Association between the relationship of bystander and neurologic recovery in pediatric out-of-hospital cardiac arrest

Abstract

Aim

This study aimed to evaluate whether the relationship between bystanders and victims is associated with neurological outcomes in paediatric out-of-hospital cardiac arrest (OHCA).

Methods

This cross-sectional, retrospective, observational study included patients with non-traumatic paediatric OHCA undergoing emergency medical service treatment between 2014 and 2021. The relationship between bystanders and patients was categorized into first responder, family, and layperson groups. The primary outcome was good neurological recovery. Further sensitivity analyses were conducted subcategorizing the cohort into four groups: first responder, family, friends or colleagues, and layperson, or two groups: family and non-family.

Results

We analysed 1,451 patients. OHCAs in the family group showed lower rate of good neurological outcomes regardless of witness status: 29.4%, 12.3%, and 38.6% in the first responder, family, and layperson groups in the witnessed and 6.7%, 2.0%, and 7.3% in the unwitnessed cohort. Multivariable logistic regression yielded no significant differences between the three groups: the adjusted odds ratios (AOR) and 95% confidence interval (CI) were 0.57 (0.28–1.15) in the family and 1.18 (0.61–2.29) in the layperson compared to the first responder group. The sensitivity analysis yielded a higher probability of good neurologic recovery in the non-family compared to the family member bystander group in witnessed cohort (AOR, 1.96; 95% CI, 1.17–3.30).

Conclusion

Paediatric OHCAs had no significant difference between good neurological recovery and the relationship of bystander.

Introduction

Paediatric out-of-hospital cardiac arrest (OHCA) is a major healthcare burden worldwide.1, 2, 3 The annual incidence of paediatric OHCA ranges from approximately four to eight cases per 100,000 person-years.4, 5, 6 Although efforts have been made to improve outcomes, poor outcomes are still common.7, 8 Paediatric cardiac arrest poses a substantial socioeconomic burden on families overall,2, 9 but patient age leads to disparities in outcomes and characteristics.¹⁰

Timely provision of bystander cardiopulmonary resuscitation (CPR) is associated with better survival rates and favourable neurologic outcomes in paediatric OHCA.11, 12 Previous studies have reported a relatively lower rate of bystander CPR in paediatric OHCA compared to adult, potentially due to insufficient public resources and unfamiliarity of bystanders with CPR.4, 8 Potential factors underlying this difference through region of study and study groups have not been fully clarified, but the importance of community-based education and training programs has been strongly emphasized.13, 14

The relationship between bystanders and patients may be associated with the provision of bystander CPR in OHCA. Family members were found to be more likely to perform bystander CPR on paediatric OHCA patients in South Korea between 2012 and 2014.¹⁵ In Japan, non-family member witness status was significantly associated with ventricular fibrillation electrocardiogram (ECG) rhythm but not with favourable neurological outcomes for school-aged children with OHCA.¹⁶ In elderly OHCA patients, bystander CPR by family members has been found to be associated with poor survival rates and neurological outcomes.¹⁷ There are several reasons for inadequate bystander CPR performance by family members, such as complicated CPR techniques, physical ability, emotional response such as fear, or willingness. In addition, depending on the bystander relationship, there will be unknown mechanisms that affect the clinical outcome besides bystander CPR.

The association between the neurologic outcomes of paediatric OHCA patients and the type of bystander who performs CPR has not been well studied. We hypothesized that neurologic outcomes would be worse when the bystander is family members of patient, especially when they witness the event. The aim of this study was to assess whether the relationship between bystanders and patients is associated with neurologic outcomes in paediatric OHCA.