What are the etiology and epidemiology of out-of-hospital pediatric cardiopulmonary arrest in Ontario, Canada?

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluation of hospital management of paediatric out-of-hospital cardiac arrest

INTRODUCTION

Pediatric out of hospital cardiac arrest (POHCA) is rare, with high mortality and neurological morbidity. Adherence to Pediatric Advanced Life Support guidelines standardizes in-hospital care and improves outcomes. We hypothesized that in-hospital care of POHCA patients was variable and deviations from guidelines were associated with higher mortality.

METHODS

POHCA patients in the London-Middlesex region between January 2012 and June 2020 were included. The care of children with ongoing arrest (intra-arrest) and post-arrest outcomes were reviewed using the Children's Hospital, London Health Sciences Centre (LHSC) patient database and the Adverse Event Management System.

RESULTS

50 POHCA patients arrived to hospital, with 15 (30%) patients admitted and 2 (4.0%) surviving to discharge, both with poor neurological outcomes and no improvement at 90 days. Deviations occurred at every event with intra-arrest care deviations occurring mostly in medication delivery and defibrillation (98%). Post-arrest deviations occurred mostly in temperature monitoring (60%). Data missingness was 15.9% in the intra-arrest and 1.7% in the post-arrest group.

DISCUSSION

Deviations commonly occurred in both in-hospital arrest and post-arrest care. The study was under-powered to identify associations between DEVs and outcomes. Future work includes addressing specific deviations in intra-arrest and post-arrest care of POHCA patients and standardizing electronic documentation.

Epidemiology of paediatric out-of-hospital cardiac arrest in Ontario, Canada

Background

There are no Canadian epidemiological studies of Paediatric Out-of-Hospital Cardiac Arrest (POHCA) for ≥20 years. Understanding the epidemiology of POHCA is key to prevention, education, and management strategies.

Methods

We applied a validated algorithm to hospital administrative databases to describe paediatric (age 1 day to ≤18 years) atraumatic OHCA in Ontario from 2004-2020.

Results

The cohort included 1,839 paediatric patients with atraumatic POHCA occurring at a median (IQR) age of 2 (0-12) years with 721 (39.2%) POHCA events in <1-year-olds. Males accounted for 71.1% (n = 1123) of the cohort. Crude incidence of children with POHCA who were transported to an Emergency Department was 4.2/100,000 with an increase annually over the study period (p = 0.0065). Thirty percent (n = 560) lived in a neighbourhood with the lowest income quintile, while 13.6% (n = 251) lived in a neighbourhood with the highest income quintile, 78.6% (n = 1444) presented to a non-academic hospital, and the majority (n = 1533, 83.4%) did not have significant comorbidities. Survival to hospital discharge was achieved in 167 (9.1%). Less than 6 (<3.6%) patients had a repeat POHCA in the year following the index event.

Conclusions

This is the largest Canadian POHCA cohort and the first to describe its incidence, comorbidities, and sociodemographic characteristics. We found an increase in annual crude incidence, POHCA mostly occurred in healthy children, and survival was similar to other cohorts. There were more than double the number of POHCA events in children living in the lowest income quintile neighborhoods compared to the highest. Most children presented to non-academic hospitals first.

The Reliability of the Resuscitation Assessment Tool (RAT) in Assessing Emergency Medicine Resident Competence in Pediatric Resuscitation Scenarios: A Prospective Observational Pilot Study

Introduction Emergency medicine (EM) postgraduate medical education in Canada has transitioned from traditional time-based training to competency-based medical education (CBME). In order to promote residents through stages of training, simulated assessments are needed to evaluate residents in high-stakes but low-frequency medical emergencies. There remains a gap in the literature pertaining to the use of evaluative tools in simulation, such as the Resuscitation Assessment Tool (RAT) in the new CBME curriculum design. Methods We completed a pilot study of resident physicians in one Canadian EM training program to evaluate the effectiveness and reliability of a simulation-based RAT for pediatric resuscitation. We recorded 10 EM trainees completing simulated scenarios and had nine EM physicians use the RAT tool to evaluate their performances. Generalizability theory was used to evaluate the reliability of the RAT tool. Results The mean RAT score for the management of pediatric myocarditis, cardiac arrest, and septic shock (appendicitis) across raters was 3.70, 3.73, and 4.50, respectively. The overall generalizability coefficient for testing simulated pediatric performance competency was 0.77 for internal consistency and 0.75 for absolute agreement. The performance of senior participants was superior to that of junior participants in the management of pediatric myocarditis (p = 0.01) but not statistically significant in the management of pediatric septic shock (p=0.77) or cardiac arrest (p =0.61). Conclusion Overall, our findings suggest that with an appropriately chosen simulated scenario, the RAT tool can be used effectively for the simulation of high-stakes and low-frequency scenarios for practice to enhance the new CBME curriculum in emergency medicine training programs.

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.

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.

Pediatric out-of-hospital cardiac arrest in Denmark

Background

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

Methods

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

Results

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

Conclusion

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

Out-of-hospital cardiac arrest with onset witnessed by emergency medical services: Implications for improvement in overall survival

Out-of-hospital cardiac arrest (OHCA) remains a major public health problem. Even in high-income countries, survival rates have plateaued in the range of ten percent, stimulating an ongoing interest in developing novel approaches to resuscitation. Emergency Medical Services (EMS)-witnessed OHCAs constitute a subgroup of overall OHCA that occur after the arrival of EMS, leading to rapid initiation of resuscitation and significantly improved survival. In this narrative review we summarize and interpret recent developments in knowledge of EMS-witnessed OHCA regarding prevalence, demographics, location, circumstances, survival outcomes and clinical profile. We examine the possibility of informing novel resuscitation approaches and enhancing mechanistic knowledge by studying EMS-witnessed OHCA, with the goal of improving overall survival from 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.

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.

Dispatcher-assisted conventional cardiopulmonary resuscitation and outcomes for paediatric out-of-hospital cardiac arrests

AIM

As asphyxial cardiac arrest is more common than cardiac arrest from a primary cardiac event in paediatric cardiac arrest, effective ventilation is important during paediatric cardiopulmonary resuscitation (CPR). We aimed to determine optimal dispatcher-assisted CPR instructions for bystanders after paediatric out-of-hospital cardiac arrest (OHCA).

METHODS

We analysed the records of 8172 children who received bystander dispatcher-assisted CPR. Data were obtained from an All-Japan Utstein-style registry from 2005 to 2017. Patients were divided into conventional CPR and compression-only CPR groups. The primary study endpoint was 1-month neurologically intact survival, defined as a Cerebral Performance Category score of 1 or 2 (CPC 1-2).

RESULTS

The 1-month CPC 1-2 rate was significantly higher in the dispatcher-assisted conventional CPR group than in the dispatcher-assisted compression-only CPR group (before propensity score matching, 5.7% [175/3077] vs. 3.1% [160/5095], p < 0.0001, adjusted odds ratio 2.48, 95% confidence interval 1.19-3.22; after propensity score matching, 6.0% [156/2618] vs. 2.6% [69/2618], p < 0.0001, adjusted odds ratio 2.42, 95% confidence interval 1.76-3.32). In most subgroup analyses after matching, dispatcher-assisted conventional CPR had a higher CPC 1-2 rate than dispatcher-assisted compression-only CPR; however, CPC 1-2 rates were similar between the two groups for patients with an initial shockable rhythm, those with total prehospital CPR time ≥ 20 min, those receiving public access defibrillation, advanced airway management, or adrenaline administration.

CONCLUSION

Within the limitations of this retrospective observational study, dispatcher-assisted conventional CPR was preferable to dispatcher-assisted compression-only CPR as optimal CPR instructions for coaching callers to perform bystander CPR.

Effects of regional differences on the outcome of cardiopulmonary resuscitation in children: How much different is Gaziantep from Izmir?

OBJECTIVES:

We aimed to compare the demographic and clinical characteristics between pediatric cardiac arrest patients treated in Gaziantep at South-eastern Anatolian region and Izmir at Aegean Shore.

MATERIALS And METHODS:

We retrospectively reviewed sociodemographic characteristics, laboratory parameters, and clinical outcomes of pediatric patients that underwent cardiopulmonary resuscitation due to prehospital cardiac arrest at two pediatric emergency departments in Izmir Hospital of Health Sciences University and Gaziantep Cengiz Gökçek Kadın Doğum ve Çocuk Hospital of Health Ministry between August 2017 and August 2018.

RESULTS:

The present study included 188 patients (112 patients from Gaziantep and 76 patients from Izmir). All patients arrived at the hospital through emergency medical services. The median age was lower (14 days vs. 15 months; P < 0.001), and the proportion of Syrian refugees was higher in patients from Gaziantep (78.6% vs. 7.9%; P < 0,001). In both centers, respiratory failure was the most common etiology. In patients from Gaziantep, pH levels were lower (median: 7.10 vs. 7.24), and lactate levels were higher (median: 6 mmol/L vs. 3.6 mmol/L; P < 0.001). The mortality rate was higher among patients from Gaziantep (27.7% vs. 7.9%; P = 0.001).

CONCLUSIONS:

The rate of Syrian refugees among children who were brought to emergency department due to pre-hospital cardiac arrest was much higher in Gaziantep compared to Izmir. Syrian children were significantly younger and had more severe tissue hypoxia, resulting in a higher mortality rate.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

Temporal trends in neurologically intact survival after paediatric bystander-witnessed out-of-hospital cardiac arrest: A nationwide population-based observational study

AIM

Trends in neurologically intact survival after paediatric out-of-hospital cardiac arrest (OHCA) remain unclear. In the present study, we aimed to determine trends in 1-month neurologically intact survival after paediatric OHCA over time.

METHODS

We reviewed the data of 5461 children (aged < 18 years) who experienced bystander-witnessed OHCA and were included in the nationwide Japanese registry from 2005 to 2017. Patients were divided into three groups according to study period: 2005-2010, 2011-2015, and 2016-2017. We analysed the trends in 1-month neurologically intact survival rates over time.

RESULTS

The risk-adjusted odds of 1-month neurologically intact survival (odds ratio, 1.86; 95% confidence interval, 1.41-2.44) were significantly improved by 2016-2017 compared with baseline. Similar improvements in 1-month neurologically intact survival rates were observed with both standard bystander cardiopulmonary resuscitation (CPR) with rescue breaths and chest compression-only bystander CPR (P for trend < 0.05 and < 0.001, respectively). In the subgroup analyses by aetiology, the 1-month neurologically intact survival rate in patients with OHCA of non-traumatic origin significantly increased from 11.8%-15.1% to 19.7% (P for trend < 0.001) but not in those with OHCA of traumatic origin (from 4.9% to 3.4% to 4.1%; P for trend = 0.29).

CONCLUSION

The 1-month neurologically intact survival rate significantly increased from 2005 to 2017 in Japanese children with bystander-witnessed OHCA, regardless of bystander CPR type; This increase was noted in patients with OHCA of non-traumatic origin but not in those with OHCA of traumatic origin.

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.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

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.

The current practice regarding neuro-prognostication for comatose children after cardiac arrest differs between and within European PICUs: A survey

PURPOSE

To describe current practices in European Paediatric Intensive Care Units (PICUs) regarding neuro-prognostication in comatose children after cardiac arrest (CA).

METHODS

An anonymous online survey was conducted among members of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) and the European Paediatric Neurology Society (EPNS) throughout January and February 2019. The survey consisted of 49 questions divided into 4 sections: general information, cardiac arrest, neuro-prognostication and follow-up.

RESULTS

The survey was sent to 1310 EPNS and 611 ESPNIC members. Of the 108 respondents, 71 (66%) (23 countries, 45 PICUs) completed the "neuro-prognostication" section. Eight PICUs (20%) had a local neuro-prognostication guideline. The 3 methods considered as most useful were neurological examination (92%), magnetic resonance imaging (MRI) (82%) and continuous electroencephalography (cEEG) (45%). In 50% a Pediatric Cerebral Performance Category (PCPC) score ≥ 4 was considered as poor neurological outcome. In 63% timing of determining neurological prognosis was based on the individual patient. Once decided that neurological prognosis was futile, 55% indicated that withdrawing life-sustaining therapy (WLST) was (one of) the options, whereas 44% continued PICU treatment (with or without restrictions). In 28 PICUs (68%) CA-survivors were scheduled for follow-up visits.

CONCLUSION

Local guidelines for neuro-prognostication in comatose children after CA are uncommon. Methods to assess neurological outcome were mainly neurological examination, MRI and cEEG. Consequences of poor outcome differed between respondents. Inaccuracies in neuro-prognostication can result in premature WLST, thereby biasing outcome research and creating a self-fulfilling cycle. Further research is needed to develop scientifically based international guidelines for neuro-prognostication in comatose children after CA.

Physician staffed emergency medical service for children: a retrospective population-based registry cohort study in Odense region, Southern Denmark

OBJECTIVES

The aim of this study is to determine diagnostic patterns in the prehospital paediatric population, age distribution, the level of monitoring and the treatment initiated in the prehospital paediatric case. Hypothesis was that advanced prehospital interventions are rare in the paediatric patient population.

SETTING

We performed a retrospective population-based registry cohort study of children attended by a physician-staffed emergency medical service (EMS) unit (P-EMS), in the Odense area of Denmark during a 10-year study period.

PARTICIPANTS

We screened 44 882 EMS contacts and included 5043 children. Patient characteristics, monitoring and interventions performed by the P-EMS crews were determined.

RESULTS

We found that paediatric patients were a minority among patients attended by P-EMS units: 11.2% (10.9 to 11.5) (95% CI) of patients were children. The majority of the children were <5 years old; one-third being <2 years old. Respiratory problems, traffic accidents and febrile seizures were the three most common dispatch codes. Oxygen supplementation, intravenous access and application of a cervical collar were the three most common interventions. Oxygen saturation and heart rate were documented in more than half of the cases, but more than one-third of the children had no vital parameters documented. Only 22% of the children had respiratory rate, saturation, heart rate and blood pressure documented. Prehospital invasive procedures such as tracheal intubation (n=74), intraosseous access (n=22) and chest drainage (n=2) were infrequently performed.

CONCLUSION

Prehospital paediatric contacts are uncommon, more frequently involving smaller children. Monitoring or at least documentation of basic vital parameters is infrequent and may be an area for improvement. Advanced and potentially life-saving prehospital interventions provide a dilemma since these likely occur too infrequently to allow service providers to maintain their technical skills working solely in the prehospital environment.

Incidence, characteristics, and outcomes of pediatric out-of-hospital cardiac arrest in nursery schools and kindergartens in Japan

BACKGROUND

A better understanding of the epidemiology of pediatric out-of-hospital cardiac arrest (OHCA) occurring in nursery schools and kindergartens is indispensable to establish an evidence-based strategy for prevention and improved outcomes. This study aimed to describe the incidence, characteristics, and outcomes of pediatric OHCAs that occurred in certified nursery schools and kindergartens.

METHODS

Stop and Prevent cardIac aRrest, Injury, and Trauma in Schools (SPIRITS) is a study to construct and analyze a nationwide registry of pediatric OHCAs occurring in school settings in Japan. Using data from the SPIRITS registry, we assessed the incidence, characteristics, and outcomes of pediatric OHCAs that occurred in certified nursery schools/kindergartens between April 2008 and December 2016.

RESULTS

During the study period, 37 OHCA patients (31 in certified nursery schools and 6 in kindergartens) were confirmed. The overall incidence rate was 0.13 per 100,000 children per year. Among 37 patients, 57% (21/37) had an OHCA while napping and 35% (13/37) experienced OHCA that was witnessed by bystanders. Although public-access automated external defibrillator pads were applied by bystanders in 24% (9/37) of cases, only 1 patient actually received defibrillation. Overall, the proportion of 1-month survival with favorable neurological outcomes after OHCA was 19% (7/37). Among those with OHCA of non-medical origins, 60% (3/5) of patients experienced arrest caused by suffocation, 60% (3/5) by drowning, and 100% (1/1) by head injury. In contrast, no patient had 1-month favorable neurological outcomes among those with OHCA of medical origins such as presumed cardiac origin (0/17), sudden infant death syndrome (0/6), acute viral myocarditis (0/1), respiratory disease (0/1), and ventricular fibrillation (0/1).

CONCLUSIONS

In this population, the majority of pediatric OHCAs occurring in certified nursery schools/kindergartens had non-ventricular fibrillation rhythm, and their outcomes after OHCA of medical origin were poor.

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.

Paediatric traumatic out-of-hospital cardiac arrest: A systematic review and meta-analysis

AIM

In this study, we sought to quantitatively describe the survival outcomes, incidence rates, and predictors of survival after paediatric traumatic out-of-hospital cardiac arrest (OHCA).

METHODS

We systematically searched MEDLINE, EMBASE, EMCARE, and CINAHL to identify observational or interventional studies reporting relevant data for paediatric traumatic OHCA. The Joanna Briggs Institute critical appraisal tool for prognostic studies was used to assess study quality. We analysed the survival outcomes and pooled incidence rates per 100,000 person-years using random-effect models.

RESULTS

Nineteen articles met the eligibility criteria involving 705 Emergency Medical Service (EMS)-attended and 973 EMS-treated traumatic paediatric OHCAs across an estimated serviceable population of 15.2 million. Four studies were conducted in the Asia-pacific region, seven in Europe, and eight in North America. Nine studies were assessed as low quality. Overall pooled survival to hospital discharge or 30-day survival for the EMS-treated cases was 1.2% (n = 6 studies; 95% confidence interval (CI): 0.1%, 3.1%; I2 = 26.1%). The pooled rate of return of spontaneous circulation in four studies was 22.1% (95% CI: 18.4%, 26.1%; I2 = 0.0%), and the pooled rate of event survival was 18.8% (n = 3 studies; 95% CI: 15.2%, 22.7%; I2 = 0.0%). The pooled incidence of EMS-treated paediatric traumatic OHCA was 1.6 cases per 100,000 person-years (n = 10 studies; 95% CI: 1.1, 2.2; I2 = 98.1%). No study reported on the impact of epidemiological or clinical factors on survival.

CONCLUSION

Survival outcomes of paediatric traumatic OHCA are poor and existing studies report varying incidence rates. The absence of large prospective and international registry data hinders the development of novel strategies to improve survival rates.

Epidemiology of Sudden Death in a Population-Based Study of Infants and Children

Objective

To describe epidemiologic data from the Sudden Death in the Young (SDY) Case Registry. Understanding the scope of SDY may optimize prevention efforts.

Study design

We analyzed sudden, unexpected deaths of infants (<365 days) and children (1–17 years) from a population-based registry of 8 states/jurisdictions in 2015 and 9 in 2016. Natural deaths and injury deaths from drowning, motor vehicle accident drivers, and infant suffocation were included; other injury deaths, homicide, suicide, intentional overdose, and terminal illness were excluded. Cases were categorized using a standardized algorithm. Descriptive statistics were used to characterize deaths, and mortality rates were calculated.

Results

Of 1319 cases identified, 92% had an autopsy. We removed incomplete cases, leaving 1132 analyzable deaths (889 infants, 243 children). The SDY rate for infants was 120/100 000 live births and for children was 1.9/100 000 children. Explained Cardiac rates were greater for infants (2.7/100 000 live births) than children (0.3/100 000 children). The pediatric Sudden Unexpected Death in Epilepsy (SUDEP) mortality rate was 0.2/100 000 live births and children. Blacks comprised 42% of infant and 43% of child deaths but only 23% of the population. In all ages, myocarditis/endocarditis was the most common Explained Cardiac cause; respiratory illness was the most common Explained Other cause. SDY occurred during activity in 13% of childhood cases.

Conclusions

Prevention strategies include optimizing identification and treatment of respiratory and cardiac diseases.

Transcutaneous Pacing of a 4-Year-Old Child

Complete heart block is rare in children and is usually owing to congenital abnormalities. These children are often pacemaker dependent. However, pacemaker complications can require emergency interventions, including external pacing. This case presents a child in complete heart block requiring external pacing and then discusses some of the literature behind such interventions.

Clinical Survey and Predictors of Outcomes of Pediatric Out-of-Hospital Cardiac Arrest Admitted to the Emergency Department

Pediatric out-of-hospital cardiac arrest (OHCA) is a rare event with severe sequelae. Although the survival to hospital-discharge (STHD) rate has improved from 2–6% to 17.6–40.2%, only 1–4% of OHCA survivors have a good neurological outcome. This study investigated the characteristics of case management before and after admittance to the emergency department (ED) associated with outcomes of pediatric OHCA in an ED. This was a retrospective study of data collected from our ED resuscitation room logbooks dating from 2005 to 2016. All records of children under 18 years old with OHCA were reviewed. Outcomes of interest included sustained return of spontaneous circulation (SROSC), STHD, and neurological outcomes. From the 12-year study period, 152 patients were included. Pediatric OHCA commonly affects males (55.3%, n = 84) and infants younger than 1 year of age (47.4%, n = 72) at home (76.3%, n = 116). Most triggers of pediatric OHCA were respiratory in nature (53.2%, n = 81). Sudden infant death syndrome (SIDS) (29.6%, n = 45), unknown medical causes (25%, n = 38), and trauma (10.5%, n = 16) were the main causes of pediatric OHCA. Sixty-two initial cardiac rhythms at the scene were obtained, most of which were asystole and pulseless electrical activity (PEA) (93.5%, n/all: 58/62). Upon ED arrival, cardiopulmonary resuscitation (CPR) was continued for 32.66 ± 20.71 min in the ED and 34.9% (n = 53) gained SROSC. Among them, 13.8% (n = 21) achieved STHD and 4.6% (n = 7) had a favorable neurological outcome. In multivariate analyses, fewer ED epinephrine doses (p < 0.05), witness of OHCA (p = 0.001), and shorter ED CPR duration (p = 0.007) were factors that increased the rate of SROSC at the ED. A longer emergency medical service (EMS) scene interval (p = 0.047) and shorter ED CPR interval (p = 0.047) improved STHD.

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.

Automated External Defibrillator Application Before EMS Arrival in Pediatric Cardiac Arrests

BACKGROUND

Little is known about the predictors of pre-emergency medical service (EMS) automated external defibrillator (AED) application in pediatric out-of-hospital cardiac arrests. We sought to determine patient- and neighborhood-level characteristics associated with pre-EMS AED application in the pediatric population.

METHODS

We reviewed prospectively collected data from the Cardiac Arrest Registry to Enhance Survival on pediatric patients (age >1 to ≤18 years old) who had out-of-hospital nontraumatic arrest (2013-2015).

RESULTS

A total of 1398 patients were included in this analysis (64% boys, 45% white, and median age of 11 years old). An AED was applied in 28% of the cases. Factors associated with pre-EMS AED application in univariable analyses were older age (odds ratio [OR]: 1.9; 12-18 years old vs 2-11 years old; P < .001), white versus African American race (OR: 1.4; P = .04), public location (OR: 1.9; P < .001), witnessed status (OR: 1.6; P < .001), arrests presumed to be cardiac versus respiratory etiology (OR: 1.5; P = .02) or drowning etiology (OR: 2.0; P < .001), white-populated neighborhoods (OR: 1.2 per 20% increase in white race; P = .01), neighborhood median household income (OR: 1.1 per $20 000 increase; P = .02), and neighborhood level of education (OR: 1.3 per 20% increase in high school graduates; P = .006). However, only age, witnessed status, arrest location, and arrests of presumed cardiac etiology versus drowning remained significant in the multivariable model. The overall cohort survival to hospital discharge was 19%.

CONCLUSIONS

The overall pre-EMS AED application rate in pediatric patients remains low.

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

The purpose of the study is to examine (1) nationally representative incidence rates of Emergency Department (ED) visits due to sudden cardiac arrest (SCA) in pediatric and young adult populations, (2) basic characteristics of the ED visits with SCA, and (3) patient and hospital factors associated with survival after SCA. We used the Nationwide Emergency Department Sample from 2006 to 2013. ICD-9-CM diagnostic codes identified ED visits due to SCA for patients ≤ 30 years old. Outcomes included yearly incidence of ED visits for SCA, and survival to hospital discharge. Predictors of interest were age groups, sex, and SCA case volume. A logistic regression model adjusted by patient- and hospital-level variables was used. Stratified analyses of age by (< 12 and ≥ 12 years old) were performed to explore the effect of pubertal development on SCA. With 71,881 ED visits due to SCA, the total incidence rate was 6.9 per 100,000 population, with a mortality rate of 89.6% and male/female ratio of 1.7. With the adjusted regression models, there were no differences in survival rate by sex; however, when stratified at 12 years old, males were less likely to survive than females above 12 years old (odds ratio [OR] 0.71, P < 0.01), but not under 12 years old. No statistically significant differences in survival rates between low- and high-SCA volume EDs were detected (OR 1.03, P = 0.77). Data showed no benefit of regionalized care for post-SCA in ≤ 30-year-old populations. With further examination of the differences between sexes, new management strategies for SCA cases can be developed.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Adherence to AHA Guidelines When Adapted for Augmented Reality Glasses for Assisted Pediatric Cardiopulmonary Resuscitation: A Randomized Controlled Trial

Background

The American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) are nowadays recognized as the world’s most authoritative resuscitation guidelines. Adherence to these guidelines optimizes the management of critically ill patients and increases their chances of survival after cardiac arrest. Despite their availability, suboptimal quality of CPR is still common. Currently, the median hospital survival rate after pediatric in-hospital cardiac arrest is 36%, whereas it falls below 10% for out-of-hospital cardiac arrest. Among emerging information technologies and devices able to support caregivers during resuscitation and increase adherence to AHA guidelines, augmented reality (AR) glasses have not yet been assessed. In order to assess their potential, we adapted AHA Pediatric Advanced Life Support (PALS) guidelines for AR glasses.

Objective

The study aimed to determine whether adapting AHA guidelines for AR glasses increased adherence by reducing deviation and time to initiation of critical life-saving maneuvers during pediatric CPR when compared with the use of PALS pocket reference cards.

Methods

We conducted a randomized controlled trial with two parallel groups of voluntary pediatric residents, comparing AR glasses to PALS pocket reference cards during a simulation-based pediatric cardiac arrest scenario—pulseless ventricular tachycardia (pVT). The primary outcome was the elapsed time in seconds in each allocation group, from onset of pVT to the first defibrillation attempt. Secondary outcomes were time elapsed to (1) initiation of chest compression, (2) subsequent defibrillation attempts, and (3) administration of drugs, as well as the time intervals between defibrillation attempts and drug doses, shock doses, and number of shocks. All these outcomes were assessed for deviation from AHA guidelines.

Results

Twenty residents were randomized into 2 groups. Time to first defibrillation attempt (mean: 146 s) and adherence to AHA guidelines in terms of time to other critical resuscitation endpoints and drug dose delivery were not improved using AR glasses. However, errors and deviations were significantly reduced in terms of defibrillation doses when compared with the use of the PALS pocket reference cards. In a total of 40 defibrillation attempts, residents not wearing AR glasses used wrong doses in 65% (26/40) of cases, including 21 shock overdoses >100 J, for a cumulative defibrillation dose of 18.7 Joules per kg. These errors were reduced by 53% (21/40, P<.001) and cumulative defibrillation dose by 37% (5.14/14, P=.001) with AR glasses.

Conclusions

AR glasses did not decrease time to first defibrillation attempt and other critical resuscitation endpoints when compared with PALS pocket cards. However, they improved adherence and performance among residents in terms of administering the defibrillation doses set by AHA.

A Mobile Device App to Reduce Time to Drug Delivery and Medication Errors During Simulated Pediatric Cardiopulmonary Resuscitation: A Randomized Controlled Trial

Background

During pediatric cardiopulmonary resuscitation (CPR), vasoactive drug preparation for continuous infusion is both complex and time-consuming, placing children at higher risk than adults for medication errors. Following an evidence-based ergonomic-driven approach, we developed a mobile device app called Pediatric Accurate Medication in Emergency Situations (PedAMINES), intended to guide caregivers step-by-step from preparation to delivery of drugs requiring continuous infusion.

Objective

The aim of our study was to determine whether the use of PedAMINES reduces drug preparation time (TDP) and time to delivery (TDD; primary outcome), as well as medication errors (secondary outcomes) when compared with conventional preparation methods.

Methods

The study was a randomized controlled crossover trial with 2 parallel groups comparing PedAMINES with a conventional and internationally used drugs infusion rate table in the preparation of continuous drug infusion. We used a simulation-based pediatric CPR cardiac arrest scenario with a high-fidelity manikin in the shock room of a tertiary care pediatric emergency department. After epinephrine-induced return of spontaneous circulation, pediatric emergency nurses were first asked to prepare a continuous infusion of dopamine, using either PedAMINES (intervention group) or the infusion table (control group), and second, a continuous infusion of norepinephrine by crossing the procedure. The primary outcome was the elapsed time in seconds, in each allocation group, from the oral prescription by the physician to TDD by the nurse. TDD included TDP. The secondary outcome was the medication dosage error rate during the sequence from drug preparation to drug injection.

Results

A total of 20 nurses were randomized into 2 groups. During the first study period, mean TDP while using PedAMINES and conventional preparation methods was 128.1 s (95% CI 102-154) and 308.1 s (95% CI 216-400), respectively (180 s reduction, P=.002). Mean TDD was 214 s (95% CI 171-256) and 391 s (95% CI 298-483), respectively (177.3 s reduction, P=.002). Medication errors were reduced from 70% to 0% (P<.001) by using PedAMINES when compared with conventional methods.

Conclusions

In this simulation-based study, PedAMINES dramatically reduced TDP, to delivery and the rate of medication errors.

Adult "termination-of-resuscitation" (TOR)-criteria may not be suitable for children - a retrospective analysis

Background

Only a small number of patients survive out-of-hospital-cardiac-arrest (OHCA). The duration of CPR varies considerably and transportation of patients under CPR is often unsuccessful. Termination-of-resuscitation (TOR)-criteria aim to preclude futile resuscitation efforts.

Our goal was to find out to which extent existing TOR-criteria can be transferred to paediatric OHCA-patients with special regard to their prognostic value.

Methods

We performed a retrospective analysis of an eleven-year single centre patient cohort. 43 paediatric patients admitted to our institution after emergency-medical-system (EMS)-confirmed OHCA from 2003 to 2013 were included. Morrison’s BLS- and ALS-TOR-rules as well as the Trauma-TOR-criteria by the American Association of EMS Physicians were evaluated for application in children, by calculating sensitivity, specificity, negative and positive predictive value for death-, as well as survival-prediction in our cohort.

Results

26 patients achieved ROSC and 14 were discharged alive (n = 7 PCPC 1/2, n = 7 PCPC 5). Sensitivity for BLS-TOR-criteria predicting death was 48.3%, specificity 92.9%, the PPV 93.3% and the NPV 46.4%. ALS-TOR-criteria for death had a sensitivity of 10.3%, specificity of 100%, a PPV of 100% and an NPV of 35%.

Conclusion

Retrospective application of the BLS-TOR-rule in our patient cohort identified the resuscitation of one later survivor as futile. ALS-TOR-criteria did not give false predictions of death. The proportion of CPRs that could have been abandoned is 48.2% for the BLS-TOR and only 10.3% for the ALS-TOR-rule. Both rules therefore appear not to be transferable to a paediatric population.

Pediatric Out-of-Hospital Cardiac Arrest Characteristics and Their Association With Survival and Neurobehavioral Outcome

OBJECTIVE

To investigate relationships between cardiac arrest characteristics and survival and neurobehavioral outcome among children recruited to the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital trial.

DESIGN

Secondary analysis of Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital trial data.

SETTING

Thirty-six PICUs in the United States and Canada.

PATIENTS

All children (n = 295) had chest compressions for greater than or equal to 2 minutes, were comatose, and required mechanical ventilation after return of circulation.

INTERVENTIONS

Neurobehavioral function was assessed using the Vineland Adaptive Behavior Scales, Second Edition at baseline (reflecting prearrest status) and 12 months postarrest. U.S. norms for Vineland Adaptive Behavior Scales, Second Edition scores are 100 (mean) ± 15 (SD). Higher scores indicate better functioning. Outcomes included 12-month survival and 12-month survival with Vineland Adaptive Behavior Scales, Second Edition greater than or equal to 70.

MEASUREMENT AND MAIN RESULTS

Cardiac etiology of arrest, initial arrest rhythm of ventricular fibrillation/tachycardia, shorter duration of chest compressions, compressions not required at hospital arrival, fewer epinephrine doses, and witnessed arrest were associated with greater 12-month survival and 12-month survival with Vineland Adaptive Behavior Scales, Second Edition greater than or equal to 70. Weekend arrest was associated with lower 12-month survival. Body habitus was associated with 12-month survival with Vineland Adaptive Behavior Scales, Second Edition greater than or equal to 70; underweight children had better outcomes, and obese children had worse outcomes. On multivariate analysis, acute life threatening event/sudden unexpected infant death, chest compressions more than 30 minutes, and weekend arrest were associated with lower 12-month survival; witnessed arrest was associated with greater 12-month survival. Acute life threatening event/sudden unexpected infant death, other respiratory causes of arrest except drowning, other/unknown causes of arrest, and compressions more than 30 minutes were associated with lower 12-month survival with Vineland Adaptive Behavior Scales, Second Edition greater than or equal to 70.

CONCLUSIONS

Many factors are associated with survival and neurobehavioral outcome among children who are comatose and require mechanical ventilation after out-of-hospital cardiac arrest. These factors may be useful for identifying children at risk for poor outcomes, and for improving prevention and resuscitation strategies.

Duration of Prehospital Cardiopulmonary Resuscitation and Favorable Neurological Outcomes for Pediatric Out-of-Hospital Cardiac Arrests: A Nationwide, Population-Based Cohort Study

BACKGROUND

The appropriate duration of cardiopulmonary resuscitation (CPR) for pediatric out-of-hospital cardiac arrests (OHCAs) remains unclear and may differ based on initial rhythm. We aimed to determine the relationship between the duration of prehospital CPR by emergency medical services (EMS) personnel and post-OHCA outcomes.

METHODS

We analyzed the records of 12 877 pediatric patients who experienced OHCAs (<18 years of age). Data were recorded in a nationwide Japanese database between 2005 and 2012. Study end points were 30-day survival and 30-day survival with favorable neurological outcomes (Cerebral Performance Category [CPC] scale 1-2). Prehospital EMS-initiated CPR duration was defined as the time from CPR initiation by EMS personnel to prehospital return of spontaneous circulation (ROSC) or to hospital arrival when prehospital ROSC was not achieved during prehospital CPR efforts.

RESULTS

The rates of 30-day survival and 30-day CPC 1 to 2 were 9.1% (n=1167) and 2.5% (n=325), respectively. Prehospital EMS-initiated CPR duration was significantly and inversely associated with 30-day outcomes (adjusted odds ratio for 1-minute increments: 0.94, 95% confidence interval: 0.93-0.95 for survival; adjusted odds ratio: 0.90, 95% confidence interval: 0.88-0.92 for CPC 1-2). The duration of prehospital EMS-initiated CPR, beyond which the chance for favorable outcomes diminished to <1%, was 42 minutes for each key outcome, 30-day survival, and 30-day survival with CPC 1 to 2. When categorized by initial rhythm, the prehospital EMS-initiated CPR durations beyond which the chance for 30-day survival with CPC 1 to 2 diminished to <1% were 39 minutes for shockable rhythms, 42 minutes for pulseless electric activity, and 46 minutes for asystole, respectively. In patients with bystander-initiated CPR, the prehospital CPR duration, beyond which the chance for favorable outcome diminished to <1%, was 46 minutes from call receipt.

CONCLUSIONS

Prehospital EMS-initiated CPR duration for pediatric OHCAs was independently and inversely associated with 30-day favorable outcomes. The duration of prehospital EMS-initiated CPR, beyond which the chance for 30-day favorable outcomes diminished to <1%, was 42 minutes. However, the CPR duration to achieve this proportion of outcomes differed based on initial rhythm. Further research is required to elucidate appropriate CPR duration for pediatric OHCAs, including in-hospital CPR time.

CLINICAL TRIAL REGISTRATION

URL: https://clinicaltrials.gov. Unique identifier: NCT02432196.

Sudden Cardiac Death in the Young

Although the occurrence of sudden cardiac death (SCD) in a young person is a rare event, it is traumatic and often widely publicized. In recent years, SCD in this population has been increasingly seen as a public health and safety issue. This review presents current knowledge relevant to the epidemiology of SCD and to strategies for prevention, resuscitation, and identification of those at greatest risk. Areas of active research and controversy include the development of best practices in screening, risk stratification approaches and postmortem evaluation, and identification of modifiable barriers to providing better outcomes after resuscitation of young SCD patients. Institution of a national registry of SCD in the young will provide data that will help to answer these questions.

Impact of pre-hospital care on the outcome of children arriving with agonal breathing to a pediatric emergency service in South India

BACKGROUND

Data on the prehospital interventions received by critically ill children at arrival to Paediatric Emergency Services (PES) is limited in developing countries. This study aims to describe the pre-hospital care scenario, transport and their impact on outcome in non-traumatic, acutely ill children presenting in PES with agonal breathing.

METHODS

Prospective observational study done on children aged below 15 years arriving in PES with agonal breathing due to non-trauma related causes.

RESULTS

Out of 75 children studied, 69% were infants. The duration of illness among 65% of them (75) was less than 3 days. Majority of them (81%) had received treatment prior to arrival. Government sector physicians (72%), half of them (51%) being pediatricians were the major treating doctors. 37% of the children had arrived to the Emergency in an ambulance. Cardiopulmonary Resuscitation (CPR) was given to 27% on arrival in PES. Other interventions included fluid boluses to correct shock (92%) and inotrope infusion (56%). Sepsis (24%) and pneumonia (24%) were the most common diagnoses. Out of 75, 57 (76%) children who were stabilized and shifted to PICU and among them 27 (47%) survived to discharge. Normal blood pressure (p=0.0410) and non-requirement of CPR (0.0047) and inotropic infusion (0.0459) in PES were associated with a higher chance of survival.

CONCLUSION

36% (27/75) of children who arrived to our PES with agonal breathing survived to hospital discharge. Survival was significantly better among those who did not need CPR.

Neurological outcomes in children dead on hospital arrival

Introduction

Obtaining favorable neurological outcomes is extremely difficult in children transported to a hospital without a prehospital return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA). However, the crucial prehospital factors affecting outcomes in this cohort remain unclear. We aimed to determine the prehospital factors for survival with favorable neurological outcomes (Cerebral Performance Category 1 or 2 (CPC 1–2)) in children without a prehospital ROSC after OHCA.

Methods

Of 9093 OHCA children, 7332 children (age <18 years) without a prehospital ROSC after attempting resuscitation were eligible for enrollment. Data were obtained from a prospectively recorded Japanese national Utstein-style database from 2008 to 2012. The primary endpoint was 1-month CPC 1–2 after OHCA.

Results

The 1-month survival and 1-month CPC 1–2 rates were 6.92 % (n = 508) and 0.99 % (n = 73), respectively. The proportions of the following prehospital variables were significantly higher in the 1-month CPC 1–2 cohort than in the 1-month CPC 3–5 cohort: age (median, 3 years (interquartile range (IQR), 0–14) versus 1 year (IQR, 0–11), p <0.05), bystander-witnessed arrest (52/73 (71.2 %) versus 1830/7259 (25.2 %), p <0.001), initial ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT) rhythm (28/73 (38.3 %) versus 241/7259 (3.3 %), p <0.001), presumed cardiac causes (42/73 (57.5 %) versus 2385/7259 (32.8 %), p <0.001), and actual shock delivery (25/73 (34.2 %) versus 314/7259 (4.3 %), p <0.0001). Multivariate logistic regression analysis indicated that 2 prehospital factors were associated with 1-month CPC 1–2: initial non-asystole rhythm (VF/pulseless VT: adjusted odds ratio ( aOR), 16.0; 95 % confidence interval (CI), 8.05–32.0; pulseless electrical activity (PEA): aOR, 5.19; 95 % CI, 2.77–9.82) and bystander-witnessed arrest (aOR, 3.22; 95 % CI, 1.84–5.79). The rate of 1-month CPC 1–2 in witnessed-arrest children with an initial VF/pulseless VT was significantly higher than that in those with other initial cardiac rhythms (15.6 % versus 2.3 % for PEA and 1.2 % for asystole, p for trend <0.001).

Conclusions

The crucial prehospital factors for 1-month survival with favorable neurological outcomes after OHCA were initial non-asystole rhythm and bystander-witnessed arrest in children transported to hospitals without a prehospital ROSC.

Survival After Out-of-Hospital Cardiac Arrest in Children

Background

Little is known about survival after out‐of‐hospital cardiac arrest (OHCA) in children. We examined whether OHCA survival in children differs by age, sex, and race, as well as recent survival trends.

Methods and Results

Within the prospective Cardiac Arrest Registry to Enhance Survival (CARES), we identified children (age <18 years) with an OHCA from October 2005 to December 2013. Survival to hospital discharge by age (categorized as infants [0 to 1 year], younger children [2 to 7 years], older children [8 to 12 years], and teenagers [13 to 17 years]), sex, and race was assessed using modified Poisson regression. Additionally, we assessed whether survival has improved over 3 time periods: 2005–2007, 2008–2010, and 2011–2013. Of 1980 children with an OHCA, 429 (21.7%) were infants, 952 (48.1%) younger children, 276 (13.9%) older children, and 323 (16.3%) teenagers. Fifty‐nine percent of the study population was male and 31.8% of black race. Overall, 162 (8.2%) children survived to hospital discharge. After multivariable adjustment, infants (rate ratio: 0.56; 95% CI: 0.35, 0.90) and younger children (rate ratio: 0.42; 95% CI: 0.27, 0.65) were less likely to survive compared with teenagers. In contrast, there were no differences in survival by sex or race. Finally, there were no temporal trends in survival across the study periods (P=0.21).

Conclusions

In a large, national registry, we found no evidence for racial or sex differences in survival among children with OHCA, but survival was lower in younger age groups. Unlike in adults with OHCA, survival rates in children have not improved in recent years.

Time on the scene and interventions are associated with improved survival in pediatric out-of-hospital cardiac arrest

BACKGROUND

Survival is less than 10% for pediatric patients following out-of-hospital cardiac arrest. It is not known if more time on the scene of the cardiac arrest and advanced life support interventions by emergency services personnel are associated with improved survival.

AIM

This study was performed to determine which times on the scene and which prehospital interventions were associated with improved survival.

METHODS

We studied patients aged 3 days to 19 years old with out-of-hospital cardiac arrest, using the Resuscitation Outcomes Consortium cardiac arrest database from 11 North American regions, from 2005 to 2012. We evaluated survival to hospital discharge according to on-scene times (<10, 10 to 35 and >35 min).

RESULTS

Data were available for 2244 patients (1017 infants, 594 children and 633 adolescents). Infants had the lowest rate of survival (3.7%) compared to children (9.8%) and adolescents (16.3%). Survival improved over the 7 year study period especially among adolescents. Survival was highest in the 10 to 35 min on-scene time group (10.2%) compared to the >35 min. group (6.9%) and the <10 min. group (5.3%, p=0.01). Intravenous or intra-osseous access attempts and fluid administration were associated with improved survival, whereas advanced airway attempts were not associated with survival and resuscitation drugs were associated with worse survival.

CONCLUSIONS

In this observational study, a scene time of 10 to 35 min was associated with the highest survival, especially among adolescents. Access for fluid resuscitation was associated with increased survival but advanced airway and resuscitation drugs were not.

Systematic review and meta-analysis of outcomes after cardiopulmonary arrest in childhood

BACKGROUND

Cardiopulmonary arrest in children is an uncommon event, and often fatal. Resuscitation is often attempted, but at what point, and under what circumstances do continued attempts to re-establish circulation become futile? The uncertainty around these questions can lead to unintended distress to the family and to the resuscitation team.

OBJECTIVES

To define the likely outcomes of cardiopulmonary resuscitation in children, within different patient groups, related to clinical features.

DATA SOURCES

MEDLINE, MEDLINE in-Process & Other non-Indexed Citations, EMBASE, Cochrane database of systematic reviews and Cochrane central register of trials, Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment database, along with reference lists of relevant systematic reviews and included articles.

STUDY ELIGIBILITY CRITERIA

Prospective cohort studies which derive or validate a clinical prediction model of outcome following cardiopulmonary arrest.

PARTICIPANTS AND INTERVENTIONS

Children or young people (aged 0 - 18 years) who had cardiopulmonary arrest and received an attempt at resuscitation, excluding resuscitation at birth.

STUDY APPRAISAL AND SYNTHESIS METHODS

Risk of bias assessment developed the Hayden system for non-randomised studies and QUADAS2 for decision rules. Synthesis undertaken by narrative, and random effects meta-analysis with the DerSimonian-Laird estimator.

RESULTS

More than 18,000 episodes in 16 data sets were reported. Meta-analysis was possible for survival and one neurological outcome; others were reported too inconsistently. In-hospital patients (average survival 37.2% (95% CI 23.7 to 53.0%)) have a better chance of survival following cardiopulmonary arrest than out-of-hospital arrests (5.8% (95% CI 3.9% to 8.6%)). Better neurological outcome was also seen, but data were too scarce for meta-analysis (17% to 71% 'good' outcomes, compared with 2.8% to 3.2%).

LIMITATION

Lack of consistent outcome reporting and short-term neurological outcome measures limited the strength of conclusions that can be drawn from this review.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

There is a need to collaboratively, prospectively, collect potentially predictive data on these rare events to understand more clearly the predictors of survival and long-term neurological outcome.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO 2013:CRD42013005102.

Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest

This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.

Early oxygenation and ventilation measurements after pediatric cardiac arrest: lack of association with outcome

OBJECTIVES

To explore oxygenation and ventilation status early after cardiac arrest in infants and children. We hypothesize that hyperoxia is common and associated with worse outcome after pediatric cardiac arrest.

DESIGN

Retrospective cohort study.

SETTING

Fifteen hospitals within the Pediatric Emergency Care Applied Research Network.

PATIENTS

Children who suffered a cardiac arrest event and survived for at least 6 hours after return of circulation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Analysis of 195 events revealed that abnormalities in oxygenation and ventilation are common during the initial 6 hours after pediatric cardiac arrest. Hyperoxia was frequent, affecting 54% of patients. Normoxia was documented in 34% and hypoxia in 22% of patients. These percentages account for a 10% overlap of patients who had both hyperoxia and hypoxia. Ventilation status was more evenly distributed with hyperventilation observed in 38%, normoventilation in 29%, and hypoventilation in 46%, with a 13% overlap of patients who had both hyperventilation and hypoventilation. Derangements in both oxygenation and ventilation were common early after cardiac arrest such that both normoxia and normocarbia were documented in only 25 patients (13%). Neither oxygenation nor ventilation status was associated with outcome. After controlling for potential confounders, arrest location and rhythm were significantly associated with worse outcome; however, hyperoxia was not (odds ratio for good outcome, 1.02 [0.46, 2.84]; p = 0.96).

CONCLUSIONS

Despite recent resuscitation guidelines that advocate maintenance of normoxia and normoventilation after pediatric cardiac arrest, this is uncommonly achieved in practice. Although we did not demonstrate an association between hyperoxia and worse outcome, the small proportion of patients kept within normal ranges limited our power. Preclinical data suggesting potential harm with hyperoxia remain compelling, and further investigation, including prospective, large studies involving robust recording of physiological derangements, is necessary to further advance our understanding of this important topic.

Incidence, causes, and survival trends from cardiovascular-related sudden cardiac arrest in children and young adults 0 to 35 years of age: a 30-year review

BACKGROUND

Sudden cardiac arrest is a leading cause of death in children and young adults. This study determined the incidence, cause, and outcomes of cardiovascular-related out-of-hospital cardiac arrest (OHCA) in individuals <35 years of age.

METHODS AND RESULTS

A retrospective cohort of OHCA in children and young adults from 1980 through 2009 was identified from the King County (Washington) Division of Emergency Medical Services' Cardiac Arrest Database. Incidence was calculated from population census data and causes of arrest determined by review of autopsy reports and all available medical records. A total of 361 cases (26 cases 0-2 years of age, 30 cases 3-13 years of age, 60 cases 14-24 years of age, and 245 cases 25-35 years of age) of OHCA were treated by emergency medical services responders, for an overall incidence of 2.28 per 100 000 person-years (2.1 in those 0-2 years of age, 0.61 in those 3-13 years of age, 1.44 in those 14-24 years of age, and 4.40 in those 25-35 years of age). The most common causes of OHCA were congenital abnormalities in those 0 to 2 years of age (84.0%) and 3 to 13 years of age (21%), presumed primary arrhythmia in those 14 to 24 of age (23.5%), and coronary artery disease in those 25 to 35 years of age (42.9%). The overall survival rate was 26.9% (3.8% in those 0-2 years of age, 40.0% in those 3-13 years of age, 36.7% in those 14-24 years of age, and 27.8% in those 25-35 years of age). Survival increased throughout the study period from 13.0% in 1980 to 1989 to 40.2% in 2000 to 2009 (P<0.001).

CONCLUSIONS

The incidence of OHCA in children and young adults is higher than previously reported, and a more specific understanding of the causes should guide future prevention programs. Survival trends support contemporary resuscitation protocols for OHCA in the young.

Age-specific differences in outcomes after out-of-hospital cardiac arrests

OBJECTIVE

We assessed out-of-hospital cardiac arrests (OHCAs) for various pediatric age groups.

METHODS

This prospective, population-based, observational study included all emergency medical service-treated OHCAs in Osaka, Japan, between 1999 and 2006 (excluding 2004). Patients were grouped as adults (>17 years), infants (<1 year), younger children (1-4 years), older children (5-12 years), and adolescents (13-17 years). The primary outcome measure was 1-month survival with favorable neurologic outcome.

RESULTS

Of 950 pediatric OHCAs, resuscitations were attempted for 875 patients (92%; 347 infants, 203 younger children, 135 older children, and 190 adolescents). The overall incidence of nontraumatic pediatric OHCAs was 7.3 cases per 100 000 person-years, compared with 64.7 cases per 100 000 person-years for adults and 65.5 cases per 100 000 person-years for infants. Most infant OHCAs occurred in homes (93%) and were not witnessed (90%). Adolescent OHCAs often occurred outside the home (45%), were witnessed by bystanders (37%), and had shockable rhythms (18%). One-month survival was more common after nontraumatic pediatric OHCAs than adult OHCAs (8% [56 of 740 patients] vs 5% [1677 of 33 091 patients]; adjusted odds ratio: 2.26 [95% confidence interval: 1.63-3.13]). One-month survival with favorable neurologic outcome was more common among children than adults (3% [21 of 740 patients] vs 2% [648 of 33 091 patients]; adjusted odds ratio: 2.46 [95% confidence interval: 1.45-4.18]). Rates of 1-month survival with favorable neurologic outcome were 1% for infants, 2% for younger children, 2% for older children, and 11% for adolescents.

CONCLUSION

Survival and favorable neurologic outcome at 1 month were more common after pediatric OHCAs than adult OHCAs.

Out-of-hospital cardiac arrests in children

Prehospital pediatric cardiac arrest is a rare event compared with adult cardiac arrest. Despite the recent advancements in postresuscitation care improving the outcome of adult patients, similar evidence is lacking in pediatric victims of cardiac arrest. In this brief article, the current data on pediatric cardiac arrest occurring in the prehospital setting are reviewed. The annual incidence of pediatric out-of-hospital cardiac arrest is approximately 8–10 cases per 100,000 persons. The outcome is generally poor, as only 2–9.6% of patients survive to hospital discharge. The neurologic outcome of survivors is good in 24–31% of patients. Current evidence is insufficient to strongly support or refute the use of mild therapeutic hypothermia during the postresuscitation phase in pediatric patients. The application of a goal-directed treatment protocol for pediatric cardiac arrest and postresuscitation syndrome needs to be evaluated.