A systematic review

BACKGROUND

Paediatric out-of-hospital cardiac arrest (POHCA) is associated with poor survival and severe neurological sequelae. We conducted a systematic review on the impact of sociodemographic factors across different stages of POHCA.

METHODS

We searched MEDLINE, EMBASE, and Web of Science from database inception to October 2022. We included studies examining the association between sociodemographic factors (i.e., race, ethnicity, migrant status and socioeconomic status [SES]) and POHCA risk, bystander cardiopulmonary resuscitation (CPR) provision, bystander automated external defibrillator (AED) application, survival (at or 30-days post-discharge), and neurological outcome. We synthesized the data qualitatively.

RESULTS

We screened 11,097 citations and included 18 articles (arising from 15 studies). There were 4 articles reporting on POHCA risk, 5 on bystander CPR provision, 3 on bystander AED application, 13 on survival, and 6 on neurological outcome. In all studies on POHCA risk, significant differences were found across racial groups, with minority populations being disproportionately impacted. There were no articles reporting on the association between SES and POHCA risk. Bystander CPR provision was consistently associated with race and ethnicity, with disparities impacting Black and Hispanic children. The association between bystander CPR provision and SES was variable. There was little evidence of socioeconomic or racial disparities in studies on bystander AED application, survival, and neurological outcome, particularly across adjusted analyses.

CONCLUSIONS

Race and ethnicity are likely associated with POHCA risk and bystander CPR provision. These findings highlight the importance of prioritizing at-risk groups in POHCA prevention and intervention efforts. Further research is needed to understand underlying mechanisms.

Out-of-hospital cardiac arrest in children: an epidemiological study based on the German Resuscitation Registry identifying modifiable factors for return of spontaneous circulation

AIM

This work provides an epidemiological overview of out-of-hospital cardiac arrest (OHCA) in children in Germany between 2007 and 2021. We wanted to identify modifiable factors associated with survival.

METHODS

Data from the German Resuscitation Registry (GRR) were used, and we included patients registered between 1st January 2007 and 31st December 2021. We included children aged between > 7 days and 17 years, where cardiopulmonary resuscitation (CPR) was started, and treatment was continued by emergency medical services (EMS). Incidences and descriptive analyses are presented for the overall cohort and each age group. Multivariate binary logistic regression was performed on the whole cohort to determine the influence of (1) CPR with/without ventilation started by bystander, (2) OHCA witnessed status and (3) night-time on the outcome hospital admission with return of spontaneous circulation (ROSC).

RESULTS

OHCA in children aged < 1 year had the highest incidence of the same age group, with 23.42 per 100 000. Overall, hypoxia was the leading presumed cause of OHCA, whereas trauma and drowning accounted for a high proportion in children aged > 1 year. Bystander-witnessed OHCA and bystander CPR rate were highest in children aged 1-4 years, with 43.9% and 62.3%, respectively. In reference to EMS-started CPR, bystander CPR with ventilation were associated with an increased odds ratio for ROSC at hospital admission after adjusting for age, sex, year of OHCA and location of OHCA.

CONCLUSION

This study provides an epidemiological overview of OHCA in children in Germany and identifies bystander CPR with ventilation as one primary factor for survival. Trial registrations German Clinical Trial Register: DRKS00030989, December 28th 2022.

Global burden of out-of-hospital cardiac arrest in children: a systematic review, meta-analysis, and meta-regression

The incidence of out-of-hospital cardiac arrest (OHCA) and its mortality among children decreased globally over the years. However, the incidence, mortality, and its determinants are heterogeneous globally. The current study was designed to investigate the incidence of OHCA, mortality, and its determinants based on a systematic review of published literature. A comprehensive search was conducted in PubMed/Medline; Science Direct, Cochrane Library, Hinari, and LILACS without language and date restrictions. The data were extracted with two independent authors in a customized format. The methodological quality of the included studies was evaluated using the Newcastle-Ottawa appraisal tool. A total of 2526 articles were identified from different databases with an initial search. Forty-eight articles with 138.3 million participants were included in the systematic review. The meta-analysis showed that the pooled rate of mortality was found to be 70% (95% CI: 57-81%, 42 studies, 28,345 participants). The incidence of OHCA and mortality among children was very high among children with significant regional disparity. Those children with cardiovascular causes of arrest, and initial nonshockable rhythm were independent predictors of OHCA-related mortality. This systematic review and meta-analysis is registered in Prospero (CRD42022316602). IMPACT: This systematic review addresses a significant health problem in a global context from 1995 to 2022. The meta-regression revealed that the incidence of OHCA and mortality of children decline over the years in high-income countries despite regional dispraises among individual studies. Body of evidence on the incidence of OHCA and mortality is lacking in low- and middle-income countries.

Ethische Aspekte mechanischer Reanimationshilfen beim Kind

BACKGROUND

While the use of mechanical resuscitation devices can be considered for adult resuscitation, the European Resuscitation Council guidelines do not yet mention their use for pediatric resuscitation. Only one device has been partially approved for use in children; further pediatric appliances are currently being used off-label. Ethical considerations arising from the use of mechanical resuscitation devices have not yet been presented in a structured way.

OBJECTIVE

To elaborate ethical considerations in the development phase of mechanical resuscitation devices for children.

METHODS

Based on several fictitious case reports, an interdisciplinary expert focus group discussion was conducted. This was followed by a moderated discussion, summarizing the results. Guiding principles and research desiderata were formulated using these results as well as existing literature.

RESULTS

According to the group of experts, ethical considerations regarding mechanical resuscitation devices in pediatrics predominantly concern the subject of indication and discontinuation criteria. Ethical aspects concerning psychosocial impacts on affected families and intervention teams cannot be generalized and need to be analyzed on a case-by-case basis.

CONCLUSION

The considerations presented regarding the use of mechanical resuscitation devices in the pediatric context, which is still in its developmental stage, could also have practical implications for adult out-of-hospital resuscitation decisions. Concerning ethical aspects of out-of-hospital resuscitation decisions, especially using mechanical resuscitation devices, the need for accompanying empirical research is substantial.

Pediatric out-of-hospital cardiac arrest in Denmark

Background

Pediatric out-of-hospital cardiac arrest (POHCA) has received limited attention. All causes of POHCA and outcomes were examined during a 4-year period in a Danish nationwide register and prehospital medical records. The aim was to describe the incidence, reversible causes, and survival rates for POHCA in Denmark.

Methods

This is a registry-based follow-up cohort study. All POHCA for a 4-year period (2016–2019) in Denmark were included. All prehospital medical records for the included subjects were reviewed manually by five independent raters establishing whether a presumed reversible cause could be assigned.

Results

We identified 173 cases within the study period. The median incidence of POHCA in the population below 17 years of age was 4.2 per 100,000 persons at risk. We found a presumed reversible cause in 48.6% of cases, with hypoxia being the predominant cause of POHCA (42.2%). The thirty-day survival was 40%. Variations were seen across age groups, with the lowest survival rate in cases below 1 year of age. Defibrillators were used more frequently among survivors, with 16% of survivors defibrillated bystanders as opposed to 1.9% in non-survivors and 24% by EMS personnel as opposed to 7.8% in non-survivors. The differences in initial rhythm being shockable was 34% for survivors and 16% for non-survivors.

Conclusion

We found pediatric out-of-hospital cardiac arrests was a rare event, with higher incidence and mortality in infants compared to other age groups of children. Use of defibrillators was disproportionally higher among survivors. Hypoxia was the most common presumed cause among all age groups.

National Surveillance of Pediatric Out-of-Hospital Cardiac Arrest in Korea: The 10-Year Trend From 2009 to 2018

BACKGROUND

This study reports trends in pediatric out-of-hospital cardiac arrest (OHCA) and factors affecting clinical outcomes by age group.

METHODS

We identified 4,561 OHCA patients younger than 18 years between January 2009 and December 2018 in the Korean OHCA Registry. The patients were divided into four groups: group 1 (1 year or younger), group 2 (1 to 5 years), group 3 (6 to 12 years), and group 4 (13 to 17 years). The primary outcome was survival to hospital discharge, and the secondary outcomes were return of spontaneous circulation (ROSC) at the emergency department (ED) and good neurological status at discharge. Multivariate logistic analyses were performed.

RESULTS

The incidence rate of pediatric OHCA in group 1 increased from 45.57 to 60.89 per 100,000 person-years, while that of the overall population decreased over the 10 years. The rates of ROSC at the ED, survival to hospital discharge, and good neurologic outcome were highest in group 4 (37.9%, 9.7%, 4.9%, respectively) and lowest in group 1 (28.3%, 7.1%, 3.2%). The positive factors for survival to discharge were event location of a public/commercial building or place of recreation, type of first responder, prehospital delivery of automated external defibrillator shock, initial shockable rhythm at the ED. The factors affecting survival outcomes differed by age group.

CONCLUSION

This study reports comprehensive trends in pediatric OHCA in the Republic of Korea. Our findings imply that preventive methods for the targeted population should be customized by age group.

Paediatric Out-of-Hospital Cardiac Arrests: An Epidemiological Study

Objective: To identify the epidemiological patterns of paediatric out-of-hospital cardiac arrests (OHCA) in Queensland, Australia and to investigate associations between patient variables and prehospital outcome.Methods: Included were paediatric (>4 days - 18 years) OHCA patients attended by paramedics in the state of Queensland (Australia) between January 2009 and December 2019. Patient and arrest characteristics were described. Factors associated with return of spontaneous circulation (ROSC) on hospital arrival were investigated.Results: A total of 1612 paediatric patients were included; 611 were deceased prior to paramedic arrival and 1001 received resuscitation attempts by paramedics. Approximately one quarter (26.8%) of resuscitation-attempted patients achieved ROSC on hospital arrival. Most arrests (49.7%) were due to medical causes. Arrests due to trauma had the lowest rate of ROSC on hospital arrival (9.6%), whereas those due to drug overdose had the highest rate (40%). Patients in rural areas had a lower rate of ROSC on hospital arrival than those in metropolitan areas (20.7% vs 32.5%, p < 0.001). The median response interval to all OHCA patients was 8 minutes. Trauma was considerably more prevalent in rural areas than in metropolitan areas, while all other aetiologies were comparable. Older paediatric age groups had higher rates of ROSC on hospital arrival than infants, particularly early adolescents (39.4% vs. 14.9%, p = 0.001). Aetiology, age, bystander witness, shockable initial rhythm, and geographic locality factors were independently associated with ROSC on hospital arrival.Conclusions: Approximately a quarter of paediatric prehospital OHCA achieved ROSC on hospital arrival. Prehospital outcome differs according to patient cohort and is associated with diverse patient demographic variables.

Palliative Care Utilization Following Out-of-Hospital Cardiac Arrest in Pediatrics

OBJECTIVES:

Pediatric out-of-hospital cardiac arrest (OHCA) is associated with significant morbidity and mortality. Pediatric palliative care (PPC) services could provide an integral component of the comprehensive care necessary for these patients and their families. The main objectives of this study are to examine the utilization of PPC following OHCA and compare the differences in characteristics between children who received PPC with those who did not.

DESIGN:

Retrospective cohort study.

SETTING:

An urban, tertiary PICU.

PATIENTS:

Children less than 21 years old admitted from October 2009 to October 2019 with an admitting diagnosis of OHCA and minimum PICU length of stay (LOS) of 48 hours.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Of the 283 patient charts reviewed, 118 patient encounters met inclusion criteria. Of those, 34 patients (28.8%) received a PPC consultation during hospitalization. Patients who received PPC had a longer PICU LOS (14.5 vs 4.0 d), a greater number of ventilator days (12.5 vs 4.0 d), and a larger proportion of do-not-resuscitate (DNR) statuses (41% vs 19%). When comparing the disposition of survivors, a greater proportion was discharged to rehab or nursing facilities (47% vs 28%), with no difference in mortality rates (53% vs 50%). In the multivariate logistic regression model, older age, longer LOS, and code status (DNR) were all associated with higher likelihood of PPC utilization. Data were analyzed using descriptive, Mann-Whitney U, and Fisher exact statistics.

CONCLUSIONS:

Our study demonstrates PPC services following OHCA are underutilized given the high degree of morbidity and mortality. The impact of automatic PPC consultation in all OHCA patients who survive beyond 48 hours should be explored further. Future studies are warranted to understand the benefits and barriers of PPC integration into standard postarrest care for patients and families.

Preparedness for paediatric cardiopulmonary resuscitation amongst medical doctors working in primary health care facilities in Cape Town, South Africa

Background

Cardiopulmonary resuscitation (CPR) is the principal medical intervention used to reduce the high mortality associated with the cardiorespiratory arrest. There is a paucity of literature on the preparedness for paediatric cardiopulmonary resuscitation (pCPR) amongst doctors in Cape Town. This study aimed to assess the preparedness for pCPR of doctors working in Western Cape Provincial Government primary health care facilities (PHCFs) in Cape Town with regard to knowledge, confidence and doctors’ knowledge of equipment availability.

Methods

A cross-sectional study using a questionnaire to collect quantitative data from a sample of 206 doctors working in Cape Town PHCFs.

Results

The questionnaire was completed by 173 doctors (84% response rate). The majority (81.8%) had not undergone pCPR training (Paediatric Advanced Life Support or Advanced Paediatric Life Support). Basic life support was done by 88.3%: 28% greater than two years ago. The average pCPR knowledge score was 61% (standard deviation [s.d.]: 20.3, range: 8.3% – 100%). Doctors in their community service and internship years had significantly higher knowledge scores compared to grade 3 Medical officers (p = 0.001 and p = 0.010, respectively). Eleven per cent had performed pCPR > 10 times in the past year; 20% had never performed pCPR and 35% did not feel confident performing pCPR. More than 35% of doctors were uncertain about the availability of equipment in their facility.

Conclusion

Doctors working in Cape Town PHCFs have poor knowledge, have low confidence levels and are poorly prepared to perform pCPR. Urgent attention needs to be given to ensuring formal pCPR training and acquaintance with equipment availability and location in Cape Town PHCFs.

Association between the types of bystander cardiopulmonary resuscitation and the survival with good neurologic outcome of preschool pediatric out-of-hospital cardiac arrest cases in Japan: A propensity score matching analysis using an extended nationwide database

BACKGROUND

Pediatric out-of-hospital cardiac arrests (OHCAs) are frequently associated with a respiratory etiology. Despite the high proportion of preschool children with OHCAs, very few studies on this special population exist. This study characterizes the epidemiologic features of preschool pediatric OHCAs and analyzes the advantage of conventional (ventilations with chest compressions) bystander cardiopulmonary resuscitation (CPR) over compression-only bystander CPR (BCPR) on the one-month post-event neurological status of the patient.

METHODS

Japanese nationwide databases for all ambulance transport events and OHCAs occurring during a 4-year period between 2016 and 2019 were combined, totalling 3,608 patient events. Children ≤6-years-old were included; physician- and EMS-witnessed events, no prehospital resuscitation effort events, and neonatal patient events were excluded. Neurologically favorable 1-month survival rates were compared among groups using univariate and multivariate analyses before and after propensity score matching.

RESULTS

From the combined database, 2,882 pediatric OHCAs meeting selection criteria were categorized as no BCPR (984), compression-only BCPR (1,428), and conventional BCPR (470). The proportion of bystander-witnessed cases was low (22.3%). Most OHCA witnesses were family members (88.5%), and most OHCAs occurred at home (88.0%). The neurologically favorable 1-month survival rates were: no BCPR 2.4%, compression only, 3.2%, and conventional 6.6% (P < 0.01). Multivariate logistic regression analysis before and after matching showed that conventional BCPR was associated with higher neurologically favorable 1-month survival than compression-only BCPR. Subgroup analyses after matching demonstrated that conventional BCPR was associated with better outcomes in nonmedical (adjusted odds ratio; 95% confidence interval, 2.83; 1.09-7.32) and unwitnessed OHCA cases (3.42; 1.09-10.8).

CONCLUSIONS

Conventional CPR is rarely performed by bystanders in preschool pediatric OHCA. However, conventional BCPR results in neurologically favorable outcomes in nonmedical and unwitnessed cases.

Clinical Significance of Gray to White Matter Ratio after Cardiopulmonary Resuscitation in Children

Cardiopulmonary resuscitation (CPR) successfully restores systemic circulation approximately 50% of the time; however, many successfully restored patients have severe neurologic damage. In adults, the gray matter to white matter attenuation ratio (GWR) in brain computed tomography (CT) correlates with the neurologic outcome. However, in children, the clinical significance of GWR still remains unclear. The aim of this study was to evaluate the clinical characteristics of children who underwent CPR for cardiac arrest according to the survival and to demonstrate the differentiation of grey/white matter by Hounsfield units of brain CT and to characterize the attenuations of grey and white matters. Methods: This is a retrospective single-center study. We enrolled those who underwent brain CT within 24 h after return of spontaneous circulation (ROSC) from January 2005 to June 2018. Brain CTs were taken within 24 h of ROSC. We measured the attenuation of grey and white matter in Hounsfield units and calculated GWR. They were compared with healthy controls. Patients were analyzed as follows: survivors vs. non-survivors and better neurologic outcome vs. worse neurologic outcome. Results: Among 100 pediatric patients who had CPR, 56 met inclusion criteria. There were 24 patients who survived and 32 non-survivors. Our study revealed that the incidence of seizure, duration of CPR, and instances of hypothermia were significantly different between survivors and non-survivors. In both survivors and non-survivors, the attenuation of the caudate nucleus, putamen, GWR-basal ganglia, and average GWR were significantly different from controls. In regression analyses, the medial cortex and average GWR were the significant variables to predict survival, and the receiver operating curves revealed areas under curve of 0.733 and 0.666, respectively. Also, the medial cortex 1 was the only variable that predicted the neurologic outcome. Conclusions: There was some predictive survival value of GWR and medial cortex at the centrum semiovale level in early brain CT within 24 h after cardiac arrest. Although we could not find the predictive value of GWR in the neurologic outcome of pediatric patients, we found that the absolute attenuation of the medial cortex was low in patients with worse neurologic outcomes. Further prospective, multicenter studies are needed to determine the predictive value of GWR and the medial cortex.

A novel retraining strategy of chest compression skills for infant CPR results in high skill retention for longer

Infant cardiopulmonary resuscitation (iCPR) is often poorly performed, predominantly because of ineffective learning, poor retention and decay of skills over time. The aim of this study was to investigate whether an individualized, competence-based approach to simulated iCPR retraining could result in high skill retention of infant chest compressions (iCC) at follow-up. An observational study with 118 healthcare students was conducted over 12 months from November 2019. Participants completed pediatric resuscitation training and a 2-min assessment on an infant mannequin. Participants returned for monthly assessment until iCC competence was achieved. Competence was determined by passing assessments in two consecutive months. After achieving competence, participants returned just at follow-up. For each 'FAIL' during assessment, up to six minutes of practice using real-time feedback was completed and the participant returned the following month. This continued until two consecutive monthly 'PASSES' were achieved, following which, the participant was deemed competent and returned just at follow-up. Primary outcome was retention of competence at follow-up. Descriptive statistics were used to analyze demographic data. Independent t-test or Mann-Whitney U test were used to analyze the baseline characteristics of those who dropped out compared to those remaining in the study. Differences between groups retaining competence at follow-up were determined using the Fisher exact test. On completion of training, 32 of 118 participants passed the assessment. Of those achieving iCC competence at month 1, 96% retained competence at 9-10 months; of those achieving competence at month 2, 86% demonstrated competence at 8-9 months; of those participants achieving competence at month 3, 67% retained competence at 7-8 months; for those achieving competence at month 4, 80% demonstrated retention at 6-7 months.   Conclusion: Becoming iCC competent after initial training results in high levels of skill retention at follow-up, regardless of how long it takes to achieve competence. What is Known: • Infant cardiopulmonary resuscitation (iCPR) is often poorly performed and skills decay within months after training. • Regular iCPR skills updates are important, but the optimal retraining interval considering individual training needs has yet to be established. What is New: • Infant chest compression (iCC) competence can be achieved within one to four months after training and once achieved, it can be retained for many months. • With skill reinforcement of up to 28 minutes after initial training, 90% of individuals were able to achieve competence in iCC and 86% retained this competence at follow-up.

Sudden out-of-hospital cardiac arrest in pediatric patients in Kyushu area in Japan

BACKGROUND

It is well-known that a neurologically favorable outcome of out-of-hospital cardiac arrest (OHCA) is associated with the presence of bystander-initiated cardiopulmonary resuscitation (bystander CPR) and use of an automated external defibrillator. However, little is known about the effect of the presence of pre-existing conditions, prior activity, and locations on the outcome of pediatric OHCA.

METHODS

We analyzed the data from questionnaires about pediatric patients with OHCA aged from 3 days to 19 years in the Kyushu area in Japan between 2012 and 2016.

RESULTS

A total of 594 OHCA cases were collected. The numbers of OHCA cases and the rate of 1 month survival with a favorable neurological outcome during sleeping, swimming / bathing, and exercise were 192 (1.0%), 83 (32.5%), and 44 (65.9%), respectively. When an OHCA occurred at school (n = 56), 88% of children / adolescents received bystander CPR, but when it occurred at home (n = 390), 15% received bystander CPR. Cardiovascular (n = 61), suicide (n = 61), and neurological / neuromuscular (n = 44) diseases were three major pre-existing conditions. The OHCA of cardiovascular disease was associated with exercise (24/61) and mainly occurred at school (22/61). The OHCA of neurological / neuromuscular disease was associated with swimming/bathing (15/44) and mainly occurred during bathing at home (12/44). Multivariate regression analysis showed that the presence of bystander CPR (P < 0.001) and occurrence of OHCA at school (P < 0.001) were independently predictive of a favorable outcome in pediatric OHCA.

CONCLUSION

The outcome was different among pre-existing conditions, prior activity, and location of OHCA. These findings might be useful for preventing OHCA and improving the outcome of pediatric OHCA.

Inequalities in Income and Education are Associated with Survival Differences after Out-of-hospital Cardiac Arrest: A Nationwide Observational Study

Supplemental Digital Content is available in the text.

Background:

Despite the acknowledged importance of socioeconomic factors as regards cardiovascular disease onset and survival, the relationship between individual-level socioeconomic factors and survival after out-of-hospital cardiac arrest is not established. Our aim was to investigate whether socioeconomic variables are associated with 30-day survival after out-of-hospital cardiac arrest.

Methods:

We linked data from the Swedish Registry for Cardiopulmonary Resuscitation with individual-level data on socioeconomic factors (ie, educational level and disposable income) from Statistics Sweden. Confounding and mediating variables included demographic factors, comorbidity, and Utstein resuscitation variables. Outcome was 30-day survival. Multiple modified Poisson regression was used for the main analyses.

Results:

A total of 31 373 out-of-hospital cardiac arrests occurring in 2010 to 2017 were included. Crude 30-day survival rates by income quintiles were as follows: Q1 (low), 414/6277 (6.6%); Q2, 339/6276 (5.4%); Q3, 423/6275 (6.7%); Q4, 652/6273 (10.4%); and Q5 (high), 928/6272 (14.8%). In adjusted analysis, the chance of survival by income level followed a gradient-like increase, with a risk ratio of 1.86 (95% CI, 1.65–2.09) in the highest-income quintile versus the lowest. This association remained after adjusting for comorbidity, resuscitation factors, and initial rhythm. A higher educational level was associated with improved 30-day survival, with the risk ratio associated with postsecondary education ≥4 years being 1.51 (95% CI, 1.30–1.74). Survival disparities by income and educational level were observed in both men and women.

Conclusions:

In this nationwide observational study using individual-level socioeconomic data, higher income and higher educational level were associated with better 30-day survival after out-of-hospital cardiac arrest in both sexes.

Bystander cardiopulmonary resuscitation for paediatric out-of-hospital cardiac arrest in England: An observational registry cohort study

INTRODUCTION

Bystander cardiopulmonary resuscitation (BCPR) is strongly advocated by resuscitation councils for paediatric out-of-hospital cardiac arrests (OHCAs). However, there are limited reports on rates of BCPR in children and its relationship with return of spontaneous circulation (ROSC) or survival outcomes.

OBJECTIVE

We describe the rate of BCPR and its association with any ROSC and survival- to- hospital-discharge.

METHODS

We conducted retrospective analysis of prospectively collected paediatric (<18 years of age) OHCA cases in England; we included specialist registry patients treated by emergency medical services (EMS) with known BCPR status and outcome between January 2014 and November 2018. Data included patient demographics, aetiology, witness status, initial rhythm, EMS, season, time of day and bystander status. Associations between BCPR, and any ROSC and survival-to-hospital-discharge outcomes were explored using multivariable logistic regression.

RESULTS

There were 2363 paediatric OHCAs treated across 11 EMS regions. BCPR was performed in 69.6% (1646/2363) of the cases overall (range 57.7% (206/367) to 83.7% (139/166) across EMS regions). Only 34.9% (550/1572) of BCPR cases were witnessed. Overall, any ROSC was achieved in 22.8% (523/2289) and survival to hospital discharge in 10.8% (225/2066). Adjusted odds ratio (aOR) for any ROSC was significantly improved following BCPR compared to no BCPR (aOR 1.37, 95% CI 1.03-1.81), but adjusted odds ratio for survival-to-hospital-discharge were similar (aOR 1.01, 95% CI 0.66-1.55).

CONCLUSIONS

BCPR was associated with improved rates of any ROSC but not survival-to-hospital-discharge. Variations in EMS BCPR rates may indicate opportunities for regional targeted increase in public BCPR education.

Racial, ethnic, and socioeconomic disparities in paediatric critical care in the USA

In an era of tremendous medical advancements, it is important to characterise and address inequities in the provision of health care and in outcomes. There is a large body of evidence describing such disparities by race or ethnicity and socioeconomic position in critically ill adults; however, this important issue has received less attention in children and adolescents (aged ≤21 years). This Review presents a summary of the available evidence on disparities in outcomes in paediatric critical illness in the USA as a result of racism and socioeconomic privilege. The majority of evidence of racial and socioeconomic disparities in paediatric critical care originates from the USA and is retrospective, with only one prospective intervention-based study. Although there is mixed evidence of disparities by race or ethnicity and socioeconomic position in general paediatric intensive care unit admissions and outcomes in the USA, there are striking trends within some disease processes. Notably, there is evidence of disparities in management and outcomes for out-of-hospital cardiac arrest, asthma, severe trauma, sepsis, and oncology, and in families' perceptions of care. Furthermore, there is clear evidence that critical care research is limited by under-enrolment of participants from minority race or ethnicity groups. We advocate for rigorous research standards and increases in the recruitment and enrolment of a diverse range of participants in paediatric critical care research to better understand the disparities observed, including the effects of racism and poverty. A clearer understanding of when, where, and how such disparities affect patients will better enable the development of effective strategies to inform practice, interventions, and policy.

Dominant versus non-dominant hand during simulated infant CPR using the two-finger technique: a randomised study

Aims

The aim of this randomised study was to compare the two-finger technique (TFT) performance using dominant hand (DH) and non-dominant hand (NH) during simulated infant CPR (iCPR).

Methods

24 participants performed 3-min iCPR using TFT with DH or NH followed by 3-min iCPR with their other hand. Perceived fatigue was rated using visual analogue scale. Primary outcomes - (i) difference between DH and NH for compression depth (CCD), compression rate (CCR), residual leaning (RL) and duty cycle (DC); (ii) difference between first and last 30 s of iCPR performance with DH and NH. Secondary outcomes - (i) perception of fatigue between DH and NH; (ii) relationship between perception of fatigue and iCPR performance.

Results

No significant difference between DH and NH for any iCPR metric. CCR (DH: P = 0.02; NH: P = 0.004) and DC (DH: P = 0.04; NH: P < 0.001) were significantly different for the last 30 s for DH and NH. Perception of fatigue for NH (76.8 ± 13.4 mm) was significantly higher (t = -3.7, P < 0.001) compared to DH (62.8 ± 12.5 mm). No significant correlation between iCPR metrics and perception of fatigue for DH. However, a significant correlation was found for CCR (r = 0.43; P = 0.04) and RL (r = -0.48; P = 0.02) for NH.

Conclusion

No difference in performance of iCPR with DH versus NH was determined. However, perception of fatigue is higher in NH and was related to CCR and RL, with no effect on quality of performance. Based on our results, individuals performing iCPR can offer similar quality of infant chest compressions regardless of the hand used or the perception of fatigue, under the conditions explored in this study.

Community-level socioeconomic status and outcomes of patients with out-of-hospital cardiac arrest: A systematic review and meta analysis

BACKGROUND

The aim of this systematic review and meta-analysis was to investigate the associations of community-level socioeconomic status (SES) on outcomes of patients with out-of hospital cardiac arrest (OHCA).

METHODS

A systematic literature review was conducted using PubMed, EMBASE, and the Cochrane database according to guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We included literature that presented the outcomes based on community-level SES among patients with OHCA. SES indicators included economic indicators such as income, wealth, and occupation, as well as combined indicators, where any of these indicators were integrated. Outcomes were bystander cardiopulmonary resuscitation (CPR) and survival to discharge.

RESULTS

From 1394 titles, 10 cross-sectional observational studies fulfilled inclusion and exclusion criteria, representing 118,942 patients with OHCA. The odds ratios (ORs) of bystander CPR and survival to discharge for lower community-level SES patients were lower than those for higher community-level SES by economic SES indicators (bystander CPR OR 0.67; 95% CI 0.51-0.89, survival to discharge OR 0.60; 95% CI 0.35-1.02). Based on combined SES indicators the results showed similar patterns (bystander CPR OR 0.80; 95% CI 0.75-0.84, survival to discharge OR 0.76; 95% CI 0.63-0.92).

CONCLUSION

In this meta-analysis, community-level SES was significantly associated with bystander CPR and survival among patients with OHCA.

The landscape of paediatric in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit

AIM

To report the patient characteristics and clinical outcome of paediatric in-hospital cardiac arrest in the United Kingdom (UK) National Cardiac Arrest Audit (NCAA) database.

METHODS

Analysis of all recorded paediatric cardiac arrests in the NCAA dataset over a seven-year period ending on 31 December 2018, within acute children's hospitals (including standalone paediatric hospitals and hospitals with tertiary paediatric services) and acute general hospitals participating in NCAA. In this period 1456 patients (with 1580 events), 1 month to 16 years of age, received chest compressions and/or defibrillation and were attended by a hospital-based resuscitation team in response to an emergency call. The main outcome measure was survival to discharge.

RESULTS

For this cohort of paediatric in-hospital cardiac arrest patients the overall rates of sustained return of spontaneous circulation (ROSC) were 69.1% with unadjusted survival to hospital discharge of 54.2%. The presenting rhythm was shockable in 4.3% of events and non-shockable in 82.1% (remainder undetermined); rates of survival to hospital discharge associated with these rhythms were 63.9% and 51.7%. A difference in outcomes was observed between Children's hospitals and acute general hospitals with ROSC rates of 79.1% and 55.5% respectively and survival to hospital discharge rates of 57.7% and 49.3% respectively.

CONCLUSIONS

These first results from the NCAA database describing the outcome of paediatric in-hospital cardiac arrest in UK hospitals will serve as a benchmark from which to assess the future impact of changes in service delivery, organisation and treatment for in-hospital cardiac arrest in young people. Outcomes for specialist paediatric centres should be studied further as higher rates of ROSC and survival to hospital discharge were observed.

Epidemiology of pediatric cardiopulmonary resuscitation

OBJECTIVE

To analyze the main epidemiological aspects of prehospital and hospital pediatric cardiopulmonary resuscitation and the impact of scientific evidence on survival.

SOURCE OF DATA

This was a narrative review of the literature published at PubMed/MEDLINE until January 2019 including original and review articles, systematic reviews, meta-analyses, annals of congresses, and manual search of selected articles.

SYNTHESIS OF DATA

The prehospital and hospital settings have different characteristics and prognoses. Pediatric prehospital cardiopulmonary arrest has a three-fold lower survival rate than cardiopulmonary arrest in the hospital setting, occurring mostly at home and in children under 1year. Higher survival appears to be associated with age progression, shockable rhythm, emergency medical care, use of automatic external defibrillator, high-quality early life support, telephone dispatcher-assisted cardiopulmonary resuscitation, and is strongly associated with witnessed cardiopulmonary arrest. In the hospital setting, a higher incidence was observed in children under 1year of age, and mortality increased with age. Higher survival was observed with shorter cardiopulmonary resuscitation duration, occurrence on weekdays and during daytime, initial shockable rhythm, and previous monitoring. Despite the poor prognosis of pediatric cardiopulmonary resuscitation, an increase in survival has been observed in recent years, with good neurological prognosis in the hospital setting.

CONCLUSIONS

A great progress in the science of pediatric cardiopulmonary resuscitation has been observed, especially in developed countries. The recognition of the epidemiological aspects that influence cardiopulmonary resuscitation survival may direct efforts towards more effective actions; thus, studies in emerging and less favored countries remains a priority regarding the knowledge of local factors.

Poor Long-Term Survival of Out-of-Hospital Cardiac Arrest in Children

The effect of post-cardiac arrest care in children with out-of-hospital cardiac arrest (OHCA) has not been adequately established, and the long-term outcome after pediatric OHCA has not been sufficiently investigated. We describe here detailed in-hospital characteristics, actual management, and survival, including neurological status, 90 days after OHCA occurrence in children with OHCA transported to critical care medical centers (CCMCs).We analyzed the database of the Comprehensive Registry of Intensive Care for OHCA Survival (CRITICAL) study, which is a multicenter, prospective observational data registry designed to accumulate both pre- and in-hospital data on OHCA treatments. We enrolled all consecutive pediatric patients aged <18 years who had an OHCA and for whom resuscitation was attempted and who were transported to CCMCs between 2012 and 2016.A total of 263 pediatric patients with OHCA were enrolled. The average age of the patients was 6.3 years, 38.0% were aged < 1 year, and 60.8% were male. After hospital arrival, 4.9% of these pediatric patients received defibrillation; 1.9%, extracorporeal life support; 6.5%, target temperature management; and 88.2% adrenaline administration. The proportions of patients with 90-day survival and a pediatric cerebral performance category (PCPC) score of 1 or 2 were 6.1% and 1.9%, respectively. The proportion of patients with a PCPC score of 1 or 2 at 90 days after OHCA occurrence did not significantly improve during the study period.The proportion of pediatric patients with a 90-day PCPC score of 1 or 2 transported to CCMCs was extremely low, and no significant improvements were observed during the study period.

Characteristics and Outcomes of Out-of-Hospital Cardiac Arrest in Educational Institutions in Japan - All-Japan Utstein Registry

BACKGROUND

Although schools are key places that conduct cardiopulmonary resuscitation (CPR) and public-access defibrillation (PAD) programs, out-of-hospital cardiac arrest (OHCA) in educational institutions is poorly understood. This study describes the characteristics and outcomes of such OHCAs.Methods and Results:Data for OHCAs of any cause occurring in educational institutions between 2013 and 2015 were extracted from the All-Japan Utstein Registry. Patient characteristics and outcomes were documented. Subjects were divided into 6 age groups (0-1, 2-5, 6-11, 12-14, 15-17, and ≥18 years). Among the 783 eligible OHCA patients, most received bystander CPR regardless of age, ranging from 73.9% in those aged ≥18 years to 90.0% in those aged 2-5 years. However, the proportion receiving PAD differed by age group, ranging from 2.9% in those aged 0-1 years to 66.7% in those aged 12-14 years. The proportion of patients with 1-month survival with favorable neurological outcome differed significantly by age group, being extremely low among patients aged 0-1 years (zero for OHCA of cardiac origin), but high among patients aged 6-11, 12-14, and 15-17 years (69.2%, 77.5%, and 70.0%, respectively) for OHCA of cardiac origin.

CONCLUSIONS

The outcomes of OHCA occurring in educational institutions, where PAD is available, differed significantly by age.

Exploring the implementation of family-witnessed resuscitation in children and young people

There are varying opinions about family-witnessed resuscitation in children and young people throughout the literature and the guidance on this practice is outdated and imprecise. Family-witnessed resuscitation can have psychological benefits for relatives; however, healthcare practitioners are often prevented from implementing this practice because of the perceived negative effect on their work through distraction or interference. Healthcare practitioners can also find it challenging to negotiate the ethics of family-witnessed resuscitation, particularly in relation to whether this practice can be considered caring or compassionate. The limited guidance on family-witnessed resuscitation in children and young people also means that it can be challenging for healthcare practitioners who want to implement the practice to identify available evidence to justify their actions. This article explores the evidence for and against the practice of family-witnessed resuscitation in children and young people and provides recommendations for healthcare practitioners who are implementing this practice.

Race/Ethnicity and Neighborhood Characteristics Are Associated With Bystander Cardiopulmonary Resuscitation in Pediatric Out-of-Hospital Cardiac Arrest in the United States: A Study From CARES

Background

Whether racial and neighborhood characteristics are associated with bystander cardiopulmonary resuscitation (BCPR) in pediatric out‐of‐hospital cardiac arrest (OHCA) is unknown.

Methods and Results

An analysis was conducted of CARES (Cardiac Arrest Registry to Enhance Survival) for pediatric nontraumatic OHCAs from 2013 to 2017. An index (range, 0–4) was created for each arrest based on neighborhood characteristics associated with low BCPR (>80% black; >10% unemployment; <80% high school; median income, <$50 000). The primary outcome was BCPR. BCPR occurred in 3399 of 7086 OHCAs (48%). Compared with white children, BCPR was less likely in other races/ethnicities (black: adjusted odds ratio [aOR], 0.59; 95% CI, 0.52–0.68; Hispanic: aOR, 0.78; 95% CI, 0.66–0.94; and other: aOR, 0.54; 95% CI, 0.40–0.72). Compared with arrests in neighborhoods with an index score of 0, BCPR occurred less commonly for arrests with an index score of 1 (aOR, 0.80; 95% CI, 0.70–0.91), 2 (aOR, 0.75; 95% CI, 0.65–0.86), 3 (aOR, 0.52; 95% CI, 0.45–0.61), and 4 (aOR, 0.46; 95% CI, 0.36–0.59). Black children had an incrementally lower likelihood of BCPR with increasing index score while white children had an overall similar likelihood at most scores. Black children with an index of 4 were approximately half as likely to receive BCPR compared with white children with a score of 0.

Conclusions

Racial and neighborhood characteristics are associated with BCPR in pediatric OHCA. Targeted CPR training for nonwhite, low‐education, and low‐income neighborhoods may increase BCPR and improve pediatric OHCA outcomes.

Retrospective population-based study of emergency medical services-attended out-of-hospital cardiac arrests in children in Belgium

OBJECTIVE

This study presents an analysis of clinical data of the circumstances and outcome of paediatric (0-16 years) out-of-hospital cardiac arrests (p-OHCA) in Belgium.

METHODS

This was a retrospective study of a prospective population-based registration of physician-attended [mobile emergency group (MUG)] emergency medical services (EMS) interventions of p-OHCA in Belgium between 2010 and 2012.

RESULTS

We identified 365 OHCA in 18 295 paediatric MUG interventions (2%). Cardiopulmonary resuscitation was performed in 260 (71.2%) cases. In 59.2%, a medical problem was presumed to be underlying. In 106 (40.7%) cases, an 'external' cause (e.g. trauma) was the reason for the OHCA. Eventually, 133 children were transported to the emergency department, with return-of-spontaneous-circulation (ROSC) in 42 cases. In the group with initial shockable rhythm (n=13), sustained ROSC was obtained in 69.2%. For those with an initial nonshockable rhythm, the prognosis was much more reserved (13.4% sustained ROSC). This number is in contrast to the high number of children who are transported from scene (51.2%). Importantly, 40.6% of the latter were proclaimed 'dead' during transport.

CONCLUSION

p-OHCA remains rare. Typically, Belgian MUGs each encounter less than two p-OHCA yearly, thus inducing a risk of being insufficiently prepared. Compared with other countries, cardiopulmonary resuscitation was not started in more cases. Even so, in many other cases, children were transported from scene to be proclaimed 'dead' very soon after, pointing to a practice of 'slow code'. This study provides 'real-life' data on p-OHCA in Belgium. As it is based on an administrative registry, it lacks information on individual cases. Large population-based registries are needed to further guide our decision making.

Neighborhood food environment, dietary fatty acid biomarkers, and cardiac arrest risk

We explored links between food environments, dietary intake biomarkers, and sudden cardiac arrest in a population-based longitudinal study using cases and controls accruing between 1990 and 2010 in King County, WA. Surprisingly, presence of more unhealthy food sources near home was associated with a lower 18:1 trans-fatty acid concentration (-0.05% per standard deviation higher count of unhealthy food sources, 95% Confidence Interval [CI]: 0.01, 0.09). However, presence of more unhealthy food sources was associated with higher odds of cardiac arrest (Odds Ratio [OR]: 2.29, 95% CI: 1.19, 4.41 per standard deviation in unhealthy food outlets). While unhealthy food outlets were associated with higher cardiac arrest risk, circulating 18:1 trans fats did not explain the association.

Awareness of cardiopulmonary resuscitation among parents of 3-year-old children

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) in infants or toddlers mainly occurs at home. Therefore, parents should be able to perform immediate cardiopulmonary resuscitation (CPR) when they witness OHCA. The status of knowledge regarding CPR among parents, however, remains unclear. The aim of the present study was therefore to determine the factors associated with awareness of CPR in parents of 3-year-old children.

METHODS

We analyzed a subset of data from a population-based, cross-sectional survey that served as an evaluation of a national campaign for maternal and child health in Japan. The questionnaire was distributed to 32 897 parents who visited public health centers for medical check-ups for their children in 2013. Multivariate logistic regression analysis was carried out using the obtained demographic data.

RESULTS

Overall, 26 971 parents (82.0%) responded to the questionnaire. On multivariate logistic regression analysis, birth order of the child, age of the mother at delivery, awareness of medical facilities for emergency services at night or during the weekend, current occupation status of the mother, and current economic status were independently associated with CPR awareness. When the mother was employed but the parents felt economically insufficient, the probability of having CPR knowledge decreased by 19%. Regardless of the parents' economic stability, the probability of having CPR knowledge declined by >35% when the mother was unemployed.

CONCLUSIONS

The current occupation status of mothers and the current parent economic status should be considered when planning educational strategies regarding CPR training for parents.

Cardiac Arrest Survival in Pediatric and General Emergency Departments

BACKGROUND AND OBJECTIVES

Pediatric out-of-hospital cardiac arrest (OHCA) has a low rate of survival to hospital discharge. Understanding whether pediatric emergency departments (EDs) have higher survival than general EDs may help identify ways to improve care for all patients with OHCA. We sought to determine if OHCA survival differs between pediatric and general EDs.

METHODS

We used the 2009-2014 Nationwide Emergency Department Sample to study children under 18 with cardiac arrest. We compared pediatric EDs (those with >75% pediatric visits) to general EDs on the outcome of survival to hospital discharge or transfer. We determined unadjusted and adjusted survival, accounting for age, region, and injury severity. Analyses were stratified by nontraumatic versus traumatic cause.

RESULTS

The incidences of nontraumatic and traumatic OHCA were 7.91 (95% confidence interval [CI]: 7.52-8.30) and 2.67 (95% CI: 2.49-2.85) per 100 000 person years. In nontraumatic OHCA, unadjusted survival was higher in pediatric EDs than general EDs (33.8% vs 18.9%, P < .001). The adjusted odds ratio of survival in pediatric versus general EDs was 2.2 (95% CI: 1.7-2.8). Children with traumatic OHCA had similar survival in pediatric and general EDs (31.7% vs 26.1%, P = .14; adjusted odds ratio = 1.3 [95% CI: 0.8-2.1]).

CONCLUSIONS

In a nationally representative sample, survival from nontraumatic OHCA was higher in pediatric EDs than general EDs. Survival did not differ in traumatic OHCA. Identifying the features of pediatric ED OHCA care leading to higher survival could be translated into improved survival for children nationally.

Epidemiology of Paediatric Out-of-Hospital Cardiac Arrest Presented to a Local Emergency Department: A Retrospective Case Series

Objective

To outline the epidemiology of paediatric out-of-hospital cardiac arrest (OHCA) cases presented to a regional hospital.

Design

Retrospective case series.

Methods

Attendance records of critical cases aged from 0 to 17 years old from year 2001 to 2014 attending Emergency Department (ED) of Yan Chai Hospital were searched. Demographic data and predictive parameters were analysed for association with outcome.

Results

There were 40 cases of paediatric OHCA throughout the study period. A total of 21 (52.5%) had witnessed arrest; 27 (67.5%) had cardiac arrest at home. Twenty-eight (70%) of the cardiac arrest were first noted by family members; 8 (20%) received bystander cardiopulmonary resuscitation (CPR). Only 13 (32.5%) cases had return of spontaneous circulation (ROSC) in the ED and were admitted. Seven patients (17.5%) survived to hospital discharge.

Conclusion

Paediatric OHCA, although a rare occurrence, has a high mortality of 82.5% in our series. Majority of the cases occur at home, and are witnessed. Family members are often the first persons to detect the arrest. Yet the rate of providing bystander CPR is low in Hong Kong.

Conventional versus chest-compression-only cardiopulmonary resuscitation by bystanders for children with out-of-hospital cardiac arrest

AIM

It is unclear whether chest-compression-only cardiopulmonary resuscitation (CC-CPR) is therapeutically equivalent to conventional CPR for children with out-of-hospital cardiac arrest (OHCA). We aimed to determine the association of CC-CPR and conventional CPR with outcomes in discrete child patient populations with OHCA.

METHODS

We analysed 6810 children (aged <18years) using Japanese registry from 2007 to 2014. Main outcomes measure was 30-day neurologically intact survival after OHCA, defined as Glasgow-Pittsburgh cerebral performance categories 1 or 2.

RESULTS

In propensity score-matched children aged 1-17 years (n=2682), overall neurologically intact survival rate was significantly higher after conventional CPR than after CC-CPR (9.4% vs. 6.0%, P=0.001). However, there was no significant difference between the two CPR modalities in patients with cardiac aetiology (14.2% vs. 11.8%, P=0.32), initial shockable rhythm (35.3% vs. 31.7%, P=0.59), or age ≥8 years (12.4% vs. 9.8%, P=0.13). For matched infants (n=1994), no significant differences were observed in overall neurological intact survival between conventional CPR and CC-CPR (2.2% vs. 1.3%, P=0.17). In infant subgroup analyses, neurologically intact survival was similar between the CPR modalities for cardiac aetiology (0.3% vs. 1.0%; P=0.37) and for witnessed arrest (6.2% vs. 6.0%; P=0.98).

CONCLUSIONS

In the majority of the paediatric subgroups, conventional CPR was associated with improved outcomes compared to CC-CPR. CC-CPR was associated with 30-day neurologically intact survival similar to conventional CPR for children with OHCA aged ≥8 years, for children aged 1-17 years with cardiac aetiology or initial shockable rhythm, and for infants with cardiac aetiology or witnessed arrest.

Pediatric out-of-hospital cardiac arrest caused by left coronary-artery agenesis with primary shockable rhythm

BACKGROUND

To illustrate a rare cause of out-of-hospital cardiac arrest in children, its differential diagnoses, emergency and subsequent treatment at various steps in the rescue chain, and potential outcomes.

CASE PRESENTATION

A 4-year-old boy with unknown agenesis of the left coronary ostium sustained out-of-hospital cardiac arrest. Bystander cardio-pulmonary resuscitation was initiated and defibrillation was performed via an automated external defibrillator (AED) shortly after paramedics arrived at the scene, restoring sinus rhythm and spontaneous circulation. After admission to the intensive care unit the child was intubated for airway and seizure control. Further diagnostic work-up by angiography revealed agenesis of the left coronary artery. After initial seizures, the boy's neurological recovery was complete. He subsequently underwent successful internal mammary artery in-situ bypass surgery to the trunk of the left coronary artery. One year after cardiac arrest, the patient had completely recovered with no physical or intellectual sequelae. A catheter examination proved excellent growth of the bypass and good cardiac function.

CONCLUSIONS

This case illustrates the long term outcome after agenesis of the LCA while reiterating that prompt access to pediatric defibrillation may be lifesaving-albeit in a minority of pediatric OHCA.

Location of cardiac arrest and impact of pre-arrest chronic disease and medication use on survival

INTRODUCTION

Cardiac arrest in a private location is associated with a higher mortality when compared to public location. Past studies have not accounted for pre-arrest factors such as chronic disease and medication.

AIM

To investigate whether the association between cardiac arrest in a private location and a higher mortality can be explained by differences in chronic diseases and medication.

METHODS

We identified 27,771 out-of-hospital cardiac arrest patients ≥18 years old from the Danish Cardiac Arrest Registry (2001-2012). Using National Registries, we identified pre-arrest chronic disease and medication. To investigate the importance of cardiac arrest related factors and chronic disease and medication use we performed adjusted Cox regression analyses during day 0-7 and day 8-365 following cardiac arrest to calculate hazard ratios (HR) for death.

RESULTS

Day 0-7: Un-adjusted HR for death day 0-7 was 1.21 (95%CI:1.18-1.25) in private compared to public location. When including cardiac arrest related factors HR for death was 1.09 (95%CI:1.06-1.12). Adding chronic disease and medication to the analysis changed HR for death to 1.08 (95%CI:1.05-1.12). 8-365 day: The un-adjusted HR for death day 8-365 was 1.70 (95% CI: 1.43-2.02) in private compared to public location. When including cardiac arrest related factors the HR decreased to 1.39 (95% CI: 1.14-1.68). Adding chronic disease and medication to the analysis changed HR for death to 1.27 (95% CI:1.04-1.54).

CONCLUSION

The higher mortality following cardiac arrest in a private location is partly explained by a higher prevalence of chronic disease and medication use in patients surviving until day 8.