Out-of-Hospital Cardiac or Respiratory Arrest in Children
Out-of-Hospital Cardiac or Respiratory Arrest in Children
ABSTRACT & COMMENTARY
Source: Schindler MB, et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996; 335:1473-1479.
Neurologists who frequently provide consultation about prognosis in persons suffering out-of- hospital cardiac or respiratory arrest will find this a useful study.
Although predictions of death or absence of serious neurological damage from out-of-hospital cardiac or respiratory arrest have been documented several times in adults, less attention has been directed at such outcomes in children. In adults, Kellerman et al (JAMA 1993; 270:1433-1436) and Bonnin et al (JAMA 1993; 270:1457-1462) concluded that only 0.4% who failed to respond to pre-hospital CPR before admission subsequently left the hospital alive. Even that small fraction suffered moderate-to-severe neurologic damage. They recommended ceasing unsuccessful CPR in adults after no more than 25 minutes. Schindler et al now describe the outcomes of 101 children with cardiac or respiratory arrest, ranging in age from 3 days to 18 years, who were admitted to Toronto's Hospital for Sick Children between 1986 and June 1993. No significant year-to-year differences in categorical outcome occurred during that time.
Of the 101 children (median age, 2 years), 21 were primarily apneic upon arrival, and the remaining 80 were pulseless. Thirty-seven failed immediate resuscitation, all of whom had been pulseless. Following cardiac arrest, the median interval between arrest and hospital arrival was five minutes for survivors compared to 20 minutes of those who died. Fifteen children survived until hospital discharge, and 13 remained alive one year later. Five of these youngsters, all of whom had been apneic but not pulseless, regained normal mental status by the time of hospital discharge. Of the remaining eight, one had a mild neurologic defect, four had moderate deficits, and five were severely damaged or vegetative. Neurological status remained the same one year later, except that one child with severe deficit and one who was vegetative had died.
Factors favoring neurological recovery included reaching the emergency department within a mean of 10 minutes, a palpable pulse upon reaching the hospital, a functional ECG, no epinephrine needed, only one defibrillation applied, and a duration of resuscitation in the emergency department of six minutes compared to a mean of 16.5 minutes among those who died. No children survived who required more than two doses of epinephrine or underwent emergency department resuscitation efforts lasting more than 20 minutes.
Causes of cardiac arrest in these children included sudden infant death syndrome (all died), trauma (all died), sepsis (4 survived), and drowning (all died); heart disease (1/7 survived) and seizures (2/7 survived) were next most common.
COMMENTARY
This well-studied and presented epidemiologic report indicates that children, like adults, seldom regain neurological normality following out-of-hospital cardiac arrest. Furthermore, only 3% achieved a level as high as moderate disability, either at hospital discharge or a year later. Regrettably, the designation of moderate disability is not neurologically described, but, if permanent as this report suggests, it almost certainly means that the child may never become independent and that subsequent social costs will be high.
The authors indicate that their data resemble others' and that studies similar to their own recommended stopping fruitless CPR efforts after 25 minutes. Based on their own data, they suggest a time limit of 20 minutes after the child reaches the emergency department. Regrettably, the authors don't provide a table or diagram that lists time-to-restoration of pulse, functional blood pressure, and breathing efforts against neurological outcome. The very gloomy observation in this paper is that any child who develops out-of-hospital cardiac arrest and who is pulseless at the time of reaching an emergency room carries a prognosis of probably permanent, severe neurological disability or death. Perhaps it's time to examine thoroughly the ethics of applying heroic medical procedures aimed at such extreme rescue efforts with such disastrously poor outcomes.
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