|Year : 2021 | Volume
| Issue : 3 | Page : 115-119
Pediatric out of hospital cardiac arrest
Saad Essa Alqahtani1, Ahmed Saleh Alhajeri2, Ayman Adel Ahmed3, Sahar Yousef Mashal4
1 Department of Research and Development, National Ambulance, Abu Dhabi, United Arab Emirate
2 Department of Research and Development, National Ambulance; Department of Clinical Services and Audits, National Ambulance, Abu Dhabi, United Arab Emirate
3 Department of Clinical Services and Audits, National Ambulance, Abu Dhabi, United Arab Emirate
4 Department of Clinical Audit, National Ambulance, Abu Dhabi, United Arab Emirate
|Date of Submission||04-Oct-2020|
|Date of Decision||22-Mar-2021|
|Date of Acceptance||10-May-2021|
|Date of Web Publication||01-Oct-2021|
Saad Essa Alqahtani
Department of Research and Development, National Ambulance, Abu Dhabi
United Arab Emirate
Source of Support: None, Conflict of Interest: None
Background: Cardiac arrest is one of the leading causes of death globally. Aim & Objectives: This study aims to investigate and identify the characteristics of pediatric out of hospital cardiac arrest (POHCA) patients who were attended to and treated by National Ambulance. It is important to understand the characteristics of the patients to improve the implementation of chain of survival and to increase the survival rate. Materials & Methods: This is a 2-year prospective, descriptive, cohort study of POHCA group between January 2018 and December 2019. Data for this study were collected using a structured electronic questionnaire for all out of hospital cardiac arrest patients under 18 years old. Results: A total of 73 POHCA cases were attended by National Ambulance during this 1-year study with a higher percentage being that of infants (59%). In this group, it was found that the percentage of male pediatrics (68%) is higher than females. More than half the total cases (53%) were witnessed by bystanders, 27.3% received bystander cardiopulmonary resuscitation (CPR), and 1% had automated external defibrillator applied on them prior to ambulance arrival. In this population, more than half of cardiac arrest cases occurred in their places of residence (53%). Non-traumatic cardiac arrest was the highest in this group (62%) while traumatic cardiac arrest was found at 22% and drawing cases were 14% of cardiac arrest in this group of patients. The highest percentage of the cardiac arrest patients had nonshockable rhythms (93%). Return of spontaneous circulation at the scene was 4.1%, and all of the cardiac arrests were witnessed and had bystander CPR. Conclusion: This 2-year study emphasised the importance of understanding the characteristics of POHCA. Inculcate a sense of community engagement in public through implementing Good Samaritan Law in UAE. Development and implementation of first aid training for both parents and caregivers were suggested to ensure proper implementation of chain of survival in UAE. Developing legislations for caregivers or babysitters who is taking care of child to receive first aid training and accredited CPR license as a precondition to work as a caregiver or a babysitter. Further linkage between pre-hospital and hospitals data is essential to conduct proper researches to improve chain of survival and reduce pediatric out of hospital cardiac arrest morbidity and mortality.
Keywords: Characteristics of pediatric out of hospital cardiac arrest, emergency medical services, pediatric out of hospital cardiac arrest
|How to cite this article:|
Alqahtani SE, Alhajeri AS, Ahmed AA, Mashal SY. Pediatric out of hospital cardiac arrest. Hamdan Med J 2021;14:115-9
| Introduction|| |
Out of hospital cardiac arrest (OHCA) is one of the leading causes of death worldwide. In the past, understanding the characteristics and outcomes of POHCA was a big concern in the medical field. POHCA events are rare globally, and it was found that survival rate of out of hospital cardiac arrest was low in pediatrics as compared to adults. This condition is typically investigated and studied by ambulance services as this type of study requires prolonged time and data continuity. Initiating cardiac arrest registry in the UAE is essential to ensure the collection of data from both out of hospital and in hospital cardiac arrest cases. This is also to ensure sufficiency of data validation and accurate epidemiological studies to guide proper implementation of chain of survivals.
In Middle Eastern countries, the amount of out of hospital cardiac arrest researches is low compared to other countries such as the USA or the UK. Therefore, this research aims to study POHCA cases attended by National Ambulance in the United Arab Emirates. National Ambulance started operating in 2010 and since then is the main emergency medical service provider in the emirates of Sharjah, Ajman, Fujairah, Umm Al Quwain and Ras Al khaimah (Northern Emirates).
Since its founding, implementation of chain of survival in the Northern Emirates has been one of the priorities of National Ambulance. All emergency medical calls are received by Ambulance Call Center (ACC). As majority of UAE's population is expats, ACC is occupied by staff from different nationalities covering eight spoken languages. Once cardiac arrest is suspected or confirmed, the call center agent will provide CPR instruction to the caller as well as immediately dispatching ambulance to ensure the proper implementation of chain of survival. Incorporating technology in the EMS system to increase public awareness and reduce response time, National Ambulance has developed NA998 application to be downloaded in smart phones. This application provides basic information about the first aid and has a feature for requesting ambulance with accurate GPS location.
The objective of this 2 years study is to determine the epidemiology, clinical characteristics, community engagement and scene outcome for all POHCA cases attended by National Ambulance crew from January 2018 to December 2019.
| Methods|| |
This study was prospective, descriptive, cohort study conducted in National Ambulance in the Northern Emirates (Sharjah, Ajman, Fujairah, Umm Al Quwain and Ras Al khaimah). Data were collected for all out of hospital cardiac arrest cases for patients under 18 years. The study's ethics and protocol was reviewed and approved by National Ambulance Ethics Review Committee.
A patient under 18 years showing unresponsiveness with an undetectable pulse or absence of respiration outside the hospital. A specifically designed electronic form, to be filled by the crew for all OHCA patients, was used for this research. Data and information were monitored by the research and development department in National Ambulance.
Descriptive statistics were analyzed to present patient's characteristics, continuous variables, independent group t-test, frequencies and percentage summary. SPSS version 21 (Statistical Package for Social Scientist, IBM, NYC, USA) was used for the entire analysis.
| Results|| |
The total number of POHCA cases attended by National Ambulance crew from January 2018 to December 2019 was 73 [Table 1]. In this pediatric group, majority of cases were male patients 68% (n = 50), whereas female patients were 32% (n = 23). These results reflect that male patients are greater in number than female patients in pediatrics, which is similar to OHCA findings for adults. It represents that there were 2 male patients for every 1 female patient. The median age of the patients included in this study was 1 year and 7 months with a standard deviation of ±1.7. The findings of this study show that majority of these cases were infants 59% (n = 43) followed by adolescents 18% (n = 13). As the majority population in UAE is expatriates, it was found in our study that pediatric cases in Asian nationalities are the highest among other nationalities 34% (n = 25). POHCA in Emiratis represented 16% (n = 12).
|Table 1: Demographics of pediatric out of hospital cardiac arrest cases attended by National Ambulance between January 2018 and December 2019|
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More than half of the cases occurred to the patients in their residence 53% (n = 39). Moreover, it was found that 42% (n = 31) patients had cardiac arrest on the road or at public places such as shopping malls, place of recreation, beach and camps. In our findings, the main cause of pediatric cardiac arrest was due to a medical condition which represents 62% (n = 64), followed by trauma cases such as motor vehicle accidents and falls 22% (n = 16). During the study period, we found that drowning was the cause of pediatric cardiac arrest for 14% (n = 10).
The first element in the chain of survival is early recognition of cardiac arrest. From the total cases attended by National Ambulance, more than half of the cases were not witnessed 52% (n = 38) and 47.8% (n = 35) were witnessed either by family, layperson, bystanders or health-care providers.
Median response time was measured during the study period for all OHCA cases in Northern Emirates. In our study, the median response time from calling ambulance to the scene arrival was 8 min and 45 s.
Bystander cardiopulmonary resuscitation (CPR) is essential prior to Ambulance arrival. In the pediatric group, it was found 27.3% (n = 20) received bystander CPR and the majority of CPR were performed by patient's families 17.8% (n = 13). Public access to automated external defibrillator (AED) was found very low and only one patient had AED applied on and no shock was given [Figure 1].
|Figure 1: The classification of witnessed Pediatric Out of Hospital Cardiac Arrest patients between January 2018 and December 2019|
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Advanced airway (supraglottic airway device) was used for 57.7% (n = 40) patients from the total pediatric cases. Mechanical CPR was used by qualified EMTs of National Ambulance; however, it is not applicable to pediatrics unless the patient is adult size. In this group, mechanical CPR was applied on 23% (n = 17) cases. These were adolescents who met the criteria of adult size. Intravenous fluid and epinephrine were administered for 12.3% (n = 9) of the cases.
Cardiac rhythm was done for all cardiac arrest cases. The majority of them had nonshockable rhythms 93% (n = 68), whereas 7% (n = 5) had shockable rhythms and defibrillation was performed for all of them.
From the total cases, 96% were transported to the nearest hospital. The remaining 4% were not transported to the hospital and were pronounced dead on the scene by physicians or they showed obvious signs of death. From the total cases, only 4% (n = 3) had sustained Return of spontaneous circulation (ROSC) prior to emergency department arrival.
| Discussion|| |
The number of published researches and studies that have been conducted on OHCA in the Middle East is very low as compared to other countries. Similarly, researches on POHCA are very low as well, and the characteristics of this group is not investigated properly enough., The findings during the 2-year study show that OHCA is rare in pediatrics as compared to adults. Furthermore, the findings show that cardiac arrest happens more in male pediatrics than females. This finding matches with the study conducted by Pan Asian Resuscitation Outcomes Study for adult OHCA and state that both adult and pediatric males are more prone to OHCA than females.,
According to the findings of this study, more than half of the cases occurred in the patient's home. Out of these, more than half of the cardiac arrest cases were witnessed and the majority of witnesses were patient's families. It was found that about 62% of cardiac arrests were due to medical conditions and their families and caregivers were aware of the patient's conditions, as declared to the ambulance crew by the same. Furthermore, it was found that 59% of cardiac arrests occurred in infants and majority of them were Asians.
To ensure proper implementation of chain of survival, National ambulance call takers give CPR instructions to callers of confirmed cardiac arrest patients until the arrival of ambulance. The CPR instructions are based on the King County Criteria Based Dispatch system. Even though the witnessed cardiac arrest cases were more than half, only 50% of them had CPR performed on them prior to ambulance arrival. It was hypothesised in previous studies that the reason why families and bystanders don't perform CPR can be due to the lack of knowledge and confidence in preforming CPR. Having said that, other studies showed that the absence of 'Good Samaritan Law' can prevent community engagement, as people don't want to have legal actions taken against them due to their intervention in such cases. Therefore, it was suggested to create Good Samaritan Law and explain the policies and requirements to everyone to ensure proper community engagement with the purpose of increasing the chance of survival. For example, they could be accredited with CPR training and license to preform CPR.
The finding shows that the highest percentage of cardiac arrests occurred in infants (59%). This emphasizes the importance of enhancing CPR culture in families. The previous study suggests that parents should get first aid and CPR training to ensure proper safety of their beloved children. The importance of first aid and CPR training can be accessed from the fact that not all children are born healthy. Some are born with medical conditions or congenital heart defects. Moreover, the signs and symptoms of the deteriorating health of an infant patient are quite difficult to recognize as compared to adults. That is why it is required to educate parents regarding their child's health, how to recognize medical emergencies and perform CPR in the case of a cardiac arrest until ambulance arrival as each second is accounted for in increasing the rate of survival. On the other hand, some families have caregivers or babysitters taking care of their child, and which brings up another importance suggestion to have all of them receive first aid education and CPR licenses as a precondition to working as a caregiver or a babysitter.,
Drowning and submersion injuries in pediatric groups are another global concern in emergency medicine. In the pediatrics group of this study, drowning caused 14% cardiac arrests. This urges the need of proper precautions at swimming pools and public beaches and to have enough lifeguards available at all times. Moreover, it is suggested to encourage volunteers to be trained as lifeguards and to have duties allocated on public beaches.
Another aspect is mechanical CPR which is used in a lot of EMS organisations to ensure the effectiveness of compression, minimizing interruptions and reducing the occupational injuries among staff when treating cardiac arrest patients. Having said that, there are a lot of arguments about advantages and disadvantages of using mechanical CPR in adults. Since it is very rare in pediatrics, only 23% of the patients were applicable to mechanical CPR in this study. That is because most manufacturers of mechanical CPR devices state that it can only be applied on pediatrics that is adult size. Keeping this in view, it is important for manufacturers and researchers to seriously consider conducting more studies about mechanical CPR as well as indication and contraindication of using mechanical CPR on the pediatric population group.,,
According to the findings of this study, sustained pre-hospital ROSC was confirmed in 4.1% patients. The entire ROSC group had received bystander CPR before ambulance arrival. The remaining cases were not accounted as mortalities of the cardiac arrest because this study is investigating the characteristics of POHCA before hospital admission. One of limitations of this was study was data linkage between Ambulance and hospitals, which limited the final outcomes of this group. Data continuity is very essential to have better evaluation of out of hospital cardiac arrest outcomes. Therefore, it is strongly recommended to conduct data linkage between both ambulance services and hospitals.
It is essential to conduct more researches to investigate out of hospital cardiac arrest among pediatrics. Developing the EMS pediatric cardiac arrest treatment protocol is crucial to improve the survival rate.
| Conclusion|| |
This 2-year study shows the importance of creating awareness in public regarding pediatric emergencies. Cardiac arrest does not only occur in adults, it can also occur in healthy pediatrics. Therefore, community engagement is essential to improve the chain of survival.
As infants have the highest percentage of cardiac arrest in this group, there is a need to develop customized training programmes for parents as a part of taking care of their children. As this group is constantly under parent supervision or they may be looked after by a caregiver, making first aid training as a mandatory requirement to work as a caregiver is emphasized.
The first three elements of chain of survival rely on community engagement to increase the survival rate. In National Ambulance, even though we give CPR instructions to the caller for cardiac arrest patients, not all of the patients receive bystander CPR as explained previously. This is a global issue and a lot of studies and researches have investigated this aspect all over the world. Therefore, it is highly recommended to implement Good Samaritan Law in the UAE to clarify community's right and limitations when they are helping cardiac arrest patients.
The limitation of this is study is data continuity. As this study investigates the characteristics of POHCA, enough hospital data is not available. Therefore, it is strongly recommended to implement a data linkage between ambulance services and hospitals under data continuity project to have better understanding of the outcomes and to conduct proper studies.
The study protocol and ethical clearance were reviewed and approved by the ethics review committee in the National Ambulance with no conflict of interest.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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