Pre-hospital Prognostic Factors of Out-of-Hospital Cardiac Arrest: The Difference Between Pediatric and Adult

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.

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.

Early coagulopathy after pediatric out-of-hospital cardiac arrest: secondary analysis of a randomized clinical trial

Background

To estimate the incidence, risk factors, and impact on mortality and functional outcomes for early coagulopathy after the return of spontaneous circulation (ROSC) in pediatric out-of-hospital cardiac arrest (OHCA) patients.

Methods

A post hoc analysis of the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital (THAPCA-OH) trial was conducted. Early coagulopathy was defined as presence of at least one of the following coagulation abnormalities upon admission: international standard ratio (INR), platelets, and age-adjusted activated partial thromboplastin time (APTT) within 6 h after OHCA and before therapeutic hypothermia initiation. The outcomes included 28-day mortality and functional prognosis. Multivariable logistic regression models were used to explore risk factors and association between early coagulopathy and outcomes.

Results

Of the 227 patients included, 152 (67%) were male and the median age was 2.3 years [interquartile range (IQR), 0.7–8.6 years]. The overall 28-day mortality was 63%. The incidence of early coagulopathy was 46%. Lower age, longer duration of chest compression, lower temperature, and higher white blood cell (WBC) upon admission increased the risk of early coagulopathy. Early coagulopathy [OR, 2.20 (95% CI, 1.12–4.39), P = 0.023] was independently associated with 28-day mortality after adjusting for confounders.

Conclusions

Early coagulopathy occurred in almost half of pediatric patients with OHCA. Lower age, longer duration of chest compression, lower temperature, and higher WBC increased the risk. The development of early coagulopathy was independently associated with increased mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12959-022-00422-x.

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.

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.