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BMJ Clin Evid. 2007; 2007: 0307.
Published online 2007 September 1.
PMCID: PMC2943773

Cardiorespiratory arrest in children (out of hospital)

Hilary Writer, Assistant Professor of Paediatrics

Abstract

Introduction

Cardiorespiratory arrest outside hospital occurs in approximately 1/10,000 children a year in resource-rich countries, with two thirds of arrests occurring in children under 18 months of age. Approximately 40% of cases have undetermined causes, including sudden infant death syndrome. Of the rest, 20% are caused by trauma, 10% by chronic disease, and 6% by pneumonia.

Methods and outcomes

We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for non-submersion out-of-hospital cardiorespiratory arrest in children? We searched: Medline, Embase, The Cochrane Library and other important databases up to February 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results

We found 13 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions

In this systematic review we present information relating to the effectiveness and safety of the following interventions: airway management and ventilation (bag-mask ventilation and intubation), bystander cardiopulmonary resuscitation, direct-current cardiac shock, hypothermia, intravenous sodium bicarbonate, standard dose of intravenous adrenaline (epinephrine), and training parents to perform resuscitation.

Key Points

Cardiorespiratory arrest outside hospital occurs in approximately 1/10,000 children a year in resource-rich countries, with two thirds of arrests occurring in children under 18 months of age.

  • Approximately 40% of cases have undetermined causes, including sudden infant death syndrome . Of the rest, 20% are caused by trauma, 10% by chronic disease, and 6% by pneumonia.

Overall survival for out-of-hospital cardiorespiratory arrest in children is poor.

  • Overall survival for children who sustain cardiorespiratory arrest outside hospital not caused by submersion in water is about 5%.
  • Of those who survive, between half and three quarters will have moderate to severe neurological sequelae.

There is very poor evidence for any intervention in cardiorespiratory arrest in children. Placebo-controlled trials would be unethical, and few observational studies have been performed.

Immediate airway management, ventilation, and high-quality chest compressions with minimal interruption are widely accepted to be key interventions.

  • Ventilation with a bag and mask seems to be as effective as intubation. The most suitable method for the situation should be used.

Direct current cardiac shock is likely to be beneficial in children with ventricular fibrillation or pulseless ventricular tachycardia.

  • Ventricular fibrillation or pulseless ventricular tachycardia are the underlying rhythms in 10% of cardiorespiratory arrests in children, and are associated with a better prognosis than asystole or pulseless electrical activity.
  • Defibrillation within 10 minutes of the arrest may improve the outcome.

Intravenous adrenaline is widely accepted to be the initial medication of choice in an arrest.

  • The standard dose of intravenous adrenaline is 0.01 mg/kg.
  • Weak evidence suggests that higher-dose adrenaline (0.1 mg/kg) is no more effective in improving survival.
  • The effects of cooling a child after arrest are unknown.

About this condition

Definition

This review covers non-submersion, out-of-hospital cardiorespiratory arrest in children. The paediatric Utstein style definition is cessation of cardiac mechanical activity, determined by the inability to palpate a central pulse, unresponsiveness, and apnoea occurring outside of a medical facility and not caused by submersion in water.

Incidence/ Prevalence

We found 15 observational studies (5 prospective, 10 retrospective) reporting the incidence of non-submersion out-of-hospital cardiorespiratory arrest in children (see table 1 ). Two studies reported the incidence in both adults and children, and 13 reported the incidence in children alone. The incidence in the general population ranged from 1.3-5.7/100,000 people a year (mean 2.9, 95% CI 0.22 to 5.58). The incidence in children ranged from 6.3-18.0/100,000 children a year (mean 9.6, 95% CI 2.27 to 16.93). Two prospective studies (761 children in total) found that 40-50% of cadiorespiratory arrests in children aged under 12 months occur out of hospital. One prospective study identified that children are aged under 18 months in approximately two thirds of out-of-hospital cardiorespiratory arrests.

Table 1
Incidence of non-submersion out of hospital cardiorespiratory arrest in children* (see text).

Aetiology/ Risk factors

We found 30 observational studies reporting the causes of non-submersion pulseless arrests in a total of 2109 children. The most common causes were undetermined (as in sudden infant death syndrome, 39%), trauma (21%), chronic disease (9%), and pneumonia (6%) (see table 2 ).

Table 2
Causes of non-submersion out of hospital cardiorespiratory arrest in children* (see text).

Prognosis

We found no observational studies that investigated non-submersion arrests alone. We found one systematic review (search date 2004) of 41 case series and cohort studies (9 prospective, 32 retrospective; total of 5363 children), which reported outcomes for out-of-hospital cardiopulmonary arrest of any cause, including submersion, in children up to 18 years. Studies were excluded if survival, with survival to hospital discharge as a minimum, was not reported as an outcome. The overall survival rate (to hospital discharge) for the children meeting the paediatric Utstein style definition for out of hospital non-submersion arrest was 5.5% (190/3475 children). Of the 190 surviving children, 43/190 (23%) had no or mild neurological disability, and 147/190 (77%) had moderate or severe neurological disability. One subsequent prospective cohort study of 503 children, including 42 children who sustained submersion events, reported a 2% survival to hospital discharge. One subsequent retrospective cohort study of 84 children with non-submersion out-of-hospital cardiac arrest reported a 4.7% survival rate to hospital discharge, with 50% of the survivors sustaining severe neurological deficits. We found one systematic review (search date 1997), which reported outcomes after cardiopulmonary resuscitation for both in-hospital and out-of-hospital arrests in children of any cause, including submersion. Studies were excluded if they did not report on survival. The review found evidence from prospective and retrospective observational studies that out-of-hospital arrest of any cause in children has a poorer prognosis than within-hospital arrest(132/1568 [8%] children survived to hospital discharge after out-of-hospital arrest v 129/544 [24%] children after in-hospital arrests). About half of the survivors were involved in studies that reported neurological outcome. Of these, survival with "good neurological outcome" (i.e. normal or mild neurological deficit) was higher in children who arrested in hospital compared with those who arrested elsewhere (60/77 [78%] surviving children in hospital v 28/68 [41%] elsewhere). See also table 3 .

Table 3
Prognosis for out of hospital cardiorespiratory arrest.

Aims of intervention

To improve survival and minimise neurological sequelae.

Outcomes

Out of hospital death rate; rate of death in hospital without return of spontaneous circulation; return of spontaneous circulation with subsequent death in hospital; and return of spontaneous circulation with successful hospital discharge with mild, moderate, severe, or no neurological sequelae; adverse effects of treatment.

Methods

BMJ Clinical Evidence search and appraisal February 2007. The following databases were used to identify studies for this review: Medline 1966 to February 2007, Embase 1980 to February 2007, and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials 2007, Issue 1. Additional searches were carried out using these websites: NHS Centre for Reviews and Dissemination (CRD) — for Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA), Turning Research into Practice (TRIP), and National Institute for Health and Clinical Excellence (NICE). Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the author for additional assessment, using pre-determined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews and RCTs in any language, at least single blinded, and containing more than 20 individuals of whom more than 80% were followed up. There was no minimum length of follow-up required to include studies. We excluded all studies described as "open", "open label", or not blinded unless blinding was impossible. We also did a search for cohort studies (prospective and retrospective) for all interventions. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which are added to the review as required. We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table ).

Table
GRADE evaluation of interventions for cardiopulmonary arrest in children (out of hospital)

Glossary

Asystole
The absence of cardiac electrical activity.
Bradyasystole
Bradycardia clinically indistinguishable from asystole.
Initial rhythm asystole
The absence of cardiac electrical activity at initial determination.
Initial rhythm ventricular fibrillation
Electrical rhythm is ventricular fibrillation at initial determination.
Paediatric Utstein style
Uniform guidelines for reporting paediatric resuscitation data, based on recommended guidelines for adult out of hospital cardiac arrest developed at the Utstein conference in 1991.
Pulseless arrest
Absence of palpable pulse, following cardiorespiratory arrest.
Pulseless electrical activity
The presence of cardiac electrical activity in the absence of a palpable pulse.
Pulseless ventricular tachycardia
Electrical rhythm of ventricular tachycardia in the absence of a palpable pulse.
Respiratory arrest
Absence of respiratory activity.
Sudden infant death syndrome
The sudden unexpected death of a child, usually between the ages of 1 month and 1 year, for which a thorough postmortem examination does not define an adequate cause of death. Near miss sudden infant death syndrome refers to survival of a child after an unexpected arrest of unknown cause.
Ventricular fibrillation
Needs updating
Very low-quality evidence
Any estimate of effect is very uncertain

Notes

Disclaimer

The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients.To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.

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2007; 2007: 0307.
Published online 2007 September 1.

Airway management and ventilation

Summary

We found no direct information about the use of airway management and ventilation, including bag-mask ventilation and intubation, in children who have arrested out of hospital.

Benefits

We found no systematic review, RCTs, or observational studies of sufficient quality.

Harms

We found no prospective evidence.

Comment

It is widely accepted, based on indirect evidence and extrapolation from adult data, that rapid establishment of an airway and effective management of ventilation should be undertaken in a child who has arrested, and it would be considered unethical to test its role in a placebo-controlled trial.

Clinical guide:

There is general consensus that rapid establishment of an airway and effective management of ventilation are crucial initial interventions in the management of a paediatric out-of-hospital cardiopulmonary arrest.

Substantive changes

No new evidence

2007; 2007: 0307.
Published online 2007 September 1.

Bystander cardiopulmonary resuscitation

Summary

SURVIVAL RATES TO HOSPITAL DISCHARGE Bystander resuscitation compared with no bystander resuscitation: Bystander resuscitation may be more effective in improving rates of survival to hospital discharge in children who have arrested out of hospital compared with no bystander resuscitation ( very low-quality evidence ). NOTE Cardiopulmonary resuscitation including compressions and or ventilations is an important intervention in out-of-hospital cardiopulmonary arrest.

Benefits

Bystander cardiopulmonary resuscitation versus placebo:

Placebo-controlled trials would be considered unethical.

Bystander cardiopulmonary resuscitation:

We found one systematic review (search date 2004, 5363 children who had arrested outside hospital, including submersion cases) of prospective and retrospective observational studies, and one subsequent observational study (85 children). The review concluded that survival was significantly improved in children who were witnessed to arrest (rates of survival to hospital discharge: 62/475 [13%] with witnessed arrest v 44/956 [5%] with unwitnessed arrest; RR 1.99, 95% CI 1.54 to 2.57). The review included nine studies that quantified bystander cardiopulmonary resuscitation data, of which seven reported on survival to hospital discharge (41/433 [9%] with bystander cardiopulmonary resuscitation v 49/1042 [5%] with no bystander cardiopulmonary resuscitation; significance not assessed because of heterogeneity). Risk ratios for survival to hospital discharge varied widely (0.53 to 4.7), and the review found significant heterogeneity among studies (P = 0.001). One study had no survivors and was excluded from pooled analysis. The review concluded that pooled analysis of the six studies failed to demonstrate a consistent association between bystander cardiopulmonary resuscitation and survival (data presented graphically in the review). Cardiopulmonary resuscitation was not randomly allocated, and children resuscitated may have been systematically different from those who did not receive resuscitation. The apparent survival rates for witnessed arrests and arrests with bystander initiated cardiopulmonary resuscitation may be artificially high because of inappropriate evaluation of true arrest. However, assuming that confounding variables were evenly distributed between groups, the best estimate of the benefit of cardiopulmonary resuscitation is a 30% absolute increase in the probability that children will be discharged alive from hospital. The subsequent observational study (85 children) found that bystander cardiopulmonary resuscitation was significantly associated with increased survival compared with no bystander cardiopulmonary resuscitation (survival to hospital discharge: 3/20 [15%] with bystander cardiopulmonary resuscitation v 1/65 [1.5%] without bystander cardiopulmonary resuscitation; P = 0.04).

Harms

Potential harms include injury resulting from unnecessary chest compression after respiratory arrest with intact circulation. The systematic review and the observational study gave no information about adverse effects.

Comment

Placebo controlled trials would be considered unethical.

Clinical guide:

It is widely accepted that cardiopulmonary resuscitation including compressions and/or ventilations should be undertaken in children who have arrested, although the evidence remains weak. On the basis of observational evidence and experience, most clinicians regard bystander cardiopulmonary resuscitation to be an important intervention in out of hospital cardiopulmonary arrest. The 2005 International Liaison Committee on Resuscitation's consensus on science treatment recommendation encourages trained rescuers to provide both ventilations and chest compressions. The consensus recommendation goes on to encourage those rescuers who are reluctant or unable to perform ventilations to institute and continue chest compressions without interruption. The Committee made this recommendation on the basis of evidence extrapolated from adult ventricular fibrillation studies as well as from animal studies of ventricular fibrillation cardiac arrest.

Substantive changes

No new evidence

2007; 2007: 0307.
Published online 2007 September 1.

Training parents to perform cardiopulmonary resuscitation

Summary

We found no direct information about the effects of training parents to perform cardiopulmonary resuscitation in children who have arrested in the community.

Benefits

Training parents to perform cardiopulmonary resuscitation:

We found no RCTs or prospective observational studies on the effects of training parents to perform cardiopulmonary resuscitation in children who have arrested in the community.

Harms

Potential harms include injury resulting from unnecessary chest compression after respiratory arrest with intact circulation. The systematic review and the observational study gave no information about adverse effects.

Comment

Placebo controlled trials would be considered unethical.

Clinical guide:

It is widely accepted that cardiopulmonary resuscitation including compressions and/or ventilations should be undertaken in children who have arrested, although the evidence remains weak. On the basis of observational evidence and experience, most clinicians regard bystander cardiopulmonary resuscitation to be an important intervention in out of hospital cardiopulmonary arrest. The 2005 International Liaison Committee on Resuscitation's consensus on science treatment recommendation encourages trained rescuers to provide both ventilations and chest compressions. The consensus recommendation goes on to encourage those rescuers who are reluctant or unable to perform ventilations to institute and continue chest compressions without interruption. The Committee made this recommendation on the basis of evidence extrapolated from adult ventricular fibrillation studies as well as from animal studies of ventricular fibrillation cardiac arrest.

Substantive changes

No new evidence

2007; 2007: 0307.
Published online 2007 September 1.

Direct current cardiac shock

Summary

We found no direct information about the use of direct current cardiac shock in children who have arrested from ventricular fibrillation or pulseless ventricular tachycardia.

Benefits

We found no systematic review, RCTs, or observational studies of sufficient quality for inclusion.

Harms

We found no prospective evidence.

Comment

Placebo controlled trials would be considered unethical.

Clinical guide:

Although the evidence for benefit from direct current cardiac shock is weak, there is widespread consensus that children who arrest outside hospital and are found to have ventricular fibrillation or pulseless ventricular tachycardia should receive direct current cardiac shock treatment.

In children with ventricular fibrillation:

One retrospective study (29 children with ventricular fibrillation who had arrested out of hospital from a variety of causes, including submersion) found that, of 27 children who were defibrillated, 11 survived (5 with no sequelae, 6 with severe disability). The five children with good outcome all received defibrillation within 10 minutes of arrest (time to defibrillation not given for those who died). Data on the two children who were not defibrillated were not presented. One retrospective study (13 children with ventricular fibrillation who arrested out of hospital, including one submersion related arrest) found that of 13 children given an initial shock (2 J/kg as initial dose) within a median time from arrest of 11 minutes, defibrillated a total of 14 times, none survived to hospital discharge.

In children with asystole:

One retrospective study in 90 children with asystole (including those who had arrested after submersion) found that 49 (54%) had received direct current cardiac shock treatment. None of the children survived to hospital discharge, regardless of whether direct current cardiac shock was given. We found one systematic review of observational studies that recorded electrocardiogram rhythm (search date 1997, 1420 children who had arrested outside hospital). Bradyasystole or pulseless electrical activity was found in 73%, whereas ventricular fibrillation or pulseless ventricular tachycardia was found in 10%. The review found that survival after ventricular fibrillation or ventricular tachycardia arrest was higher than after asystolic arrest in children. Survival to discharge reported in the systematic review was 39/802 (5%) for children with initial rhythm asystole and 29/97 (30%) with initial rhythm ventricular fibrillation or ventricular tachycardia.

Substantive changes

No new evidence

2007; 2007: 0307.
Published online 2007 September 1.

Standard dose intravenous adrenaline (epinephrine)

Summary

MORTALITY Standard dose compared with high dose: Standard-dose adrenaline may be no more effective than high-dose adrenaline in returning spontaneous circulation or increasing survival rates to hospital discharge in children who have arrested in the community ( very low-quality evidence ). NEUROLOGICAL OUTCOMES Standard dose compared with high dose: Standard-dose adrenaline may be no more effective than high-dose adrenaline in improving neurological outcomes in children who have arrested in the community (very low-quality evidence). NOTE We found no direct information about whether intravenous adrenaline is better than no active treatment in establishing spontaneous circulation in children who have arrested out of hospital.

Benefits

Intravenous adrenaline versus placebo:

We found no RCTs or prospective observational studies in children who have arrested in the community comparing adrenaline versus placebo, and such trials would be considered unethical.

Standard dose versus high dose intravenous adrenaline:

See benefits of high dose intravenous adrenaline.

Harms

We found no RCTs.

Comment

Intravenous adrenaline (epinephrine) at “standard dose” (0.01 mg/kg) is a widely accepted treatment for establishing return of spontaneous circulation and it would be considered unethical to test its role in a placebo controlled trial.

High versus low dose adrenaline:

See comments on high dose intravenous adrenaline.

Clinical guide:

Despite a lack of direct evidence for its benefit, there is consensus that standard dose (0.01 mg/kg) adrenaline is the first medication to be used for the management of out of hospital cardiopulmonary arrest in children. Although many clinicians have in the past used high dose (0.1 mg/kg) adrenaline for second and subsequent doses, there is no satisfactory evidence of any benefit in improving survival and weak evidence for a trend towards worse neurological outcomes with its use. Further RCTs would be feasible, but would need to be undertaken in larger numbers of children, with consistent outcomes measured in accordance with Utstein guidelines.

Substantive changes

No new evidence

2007; 2007: 0307.
Published online 2007 September 1.

Intravenous adrenaline at high dose (compared with standard dose)

Summary

MORTALITY High dose compared with standard dose: High-dose adrenaline may be no more effective than standard dose adrenaline in returning spontaneous circulation or increasing survival rates to hospital discharge in children who have arrested in the community ( very low-quality evidence ). NEUROLOGICAL OUTCOMES High dose compared with standard dose: High-dose adrenaline may be no more effective in improving neurological outcomes in children who have arrested in the community compared with standard dose adrenaline (very low-quality evidence).

Benefits

High dose versus standard dose intravenous adrenaline:

We found no systematic reviews. We found one RCT (multicentre, non-blinded, 213 people aged up to 22 years, mean age: 33.7 months) with out of hospital cardiopulmonary arrest from various causes, including submersion) and one prospective cohort study (87 children). The RCT compared high dose (0.1 mg/kg for the first dose; 0.2 mg/kg for subsequent doses) versus standard dose (0.01 mg/kg for the first dose; 0.02 mg/kg for subsequent doses) adrenaline administered intravenously, intraosseously, or endotracheally; all doses administered via the endotracheal route were doubled. Analysis was by intent to treat. Subgroup analysis in people with either medical (72%) or traumatic (28%) aetiology of arrest found no significant difference between high dose and standard dose adrenaline in return of spontaneous circulation, survival to 24 hours, or survival to hospital discharge (see table 3 ). Subgroup analysis, excluding children with sudden infant death syndrome, found no significant difference in outcomes between high and standard doses (see table 3 ). However, caution should be used when interpreting these results because of methodological limitations of the RCT. It was not adequately powered to demonstrate any significant effect convincingly, because it was stopped after a change in waiver of informed consent legislation before it achieved the calculated sample size of 240. There was possible enrolment bias towards high dose adrenaline, because the study protocol was modified after revision of the paediatric advanced life support guidelines, allowing for higher doses of adrenaline to be used in people requiring multiple doses. The randomisation method was not consistent across all centres, although a biased randomisation process could not be demonstrated. The prospective cohort study (283 children, containing subgroup analysis of 87 children given at least 1 dose of adrenaline: 11 children given 0.01 mg/kg; 76 children given 0.01 mg/kg for the first dose and 0.1 mg/kg for subsequent doses) reported no significant difference between the high dose and standard dose groups in return of spontaneous circulation, survival to hospital discharge, or survival at 1 year (see table 3 ). Mean age and weight at baseline were significantly higher in the standard dose group than in the high dose group (mean age: 97.1 months v 29.9 months; P = 0.03; mean weight: 24.7 kg v 11.9 kg; P = 0.037).

Table 4
Results of studies comparing high-dose versus standard-dose intravenous adrenaline for cardiorespiratory arrest in children.

Harms

The RCT and the prospective cohort study gave no information about adverse effects of treatment.

Comment

High versus low dose adrenaline:

We found two small retrospective observational studies (128 children), which found no significant difference in rates of survival to hospital discharge between low or single dose and high or multiple dose adrenaline, although these studies may have been too small to detect a significant difference. In all, one RCT and three small observational studies (1 prospective, 2 retrospective) found no evidence of a difference in return of spontaneous circulation, survival to hospital discharge, or neurological outcome between standard dose and high dose adrenaline, although the study sample sizes were all too small to detect a significant difference. On the basis of 2 in-hospital and 2 out-of-hospital paediatric studies demonstrating no improvement in survival rates and trends towards worse neurological outcome for the high-dose epinephrine group, the 2005 International Liaison Committee consensus statement recommends against routine use of high dose epinephrine.

Clinical guide:

Despite a lack of direct evidence for its benefit, there is consensus that standard dose (0.01 mg/kg) adrenaline is the first medication to be used for the management of out of hospital cardiopulmonary arrest in children. Although many clinicians have in the past used high dose (0.1 mg/kg) adrenaline for second and subsequent doses, there is no satisfactory evidence of any benefit in improving survival and weak evidence for a trend towards worse neurological outcomes with its use. Further RCTs would be feasible, but would need to be undertaken in larger numbers of children, with consistent outcomes measured in accordance with Utstein guidelines.

Substantive changes

No new evidence

2007; 2007: 0307.
Published online 2007 September 1.

Intravenous sodium bicarbonate

Summary

We found no direct information about the effects of intravenous sodium bicarbonate in children who have arrested in the community.

Benefits

We found no systematic review, RCTs, or observational studies of sufficient quality.

Harms

We found no prospective evidence.

Comment

Sodium bicarbonate is widely believed to be effective in arrest associated with hyperkalaemic ventricular tachycardia or fibrillation, but we found no prospective evidence supporting this.

Substantive changes

No new evidence

2007; 2007: 0307.
Published online 2007 September 1.

Intubation versus bag–mask ventilation

Summary

MORTALITY Intubation compared with bag–mask ventilation: Intubation may be no more effective in reducing mortality rates in children who have arrested in the community compared with bag–mask ventilation ( very low-quality evidence ). NEUROLOGICAL OUTCOMES Intubation compared with bag–mask ventilation: Intubation may be no more effective in improving neurological outcomes in children who have arrested in the community compared with bag–mask ventilation (very low-quality evidence). NOTE It is essential to establish a rapid airway and effectively manage ventilation by whatever method is appropriate or feasible in each individual circumstance.

Benefits

We found no systematic review or RCTs. We found one non-randomised controlled trial (830 children requiring airway management in the community, including 98 children who had arrested after submersion) comparing bag–mask ventilation versus endotracheal intubation (given by paramedic staff trained in these techniques). Treatments were allocated on alternate days. The trial found no significant difference in rates of survival or good neurological outcome (normal, mild deficit, or no change from baseline function) between the two treatment groups (survival: 123/404 [30%] with bag–mask ventilation v 110/416 [26%] with intubation OR 0.82, 95% CI 0.61 to 1.11; good neurological outcome: 92/404 [23%] with bag–mask ventilation v 85/416 [20%] with intubation, OR 0.87, 95% CI 0.62 to 1.22). The trial did not report on the frequency of cardiorespiratory arrest compared with that of respiratory arrest. Analysis was by intention to treat. Intubation and bag–mask ventilation were not mutually exclusive in the trial. The trial protocol allowed bag–mask ventilation before intubation and after unsuccessful intubation. Of 420 children allocated to intubation, 115 (27%) received bag–mask ventilation before intubation, 128 (30%) received bag–mask ventilation after attempted intubation, 4 (1%) were lost to follow up, and the remaining 177 (42%) received intubation that was believed to be successful. Of 410 children allocated to bag–mask ventilation, 10 (2%) children were intubated successfully (although in violation of study protocol), nine (2%) received bag–mask ventilation after attempted intubation, six (1.5%) were lost to follow up, and the remainder received bag–mask ventilation in accordance with study protocol.

Harms

The trial found that the time spent at the scene of the arrest was longer when intubation was intended, and this was the only significant determinant of a longer total time from dispatch of paramedic team to arrival at hospital (mean time at scene: 9 minutes with bag–mask v 11 minutes with intubation, P < 0.001; mean total time: 20 minutes with bag–mask v 23 minutes with intubation, P < 0.001). However, it found no significant difference between bag–mask ventilation and intubation in complications (complications in 727 children for whom data were available: gastric distension: 31% with bag–mask v 7% with intubation, P = 0.20; vomiting: 14% v 14%, P = 0.82; aspiration: 14% v 15%, P = 0.84; oral or airway trauma: 1% v 2%, P = 0.24). A total of 186 children across both treatment groups were considered by paramedical staff to be successfully intubated. Of these, oesophageal intubation occurred in three children (2%); the tube became dislodged in 27 children (14%; unrecognised in 12 children, recognised in 15); right main bronchus intubation occurred in 33 children (18%); and an incorrect size of tube was used in 44 children (24%). Death occurred in all but one of the children with oesophageal intubation or unrecognised dislodging of the tube.

Comment

Clinical guide:

In choosing between bag–mask ventilation and intubation, different factors need to be considered, such as the skill set of the emergency medical personnel attending the scene, distance and time away from the closest hospital with paediatric expertise, and the mode of transport to hospital. Healthcare professionals with little experience of intubation may be reassured to know that we found no evidence to suggest that intubation was better than bag–mask ventilation for improving survival or neurological outcomes following cardiorespiratory arrest in the community. The most important factors are the rapid establishment of an airway and effective management of ventilation, by whatever method is most appropriate or feasible in each individual circumstance.

Substantive changes

No new evidence

2007; 2007: 0307.
Published online 2007 September 1.

Cooling a child after out of hospital arrest (induced hypothermia)

Summary

We found no direct information about the effects of induced hypothermia after out-of-hospital cardiac arrest in children.

Benefits

We found no systematic review, RCTs, or cohort studies.

Harms

We found no systematic review, RCTs, or cohort studies.

Comment

Animal models of cardiac arrest have indicated that hypothermia may be beneficial to the injured brain. Two RCTs of induced hypothermia (temperature 32-34°C) in a highly selected population of adults following out of hospital cardiac arrest due to ventricular fibrillation found increased survival and good neurological outcomes. The rates of sepsis, pneumonia, bleeding, arrhythmias and hyperglycemia were higher in adults receiving hypothermia, but these differences were not significant. Lower heart rates and increased systemic vascular resistance were also identified in the hypothermia groups, but these differences were also not significant.

Clinical guide:

Although there is currently no direct evidence to support the use of therapeutic hypothermia in children who have arrested outside hospital, on the basis of indirect evidence and extrapolation from adult data, a recent consensus statement of the International Liaison Committee on Resuscitation (ILCOR) states that induction of hypothermia to 32-34°C for a period of 12-24 hours may be considered in those children who remain comatose following resuscitation from cardiac arrest. Randomised trials of therapeutic hypothermia in children following out of hospital cardiac arrest are needed.

Substantive changes


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