Early On-Scene Management of Pediatric Out-of-Hospital Cardiac Arrest Can Result in Improved Likelihood for Neurologically-Intact Survival

Survival After Intra-Arrest Transport vs On-Scene Cardiopulmonary Resuscitation in Children

Importance

For pediatric out-of-hospital cardiac arrest (OHCA), emergency medical services (EMS) may elect to transport to the hospital during active cardiopulmonary resuscitation (CPR) (ie, intra-arrest transport) or to continue on-scene CPR for the entirety of the resuscitative effort. The comparative effectiveness of these strategies is unclear.

Objective

To evaluate the association between intra-arrest transport compared with continued on-scene CPR and survival after pediatric OHCA, and to determine whether this association differs based on the timing of intra-arrest transport.

Design, Setting, and Participants

This cohort study included pediatric patients aged younger than 18 years with EMS-treated OHCA between December 1, 2005 and June 30, 2015. Data were collected from the Resuscitation Outcomes Consortium Epidemiologic Registry, a prospective 10-site OHCA registry in the US and Canada. Data analysis was performed from May 2022 to February 2024.

Exposures

Intra-arrest transport, defined as an initiation of transport prior to the return of spontaneous circulation, and the interval between EMS arrival and intra-arrest transport.

Main Outcomes and Measures

The primary outcome was survival to hospital discharge. Patients who underwent intra-arrest transport at any given minute after EMS arrival were compared with patients who were at risk of undergoing intra-arrest transport within the same minute using time-dependent propensity scores calculated from patient demographics, arrest characteristics, and EMS interventions. We examined subgroups based on age (<1 year vs ≥1 year).

Results

Of 2854 eligible pediatric patients (median [IQR] age, 1 [0-9] years); 1691 males [59.3%]) who experienced OHCA between December 2005 and June 2015, 1892 children (66.3%) were treated with intra-arrest transport and 962 children (33.7%) received continued on-scene CPR. The median (IQR) time between EMS arrival and intra-arrest transport was 15 (9-22) minutes. In the propensity score-matched cohort (3680 matched cases), there was no significant difference in survival to hospital discharge between the intra-arrest transport group and the continued on-scene CPR group (87 of 1840 patients [4.7%] vs 95 of 1840 patients [5.2%]; risk ratio [RR], 0.81 [95% CI, 0.59-1.10]). Survival to hospital discharge was not modified by the timing of intra-arrest transport (P value for the interaction between intra-arrest transport and time to matching = .10). Among patients aged younger than 1 year, intra-arrest transport was associated with lower survival to hospital discharge (RR, 0.52; 95% CI, 0.33-0.83) but there was no association for children aged 1 year or older (RR, 1.22; 95% CI, 0.77-1.93).

Conclusions and Relevance

In this cohort study of a North American OHCA registry, intra-arrest transport compared with continued on-scene CPR was not associated with survival to hospital discharge among children with OHCA. However, intra-arrest transport was associated with a lower likelihood of survival to hospital discharge among children aged younger than 1 year.

Trends in community response and long-term outcomes from pediatric cardiac arrest: A retrospective observational study

AIM

This study aimed to investigate trends over time in pre-hospital factors for pediatric out-of-hospital cardiac arrest (pOHCA) and long-term neurological and neuropsychological outcomes. These have not been described before in large populations.

METHODS

Non-traumatic arrest patients, 1 day-17 years old, presented to the Sophia Children's Hospital from January 2002 to December 2020, were eligible for inclusion. Favorable neurological outcome was defined as Pediatric Cerebral Performance Categories (PCPC) 1-2 or no difference with pre-arrest baseline. The trend over time was tested with multivariable logistic and linear regression models with year of event as independent variable.

FINDINGS

Over a nineteen-year study period, the annual rate of long-term favorable neurological outcome, assessed at a median 2.5 years follow-up, increased significantly (OR 1.10, 95%-CI 1.03-1.19), adjusted for confounders. Concurrently, annual automated external defibrillator (AED) use and, among adolescents, initial shockable rhythm increased significantly (OR 1.21, 95% CI 1.10-1.33 and OR 1.15, 95% CI 1.02-1.29, respectively), adjusted for confounders. For generalizability purposes, only the total intelligence quotient (IQ) was considered for trend analysis of all tested domains. Total IQ scores and bystander basic life support (BLS) rate did not change significantly over time.

INTERPRETATION

Long-term favorable neurological outcome, assessed at a median 2.5 years follow-up, improved significantly over the study period. Total IQ scores did not significantly change over time. Furthermore, AED use (OR 1.21, 95%CI 1.10-1.33) and shockable rhythms among adolescents (OR1.15, 95%CI 1.02-1.29) increased over time.

Prehospital Resuscitation: What Should It Be?

Prehospital resuscitation is a dynamic field now being energized by new technologies and a shift in thinking regarding intravascular resuscitation. Growing evidence discourages use of intravenous (IV) crystalloid and colloid solutions in trauma, whereas blood products, particularly whole blood, are becoming preferred. Although randomized clinical trials validating definitive resuscitative protocols are still lacking, most preclinical and clinical indicators support this approach. In addition, emerging technologies such as external and endovascular hemorrhage control devices and extracorporeal perfusion are now being used routinely, even in the prehospital setting in many countries, generating new lines of emerging investigations for trauma specialists.

Changes in pre- and in-hospital management and outcomes among children with out-of-hospital cardiac arrest between 2012 and 2017 in Kanto, Japan

Previously, the SOS-KANTO 2012 studies, conducted in the Kanto area of Japan, reported a summary of outcomes in patients with out-of-hospital cardiac arrest (OHCA). This sub-analysis of the SOS-KANTO study 2017 aimed to evaluate the neurological outcomes of paediatric OHCA patients, by comparing the SOS-KANTO 2012 and 2017 studies. All OHCA patients, aged < 18 years, who were transported to the participating hospitals by EMS personnel were included in both SOS-KANTO studies (2012 and 2017). The number of survival patients with favourable neurological outcomes (paediatric cerebral performance category 1 or 2) at 1 month did not improve between 2012 and 2017. There was no significant difference in achievement of pre-hospital return of spontaneous circulation (ROSC) [odds ratio (OR): 2.00, 95% confidence interval (95% CI): 0.50-7.99, p = 0.50] and favourable outcome at 1 month [OR: 0.67, 95% CI: 0.11-3.99, p = 1] between the two studies, matched by age, witnessed arrest, bystander CPR, aetiology of OHCA, and time from call to EMS arrival. Multivariable logistic regression showed no significant difference in the achievement of pre-hospital ROSC and favourable outcomes at 1 month between the two studies.

Prehospital transport and termination of resuscitation of cardiac arrest patients: A review of prehospital care protocols in the United States

Background

The objective was to describe emergency medical services (EMS) protocol variability in transport expectations for out-of-hospital cardiac arrest (OHCA) patients and the involvement of online medical control for on-scene termination of resuscitation in the United States. Whether other aspects of OHCA care were mentioned, including the definition of a "pediatric" patient, and use of end-tidal carbon dioxide monitoring, mechanical chest compression devices (MCCDs), and extracorporeal membrane oxygenation (ECMO), were also described.

Methods and Results

Review of EMS protocols publicly accessible from https://www.emsprotocols.org and through searches on the internet when protocols were unavailable on the website from June 2021 to January 2022. Frequencies and proportions were used to describe outcomes. Of 104 protocols reviewed, 51.9% state to initiate transport after return of spontaneous circulation (ROSC), 26.0% do not specify when to initiate transport, and 6.7% state to transport after ≥20 minutes of on-scene cardiopulmonary resuscitation for adults. For pediatric patients, 38.5% of protocols do not specify when to initiate transport, 32.7% state to transport after ROSC, and 10.6% state to transport as soon as possible. Most protocols (42.3%) did not specify the age that defines "pediatric" in cardiac arrest. More than half (51.9%) of the protocols require online medical control for termination of resuscitation. Most protocols mention the use of end-tidal carbon dioxide monitoring (81.7%), 50.0% mention the use of MCCDs, and 4.8% mention ECMO for cardiac arrest.

Conclusions

In the United States, EMS protocols for initiation of transport and termination of resuscitation for OHCA patients are highly variable.

Association of Prehospital Physician Presence During Pediatric Out-of-Hospital Cardiac Arrest With Neurologic Outcomes

OBJECTIVES

To examine the association of prehospital physician presence with neurologic outcomes of pediatric patients with out-of-hospital cardiac arrest (OHCA).

DESIGN

Retrospective cohort study.

SETTING

Data from the Japanese Association for Acute Medicine-OHCA Registry.

INTERVENTIONS

None.

PATIENTS

Pediatric patients (age 17 yr old or younger) registered in the database between June 2014 and December 2019.

MEASUREMENT AND MAIN RESULTS

We used logistic regression models with stabilized inverse probability of treatment weighting (IPTW) to estimate the associated treatment effect of a prehospital physician with 1-month neurologically intact survival. Secondary outcomes included in-hospital return of spontaneous circulation (ROSC) and 1-month survival after OHCA. A total of 1,187 patients (276 in the physician presence group and 911 in the physician absence group) were included (median age 3 yr [interquartile range 0-14 yr]; 723 [61%] male). Comparison of the physician presence group, versus the physician absence, showed 1-month favorable neurologic outcomes of 8.3% (23/276) versus 3.6% (33/911). Physician presence was associated with greater odds of 1-month neurologically intact survival after stabilized IPTW adjustment (adjusted odds ratio [aOR] 1.98, 95% CI 1.08-3.66). We also found an association in the secondary outcome between physician presence, opposed to absence, and in-hospital ROSC (aOR 1.48, 95% CI 1.08-2.04). However, we failed to identify an association with 1-month survival (aOR 1.49, 95% CI 0.97-2.88).

CONCLUSIONS

Among pediatric patients with OHCA, prehospital physician presence, compared with absence, was associated almost two-fold greater odds of 1-month favorable neurologic outcomes.

Evaluation of optimal scene time interval for out-of-hospital cardiac arrest using a deep neural network

AIM

This study aims to develop a cardiac arrest prediction model using deep learning (CAPD) algorithm and to validate the developed algorithm by evaluating the change in out-of-hospital cardiac arrest patient prognosis according to the increase in scene time interval (STI).

METHODS

We conducted a retrospective cohort study using smart advanced life support trial data collected by the National Emergency Center from January 2016 to December 2019. The smart advanced life support data were randomly partitioned into derivation and validation datasets. The performance of the CAPD model using the patient's age, sex, event witness, bystander cardiopulmonary resuscitation (CPR), administration of epinephrine, initial shockable rhythm, prehospital defibrillation, provision of advanced life support, response time interval, and STI as prediction variables for prediction of a patient's prognosis was compared with conventional machine learning methods. After fixing other values of the input data, the changes in prognosis of the patient with respect to the increase in STI was observed.

RESULTS

A total of 16,992 patients were included in this study. The area under the receiver operating characteristic curve values for predicting prehospital return of spontaneous circulation (ROSC) and favorable neurological outcomes were 0.828 (95% confidence interval 0.826-0.830) and 0.907 (0.914-0.910), respectively. Our algorithm significantly outperformed other artificial intelligence algorithms and conventional methods. The neurological recovery rate was predicted to decrease to 1/3 of that at the beginning of cardiopulmonary resuscitation when the STI was 28 min, and the prehospital ROSC was predicted to decrease to 1/2 of its initial level when the STI was 30 min.

CONCLUSION

The CAPD exhibits potential and effectiveness in identifying patients with ROSC and favorable neurological outcomes for prehospital resuscitation.

Identification of factors associated with return of spontaneous circulation after pediatric out-of-hospital cardiac arrest using natural language processing

Introduction: Prior studies examining prehospital characteristics related to return of spontaneous circulation (ROSC) in pediatric out-of-hospital cardiac arrest (OHCA) are limited to structured data. Natural language processing (NLP) could identify new factors from unstructured data using free-text narratives. The purpose of this study was to use NLP to examine EMS clinician free-text narratives for characteristics associated with prehospital ROSC in pediatric OHCA.Methods: This was a retrospective analysis of patients ages 0-17 with OHCA in 2019 from the ESO Data Collaborative. We performed an exploratory analysis of EMS narratives using NLP with an a priori token library. We then constructed biostatistical and machine learning models and compared their performance in predicting ROSC.Results: There were 1,726 included EMS encounters for pediatric OHCA; 60% were male patients, and the median age was 1 year (IQR 0-9). Most cardiac arrest events (61.3%) were unwitnessed, 87.3% were identified as having medical causes, and 5.9% had initial shockable rhythms. Prehospital ROSC was achieved in 23.1%. Words most positively correlated with ROSC were "ROSC" (r = 0.42), "pulse" (r = 0.29), "drowning" (r = 0.13), and "PEA" (r = 0.12). Words negatively correlated with ROSC included "asystole" (r = -0.25), "lividity" (r = -0.14), and "cold" (r = -0.14). The terms 'asystole,' 'pulse', 'no breathing', 'PEA', and 'dry' had the greatest difference in frequency of appearance between encounters with and without ROSC (p < 0.05). The best-performing model for predicting prehospital ROSC was logistic regression with random oversampling using free-text data only (area under the receiver operating characteristic curve 0.92).Conclusions: EMS clinician free-text narratives reveal additional characteristics associated with prehospital ROSC in pediatric OHCA. Incorporating those terms into machine learning models of prehospital ROSC improves predictive ability. Therefore, NLP holds promise as a tool for use in predictive models with the goal to increase evidence-based management of pediatric OHCA.

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.

Applying a set of termination of resuscitation criteria to paediatric out-of-hospital cardiac arrest

OBJECTIVE

Prehospital Termination of Resuscitation (TOR) protocols for adults can reduce the number of futile transports of patients in cardiac arrest, yet similar protocols are not widely available for paediatric out-of-hospital cardiac arrest (POHCA). The objective of this study was to apply a set of criteria for paediatric TOR (pTOR) from the Maryland Institute for Emergency Medical Services Systems (MIEMSS) to a large national cohort and determine its association with return of spontaneous circulation (ROSC) after POHCA.

METHODS

We identified patients ages 0-17 treated by Emergency Medical Services (EMS) with cardiac arrest in 2019 from the ESO dataset and and applied the applicable pTOR certeria for medical or traumatic arrests. We calculated predictive test characteristics for the outcome of prehospital ROSC, stratified by medical and traumatic cause of arrest.

RESULTS

We analyzed records for 1595 POHCA patients. Eighty-eight percent (n = 1395) were classified as medical. ROSC rates were 23% among medical POHCA and 27% among traumatic POHCA. The medical criteria correctly classified >99% (322/323) of patients who achieved ROSC as ineligible for TOR. The trauma criteria correctly classified 93% (50/54) of patients with ROSC as ineligible for TOR. Of the five misclassified patients, three were involved in drowning incidents.

CONCLUSIONS

The Maryland pTOR criteria identified eligible patients who did not achieve prehospital ROSC, while reliably excluding those who did achieve prehospital ROSC. As most misclassified patients were victims of drowning, we recommend considering the exclusion of drowning patients from future pTOR guidelines. Further studies are needed to evaluate the long-term survival and neurologic outcome of patients misclassified by pTOR criteria.

The association of intraosseous vascular access and survival among pediatric patients with out-of-hospital cardiac arrest

INTRODUCTION

In pediatric out-of-hospital cardiac arrest (OHCA) the effect of intraosseous (IO) or intravenous (IV) access on outcomes is unclear.

METHODS

We analyzed prospectively collected data of non-traumatic OHCA in the Resuscitation Outcomes Consortium registry from 2011 to 2015. We included EMS-treated patients ≤17 years of age, classified patients based on vascular access routes, and calculated success rates of IO and IV attempts. After excluding patients with obvious non-cardiac etiologies and those with unsuccessful vascular access or multiple routes, we fit a logistic regression model to evaluate the association of IO vascular access (reference IV access) with the primary outcome of survival, using multiple imputation to address missing data. We analyzed a subgroup of patients at least 2 years of age.

RESULTS

There were 1549 non-traumatic OHCA: 895 (57.8%) patients had an IO line attempted with 822 (91.8%) successful; 488 (31.5%) had an IV line attempted with 345 (70.7%) successful (difference 21%, 95% CI 17 to 26%). Of the 761 patients included in our logistic regression, 601 received IO (30 [5.2%] survived) and 160 received IV (40 [25%] survived) vascular access. Intraosseous access was associated with a decreased probability of survival (adjusted OR 0.46; 95% CI 0.21-0.98). Patients at least 2 years of age showed a similar association (adjusted OR 0.36; CI 0.15-0.86).

CONCLUSIONS

Intraosseous access was associated with decreased survival among pediatric non-traumatic OHCA. These results are exploratory and support the need for further study to evaluate the effect of intravascular access method on outcomes.

Association between shockable rhythms and long-term outcome after pediatric out-of-hospital cardiac arrest in Rotterdam, the Netherlands: An 18-year observational study

INTRODUCTION

Shockable rhythm following pediatric out-of-hospital cardiac arrest (pOHCA) is consistently associated with hospital and short-term survival. Little is known about the relationship between shockable rhythm and long-term outcomes (>1 year) after pOHCA. The aim was to investigate the association between first documented rhythm and long-term outcomes in a pOHCA cohort over 18 years.

METHODS

All children aged 1 day-18 years who experienced non-traumatic pOHCA between 2002-2019 and were subsequently admitted to the emergency department (ED) or pediatric intensive care unit (PICU) of Erasmus MC-Sophia Children's Hospital were included. Data was abstracted retrospectively from patient files, (ground) ambulance and Helicopter Emergency Medical Service (HEMS) records, and follow-up clinics. Long-term outcome was determined using a Pediatric Cerebral Performance Category (PCPC) score at the longest available follow-up interval through august 2020. The primary outcome measure was survival with favorable neurologic outcome, defined as PCPC 1-2 or no difference between pre- and post-arrest PCPC. The association between first documented rhythm and the primary outcome was calculated in a multivariable regression model.

RESULTS

369 children were admitted, nine children were lost to follow-up. Median age at arrest was age 3.4 (IQR 0.8-9.9) years, 63% were male and 14% had a shockable rhythm (66% non-shockable, 20% unknown or return of spontaneous circulation (ROSC) before emergency medical service (EMS) arrival). In adolescents (aged 12-18 years), 39% had shockable rhythm. 142 (39%) of children survived to hospital discharge. On median follow-up interval of 25 months (IQR 5.1-49.6), 115/142 (81%) of hospital survivors had favorable neurologic outcome. In multivariable analysis, shockable rhythm was associated with survival with favorable long-term neurologic outcome (OR 8.9 [95%CI 3.1-25.9]).

CONCLUSION

In children with pOHCA admitted to ED or PICU shockable rhythm had significantly higher odds of survival with long-term favorable neurologic outcome compared to non-shockable rhythm. Survival to hospital discharge after pOHCA was 39% over the 18-year study period. Of survivors to discharge, 81% had favorable long-term (median 25 months, IQR 5.1-49.6) neurologic outcome. Efforts for improving outcome of pOHCA should focus on early recognition and treatment of shockable pOHCA at scene.

Experience of using video support by prehospital emergency care physician in ambulance care - an interview study with prehospital emergency nurses in Sweden

Introduction

When in need of emergency care and ambulance services, the ambulance nurse is often the first point of contact for the patient with healthcare. This role requires comprehensive knowledge of the ambulance nurse to be able to assign the right level of care and, if necessary, to provide self-care advice for patients with no further conveyance to hospital. Recently, an application was developed for transmitting real-time video to facilitate consultation between ambulance nurses and prehospital physicians in the role of regional medical support (RMS) for ambulance care. The use of video communication as a complement of medical support when referring to self-care is still an unexplored method in a prehospital setting.

Our study aimed to elucidate ambulance nurses’ experience of video consultation with RMS physician during the assessment of patients considered to be triaged to self-care.

Method

We conducted a qualitative design study using semi-structured interviews with open questions. Twelve ambulance nurses were included in the study. To explore the ambulance nurses’ experience of performing video consultation with RMS physician, in cases when a patient was assessed and triaged to self-care, a content analysis was performed.

Results

A main category emerged from the results: “ Video consultation as decision support in the ambulance care promotes increased patient participation and for the ambulance nurses, it creates a feeling of increased patient safety “. The main category was based and formed on the following categories: “ Simultaneous presence of ambulance nurse and a physician increases patient participation during the assessment resulting in a confident care decision “. “Interprofessional collaboration strengthens the medical assessment”. “Video technology promotes accessibility for patients needs in the ambulance care regardless of emergency level”.

Conclusions

Ambulance nurses experienced that the use of video consultation increases patient involvement and confidence in healthcare when both the ambulance nurse and the physician were present when deciding on self-care advice. The live imaging allowed the ambulance nurse and prehospital physician to reach a consensus on the patient’s current medical care needs, which in turn led to a feeling of increased patient safety for the ambulance nurses.

The relationship of large city out-of-hospital cardiac arrests and the prevalence of COVID-19

BACKGROUND

Though variable, many major metropolitan cities reported profound and unprecedented increases in out-of-hospital cardiac arrest (OHCA) in early 2020. This study examined the relative magnitude of those increases and their relationship to COVID-19 prevalence.

METHODS

EMS (9-1-1 system) medical directors for 50 of the largest U.S. cities agreed to provide the aggregate, de-identified, pre-existing monthly tallies of OHCA among adults (age >18 years) occurring between January and June 2020 within their respective jurisdictions. Identical comparison data were also provided for corresponding time periods in 2018 and 2019.  Equivalent data were obtained from the largest cities in Italy, United Kingdom and France, as well as Perth, Australia and Auckland, New Zealand.

FINDINGS

Significant OHCA escalations generally paralleled local prevalence of COVID-19. During April, most U.S. cities (34/50) had >20% increases in OHCA versus 2018-2019 which reflected high local COVID-19 prevalence. Thirteen observed 1·5-fold increases in OHCA and three COVID-19 epicenters had >100% increases (2·5-fold in New York City). Conversely, cities with lesser COVID-19 impact observed unchanged (or even diminished) OHCA numbers. Altogether (n = 50), on average, OHCA cases/city rose 59% during April (p = 0·03). By June, however, after mitigating COVID-19 spread, cities with the highest OHCA escalations returned to (or approached) pre-COVID OHCA numbers while cities minimally affected by COVID-19 during April (and not experiencing OHCA increases), then had marked OHCA escalations when COVID-19 began to surge locally. European, Australian, and New Zealand cities mirrored the U.S. experience.

INTERPRETATION

Most metropolitan cities experienced profound escalations of OHCA generally paralleling local prevalence of COVID-19.  Most of these patients were pronounced dead without COVID-19 testing.

FUNDING

No funding was involved. Cities provided de-identified aggregate data collected routinely for standard quality assurance functions.

Every one-minute delay in EMS on-scene resuscitation after out-of-hospital pediatric cardiac arrest lowers ROSC by 5

Objective

To determine which aspects of prehospital care impact outcomes after pediatric cardiac arrest.

Methods

In this study, the authors examine 5 years of consecutive data from their county emergency medical system (EMS), to identify predictors of good outcome after pediatric cardiac arrest, including return of spontaneous circulation (ROSC), survival to hospital admission (HA) and survival to hospital discharge (HD). Three logistic regression models were performed using JMP 14.1 Pro for Windows, each with the following nine predictors: age, sex, ventilation method (endotracheal intubation vs. supraglottic airway), initial rhythm (pulseless electrical activity vs. asystole), epinephrine administration, bystander treatment prior to EMS arrival, time from collapse to EMS arrival, automatic external defibrillator (AED) placement, and whether the arrest was witnessed. Odds ratio confidence intervals were calculated using the Wald method, and corresponding p-values were obtained with the likelihood ratio χ² test.

Results

From January 1, 2012 to December 31, 2016, there were 133 pediatric cardiac arrests, of which we had complete data on 109 patients for pediatric cardiac arrest. The median age was 8 months, with an IQR of 2.25–24 months, and a range of 0–108 months (0–9 years). There was return of spontaneous circulation (ROSC) in 20% of cases overall, with 16% making it to hospital admission, and 9% making it alive out of the hospital.

The median time to EMS arrival for witnessed events was 10 min, with an interquartile range (IQR) of 6.5−16 min, and a range of 0−25 min. The median time to EMS arrival for unwitnessed events was 30 min, with an IQR of 19–62.5 min, and a range of 9−490 min.

Predictors of ROSC included epinephrine administration (p = .00007), bystander treatment before EMS arrival (p = .0018), older age (p = .0025), shorter time to EMS arrival (p = .0048), and AED placement. Predictors of hospital admission included epinephrine NOT being administered (p = .0004), bystander treatment before EMS arrival (p = .0088), shorter time to EMS arrival (p = .0141), and AED placement (p = .0062). The only significant predictor of survival to hospital discharge alive that was identified was shorter time to EMS arrival (p = .0014), as there was insufficient data for many of the predictor variables in this analysis.

Conclusion

Shorter time to EMS arrival from time of arrest, any bystander treatment prior to EMS arrival, and AED placement resulted in significantly higher rates of return of spontaneous circulation. Epinephrine administration significantly improved ROSC, but had the opposite effect on HA. Only shorter time to EMS arrival from time of arrest was significantly associated with survival to hospital discharge. Each additional minute for the EMS to arrive resulted in 5% decreased odds of ROSC and hospital admission, and 12% decreased odds of surviving to hospital discharge.

Cardiac arrest: An interdisciplinary scoping review of the literature from 2019

Objectives

The Interdisciplinary Cardiac Arrest Research Review (ICARE) group was formed in 2018 to conduct a systematic annual search of peer-reviewed literature relevant to cardiac arrest. Now in its second year, the goals of the review are to illustrate best practices in research and help reduce compartmentalization of knowledge by disseminating clinically relevant advances in the field of cardiac arrest across disciplines.

Methods

An electronic search of PubMed using keywords related to cardiac arrest was conducted. Title and abstracts retrieved by these searches were screened for relevance, classified by article type (original research or review), and sorted into 7 categories. Screened manuscripts underwent standardized scoring of overall methodological quality and impact on the categorized fields of study by reviewer teams lead by a subject-matter expert editor. Articles scoring higher than 99 percentiles by category-type were selected for full critique. Systematic differences between editors’ and reviewers’ scores were assessed using Wilcoxon signed-rank test.

Results

A total of 3348 articles were identified on initial search; of these, 1364 were scored after screening for relevance and deduplication, and forty-five underwent full critique. Epidemiology & Public Health represented 24% of fully reviewed articles with Prehospital Resuscitation, Technology & Care, and In-Hospital Resuscitation & Post-Arrest Care Categories both representing 20% of fully reviewed articles. There were no significant differences between editor and reviewer scoring.

Conclusions

The sheer number of articles screened is a testament to the need for an accessible source calling attention to high-quality and impactful research and serving as a high-yield reference for clinicians and scientists seeking to follow the ever-growing body of cardiac arrest-related literature. This will promote further development of the unique and interdisciplinary field of cardiac arrest medicine.

Rationale and Strategies for Development of an Optimal Bundle of Management for Cardiac Arrest

Objectives

To construct a highly detailed yet practical, attainable roadmap for enhancing the likelihood of neurologically intact survival following sudden cardiac arrest.

Design Setting and Patients

Population-based outcomes following out-of-hospital cardiac arrest were collated for 10 U.S. counties in Alaska, California, Florida, Ohio, Minnesota, Utah, and Washington. The 10 identified emergency medical services systems were those that had recently reported significant improvements in neurologically intact survival after introducing a more comprehensive approach involving citizens, hospitals, and evolving strategies for incorporating technology-based, highly choreographed care and training. Detailed inventories of in-common elements were collated from the ten 9-1-1 agencies and assimilated. For reference, combined averaged outcomes for out-of-hospital cardiac arrest occurring January 1, 2017, to February 28, 2018, were compared with concurrent U.S. outcomes reported by the well-established Cardiac Arrest Registry to Enhance Survival.

Interventions

Most commonly, interventions and components from the ten 9-1-1 systems consistently included extensive public cardiopulmonary resuscitation training, 9-1-1 system-connected smart phone applications, expedited dispatcher procedures, cardiopulmonary resuscitation quality monitoring, mechanical cardiopulmonary resuscitation, devices for enhancing negative intrathoracic pressure regulation, extracorporeal membrane oxygenation protocols, body temperature management procedures, rapid cardiac angiography, and intensive involvement of medical directors, operational and quality assurance officers, and training staff.

Measurements and Main Results

Compared with Cardiac Arrest Registry to Enhance Survival (n = 78,704), the cohorts from the 10 emergency medical services agencies examined (n = 2,911) demonstrated significantly increased likelihoods of return of spontaneous circulation (mean 37.4% vs 31.5%; p < 0.001) and neurologically favorable hospital discharge, particularly after witnessed collapses involving bystander cardiopulmonary resuscitation and shockable cardiac rhythms (mean 10.7% vs 8.4%; p < 0.001; and 41.6% vs 29.2%; p < 0.001, respectively).

Conclusions

The likelihood of neurologically favorable survival following out-of-hospital cardiac arrest can improve substantially in communities that conscientiously and meticulously introduce a well-sequenced, highly choreographed, system-wide portfolio of both traditional and nonconventional approaches to training, technologies, and physiologic management. The commonalities found in the analyzed systems create a compelling case that other communities can also improve out-of-hospital cardiac arrest outcomes significantly by conscientiously exploring and adopting similar bundles of system organization and care.

Relationship Between Institutional Volume of Out-of-Hospital Cardiac Arrest Cases and 1-Month Neurologic Outcomes: A Post Hoc Analysis of a Prospective Observational Study

BACKGROUND

The influence of institutional volume of out-of-hospital cardiac arrest (OHCA) cases on outcomes remains unclear.

OBJECTIVES

This study evaluated the relationship between institutional volume of adult, nontraumatic OHCA cases and 1-month favorable neurologic outcomes.

METHODS

This study retrospectively analyzed data between January 2012 and March 2013 from a prospective observational study in the Kanto area of Japan. We analyzed adult patients with nontraumatic OHCA who underwent cardiopulmonary resuscitation by emergency medical service personnel and in whom spontaneous circulation was restored. Based on the institutional volume of OHCA cases, we divided institutions into low-, middle-, or high-volume groups. The primary and secondary outcomes were 1-month favorable neurologic outcomes and 1-month survival, respectively. A multivariate logistic regression analysis adjusted for propensity score and in-hospital variables was performed.

RESULTS

Of 2699 eligible patients, 889, 898, and 912 patients were transported to low-volume (40 institutions), middle-volume (14 institutions), and high-volume (9 institutions) centers, respectively. Using low-volume centers as the reference, transport to a middle- or high-volume center was not significantly associated with a favorable 1-month neurologic outcome (adjusted odds ratio [OR] 1.21 [95% confidence interval {CI} 0.84-1.75] and adjusted OR 0.77 [95% CI 0.53-1.12], respectively) or 1-month survival (adjusted OR 1.10 [95% CI 0.82-1.47] and adjusted OR 0.76 [95% CI 0.56-1.02], respectively).

CONCLUSIONS

Institutional volume was not significantly associated with favorable 1-month neurologic outcomes or 1-month survival in OHCA. Further investigation is needed to determine the association between hospital characteristics and outcomes in patients with OHCA.

A mobile device app to reduce prehospital medication errors and time to drug preparation and delivery by emergency medical services during simulated pediatric cardiopulmonary resuscitation: study protocol of a multicenter, prospective, randomized controlled trial

BACKGROUND

Emergency drug preparation and administration in children is both complex and time-consuming and places this population at a higher risk than adults for medication errors. Moreover, survival and a favorable neurological outcome from cardiopulmonary resuscitation are inversely correlated to drug preparation time. We developed a mobile device application (the pediatric Accurate Medication IN Emergency Situations (PedAMINES) app) as a step-by-step guide for the preparation to delivery of drugs requiring intravenous injection. In a previous multicenter randomized trial, we reported the ability of this app to significantly reduce in-hospital continuous infusion medication error rates and drug preparation time compared to conventional preparation methods during simulation-based pediatric resuscitations. This trial aims to evaluate the effectiveness of this app during pediatric out-of-hospital cardiopulmonary resuscitation.

METHODS/DESIGN

We will conduct a multicenter, prospective, randomized controlled trial to compare the PedAMINES app with conventional calculation methods for the preparation of direct intravenously administered emergency medications during standardized, simulation-based, pediatric out-of-hospital cardiac arrest scenarios using a high-fidelity manikin. One hundred and twenty paramedics will be randomized (1:1) in several emergency medical services located in different regions of Switzerland. Each paramedic will be asked to prepare, sequentially, four intravenously administered emergency medications using either the app or conventional methods. The primary endpoint is the medication error rates. Enrollment will start in mid-2019 and data analysis in late 2019. We anticipate that the intervention will be completed in early 2020 and study results will be submitted in late 2020 for publication (expected in early 2021).

DISCUSSION

This clinical trial will assess the impact of an evidence-based mobile device app to reduce the rate of medication errors, time to drug preparation and time to drug delivery during prehospital pediatric resuscitation. As research in this area is scarce, the results generated from this study will be of great importance and may be sufficient to change and improve prehospital pediatric emergency care practice.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03921346. Registered on 18 April 2019.

Confirming the Clinical Safety and Feasibility of a Bundled Methodology to Improve Cardiopulmonary Resuscitation Involving a Head-Up/Torso-Up Chest Compression Technique

OBJECTIVES

Combined with devices that enhance venous return out of the brain and into the thorax, preclinical outcomes are improved significantly using a synergistic bundled approach involving mild elevation of the head and chest during cardiopulmonary resuscitation. The objective here was to confirm clinical safety/feasibility of this bundled approach including use of mechanical cardiopulmonary resuscitation provided at a head-up angle.

DESIGN

Quarterly tracking of the frequency of successful resuscitation before, during, and after the clinical introduction of a bundled head-up/torso-up cardiopulmonary resuscitation strategy.

SETTING

9-1-1 response system for a culturally diverse, geographically expansive, populous jurisdiction.

PATIENTS

All 2,322 consecutive out-of-hospital cardiac arrest cases (all presenting cardiac rhythms) were followed over 3.5 years (January 1, 2014, to June 30, 2017).

INTERVENTIONS

In 2014, 9-1-1 crews used LUCAS (Physio-Control Corporation, Redmond, WA) mechanical cardiopulmonary resuscitation and impedance threshold devices for out-of-hospital cardiac arrest. After April 2015, they also 1) applied oxygen but deferred positive pressure ventilation several minutes, 2) solidified a pit-crew approach for rapid LUCAS placement, and 3) subsequently placed the patient in a reverse Trendelenburg position (~20°).

MEASUREMENTS AND MAIN RESULTS

No problems were observed with head-up/torso-up positioning (n = 1,489), but resuscitation rates rose significantly during the transition period (April to June 2015) with an ensuing sustained doubling of those rates over the next 2 years (mean, 34.22%; range, 29.76-39.42%; n = 1,356 vs 17.87%; range, 14.81-20.13%, for 806 patients treated prior to the transition; p < 0.0001). Outcomes improved across all subgroups. Response intervals, clinical presentations and indications for attempting resuscitation remained unchanged. Resuscitation rates in 2015-2017 remained proportional to neurologically intact survival (~35-40%) wherever tracked.

CONCLUSIONS

The head-up/torso-up cardiopulmonary resuscitation bundle was feasible and associated with an immediate, steady rise in resuscitation rates during implementation followed by a sustained doubling of the number of out-of-hospital cardiac arrest patients being resuscitated. These findings make a compelling case that this bundled technique will improve out-of-hospital cardiac arrest outcomes significantly in other clinical evaluations.