Out-of-Hospital Cardiopulmonary Arrest Has a Very Poor Prognosis
ABSTRACT & COMMENTARY
Synopsis: Out-of-hospital cardiac and/or respiratory arrest of 101 children treated with CPR in a hospital emergency department was associated with only a 15% rate of survival to discharge. Children who responded to CPR in less than 20 minutes had a higher rate of survival.
Source: Schindler MB, et al. Outcome of out of hospital cardiac or respiratory arrest in children. N Engl J Med 1996;335:1473-1479.
One hundred one children presented to the Emergency Department of the Toronto Hospital for Sick Children during a seven-year period with cardiac and/or pulmonary arrest. The predominant causes of the arrest were SIDS, trauma, sepsis, drowning, heart disease, and seizures. Resuscitation was unsuccessful in 37 children, but 64 patients responded and were transferred to their ICU.
Fifteen of these patients survived to the time of hospital discharge, and 13 of these were still alive 12 months later. Ten of 15 survivors had moderate-to-severe neurologic sequelae. No child who required CPR for more than 20 minutes or who required more than two doses of epinephrine survived to hospital discharge.
COMMENT BY JOHN T. FAHEY, MD
This important but discouraging paper describes the results of cardiopulmonary resuscitation (CPR) of children less than 16 years of age who suffered either a cardiac arrest (i.e., were pulseless and apneic) or a respiratory arrest (i.e., were apneic but still had a palpable pulse) outside the hospital. Of the 101 patients overall, only 15 survived to hospital discharge; and, of these, only five were neurologically normal. Second, when analyzed by groups, the outcomes were also discouraging. Of the 80 children who arrived pulseless to the ED, only six survived to hospital discharge, and none were neurologically normal. Twenty-one children with respiratory arrest but a palpable pulse could only have been apneic for a relatively short period of time, because prolonged hypoxia would have led to cardiac arrest. With oxygenation and ventilation, the apnea and respiratory failure should have been rapidly reversed. Of the 21, only nine (43%) survived to hospital discharge, and only five were neurologically normal. Third, the application of pre-hospital advanced CPR did not make a difference in survival. Fourth, and perhaps most discouraging, there was no difference in survival when those resuscitated in 1986 were compared to those resuscitated in 1993.
Most children who arrest begin with respiratory failure that progresses to respiratory arrest and apnea. Prolonged global myocardial hypoxia and hypercapnia then leads to asystole. In this and other studies, approximately 70% of pulseless children receiving CPR are asystolic. This is much different than an adult who has a myocardial infarction where a localized area of ischemia often produces ventricular tachycardia or fibrillation. Because arrhythmias may respond to electrical defibrillation, there is a better chance of re-establishing a pulse and successful resuscitation. About 70% of pulseless adult patients receiving CPR have ventricular fibrillation or ventricular tachycardia, and it is this subgroup of patients that makes the outcome of CPR in adults somewhat better.
The predictors for survival to hospital discharge of these children showed no surprises. They included: a short interval between arrest and arrival at the hospital, a palpable pulse on presentation, fewer doses of epinephrine, and a short duration of resuscitation in the ED. These all suggest that perfusion must be re-established before there is time for ischemic damage.
This study showed, as have others, that we are quite good at resuscitating and re-establishing a pulse once the children arrive at the ED. All 21 of the children with respiratory arrest alone were resuscitated, stabilized, and admitted to the ICU for further management. Of the 80 children with cardiopulmonary arrest (pulseless), 54% had a pulse re-established and were admitted to the ICU. However, reinstitution of respiration and a perfusing pulse occurred too late to prevent or reverse hypoxic organ, particularly CNS, damage, and the majority of children died from organ failure and/or brain death.
It is unlikely that progress will be made in shortening the time from the outside arrest to the arrival in the ED. The best hope for improvement in successful survival with normal neurologic outcome is to initiate at the scene and sustain during transport those same kinds of resuscitation that are successful in the ED. This is especially true because SIDS, trauma, and drowning account for more than half (54%) of the patients. These are acute events in previously healthy children.
Why was pre-hospital "advanced CPR" not successful in improving outcome in the present study? As the authors point out, the term "advanced CPR" refers only to bag-valve-mask ventilation and chest compressions. They are really only somewhat advanced basic life support. Advanced life support includes establishing vascular access for infusion of saline, epinephrine, and/or glucose and endotracheal intubation for improved ventilation, oxygenation, and delivery of epinephrine until vascular access is established. These are the interventions used in the ED and, with training, possibly transferable to the field.
Finally, the authors tackle perhaps the most difficult decision in any arrest situation: when to stop. They recommend that resuscitative methods in the ED be limited to 20 minutes and two doses of epinephrine, with the important exception of children who are hypothermic (< 30°C). The 20-minute cutoff seems reasonable and appropriate, since many studies have shown that if a pulse is not re-established within 20 minutes, the chance for neurologic survival approaches zero. The recommendation that epinephrine should be limited to two doses is more problematic, since the authors do not specify dose or via what route. The upper limit for the dosage of epinephrine in arrest situations is not clearly established. (Dr. Fahey is Associate Professor of Pediatric Cardiology and Director of the Pediatric Advanced Life Support Course at Yale Medical School.)
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