First Documented Rhythm and Clinical Outcome From In-Hospital Cardiac Arrest Among Children and Adults

Departments of Anesthesia, Critical Care, and Pediatrics, University of Pennsylvania School of Medicine, Philadelphia 19104-4399, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 01/2006; 295(1):50-7. DOI: 10.1001/jama.295.1.50
Source: PubMed


Cardiac arrests in adults are often due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), which are associated with better outcomes than asystole or pulseless electrical activity (PEA). Cardiac arrests in children are typically asystole or PEA.
To test the hypothesis that children have relatively fewer in-hospital cardiac arrests associated with VF or pulseless VT compared with adults and, therefore, worse survival outcomes.
A prospective observational study from a multicenter registry (National Registry of Cardiopulmonary Resuscitation) of cardiac arrests in 253 US and Canadian hospitals between January 1, 2000, and March 30, 2004. A total of 36,902 adults (> or =18 years) and 880 children (<18 years) with pulseless cardiac arrests requiring chest compressions, defibrillation, or both were assessed. Cardiac arrests occurring in the delivery department, neonatal intensive care unit, and in the out-of-hospital setting were excluded.
Survival to hospital discharge.
The rate of survival to hospital discharge following pulseless cardiac arrest was higher in children than adults (27% [236/880] vs 18% [6485/36,902]; adjusted odds ratio [OR], 2.29; 95% confidence interval [CI], 1.95-2.68). Of these survivors, 65% (154/236) of children and 73% (4737/6485) of adults had good neurological outcome. The prevalence of VF or pulseless VT as the first documented pulseless rhythm was 14% (120/880) in children and 23% (8361/36,902) in adults (OR, 0.54; 95% CI, 0.44-0.65; P<.001). The prevalence of asystole was 40% (350) in children and 35% (13 024) in adults (OR, 1.20; 95% CI, 1.10-1.40; P = .006), whereas the prevalence of PEA was 24% (213) in children and 32% (11,963) in adults (OR, 0.67; 95% CI, 0.57-0.78; P<.001). After adjustment for differences in preexisting conditions, interventions in place at time of arrest, witnessed and/or monitored status, time to defibrillation of VF or pulseless VT, intensive care unit location of arrest, and duration of cardiopulmonary resuscitation, only first documented pulseless arrest rhythm remained significantly associated with differential survival to discharge (24% [135/563] in children vs 11% [2719/24,987] in adults with asystole and PEA; adjusted OR, 2.73; 95% CI, 2.23-3.32).
In this multicenter registry of in-hospital cardiac arrest, the first documented pulseless arrest rhythm was typically asystole or PEA in both children and adults. Because of better survival after asystole and PEA, children had better outcomes than adults despite fewer cardiac arrests due to VF or pulseless VT.

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Available from: Gregory Luke Larkin
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    • "After successful resuscitation from cardiac arrest, even with therapeutic hypothermia treatment [1-3], most patients either die in the hospital or suffer permanent, crippling neurological disability due to anoxic brain injury [4]. Finding new approaches to attenuate brain injury after return of spontaneous circulation (ROSC) is a high priority for resuscitation science. "
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    ABSTRACT: Post-cardiac arrest hypocapnia/hypercapnia have been associated with poor neurological outcome. However, the impact of arterial carbon dioxide (CO2) derangements during the immediate post-resuscitation period following cardiac arrest remains uncertain. We sought to test the correlation between prescribed minute ventilation and post-resuscitation partial pressure of CO2 (PaCO2), and to test the association between early PaCO2 and neurological outcome. We retrospectively analyzed a prospectively compiled single-center cardiac arrest registry. We included adult (age >= 18 years) patients who experienced a non-traumatic cardiac arrest and required mechanical ventilation. We analyzed initial post-resuscitation ventilator settings and initial arterial blood gas analysis (ABG) after initiation of post-resuscitation ventilator settings. We calculated prescribed minute ventilation:MVmL/kg/min=tidalvolumeTV/idealbodyweightIBWxrespiratoryrateRRfor each patient. We then used Pearson's correlation to test the correlations between prescribed MV and PaCO2. We also determined whether patients had normocapnia (PaCO2 between 30 and 50 mmHg) on initial ABG and tested the association between normocapnia and good neurological function (Cerebral Performance Category 1 or 2) at hospital discharge using logistic regression analyses. Seventy-five patients were included. The majority of patients were in-hospital arrests (85%). Pulseless electrical activity/asystole was the initial rhythm in 75% of patients. The median (IQR) TV, RR, and MV were 7 (7 to 8) mL/kg, 14 (14 to 16) breaths/minute, and 106 (91 to 125) mL/kg/min, respectively. Hypocapnia, normocapnia, and hypercapnia were found in 15%, 62%, and 23% of patients, respectively. Good neurological function occurred in 32% of all patients, and 18%, 43%, and 12% of patients with hypocapnia, normocapnia, and hypercapnia respectively. We found prescribed MV had only a weak correlation with initial PaCO2, R = -0.40 (P < 0.001). Normocapnia was associated with good neurological function, odds ratio 4.44 (95%CI 1.33 to 14.85). We found initial prescribed MV had only a weak correlation with subsequent PaCO2 and that early Normocapnia was associated with good neurological outcome. These data provide rationale for future research to determine the impact of PaCO2 management during mechanical ventilation in post-cardiac arrest patients.
    Full-text · Article · Mar 2014 · Annals of Intensive Care
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    • "According to recent epidemiological studies, approximately 70% of cardiac arrest (CA) patients who had restoration of spontaneous circulation (ROSC) died before hospital discharge [1]–[3]. Postresuscitation myocardial dysfunction is one of the major factors contributing to the high mortality after initial resuscitation [4]. "
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    ABSTRACT: Sarcoplasmic reticulum (SR) Ca(2+)-handling proteins play an important role in myocardial dysfunction after acute ischemia/reperfusion injury. We hypothesized that nitrite would improve postresuscitation myocardial dysfunction by increasing nitric oxide (NO) generation and that the mechanism of this protection is related to the modulation of SR Ca(2+)-handling proteins. We conducted a randomized prospective animal study using male Sprague-Dawley rats. Cardiac arrest was induced by intravenous bolus of potassium chloride (40 µg/g). Nitrite (1.2 nmol/g) or placebo was administered when chest compression was started. No cardiac arrest was induced in the sham group. Hemodynamic parameters were monitored invasively for 90 minutes after the return of spontaneous circulation (ROSC). Echocardiogram was performed to evaluate cardiac function. Myocardial samples were harvested 5 minutes and 1 hour after ROSC. Myocardial function was significantly impaired in the nitrite and placebo groups after resuscitation, whereas cardiac function (i.e., ejection fraction and fractional shortening) was significantly greater in the nitrite group than in the placebo group. Nitrite administration increased the level of nitric oxide in the myocardium 5 min after resuscitation compared to the other two groups. The levels of phosphorylated phospholamban (PLB) were decreased after resuscitation, and nitrite increased the phosphorylation of phospholamban compared to the placebo. No significant differences were found in the expression of sarcoplasmic reticulum Ca(2+) ATPase (SERCA2a) and ryanodine receptors (RyRs). postresuscitation myocardial dysfunction is associated with the impairment of PLB phosphorylation. Nitrite administered during resuscitation improves postresuscitation myocardial dysfunction by preserving phosphorylated PLB protein during resuscitation.
    Full-text · Article · Dec 2013 · PLoS ONE
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    • "Pediatric in-hospital cardiac arrest survival outcomes have improved substantially over the past decade with nearly 40% of children having a good neurological outcome [1] [2] [3]. However, Abbreviations: AHA, American Heart Association; CPR, cardiopulmonary resuscitation ; CC, chest compression. "
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    ABSTRACT: Aim: Cardiopulmonary resuscitation (CPR) quality is associated with survival outcomes after out-of-hospital cardiac arrest. The objective of this study was to evaluate the effectiveness of simplified dispatcher CPR instructions to improve the chest compression (CC) quality during simulated pediatric cardiac arrest in public places. Methods: Adult bystanders recruited in public places were randomized to receive one of two scripted dispatcher CPR instructions: (1) "Push as hard as you can" (PUSH HARD) or (2) "Push approximately 2 inches" (TWO INCHES). A pediatric manikin with realistic CC characteristics (similar to a 6-year-old child), and a CPR recording defibrillator was used for quantitative CC data collection during a 2-min simulated pediatric scenario. The primary outcome was average CC depth treated as a continuous variable. Secondary outcomes included compliance with American Heart Association (AHA) CPR targets. Analysis was by two-sided unpaired t-test and Chi-square test, as appropriate. Results: 128 out of 140 providers screened met inclusion/exclusion criteria and all 128 consented. The average CC depth (mean (SEM)) was greater in PUSH HARD compared to TWO INCHES (43 (1) vs. 36 (1) mm, p<0.01) and met AHA targets more often (39% (25/64) vs. 20% (13/64), p=0.02). CC rates trended higher in the PUSH HARD group (93 (4) vs. 82 (4) CC/min, p=0.06). More providers did not achieve full chest recoil with PUSH HARD compared to TWO INCHES (53% (34/64) vs. 75% (48/64), p=0.01). Conclusions: Simplified dispatcher assisted pediatric CPR instructions: "Push as hard as you can" was associated with lay bystanders providing deeper and faster CCs on a simulated, 6-year-old pediatric manikin. However, percentage of providers leaning between CC increased. The potential effect of these simplified instructions in younger children remains unanswered.
    Full-text · Article · Sep 2013 · Resuscitation
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