Application of adult prehospital resuscitation rules to pediatric out of hospital cardiac arrest

doi:10.1016/j.resuscitation.2022.109684

Resuscitation

Volume 184, March 2023, 109684

https://doi.org/10.1016/j.resuscitation.2022.109684 Get rights and content

Abstract

Background

Prehospital termination of resuscitation (TOR) rules can be recommended for adults with out-of-hospital cardiac arrests (OHCAs). This study aimed to investigate whether adult basic life support (BLS) and advanced life support (ALS) TOR rules can predict neurologically unfavorable one-month outcome for pediatric OHCA patients.

Methods

From a nationwide population-based observational cohort study, we extracted data of consecutive pediatric OHCA patients (0–17 years old) from January 1, 2005, to December 31, 2011. The BLS TOR rule has three criteria, whereas the ALS TOR rule includes two additional criteria. We selected pediatric OHCA patients that met all criteria for each TOR rule and calculated the specificity and positive predictive value (PPV) of each TOR rule for identifying pediatric OHCA patients who did not have neurologically favorable one-month outcome.

Results

Of the 12,740 pediatric OHCA patients eligible for the evaluation of the BLS TOR rule, 10,803 patients met the BLS TOR rule, with a specificity of 0.785 and a PPV of 0.987 for predicting a lack of neurologically favorable one-month survival. Of the 2,091 for the ALS TOR rule, 381 patients met the ALS TOR rule, with a specificity of 0.986 and a PPV of 0.997 for predicting neurologically unfavorable one-month outcome.

Conclusions

The adult BLS and ALS TOR rules had a high PPV for predicting pediatric OHCA patients without a neurologically favorable survival at one month after onset.

Introduction

Cardiac arrest remains a leading cause of mortality and morbidity in the United States and other countries worldwide.1, 2 Despite improvements in the chain of survival, including a public-access defibrillation system and revisions to cardiopulmonary resuscitation (CPR) guidelines,1, 2, 3 survival rates from pediatric and adult out-of-hospital cardiac arrests (OHCAs) remain poor.1, 2

Prehospital termination of resuscitation (TOR) is considered instead of transporting OHCA patients to the hospitals for ongoing resuscitation because of their poor survival and heavy economic burdens.1, 4, 5, 6, 7, 8 Several studies and a meta-analysis have validated the basic life support (BLS) and advanced life support (ALS) TOR rules which were originally developed in North America, and have shown that these rules have high specificity and positive predictive value (PPV) and performed well in identifying adults with OHCA who had little or no chance of survival.6, 7, 8 Both the American Heart Association (AHA) and European Resuscitation Council (ERC) 2020 cardiopulmonary resuscitation (CPR) guidelines recommend that emergency medical services (EMS) personnel consider TOR for adult OHCA patients that have failed to respond to BLS and/or ALS treatment efforts.1, 5 However, few clinical studies have assessed the performance of the BLS and ALS TOR rules for pediatric OHCA patients⁹ and there is no such study in Asia.

Recently, we demonstrated that ‘North American TOR rules’ performed well in Japan with high specificity and PPV for predicting the lack of neurologically favorable one-month survival in Japan.¹⁰ Herein, we believed that evaluating whether these rules would also apply to pediatric OHCA patients was important. In Japan, EMS personnel are not legally permitted to terminate resuscitation for OHCA patients in the prehospital setting. Therefore, EMS personnel in Japan are required to transport almost all pediatric OHCA patients to a hospital regardless of the success or failure of their resuscitation efforts. Therefore, this study aimed to investigate whether BLS and ALS TOR rules can predict neurologically favorable one-month outcome for pediatric OHCA patients in Japan using a large population-based registry covering the whole of Japan.

Section snippets

Study design and settings

The All-Japan Registry of the Fire and Disaster Management Agency (FDMA) is a nationwide, population-based registry of OHCAs that is based on the standardized Utstein style.¹¹ This study enrolled all pediatric OHCA patients aged 0–17 years, treated by EMS personnel, and transported to medical institutions from January 1, 2010, to December 31, 2019. The Ethics Committee of Osaka University Graduate School of Medicine approved this registry. The requirement of written informed consent was waived.

Results

From January 2010 to December 2019, there were 16,209 pediatric OHCAs in Japan, of which 14,910 were received resuscitation, 12,812 received only BLS care by EMS personnel and 2,098 received both BLS and ALS care by EMS personnel. Finally, 12,740 were eligible for the evaluation of the BLS TOR rule and 2,091 for the ALS TOR rule after excluding cases without complete data (Fig. 1).

Discussion

This study used the nationwide population-based Utstein Registry of OHCA in Japan to investigate whether adult BLS and ALS TOR rules developed in Canada and the United States could predict death within one month of OHCA onset and poor neurological outcome in pediatric OHCA patients in Japan. The results showed that the adult ALS rule had high specificity and PPV for death and neurologically unfavorable outcome one month after the onset.

Regarding the TOR rule for pediatric OHCA, a previous study

Conclusions

The adult BLS and ALS TOR rules had a high PPV for predicting neurologically unfavorable one-month outcome. Especially, the ALS rule had very good prediction especially for infants. In Japan, the ALS TOR rule would be used as one of the prognostic predictors for OHCA patients after arrival at the hospital, especially for infants.

Ethical approval

This study was conducted according to the Declaration of Helsinki. The Ethics Committee of Osaka University Graduate School of Medicine approved this registry.

Consent for publication

Not applicable.

Availability of data and materials

The datasets and/or analysis in this study are not publicly available because the ethics committee did not permit it.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was supported by a scientific research grant from the JSPS KAKENHI of Japan 22 K09139 to Kitamura).

Acknowledgments

We are greatly indebted to all of the EMS personnel and concerned physicians in Japan, and to the Fire and Disaster Management Agency and Institute for Fire Safety and Disaster Preparedness of Japan for their generous cooperation in establishing and maintaining the Utstein database.

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This article highlights ten impactful articles from the year 2023 whose findings can improve the care of children in the Emergency Department (ED). These studies address pediatric resuscitation, traumatic arrest, septic shock, airway management, nailbed injuries, bronchiolitis, infant fever, cervical spine injuries, and cancer risk from radiation (Table 1). The findings in these articles have the potential to impact the evaluation and management of children (Table 2).
Identifying individuals satisfying the termination of resuscitation rule but having potential to achieve favourable neurological outcome following out-of-hospital cardiac arrest
2023, Resuscitation
To develop a simple scoring model that identifies individuals satisfying the termination of resuscitation (TOR) rule but having potential to achieve favourable neurological outcome following out-of-hospital cardiac arrest (OHCA).
This study analysed the All-Japan Utstein Registry from 1 January 2010 to 31 December 2019. We identified patients satisfying basic life support (BLS) and advanced life support (ALS) TOR rules and determined factors associated with favourable neurological outcome (cerebral performance category scale of 1 or 2) for each cohort using multivariable logistic regression analysis. Scoring models were derived and validated to identify patient subgroups that might benefit from continued resuscitation efforts.
Among 1,695,005 eligible patients, 1,086,092 (64.1%) and 409,498 (24.2%) satisfied BLS and ALS TOR rules, respectively. One month post-arrest, 2038 (0.2%) and 590 (0.1%) patients in the BLS and ALS cohorts, respectively, achieved favourable neurological outcome. A scoring model derived for the BLS cohort (2 points for age <17 years or ventricular fibrillation/ventricular tachycardia rhythm; 1 point for age <80 years, pulseless electrical activity rhythm, or transport time <25 min) effectively stratified the probability of achieving 1-month favourable neurological outcome, with patients scoring <4 having a probability of <1%, whereas those scoring 4, 5, and 6 having probabilities of 1.1%, 7.1%, and 11.1%, respectively. In the ALS cohort, the probability increased with scores; however, it remained <1%.
A simple scoring model comprising age, first documented cardiac rhythm, and transport time effectively stratified the likelihood of achieving favourable neurological outcome in patients satisfying the BLS TOR rule.

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Clinical paperApplication of adult prehospital resuscitation rules to pediatric out of hospital cardiac arrest

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Study design and settings

Results

Discussion

Conclusions

Ethical approval

Consent for publication

Availability of data and materials

Competing interests

Funding

Acknowledgments

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

J Emerg Med

Resuscitation

Part 1: Executive Summary: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care

Circulation

Prehospital termination of resuscitation in cases of refractory out-of-hospital cardiac arrest

JAMA

Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care

Circulation

Clinical paper
Application of adult prehospital resuscitation rules to pediatric out of hospital cardiac arrest