Incidence, Causes and Outcome of Out-of-Hospital Cardiac Arrest in Children

A Comprehensive, Prospective, Population-Based Study in The Netherlands

Abdennasser Bardai, MD,* Jocelyn Berdowski, MSc, MSE,* Christian van der Werf, MD,* Marieke T. Blom, MA,

Manon Ceelen, PhD, Irene M. van Langen, MD, PhD, Jan G.P. Tijssen, PhD, Arthur A.M. Wilde, MD, PhD,

Rudolph W. Koster, MD, PhD, Hanno L. Tan, MD, PhD

Amsterdam and Groningen, The NetherlandsAmsterdam and Groningen, The Netherlands* These authors contributed equally

Background

There is a paucity of complete studies on incidence, causes and outcome of pediatric out-of-hospital cardiac arrest (OHCA) Previous large studies only included OHCA

cases that involved emergency medical services (EMS)

Few studies reported the single (groups of) causes of pediatric OHCA

J Am Coll Cardiol 2011;57:1822-8

Objective

To comprehensively determine: The incidence of pediatric OHCA The contribution of OHCA to total pediatric

mortality, The causes of pediatric OHCAThe outcome of resuscitation of pediatric

OHCA patients

J Am Coll Cardiol 2011;57:1822-8

Prospective population-based study of children suffering OHCA between October 1, 2005 and February 1, 2010 in the North-Holland province of The Netherlands

Population: 2.4 million people, including 588,389 aged <21 years

J Am Coll Cardiol 2011;57:1822-8

OHCA was non-cardiac when EMS rescuers, hospital physicians or coroners identified a natural, non-cardiac cause or non-natural cause

All other cases had a (presumed) cardiac cause and were termed cardiac OHCA

J Am Coll Cardiol 2011;57:1822-8

Death certificate data

We retrieved death certificate data from Statistics Netherlands, a Dutch governmental institution that collects age/gender-specific statistics of all deaths in The Netherlands to: Establish the contribution of OHCA to total

mortality in pediatric age groupsGain insight into the completeness of our data

collection

J Am Coll Cardiol 2011;57:1822-8

Survival analysis

We analyzed only truly resuscitatable OHCA cases by excluding OHCA victims who were found dead by EMS personnel upon arrival

Survival status at hospital discharge obtained by contacting the designated hospital

The pediatric Cerebral Performance Category (CPC) of each patient was estimated by reviewing the hospital charts

J Am Coll Cardiol 2011;57:1822-8

Patient characteristics

233 pediatric OHCA cases83 EMS-only, 100 coroners-only cases, 50

cases registered by both sources

24% of total pediatric mortalityWe registered 90 (87%) of the 103

potential pediatric cardiac OHCA cases according to the death certificate data, and 143 (99%) of the 144 potential pediatric non-cardiac OHCA cases

J Am Coll Cardiol 2011;57:1822-8

Incidences of pediatric OHCA

All causes

(n=233)

Cardiac causes

(n=90)

Non-cardiac causes

(n=143)

Overall 9.0 (7.8-10.3) 3.2 (2.5-3.9) 5.8 (4.9-6.8)

Age <1 years 33.8 (23.1-44.5) 25.8 (16.4-35.2) 8.0 (2.8-13.2)

Age 1-11 years 4.8 (3.6-6.0) 1.6 (0.9-2.3) 3.2 (2.2-4.2)

Age 12-20 years 11.7 (9.5-13.8) 2.7 (1.7-3.7) 9.0 (7.1-10.8)

Data are expressed as number per 100,000 pediatric person-years (95% confidence interval). Data are expressed as number per 100,000 pediatric person-years (95% confidence interval). Adjusted by age/sex to the European Union populationAdjusted by age/sex to the European Union population

J Am Coll Cardiol 2011;57:1822-8

Causes of out-of-hospital cardiac arrest

J Am Coll Cardiol 2011;57:1822-8

Survival and neurologic outcome

CPR was initiated in 69 OHCA victims, but only 51 were truly resuscitatable

Of 51 resuscitated patients, 12 (24%) survived29% [4/14] in infants, 12% [2/17] in children, 30%

[6/20] in adolescents (NS)10/12 (83%) had a neurologically-intact

outcome83% (75% [3/4] in infants, 100% [2/2] in children,

83% [5/6] in adolescents

J Am Coll Cardiol 2011;57:1822-8

Operational characteristics of resuscitated victims of OHCA from cardiac causes

All Age <1 year

Age 1-11 years

Age 12-20 years

P-value

Variable (n=69) (n=29) (n=18) (n=22)

Witnessed collapse, n (%) 41 (59) 11 (38) 14 (78) 16 (73) 0.03

Bystander CPR, n (%) 52 (75) 19 (66) 14 (78) 19 (86) 0.53

Collapse at home, n (%) 48 (70) 28 (97) 11 (61) 9 (41) <0.001

AED connected, n (%) 9 (13) 1 (3) 1 (6) 7 (32) 0.02

Time between emergency call and arrival, min, median (25th to 75th percentile)

12.1 (8.8-14.8)

12.2 (9.8-13.9)

11.1 (8.4-15.3)

12.0 (9.0-15.6)

0.99

Shockable initial rhythm, n (%) 25 (36) 1 (3) 6 (33) 18 (82) <0.001

J Am Coll Cardiol 2011;57:1822-8

Conclusions

OHCA accounts for a significant proportion of pediatric mortality

Cardiac causes are the most prevalent causes of OHCA

The vast majority of OHCA survivors have a neurologically-intact outcome

J Am Coll Cardiol 2011;57:1822-8