A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest.
ABSTRACT STUDY OBJECTIVEs: To perform a population-based study addressing the demography, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest (PCPA).
Prospective, population-based study of all children (17 years of age or younger) in a large urban municipality who were treated by EMS personnel for apneic, pulseless conditions. Data were collected prospectively for 3(1/2) years using a comprehensive data collection tool and on-line computerized database. Each child received standard pediatric advanced cardiac life support.
During the 3(1/2)-year period, 300 children presented with PCPA (annual incidence of 19. 7/100,000 at risk). Of these, 60% (n=181) were male (P =.0003), and 54% (n=161) were patients 12 months of age or younger (152,500 at risk). Compared with the population at risk (32% black patients, 36% Hispanic patients, 26% white patients), a disproportionate number of arrests occurred in black children (51.6% versus 26.6% in Hispanics, and 17% in white children; P <.0001). Over 60% of all cases (n=181) occurred in the home with family members present, and yet those family members initiated basic CPR in only 31 (17%) of such cases. Only 33 (11%) of the total 300 PCPA cases had a return of spontaneous circulation, and 5 of the 6 discharged survivors had significant neurologic sequelae. Only 1 factor, endotracheal intubation, was correlated positively with return of spontaneous circulation (P =.032).
This population-based study underscores the need to investigate new therapeutic interventions for PCPA, as well as innovative strategies for improving the frequency of basic CPR for children.
- SourceAvailable from: PubMed Central[Show abstract] [Hide abstract]
ABSTRACT: Objective We aimed to compare rescuer fatigue and cardiopulmonary resuscitation (CPR) quality between standard 30:2 CPR (ST-CPR) and chest compression only CPR (CO-CPR) performed for 8 minutes on a realistic manikin by following the 2010 CPR guidelines.Methods All 36 volunteers (laypersons; 18 men and 18 women) were randomized to ST-CPR or CO-CPR at first, and then each CPR technique was performed for 8 minutes with a 3-hour rest interval. We measured the mean blood pressure (MBP) of the volunteers before and after performing each CPR technique, and continuously monitored the heart rate (HR) of the volunteers during each CPR technique using the MRx monitor. CPR quality measures included the depth of chest compression (CC) and the number of adequate CCs per minute.ResultsThe adequate CC rate significantly differed between the 2 groups after 2 minutes, with it being higher in the ST-CPR group than in the CO-CPR group. Additionally, the adequate CC rate significantly differed between the 2 groups during 8 minutes for male volunteers (p =0.012). The number of adequate CCs was higher in the ST-CPR group than in the CO-CPR group after 3 minutes (p =0.001). The change in MBP before and after performing CPR did not differ between the 2 groups. However, the change in HR during 8 minutes of CPR was higher in the CO-CPR group than in the ST-CPR group (p =0.007).Conclusions The rate and number of adequate CCs were significantly lower with the CO-CPR than with the ST-CPR after 2 and 6 minutes, respectively, and performer fatigue was higher with the CO-CPR than with the ST-CPR during 8 minutes of CPR.Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 10/2014; 22(1):59. · 1.93 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Endotracheal intubation (ETI) is currently considered superior to supraglottic airway devices (SGA) for survival and other outcomes among adults with non-traumatic out-of-hospital cardiac arrest (OHCA). We aimed to determine if the research supports this conclusion by conducting a systematic review. We searched the MEDLINE, Scopus and CINAHL databases for studies published between January 1, 1980, and 30 April 30, 2013, which compared pre-hospital use of ETI with SGA for outcomes of return of spontaneous circulation (ROSC); survival to hospital admission; survival to hospital discharge; and favorable neurological or functional status. We selected studies using pre-specified criteria. Included studies were independently screened for quality using the Newcastle-Ottawa scale. We did not pool results because of study variability. Study outcomes were extracted and results presented as summed odds ratios with 95% CI. We identified five eligible studies: one quasi-randomized controlled trial and four cohort studies, involving 303,348 patients in total. Only three of the five studies reported a higher proportion of ROSC with ETI versus SGA with no difference reported in the remaining two. None found significant differences between ETI and SGA for survival to hospital admission or discharge. One study reported better functional status at discharge for ETI versus SGA. Two studies reported no significant difference for favorable neurological status between ETI and SGA. Current evidence does not conclusively support the superiority of ETI over SGA for multiple outcomes among adults with OHCA.The western journal of emergency medicine 11/2014; 15(7):749-757.
- [Show abstract] [Hide abstract]
ABSTRACT: Objective To analyze the characteristics and outcome of cardiorespiratory arrest secondary to trauma in children. Patients and methods We performed a secondary analysis of data from a prospective, multicenter study of cardiorespiratory arrest in children. Data were recorded according to the Utstein style. Twenty-eight children (age range: 7 days to 16 years) with cardiorespiratory arrest secondary to trauma were evaluated. The outcome variables were return of spontaneous circulation, sustained (more than 20 minutes) return of spontaneous circulation (initial sur vival), and survival at hospital discharge (final survival) in relation to the characteristics of the cardiorespiratory arrest and cardiopulmonary resuscitation. Neurological and general performance outcome was assessed by means of the Pediatric Cerebral Performance Category scale and the Pediatric Overall Performance Category scale. Results Return of spontaneous circulation was obtained in 18 patients (64.2 %), initial survival was achieved in 14 (50 %) and final survival was achieved in three (10.7 %) (two without neurological sequelae and one with vegetative status). Final survival was significantly higher in patients with respiratory arrest (33.3 %) than in those with cardiac arrest (4.5 %), p = 0.04. Final survival was also higher in patients with a duration of cardiopulmonary resuscitation shorter than 20 minutes (27.2 %) than in the remaining patients (0 %), p = 0.05. The two survivors without neurologic sequelae had respiratory arrest. Conclusions Survival until hospital discharge in children with cardiorespiratory arrest secondary to trauma is lower than that in children with cardiorespiratory arrest. Patients with respiratory arrest when resuscitation is started and those with a duration of cardiopulmonary resuscitation of less than 20 minutes showed better survival than the remaining patients.Anales de Pediatría 11/2006; 65(5):439–447. · 0.72 Impact Factor
Kelly D. Young, Marianne Gausche-Hill, Christian D. McClung and Roger J. Lewis
Out-of-Hospital Pediatric Cardiopulmonary Arrest
A Prospective, Population-Based Study of the Epidemiology and Outcome of
located on the World Wide Web at:
The online version of this article, along with updated information and services, is
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Grove Village, Illinois, 60007. Copyright © 2004 by the American Academy of Pediatrics. All
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
. Provided by Univ of Miami on April 7, 2010 www.pediatrics.orgDownloaded from
A Prospective, Population-Based Study of the Epidemiology and
Outcome of Out-of-Hospital Pediatric Cardiopulmonary Arrest
Kelly D. Young, MD, MS*‡§; Marianne Gausche-Hill, MD‡§?¶; Christian D. McClung, MD, MPhil#**; and
Roger J. Lewis, MD, PhD‡§?
demiologic features, survival rates, and neurologic out-
comes of the largest population-based series of pediatric
out-of-hospital cardiopulmonary arrest patients with
prospectively collected data.
Secondary analysis of data from a prospec-
tive, interventional trial of out-of-hospital pediatric air-
way management conducted from 1994 to 1997 (Gausche
M, Lewis RJ, Stratton SJ, et al. JAMA. 2000;283:783-790).
Consecutive out-of-hospital patients from 2 large urban
counties in California <12 years old or 40 kg in body-
weight who were determined by paramedics to be pulse-
less and apneic were included. Main outcome measures
included survival to hospital discharge, patient demo-
graphics, arrest etiology, arrest rhythm, event intervals,
and neurologic outcomes.
In 599 patients, 601 events were studied (54%
were <1 year old, 58% were male). Return of spontane-
ous circulation was achieved in 29%; 25% were admitted
to the hospital, and 8.6% (51) survived to hospital dis-
charge. The most prevalent etiologies were sudden infant
death syndrome and trauma; these resulted in relatively
higher mortality. Respiratory etiologies and submersions
followed; these resulted in relatively lower mortality.
Twenty-six percent of the arrests were witnessed by cit-
izens, and an additional 8% were witnessed by rescue
personnel. Witnessed arrests had a higher survival rate
(16%). Thirty-one percent of patients received bystander
cardiopulmonary resuscitation, which was not demon-
strated to result in improved survival rates. Arrest
rhythms were asystole (67%), pulseless electrical activity
(24%), and ventricular fibrillation (9%); children with the
latter 2 rhythms had better survival rates. One third of
the survivors (16 of 51) had good neurologic outcome,
none of whom received >3 doses of epinephrine or were
resuscitated for >31 minutes in the emergency depart-
The 8.6% survival rate after out-of-
hospital pediatric cardiopulmonary arrest is poor. Ad-
ministration of >3 doses of epinephrine or prolonged
resuscitation is futile. Pediatrics 2004;114:157–164; cardio-
This study reports the epi-
pulmonary arrest, cardiopulmonary resuscitation, out-of-
hospital, prehospital, pediatric.
ABBREVIATIONS. EMS, emergency medical services; BMV, bag-
mask ventilation; CPR, cardiopulmonary resuscitation; ED, emer-
gency department; ROSC, return of spontaneous circulation;
PCPC, Pediatric Cerebral Performance Category; PEA, pulseless
electrical activity; IQR, interquartile range; SIDS, sudden infant
death syndrome; VF, ventricular fibrillation; VT, ventricular
prevention and therapy and to optimize emergency
medical services (EMS) protocols is needed to im-
prove outcomes. Unfortunately, the current litera-
ture is limited mostly to small retrospective case
series. Lack of uniformity in case definitions and
outcomes reported has further inhibited data inter-
pretation and meta-analyses. The pediatric Utstein
style is a set of international guidelines for uniform
reporting of pediatric advanced life support data that
was published in 1995.2Recent studies have begun
using these standardized definitions and reporting
Even in studies in which data collection has been
prospective, population based, and reported by us-
ing the Utstein criteria, data have been drawn pri-
marily from EMS personnel written documentation.
This study uses the pediatric Utstein style to record
and report data and represents the largest prospec-
tive, population-based series of pediatric cardiopul-
monary arrest patients to date. This study is unique
in that additional data were gathered through direct
telephone communication with EMS personnel after
transfer of patient care to the receiving hospital, thus
minimizing recall bias, missing data, and recording
atient outcomes after pediatric cardiopulmo-
nary arrest are dismal and have not improved
over the last 3 decades.1Research to improve
This is a secondary analysis of data from an interventional,
randomized, controlled trial of pediatric airway management con-
ducted from March 15, 1994, to January 1, 1997, the methodology
and primary results of which have been described elsewhere.6,7
Briefly, the original study was a controlled, clinical trial of out-of-
hospital airway management in children ?12 years old or esti-
mated to weigh ?40 kg. Patients requiring airway management
were assigned by calendar day to receive either bag-mask venti-
lation (BMV) (odd days; n ? 410) or BMV followed by endotra-
cheal intubation (even days; n ? 420). This study showed that
there was no significant difference in patient survival rates in the
BMV group and the endotracheal intubation group for either the
overall patient sample or the cardiopulmonary arrest subgroup.
From the Departments of *Pediatrics and ?Medicine, David Geffen Univer-
sity of California Los Angeles School of Medicine, Los Angeles, California;
Departments of ‡Emergency Medicine and #Surgery, Harbor-University of
California Los Angeles Medical Center, Torrance, California; §Harbor-Uni-
versity of California Los Angeles Research and Education Institute, Los
Angeles, California; ¶Little Company of Mary Hospital, Torrance, Califor-
nia; and **Department of Emergency Medicine, University of Southern
California Medical Center, Los Angeles, California.
Received for publication Sep 29, 2003; accepted Jan 28, 2004.
Reprint requests to (K.D.Y.) Department of Emergency Medicine, Harbor-
UCLA Medical Center, 1000 W Carson St, Box 21, Torrance, CA 90509.
PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad-
emy of Pediatrics.
PEDIATRICS Vol. 114 No. 1 July 2004
. Provided by Univ of Miami on April 7, 2010
This study population consisted of consecutive patients ?12
years old or ?40 kg estimated body weight entered into the
original interventional study who were noted to be in cardiac
arrest, defined as inability by paramedics to palpate a central
pulse, unresponsiveness, and apnea. Patients who were consid-
ered pulseless and/or given cardiopulmonary resuscitation (CPR)
before EMS arrival but who had a pulse on EMS arrival were not
included. Patients who became pulseless during evaluation and
transport by paramedics were included.
Los Angeles and Orange Counties, California, are 2 contiguous
metropolitan urban areas with an area of 4869 square miles and a
population of ?12 million persons,8,9?25% of which are ?13
years old. Both counties have a 2-tiered EMS response consisting
of basic and advanced life support units. Los Angeles County
patients were transported to the nearest emergency department
(ED) approved for pediatric patients or to 1 of 13 trauma centers
(if a trauma patient).10Orange County patients were transported
to a designated receiving hospital for stabilization and later trans-
ferred to a pediatric tertiary care facility as needed.
A closed-response data-collection form was completed in the
ED by the paramedic and emergency physician and mailed to
study investigators. Paramedics paged a 24-hour on-call investi-
gator immediately after transfer of patient care to the ED staff. The
on-call investigator interviewed the paramedic by using a struc-
tured format and recorded information on the precipitating event;
presenting and arrest rhythms; presence of witnesses and provi-
sion of bystander CPR; estimated down time before arrest; out-of-
hospital interventions; and whether there was return of spontane-
ous circulation (ROSC).
Two research nurses retrospectively reviewed inpatient medi-
cal records, coroner reports, investigator report forms, and EMS
report forms to obtain demographic information, process-of-care
data (eg, elapsed times), and outcome data on all patients. For
patients transferred from one acute care hospital to another,
records at the second hospital were obtained, and the patient was
followed until discharged from the hospital or a chronic care
During the original study, several safeguards were put in place
to ensure that eligible patients were not missed.7These safeguards
included regular review of all pediatric EMS calls, monthly eval-
uation of patient accrual rates, and a systematic review of cases for
a 3-month period midway into the study period.6During this
systematic review, investigators comprehensively surveyed all
out-of-hospital care coordinators and reviewed all pediatric EMS
records; only 1 possible missed subject was detected.
The primary study outcome, survival to discharge from an
acute care hospital, and the secondary outcome, neurologic status
using the Pediatric Cerebral Performance Category (PCPC)11at
hospital discharge, were evaluated retrospectively as described.6
The PCPC categorizes outcome as 1 (normal), 2 (mild disability), 3
(moderate disability), 4 (severe disability), 5 (coma/vegetative
state), and 6 (death). We added category 7 (no change from pre-
viously abnormal neurologic status).
Although data were collected prospectively, not all EMS event
intervals as outlined by the Utstein style2were feasible to collect or
collected accurately. We established definitions for important EMS
event intervals (Table 1).
EMS personnel were defined as “those who responded in an
official capacity as part of an organized specifically-trained re-
sponse team” per the Utstein definitions.2Law enforcement per-
sonnel often arrived on the scene first; therefore, EMS personnel
performing CPR included trained first responders, law enforce-
ment officers on duty, EMS-basic providers, paramedics, nurses,
and physicians. Bystander CPR included CPR performed by non-
medically trained people as well as medically trained personnel
who were bystanders and not part of an organized response team.
Although the Utstein style recommends broad categorization of
arrest etiology as respiratory compromise, circulatory compro-
mise, or cardiorespiratory failure, we wished to report more de-
tailed data.2Etiology subgroup assignments were based on all the
information available from EMS run forms, investigator forms,
inpatient medical records, and coroner reports.
Age categories of neonate (0-28 days old), infant (30-364 days),
toddler (1-4 years), and child (5-12 years) were used, consistent
with the pediatric Utstein style.2Because of inclusion criteria that
allowed for patients ?12 years old to be enrolled if their estimated
weight was ?40 kg, 3 patients ?12 years old were enrolled. We
included these patients in the “child” category.
Arrest rhythm consisted of the rhythm noted by paramedics
when the patient was found to be pulseless. Patients reported by
paramedics to have organized electrical activity on the cardiac
monitor yet to be without a palpable central pulse were defined as
having an arrest rhythm of pulseless electrical activity (PEA).
Definitions for EMS Event Intervals
EMS Event IntervalDecision Rule
Estimated time last seen to time EMS notified (dispatch called)
Time EMS unit notified (dispatch called) to time of BLS or ALS
arrival at scene
Time of BLS or ALS arrival at scene to time EMS unit left scene
If the arrest is witnessed and with bystander CPR or the arrest
occurs in the presence of EMS, then minutes to CPR ? 0
If arrest is witnessed and without bystander CPR, minutes to CPR ?
time EMS unit notified (dispatch called) to time BLS or ALS
arrived at scene
If arrest is unwitnessed and without bystander CPR, minutes to CPR
? estimated time last seen to arrival of BLS or ALS at scene
If arrest is unwitnessed and with bystander CPR on discovery,
minutes to CPR ? time patient last seen to time EMS unit notified
If bystander CPR present, start-stop CPR interval ? the time EMS
unit notified (dispatch called) to time of ROSC or death
If patient arrested in presence of EMS providers or there is no
bystander CPR, start-stop CPR interval ? time of EMS unit arrival
to time of ROSC or death
Time EMS unit left scene to time of arrival in ED
If known ROSC ?20 min or ROSC in the field or in the ED that
results in the patient being admitted to the hospital alive
Minutes to CPR
BLS, indicates basic life support; ALS, advanced life support.
OUT-OF-HOSPITAL PEDIATRIC CARDIOPULMONARY ARREST
www.pediatrics.orgDownloaded from . Provided by Univ of Miami on April 7, 2010
When the paramedic described only “full arrest” or “pulseless”
without information on electrical rhythm, we considered arrest
rhythm to be missing.
Institutional Review Board Approvals
The primary study was approved by all 115 institutional re-
view boards or medical staff offices of participating hospitals.
Patients were enrolled under a waiver of consent as described
Data analysis was performed with Stata 6.0 software (Stata
Corp, College Station, TX) and SAS 8.1 (SAS Institute Inc, Cary,
NC) by K.D.Y. and C.D.M. Continuous variables are reported by
median and interquartile range (IQR) and compared by using the
Wilcoxon rank sum test. Categorical variables are expressed as
proportions and compared with the ?2test.
There were 601 cardiopulmonary arrest events in
599 subjects from the 830 patients enrolled in the
original interventional study. Arrests were distrib-
uted evenly over the days of the week and months of
Status of survival to hospital discharge was known
for 596 arrest events, and status of ROSC was known
for 594. ROSC was never achieved in 71% (424 of
594); in 25% (148 of 594) of the events, patients were
admitted to the hospital, and 8.6% (51 of 596) sur-
vived to hospital discharge (Fig 1). One child sur-
vived 2 arrest events, ie, there were 50 survivors of 51
Fig. 1. Flow diagram of patient enrollment and outcomes. PCPC: 1 indicates no disability; 2, mild disability; 3, moderate disability; 4,
severe disability; 5, coma or vegetative state.
. Provided by Univ of Miami on April 7, 2010 www.pediatrics.orgDownloaded from
Table 2 lists characteristics of the subjects. For each
variable, there are different numbers of events with
missing data; the table lists the number of events
with complete information. Fifty-eight percent of the
subjects were male (P ? .001, relative to an expected
proportion of 50%). African Americans made up 25%
(104 of 410) of our Los Angeles County cardiopul-
monary arrest population but account for only 12%
of the overall population of children 0 to 14 years old
during this time period as reported in census data.12
Thus, although there were no significant differences
in survival by gender or ethnicity, African American
children in Los Angeles County had twice the risk of
sustaining cardiopulmonary arrest compared with
the total population. There was a trend toward a
higher proportion of sudden infant death syndrome
(SIDS) as the arrest etiology in the African American
patients (29% vs 23%; P ? .08).
Children ?1 year old predominated (328 of 601,
54%). Ten percent of the population consisted of
neonates (0-28 days old), and approximately half of
these neonates were newly born. Newborns had a
high survival rate of 36% (11 of 31). Survival for
infants 29 to 364 days old was low (10 of 265, 4%), as
was survival for children 5 to 12 years old (4 of 92,
Table 3 lists the primary arrest etiologies. Patients
with traumatic arrests had relatively lower survival
rates, whereas patients with a respiratory or submer-
sion-associated etiology had better survival rates.
Data were available regarding the presence of a
witness to the arrest for 561 subjects: 26% (147) of the
arrests were witnessed by a citizen, and an addi-
tional 8% (45) of the arrests occurred in the presence
of EMS personnel. Witnessed arrests had a signifi-
cantly higher survival rate (31 of 192, 16%), com-
pared with the overall survival rate of 8.6% (P ?
.0001). Bystander CPR was given in 181 of 590 (31%)
of the cases in which data were recorded. There was
no observed gain in survival with bystander CPR.
Only 28% (41 of 147) of victims whose arrest was
witnessed by a citizen received bystander CPR. For
arrests witnessed by citizens, there was a trend to-
ward higher survival for those who received by-
stander CPR (9 of 41, 22%), versus those who didn’t
(14 of 105, 13%) (P ? .2).
Arrest rhythms could be determined for 548 sub-
jects, with asystole accounting for 67%, followed by
PEA in 24%, and ventricular fibrillation (VF) in 9%.
There were no cases of ventricular tachycardia (VT).
Only 3% of patients in asystole survived to hospital
discharge, compared with 19% of those in PEA and
10% of those in VF (P ? .0001). VF was more com-
mon in the following subgroups: children ?5 years
old (17 of 87, 20%), patients with an underlying
cardiac etiology (10 of 47, 21%) or submersion etiol-
ogy (10 of 72, 14%), and among those with witnessed
arrests (22 of 165, 13%). Eighty-seven percent of SIDS
patients (115 of 132) were in asystole, whereas 6% (8
of 132) were in VF.
Airway management was randomized as part of
the original interventional study. Of the 51 survival
Patient Characteristic Nonsurvivors
(n ? 545)
Survivors to Hospital
Discharge (n ? 51)
(n ? 601)
Neonate (0–28 days)
Infant (29–364 days)
Toddler (1–4 years)
Child (5–12 years)
Los Angeles County
By any witness
310/545 (57%) 34/51 (67%)349/601 (58%).18
Note that the denominators reflect the total number of patients for that subcategory with available data. The denominators for survivors
and nonsurvivors do not add up to the total, because there were 5 patients missing data with respect to survival.
OUT-OF-HOSPITAL PEDIATRIC CARDIOPULMONARY ARREST
www.pediatrics.org Downloaded from . Provided by Univ of Miami on April 7, 2010