Epidemiology and outcome of paediatric out-of-hospital cardiac arrests: A paediatric sub-study of the Pan-Asian resuscitation outcomes study (PAROS)

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

Verification of the termination of resuscitation rules in pediatric out-of-hospital cardiac arrest cases

Aim

Pediatric out-of-hospital cardiac arrest has an unfavorable prognosis; therefore, making accurate predictions of outcomes is crucial for tailoring treatment plans. The termination of resuscitation rules must accurately predict unfavorable outcomes. In this study, we aimed to assess if the current termination of resuscitation rules for adults can predict factors associated with unfavorable outcomes in pediatric out-of-hospital cardiac arrest and examine the relationship between these factors and unfavorable outcomes.

Methods

A retrospective nationwide cohort study of pediatric cases registered in the Japanese Association for Acute Medicine Multicenter Out-of-Hospital Cardiac Arrest Registry from June 1, 2014, to December 31, 2020, was conducted. The association between the current termination of resuscitation rules and outcomes, such as 30-day mortality and unfavorable 30-day neurological outcomes following out-of-hospital cardiac arrest, was evaluated.

Results

A total of 1,216 participants were included. The positive predictive value for predicting 30-day mortality for each termination of resuscitation rule exceeded 0.9. The specificity and positive predictive value for predicting unfavorable 30-day neurological outcomes were 1.00, indicating that no rules identified favorable outcomes. Factors such as no bystander witness, no return of spontaneous circulation before hospital arrival, no automated external defibrillator or defibrillator use, and no bystander cardiopulmonary resuscitation were associated with poor 30-day mortality and neurological outcomes.

Conclusion

Adult termination of resuscitation rules had a high positive predictive value for predicting pediatric out-of-hospital cardiac arrest. However, surviving cases make it challenging to use these rules for end-of-resuscitation decisions, indicating the need for identifying new rules to help predict neurological outcomes.

Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: 2024 Update of the Utstein Out-of-Hospital Cardiac Arrest Registry Template

The Utstein Out-of-Hospital Cardiac Arrest Resuscitation Registry Template, introduced in 1991 and updated in 2004 and 2015, standardizes data collection to enable research, evaluation, and comparisons of systems of care. The impetus for the current update stemmed from significant advances in the field and insights from registry development and regional comparisons. This 2024 update involved representatives of the International Liaison Committee on Resuscitation and used a modified Delphi process. Every 2015 Utstein data element was reviewed for relevance, priority (core or supplemental), and improvement. New variables were proposed and refined. All changes were voted on for inclusion. The 2015 domains-system, dispatch, patient, process, and outcomes-were retained. Further clarity is provided for the definitions of out-of-hospital cardiac arrest attended resuscitation and attempted resuscitation. Changes reflect advancements in dispatch, early response systems, and resuscitation care, as well as the importance of prehospital outcomes. Time intervals such as emergency medical service response time now emphasize precise reporting of the times used. New flowcharts aid the reporting of system effectiveness for patients with an attempted resuscitation and system efficacy for the Utstein comparator group. Recognizing the varying capacities of emergency systems globally, the writing group provided a minimal dataset for settings with developing emergency medical systems. Supplementary variables are considered useful for research purposes. These revisions aim to elevate data collection and reporting transparency by registries and researchers and to advance international comparisons and collaborations. The overarching objective remains the improvement of outcomes for patients with out-of-hospital cardiac arrest.

Cardiac arrest and cardiopulmonary resuscitation outcome reports: 2024 update of the Utstein Out-of-Hospital Cardiac Arrest Registry template

The Utstein Out-of-Hospital Cardiac Arrest Resuscitation Registry Template, introduced in 1991 and updated in 2004 and 2015, standardizes data collection to enable research, evaluation, and comparisons of systems of care. The impetus for the current update stemmed from significant advances in the field and insights from registry development and regional comparisons. This 2024 update involved representatives of the International Liaison Committee on Resuscitation and used a modified Delphi process. Every 2015 Utstein data element was reviewed for relevance, priority (core or supplemental), and improvement. New variables were proposed and refined. All changes were voted on for inclusion. The 2015 domains-system, dispatch, patient, process, and outcomes-were retained. Further clarity is provided for the definitions of out-of-hospital cardiac arrest attended resuscitation and attempted resuscitation. Changes reflect advancements in dispatch, early response systems, and resuscitation care, as well as the importance of prehospital outcomes. Time intervals such as emergency medical service response time now emphasize precise reporting of the times used. New flowcharts aid the reporting of system effectiveness for patients with an attempted resuscitation and system efficacy for the Utstein comparator group. Recognizing the varying capacities of emergency systems globally, the writing group provided a minimal dataset for settings with developing emergency medical systems. Supplementary variables are considered useful for research purposes. These revisions aim to elevate data collection and reporting transparency by registries and researchers and to advance international comparisons and collaborations. The overarching objective remains the improvement of outcomes for patients with out-of-hospital cardiac arrest.

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.

Early Versus Late Advanced Airway Management for Pediatric Patients With Out-of-Hospital Cardiac Arrest

STUDY OBJECTIVE

To determine the association between early versus late advanced airway management and improved outcomes in pediatric out-of-hospital cardiac arrest.

METHODS

We performed a retrospective cohort study using data from the out-of-hospital cardiac arrest registry in Japan. We included pediatric patients (<18 years) with out-of-hospital cardiac arrest who had received advanced airway management (tracheal intubation, supraglottic airway, and esophageal obturator). The main exposure was early (≤20 minutes) versus late (>20 minutes) advanced airway management. The primary and secondary outcome measurements were survival and favorable neurologic outcomes at 1 month, respectively. To address resuscitation time bias, we performed risk-set matching analyses using time-dependent propensity scores.

RESULTS

Out of the 864 pediatric patients with both out-of-hospital cardiac arrest and advanced airway management over 67 months (2014 to 2019), we included 667 patients with adequate data (77%). Of these 667 patients, advanced airway management was early for 354 (53%) and late for 313 (47%) patients. In the risk-set matching analysis, the risk of both survival (risk ratio 0.98 for early versus late [95% confidence interval 0.95 to 1.02]) and favorable 1-month neurologic outcomes (risk ratio 0.99 [95% confidence interval 0.97 to 1.00]) was similar between early and late advanced airway management groups. In sensitivity analyses, with time to early advanced airway management defined as ≤10 minutes and ≤30 minutes, both outcomes were again similar.

CONCLUSION

In pediatric out-of-hospital cardiac arrest, the timing of advanced airway management may not affect patient outcomes, but randomized controlled trials are needed to address this question further.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Parental supporter during pediatric resuscitation: Qualitative exploration of caregivers' and healthcare professionals' experiences and perceptions

BACKGROUND

Child resuscitation is a critical and stressful time for family caregivers and healthcare professionals. The aim of this study was to explore caregivers' and healthcare professionals' experiences and perceptions of a parental supporter during pediatric cardiopulmonary resuscitation to provide guidance to healthcare professionals on supporting parents and other family caregivers during resuscitation.

METHODS

This study used an exploratory descriptive qualitative approach. The setting was two large referral pediatric governmental hospitals. Participants were 17 caregivers who had experienced their child's resuscitation, and 13 healthcare professionals who served on resuscitation teams in emergency rooms or intensive care wards. Semi-structured, in-depth interviews were conducted and data were analyzed using thematic analysis. COREQ guidelines were followed.

RESULTS

Participants shared their experiences and perceptions of a parental supporter during pediatric resuscitation in three themes: 1) Requirement for the presence of a parental supporter, 2) Expectations of the parental supporter, and 3) Characteristics of the parental supporter.

CONCLUSIONS

Study findings highlight the need for a parental supporter during pediatric resuscitation; however, there is no defined parental supporter role in current guiding policies due to limited research on this role. More research on the parental supporter role is needed so effective policies and protocols can be developed to enhance family-centered care practices in pediatric emergency and acute care settings.

Favourable neurological outcome following paediatric out-of-hospital cardiac arrest: a retrospective observational study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) in children is rare and can potentially result in severe neurological impairment. Our study aimed to identify characteristics of and factors associated with favourable neurological outcome following the resuscitation of children by the Swiss helicopter emergency medical service.

MATERIALS AND METHODS

This retrospective observational study screened the Swiss Air-Ambulance electronic database from 01-01-2011 to 31-12-2021. We included all primary missions for patients ≤ 16 years with OHCA. The primary outcome was favourable neurological outcome after 30 days (cerebral performance categories (CPC) 1 and 2). Multivariable linear regression identified potential factors associated with favourable outcome (odd ratio - OR).

RESULTS

Having screened 110,331 missions, we identified 296 children with OHCA, which we included in the analysis. Patients were 5.0 [1.0; 12.0] years old and 61.5% (n = 182) male. More than two-thirds had a non-traumatic OHCA (67.2%, n = 199), while 32.8% (n = 97) had a traumatic OHCA. Thirty days after the event, 24.0% (n = 71) of patients were alive, 18.9% (n = 56) with a favourable neurological outcome (CPC 1 n = 46, CPC 2 n = 10). Bystander cardiopulmonary resuscitation (OR 10.34; 95%CI 2.29-51.42; p = 0.002) and non-traumatic aetiology (OR 11.07 2.38-51.42; p = 0.002) were the factors most strongly associated with favourable outcome. Factors associated with an unfavourable neurological outcome were initial asystole (OR 0.12; 95%CI 0.04-0.39; p < 0.001), administration of adrenaline (OR 0.14; 95%CI 0.05-0.39; p < 0.001) and ongoing chest compression at HEMS arrival (OR 0.17; 95%CI 0.04-0.65; p = 0.010).

CONCLUSION

In this study, 18.9% of paediatric OHCA patients survived with a favourable neurologic outcome 30 days after treatment by the Swiss helicopter emergency medical service. Immediate bystander cardiopulmonary resuscitation and non-traumatic OHCA aetiology were the factors most strongly associated with a favourable neurological outcome. These results underline the importance of effective bystander and first-responder rescue as the foundation for subsequent professional treatment of children in cardiac arrest.

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.

Comparison of paediatric basic life support guidelines endorsed by member councils of Resuscitation Council of Asia

Background

Paediatric cardiac arrest outcomes, especially for infants, remain poor. Due to different training, resource differences, and historical reasons, paediatric cardiac arrest algorithms for various Asia countries vary. While there has been a common basic life support algorithm for adults by the Resuscitation Council of Asia (RCA), there is no common RCA algorithm for paediatric life support.We aimed to review published paediatric life support guidelines from different Asian resuscitation councils.

Methods

Pubmed and Google Scholar search were performed for published paediatric basic and advanced life support guidelines from January 2015 to June 2023. Paediatric representatives from the Resuscitation Council of Asia were sought and contacted to provide input from September 2022 till June 2023.

Results

While most of the components of published paediatric life support algorithms of Asian countries are similar, there are notable variations in terms of age criteria for recommended use of adult basic life support algorithms in the paediatric population less than 18 years old, recommended paediatric chest compression depth targets, ventilation rates post-advanced airway intra-arrest, and first defibrillation dose for shockable rhythms in paediatric cardiac arrest.

Conclusion

This was an overview and mapping of published Asian paediatric resuscitation algorithms. It highlights similarities across paediatric life support guidelines in Asian countries. There were some differences in components of paediatric life support which highlight important knowledge gaps in paediatric resuscitation science. The minor differences in the paediatric life support guidelines endorsed by the member councils may provide a framework for prioritising resuscitation research and highlight knowledge gaps in paediatric resuscitation.

Multicentric validation of a prognostic tool for predicting brain death following out-of-hospital cardiac arrest in children

AIM

Out-of-hospital cardiac arrest (OHCA) in pediatric patients is associated with high rates of mortality and neurologic injury, with no definitive evidence-based method to predict outcomes available. A prognostic scoring tool for adults, The Brain Death After Cardiac Arrest (BDCA) score, was recently developed and validated. We aimed to validate this score in pediatric patients.

METHODS

Retrospective cohort study of pediatric patients admitted to 5 PICUs after OHCA between 2011 and 2021. We extracted BDCA score elements for those who survived at least 24 hours but died as a result of their OHCA. We assessed score discrimination for the definitive outcome of brain death. Subgroup analysis was performed for infants < 12mo versus children ≥ 12mo, those who likely had brain death but had withdrawal of life sustaining therapy (WLST) prior to declaration, and by etiology and duration of arrest.

RESULTS

389 subjects were identified across 5 institutions, with 282 meeting inclusion criteria. 169 (59.9%) were formally declared brain dead; 58 (20.6%) had findings consistent with brain death but had withdrawal of life sustaining therapies prior to completion of formal declaration. Area under the receiver operating characteristic curve for the age ≥ 12mo cohort was 0.82 [95% CI 0.75, 0.90], which mirrored the adult subject AUCs of 0.82 [0.77, 0.86] and 0.81 [0.76, 0.86] in the development and validation cohorts. Scores demonstrated worse discrimination in the infant cohort (AUC = 0.61).

CONCLUSIONS

The BDCA score shows promise in children ≥ 12mo following OHCA and may be considered in conjunction with existing multimodal prognostication approaches.

Advanced airway management for pediatric out-of-hospital cardiac arrest: A systematic review and network meta-analysis

OBJECTIVES

Although airway management is important in pediatric resuscitation, the effectiveness of bag-mask ventilation (BMV) and advanced airway management (AAM), such as endotracheal intubation (ETI) and supraglottic airway (SGA) devices, for prehospital resuscitation of pediatric out-of-hospital cardiac arrest (OHCA) remains unclear. We aimed to determine the efficacy of AAM during prehospital resuscitation of pediatric OHCA cases.

METHODS

We searched four databases from their inception to November 2022 and included randomized controlled trials and observational studies with appropriate adjustments for confounders that evaluated prehospital AAM for OHCA in children aged <18 years in quantitative synthesis. We compared three interventions (BMV, ETI, and SGA) via network meta-analysis using the GRADE Working Group approach. The outcome measures were survival and favorable neurological outcomes at hospital discharge or 1 month after cardiac arrest.

RESULTS

Five studies (including one clinical trial and four cohort studies with rigorous confounding adjustment) involving 4852 patients were analyzed in our quantitative synthesis. Compared with ETI, BMV was associated with survival (relative risk [RR] 0.44 [95% confidence intervals (CI) 0.25-0.77]) (very low certainty). There were no significant association with survival in the other comparisons (SGA vs. BMV: RR 0.62 [95% CI 0.33-1.15] [low certainty], ETI vs. SGA: RR 0.71 [95% CI 0.39-1.32] [very low certainty]). There was no significant association with favorable neurological outcomes in any comparison (ETI vs. BMV: RR 0.33 [95% CI 0.11-1.02]; SGA vs. BMV: RR 0.50 [95% CI 0.14-1.80]; ETI vs. SGA: RR 0.66 [95% CI 0.18-2.46]) (all very low certainty). In the ranking analysis, the hierarches for efficacy for survival and favorable neurological outcome were BMV > SGA > ETI.

CONCLUSION

Although the available evidence is from observational studies and its certainty is low to very low, prehospital AAM for pediatric OHCA did not improve outcomes.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

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.

Effect of Intermediate Airway Management on Ventilation Parameters in Simulated Pediatric Out-of-Hospital Cardiac Arrest: Protocol for a Multicenter, Randomized, Crossover Trial

Most pediatric out-of-hospital cardiac arrests (OHCAs) are caused by hypoxia, which is generally consecutive to respiratory failure. To restore oxygenation, prehospital providers usually first use basic airway management techniques, i.e., bag-valve-mask (BVM) devices. These devices present several drawbacks, most of which could be avoided using supraglottic airway devices. These intermediate airway management (IAM) devices also present significant advantages over tracheal intubation: they are associated with higher success and lower complication rates in the prehospital setting. There are, however, few data regarding the effect of early IAM in pediatric OHCA. This paper details the protocol of a trial designed to evaluate the impact of this airway management strategy on ventilation parameters through a simulated, multicenter, randomized, crossover trial. The hypothesis underlying this study protocol is that early IAM without prior BVM ventilations could improve the ventilation parameters in comparison with the standard approach, which consists in BVM ventilations only.

Characteristics and Outcomes of Cardiac Arrest in Adult Patients Admitted to Pediatric Services: A Descriptive Analysis of the American Heart Association's Get With The Guidelines-Resuscitation Data

OBJECTIVES

Differences between adult and pediatric in-hospital cardiac arrest (IHCA) are well-described. Although most adults are cared for on adult services, pediatric services often admit adults, particularly those with chronic conditions. The objective of this study is to describe IHCA in adults admitted to pediatric services.

DESIGN

Retrospective cohort analysis from the American Heart Association's Get With The Guidelines-Resuscitation registry of a subpopulation of adults with IHCA while admitted to pediatric services. Multivariable logistic regression was used to evaluate adjusted survival outcomes and compare outcomes between age groups (18-21, 22-25, and ≥26 yr old).

SETTING

Hospitals contributing to the Get With The Guidelines-Resuscitation registry.

PATIENTS

Adult-aged patients (≥ 18 yr) with an index pulseless IHCA while admitted to a pediatric service from 2000 to 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 491 adult IHCAs were recorded on pediatric services at 17 sites, during the 19 years of review, and these events represented 0.1% of all adult IHCAs. In total, 221 cases met inclusion criteria with 139 events excluded due to an initial rhythm of bradycardia with poor perfusion. Median patient age was 22 years (interquartile range, 19-28 yr). Ninety-eight percent of patients had at least one pre-existing condition. Return of spontaneous circulation occurred in 63% of events and 30% of the patients survived to discharge. All age groups had similar rates of survival to discharge (range 26-37%; p = 0.37), and survival did not change over the study period (range 26-37%; p = 0.23 for adjusted survival to discharge).

CONCLUSIONS

In this cohort of adults with IHCA while admitted to a pediatric service, we failed to find an association between survival outcomes and age. Additional research is needed to better understand resuscitation in this population.

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.

Lay rescuer use of automated external defibrillators in infants, children and adolescents: A systematic review

Importance

Automated external defibrillator (AED) use is increasing, but use in children is uncommon. A growing literature of use in children by lay rescuers warrants review.

Objective

A systematic review of AED effectiveness in children experiencing out-of-hospital cardiac arrest (OHCA).

Data Sources

PubMed, EMBASE, Cochrane Register of Controlled Trials.

Study Selection

Children, ages 0-18, experiencing OHCA with an AED applied by a lay rescuer. Control population: children with no AED application.

Data Extraction and Synthesis

Results are reported according to PRISMA guidelines. Two authors independently reviewed all titles and abstracts of references identified by the search strategy, then generated a subset which all authors reviewed.

Main Outcomes and Measures

Critical outcomes were survival with Cerebral Performance Category (CPC) 1-2 at hospital discharge or 30 days and survival to hospital discharge.

Results

Population: age categories: <1 year, 1-12 years, 13-18 years. Lay rescuer AED application resulted in improved survival with CPC 1-2 at hospital discharge or 30 days to hospital discharge in age groups 1-12 and 13-18 years (RR 3.84 [95 % CI 2.69-5.5], RR 3.75 [95 %CI 2.97-4.72]), respectively and hospital discharge in both groups(RR 3.04 [95 % CI 2.18-4.25], RR 3.38 [95 % CI 2.17-4.16]), respectively. AED use with CPR improved CPC 1-2 at hospital discharge and hospital discharge (RR 1.49 [95 % CI 1.11-1.97], RR 1.55[1.12-2.12]).

Conclusions

AED application by lay rescuers is associated with improved survival with a CPC of 1-2 at 30 days, and improved survival to hospital discharge for children 1-18 years. There are limited data for children < 1 year.

Long-Term Outcomes after Non-Traumatic Out-of-Hospital Cardiac Arrest in Pediatric Patients: A Systematic Review

Long-term outcomes after non-traumatic pediatric out-of-hospital cardiac arrest (OHCA) are not well understood. This systematic review aimed to summarize long-term outcomes (1 year and beyond), including overall survival, survival with favorable neurological outcomes, and health-related quality of life (HRQoL) outcomes) amongst pediatric OHCA patients who survived to discharge. Embase, Medline, and The Cochrane Library were searched from inception to October 6, 2021. Studies were included if they reported outcomes at 1 year or beyond after pediatric OHCA. Data abstraction and quality assessment was conducted by three authors independently. Qualitative outcomes were reported systematically. Seven studies were included, and amongst patients that survived to hospital discharge or to 30 days, longer-term survival was at least 95% at 24 months of follow up. A highly variable proportion (range 10–71%) of patients had favorable neurological outcomes at 24 months of follow up. With regard to health-related quality of life outcomes, at a time point distal to 1 year, at least 60% of pediatric non-traumatic OHCA patients were reported to have good outcomes. Our study found that at least 95% of pediatric OHCA patients, who survived to discharge, survived to a time point distal to 1 year. There is a general paucity of data surrounding the pediatric OHCA population.

Parents' and healthcare professionals' experiences and perceptions of parental readiness for resuscitation in Iranian paediatric hospitals: a qualitative study

OBJECTIVE

The aim of this study was to examine parents' and healthcare professionals' experiences and perceptions of parental readiness for resuscitation of their child in a paediatric hospital.

DESIGN

This exploratory descriptive qualitative study used content analysis. Participants shared their experiences and perceptions about parental readiness for cardiopulmonary resuscitation through semi-structured and in-depth interviews. MAXQDA 2020 software was also used for data analysis.

SETTING

The setting was two large teaching paediatric hospitals in Iran (Este Azerbaijan and Mashhad).

PARTICIPANTS

Participants were 10 parents and 13 paediatric healthcare professionals (8 nurses and 5 physicians). Selection criteria were: (a) parents who experienced their child's resuscitation crisis at least 3 months prior and (b) nurses and physicians who were working in emergency rooms or intensive care wards with at least 2 years of experience on the resuscitation team.

RESULTS

Participants shared their experiences about parental readiness for resuscitation of their child in four categories: awareness (acceptance of resuscitation and its consequences; providing information about the child's current condition and prognosis), chaos in providing information (defect of responsibility in informing; provide selective protection of information; hardness in obtaining information), providing situational information (honest information on the border of hope and hopeless; providing information with apathy; providing information as individual; dualism in blaming; assurance to parents; presence of parents to better understand the child's situation) and psychological and spiritual requirements (reliance on supernatural power; need for access to a psychologist; sharing emotions; collecting mementos).

CONCLUSION

The results of this study provide insight on the needs of parents and strategies to use to prepare them for their child's resuscitation crisis, which can be used to enhance family centred care practices in paediatric acute care settings.

PRE-HOSPITAL AIRWAY MANAGEMENT AND SURVIVAL OUTCOMES AFTER PAEDIATRIC OUT-OF-HOSPITAL CARDIAC ARRESTS

BACKGROUND

Paediatric out-of-hospital cardiac arrest (OHCA) results in high mortality and poor neurological outcomes. We conducted this study to describe and compare the effects of pre-hospital airway management on survival outcomes for paediatric OHCA in the Asia-pacific region.

METHODS

We performed a retrospective analysis of the Pan Asian Resuscitation Outcomes Study (PAROS) data from January 2009 to June 2018. PAROS is a prospective, observational, multi-centre cohort study from eleven countries. The primary outcomes were one-month survival and survival with favourable neurological status, defined as Cerebral Performance Category1 or 2. We performed multivariate analyses of the unmatched and propensity matched cohort.

RESULTS

We included 3131 patients less than 18 years in the study. 2679 (85.6%) children received bag-valve-mask (BVM) ventilations, 81 (2.6%) endotracheal intubations (ETI) and 371 (11.8%) supraglottic airways (SGA). 792 patients underwent propensity score matching. In the matched cohort, advanced airway management (AAM: SGA and ETI) when compared with BVM group was associated with decreased one-month survival [AAM: 28/396 (7.1%) versus BVM: 55/396 (13.9%); adjusted odds ratio (aOR), 0.46 (95% CI, 0.29 - 0.75); p = 0.002] and survival with favourable neurological status [AAM: 8/396 (2.0%) versus BVM: 31/396 (7.8%); aOR, 0.22 (95% CI, 0.10 - 0.50); p < 0.001]. For SGA group, we observed less 1-month survival [SGA: 24/337 (7.1%) versus BVM: 52/337 (15.4%); aOR, 0.41 (95%CI, 0.25 - 0.69), p = 0.001] and survival with favourable neurological status.

CONCLUSION

In children with OHCA in the Asia-Pacific region, pre-hospital AAM was associated with decreased one-month survival and less favourable neurological status.

Global variation in the incidence and outcome of emergency medical services witnessed out-of-hospital cardiac arrest: A systematic review and meta-analysis

AIM OF THE REVIEW

To examine global variation in the incidence and outcomes of emergency medical services (EMS) witnessed out-of-hospital cardiac arrest (OHCA).

DATA SOURCES

We systematically reviewed four electronic databases for studies between 1990 and 5th April 2021 reporting EMS-witnessed OHCA populations. Studies were included if they reported sufficient data to calculate the primary outcome of survival to hospital discharge or 30-day survival. Random-effects models were used to pool incidence and survival outcomes, and meta-regression was used to examine sources of heterogeneity. Study quality was appraised using the Joanna Briggs Institute critical appraisal tools.

RESULTS

The search returned 1178 non-duplicate titles of which 66 articles comprising 133,981 EMS-witnessed patients treated by EMS across 33 countries were included. All but one study was observational and only 12 studies (18%) were deemed to be at low risk of bias. The pooled incidence of EMS-treated cases was 4.1 per 100,000 person-years (95% CI: 3.5, 4.7), varying almost 4-fold across continents. The pooled proportion of survivors to hospital discharge or 30-days was 20% overall (95% CI: 18%, 22%; I² = 98%), 43% (95% CI: 37%, 49%; I² = 94%) for initial shockable rhythms and 6% (95% CI: 5%, 8%; I² = 79%) for initial non-shockable rhythms. In the meta-regression analysis, only region and aetiology were significantly associated with survival. When compared to studies from North America, pooled survival was significantly higher in studies from Europe (14% vs. 26%; p = 0.04) and Australasia (14% vs. 31%, p < 0.001).

CONCLUSION

We identified significant global variation in the incidence and survival outcome of EMS-witnessed OHCA. Further research is needed to understand the factors contributing to these variations.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Evaluation of Local Pediatric Out-of-Hospital Cardiac Arrest and Emergency Services Response

Background

Survival after pediatric out-of-hospital cardiac arrest is poor. Paramedic services provide critical interventions that impact survival outcomes. We aimed to describe local pediatric out-of-hospital cardiac arrest (POHCA) events and evaluate the impact of the paramedic service response to POHCA.

Methods

The Canadian Resuscitation Outcomes Consortium and corresponding ambulance call records were used to evaluate deviations from best practice by paramedics for patients aged 1 day to <18 years who had an atraumatic out-of-hospital cardiac arrest between 2012 and 2020 in Middlesex-London County. Deviations were any departure from protocol as defined by Middlesex-London Paramedic Services.

Results

Fifty-one patients were included in this study. All POHCA events had at least one deviation, with a total of 188 deviations for the study cohort. Return of spontaneous circulation (ROSC) was achieved in 35.3% of patients and 5.8% survived to hospital discharge. All survivors developed a new, severe neurological impairment. Medication deviations were most common (n = 40, 21.3%) followed by process timing (n = 38, 20.2%), vascular access (n = 27, 14.4%), and airway (n = 27, 14.4%). A delay in vascular access was the most common deviation (n = 25, 49.0%). The median (IQR) time to epinephrine administration was 8.6 (5.90-10.95) min from paramedic arrival. Cardiac arrests occurring in public settings had more deviations than private settings (p = 0.04). ROSC was higher in events with a deviation in any circulation category (p = 0.03).

Conclusion

Patient and arrest characteristics were similar to other POHCA studies. This cohort exhibited high rates of ROSC and bystander cardiopulmonary resuscitation but low survival to hospital discharge. The study was underpowered for its primary outcome of survival. The total deviations scored was low relative to the total number of tasks in a resuscitation. Epinephrine was frequently administered outside of the recommended timeframe, highlighting an important quality improvement opportunity.

Can Video Assistance Improve the Quality of Pediatric Dispatcher-Assisted Cardiopulmonary Resuscitation?

OBJECTIVES

This study aimed to evaluate the impact of adding video conferencing to dispatcher-assisted telephone cardiopulmonary resuscitation (CPR) on pediatric bystander CPR quality.

METHODS

We conducted a prospective, randomized manikin study among volunteers with no CPR training and among bachelor nurses. Volunteers randomly received either video or audio assistance in a 6-minute pediatric cardiac arrest scenario. The main outcome measures were the results of the Cardiff Test to assess compression and ventilation performance.

RESULTS

Of 255 candidates assessed for eligibility, 120 subjects were randomly assigned to 1 of the 4 following groups: untrained telephone-guided (U-T; n = 30) or video-guided (U-V; n = 30) groups and trained telephone-guided (T-T; n = 30) or video-guided (T-V; n = 30) groups. Cardiac arrest was appropriately identified in 86.7% of the U-T group and in 100% in the other groups (P = 0.0061). Hand positioning was adequate in 76.7% of T-T, 80% of T-V, and 60% of U-V, as compared with 23.4% of the U-T group (P = 0.0001). Fewer volunteers managed to deliver 2 rescue breaths/cycle (P = 0.0001) in the U-T (16.7%) compared with the U-V (43.3%), the T-T (56.7%), and the T-V groups (60%).Subjects in the video groups had a lower fraction of minute to ventilate as compared with the telephone groups (P = 0.0005).

CONCLUSIONS

In dispatcher-instructed children CPR simulation, using video assistance improves cardiac arrest recognition and CPR quality with more appropriate chest compression technique and ventilation delivering. The long interruptions in chest compression combined with the mixed success rate to deliver proper ventilation raise question about ventilation quality and its effectiveness.

Two-Thumb Technique Is Superior to Two-Finger Technique in Cardiopulmonary Resuscitation of Simulated Out-of-Hospital Cardiac Arrest in Infants

Background

To compare the 2‐finger and 2‐thumb chest compression techniques on infant manikins in an out‐of‐hospital setting regarding efficiency of compressions, ventilation, and rescuer pain and fatigue.

Methods and Results

In a randomized crossover design, 78 medical students performed 2 minutes of cardiopulmonary resuscitation with mouth‐to‐nose ventilation at a 30:2 rate on a Resusci Baby QCPR infant manikin (Laerdal, Stavanger, Norway), using a barrier device and the 2‐finger and 2‐thumb compression techniques. Frequency and depth of chest compressions, proper hand position, complete chest recoil at each compression, hands‐off time, tidal volume, and number of ventilations were evaluated through manikin‐embedded SkillReporting software. After the interventions, standard Likert questionnaires and analog scales for pain and fatigue were applied. The variables were compared by a paired t‐test or Wilcoxon test as suitable. Seventy‐eight students participated in the study and performed 156 complete interventions. The 2‐thumb technique resulted in a greater depth of chest compressions (42 versus 39.7 mm; P<0.01), and a higher percentage of chest compressions with adequate depth (89.5% versus 77%; P<0.01). There were no differences in ventilatory parameters or hands‐off time between techniques. Pain and fatigue scores were higher for the 2‐finger technique (5.2 versus 1.8 and 3.8 versus 2.6, respectively; P<0.01).

Conclusions

In a simulation of out‐of‐hospital, single‐rescuer infant cardiopulmonary resuscitation, the 2‐thumb technique achieves better quality of chest compressions without interfering with ventilation and causes less rescuer pain and fatigue.

The rCAST score is useful for estimating the neurological prognosis in pediatric patients with post-cardiac arrest syndrome before ICU admission: External validation study using a nationwide prospective registry

INTRODUCTION

The objective of this cohort study was to investigate whether the revised post-Cardiac Arrest Syndrome for Therapeutic hypothermia score (rCAST), which we previously developed as a prognostic score for adult patients with post-cardiac arrest syndrome (PCAS), is also applicable to pediatric patients.

METHODS

Pediatric PCAS patients were included from an out-of-hospital cardiac arrest (OHCA) registry of the Japanese Association for Acute Medicine (JAAM). We validated the predictive accuracy of the rCAST for the neurological outcomes at 30 and 90 days. We also evaluated the probability of a good neurological outcome in each of the three specified severity categories based on the rCAST (low severity: ≤5.5; moderate severity: 6.0-14.0; high severity: ≥14.5).

RESULTS

Among the 737 pediatric patients with OHCA, the data of 179 pediatric PCAS patients in whom return of spontaneous circulation was achieved were analyzed. The areas under the curve (AUC) of the rCAST for predicting the neurological outcomes at 30 days and 90 days were 0.95 (95% CI: 0.90-0.99) and 0.96 (0.91-1.00), respectively. The proportions of patients with a good neurological outcome at 30 days were 100% (12/12) in the low severity group, 36.1% (13/36) in the moderate severity group, and 2.3% (3/131) in the high severity group.

CONCLUSIONS

The AUC of the rCAST for pediatric PCAS patients was found to be greater than 0.9 in the external validation, which corresponds to excellent predictive accuracy. There was no patient with good neurological outcome among the patients with more than 17.0 points (extremely high severity group).

Singapore Paediatric Resuscitation Guidelines 2021

We present the 2021 Singapore Paediatric Resuscitation Guidelines. The International Liaison Committee on Resuscitation's Pediatric Taskforce Consensus Statements on Science and Treatment Recommendations, which was published in October 2020, and the updated resuscitation guidelines from the American Heart Association and European Resuscitation Council, were reviewed and discussed by the committee. These recommendations were derived after deliberation of peer-reviewed evidence updates on paediatric resuscitation and took into consideration the local setting and clinical practice.

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.

Intraosseous or Peripheral IV Access in Pediatric Cardiac Arrest? Results From the French National Cardiac Arrest Registry

OBJECTIVES

Despite the evolving recommendations that favor the use of intraosseous access in pediatric resuscitation, the impact of vascular access type on survival in young children has not been demonstrated. The aim of this study was to assess the impact of the intravascular injection route on the return on spontaneous circulation, survival to hospital admission (0 day), and 30 days or survival to hospital discharge, by comparing survival rates in young children having intraosseous and peripheral IV access. The second aim was to compare the rates of favorable neurologic outcome after 30 days or survival to hospital discharge.

DESIGN

This was a multicenter retrospective comparative study between July 2011 and October 2018.

SETTING

Based on the French cardiac arrest registry data.

PATIENTS

All prepubescent (males < 12 yr old, females < 10 yr old) victims of an out-of-hospital cardiac arrest.

INTERVENTIONS

Patients with adrenaline administration by intraosseous versus peripheral venous technique were compared, using propensity score matching.

MEASUREMENTS AND MAIN RESULTS

The analysis included 603 prepubescent patients, 351 (58%) in the intraosseous group and 252 (42%) in the peripheral IV group. Intraosseous group patients were younger, lighter, with more medical cause for arrest. The intraosseous group had lower survival rates at 30 days or hospital discharge (n = 6; 1.7%) than the peripheral IV group (n = 12; 4.8%) (p = 0.030). After matching, 101 pairs of patients were created. No difference was observed on return of spontaneous circulation or 0-day survival rates (odds ratio = 1.000 [95% CI, 0.518-1.930]; odds ratio = 0.946 [95% CI, 0.492-1.817], respectively) and on 30 days or hospital discharge survival (n = 3 in both groups) (odds ratio = 1.000 [95% CI, 0.197-5.076]). Meaningful statistical evaluation of neurologic status among survivors was precluded by inadequate numbers.

CONCLUSIONS

The type of injection route (intraosseous or peripheral venous access) does not appear to have an impact on survival of out-of-hospital cardiac arrest in a prepubescent population, but limitations of propensity matching limit a definitive conclusion.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

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.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

2019 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

This 2019 focused update to the American Heart Association pediatric advanced life support guidelines follows the 2018 and 2019 systematic reviews performed by the Pediatric Life Support Task Force of the International Liaison Committee on Resuscitation. It aligns with the continuous evidence review process of the International Liaison Committee on Resuscitation, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update provides the evidence review and treatment recommendations for advanced airway management in pediatric cardiac arrest, extracorporeal cardiopulmonary resuscitation in pediatric cardiac arrest, and pediatric targeted temperature management during post-cardiac arrest care. The writing group analyzed the systematic reviews and the original research published for each of these topics. For airway management, the writing group concluded that it is reasonable to continue bag-mask ventilation (versus attempting an advanced airway such as endotracheal intubation) in patients with out-of-hospital cardiac arrest. When extracorporeal membrane oxygenation protocols and teams are readily available, extracorporeal cardiopulmonary resuscitation should be considered for patients with cardiac diagnoses and in-hospital cardiac arrest. Finally, it is reasonable to use targeted temperature management of 32°C to 34°C followed by 36°C to 37.5°C, or to use targeted temperature management of 36°C to 37.5°C, for pediatric patients who remain comatose after resuscitation from out-of-hospital cardiac arrest or in-hospital cardiac arrest.

What is known about the quality of out-of-hospital emergency medical services in the Arabian Gulf States? A systematic review

BACKGROUND

The Emergency Medical Services (EMS) have been developed in the Arabian Gulf States (AGS) in the last three decades. The EMS needs continuous quality assessment of their performance to improve and provide the best out-of-hospital care. This study aims to assess the quality of EMS in the AGS according to the six quality domains of the Institute of Medicine.

METHODS

We searched four databases (i.e., PubMed, EMBASE, Web of Science, and CINAHL) for studies that reported on the quality of EMS in any of the AGS using clinical or non-clinical performance indicators. To quantify study quality and risk of bias, the adapted Newcastle Ottawa Scale was used. We focused on structural and functional indicators, clinical and non-clinical.

RESULTS

Twenty-five studies were eligible for inclusion. One study contained result of safety, fifteen time-centeredness, twenty effectiveness, five patient-centeredness, and thirteen studies reported on equity of EMS. None of the studies reported on efficiency of EMS. A significant proportion of studies showed high scores on the Newcastle-Ottawa scale. Limited studies on EMS quality were available, not covering all relevant quality domains and not covering the whole AGS region. The equity domain showed the best outcome performance finding, whereas finding of the patient-centeredness domain showed room for improvement in the foreseeable future.

CONCLUSION

This review highlights the need for more and better studies of sufficient quality about all domains of quality in EMS in all the AGS. EMS research in Kuwait and Bahrain is warranted, as currently studies of EMS quality are unavailable for these States. Moreover, efficiency researches exploring this discipline should be conducted specially no studies were found has been searching this domain.

TRIAL REGISTRATION

PROSPERO registration number: CRD42019123896.

2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.

2019 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

This 2019 focused update to the American Heart Association pediatric advanced life support guidelines follows the 2018 and 2019 systematic reviews performed by the Pediatric Life Support Task Force of the International Liaison Committee on Resuscitation. It aligns with the continuous evidence review process of the International Liaison Committee on Resuscitation, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update provides the evidence review and treatment recommendations for advanced airway management in pediatric cardiac arrest, extracorporeal cardiopulmonary resuscitation in pediatric cardiac arrest, and pediatric targeted temperature management during post-cardiac arrest care. The writing group analyzed the systematic reviews and the original research published for each of these topics. For airway management, the writing group concluded that it is reasonable to continue bag-mask ventilation (versus attempting an advanced airway such as endotracheal intubation) in patients with out-of-hospital cardiac arrest. When extracorporeal membrane oxygenation protocols and teams are readily available, extracorporeal cardiopulmonary resuscitation should be considered for patients with cardiac diagnoses and in-hospital cardiac arrest. Finally, it is reasonable to use targeted temperature management of 32°C to 34°C followed by 36°C to 37.5°C, or to use targeted temperature management of 36°C to 37.5°C, for pediatric patients who remain comatose after resuscitation from out-of-hospital cardiac arrest or in-hospital cardiac arrest.

Advanced airway interventions for paediatric cardiac arrest: A systematic review and meta-analysis

AIM

To assess the use of advanced airway interventions (tracheal intubation (TI) or supraglottic airway (SGA) placement), compared with bag mask ventilation (BMV) alone, for resuscitation of children in cardiac arrest.

METHODS

We searched Medline, EMBASE, and Cochrane Controlled Register of Trials (CENTRAL) for human trials and observational studies published before September 24, 2018 for clinical trials and observational studies with a comparison group. Two investigators reviewed studies for relevance, extracted data, and assessed risk of bias using the GRADE and CLARITY frameworks. Study authors were contacted when necessary to obtain additional data. Critically important outcomes included survival to hospital discharge and survival with good neurological outcome.

RESULTS

We identified 14 studies, including 1 pseudorandomised clinical trial, 3 observational cohort studies using propensity matching, and 8 simple cohort studies suitable for meta-analysis. The overall certainty of evidence was low to very low. For the critically important outcomes of survival to hospital discharge with good neurologic outcome and survival to hospital discharge results suggested better outcomes achieved with BMV than either TI or SGA; limited data favored SGA over TI. The majority of studies involved out-of-hospital cardiac arrest, with few studies of in-hospital cardiac arrest.

CONCLUSIONS

TI or SGA are not superior to BMV for resuscitation of children in cardiac arrest, but the overall certainty of evidence is low to very low. Well designed randomised efficacy trials are needed to address this important question.

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.