Cardiorespiratory arrest in children (out of hospital)
Out-of-hospital cardiorespiratory arrest in children, although rare, is associated with low survival rates and poor functional neurological outcomes in children who survive.
Focus of the review
This overview aims to determine the evidence available to support the use of widely practised and taught interventions such as Paediatric Advanced Life Support measures in the management of out-of-hospital cardiorespiratory arrest in children. These include airway management and ventilation, bystander cardiopulmonary resuscitation, direct current cardiac shock, standard-dose intravenous adrenaline, and induced hypothermia. Evidence for the use of high-dose intravenous adrenaline and intravenous sodium bicarbonate has also been reviewed. These interventions are not currently recognised to be standard practice, but have been widely used in the past. Training programmes for parents to perform cardiopulmonary resuscitation exist widely and are popularly recommended; as such, this intervention has also been included in this overview.
Comments on evidence
Very few clinical trials have been conducted to evaluate the effectiveness of therapies for out-of-hospital cardiorespiratory arrest in children. Despite the lack of evidence, placebo-controlled trials for most accepted interventions would be ethically challenging in this population. Because of the paucity of RCT evidence, some data from observational studies have also been included in the Comment sections of this overview.
Search and appraisal summary
The update literature search for this overview was carried out from the date of the last search, December 2009, to November 2014. For more information on the electronic databases searched and criteria applied during assessment of studies for potential relevance to the overview, please see the Methods section. Searching of electronic databases retrieved 192 studies. After deduplication and removal of conference abstracts, 81 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 68 studies and the further review of 13 full publications. Of the 13 full articles evaluated, three systematic reviews were added at this update. Based upon their own search, the contributors added eight studies to the Comment sections.
Although out-of-hospital cardiorespiratory arrest in children is associated with low survival rates, high-quality chest compressions with minimal interruption, immediate airway management, and ventilation are widely accepted to be key interventions. Ventilation with a bag and mask seems 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. These are the underlying rhythms present 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. Evidence from observational studies suggests that standard-dose intravenous adrenaline and bystander cardiopulmonary resuscitation are likely to be beneficial.
Substantive changes at this update
Standard dose intravenous adrenaline (epinephrine) One systematic review added to the Comment section. Evidence re-evaluated. Categorisation unchanged (likely to be beneficial).
High dose intravenous adrenaline (compared with standard dose) One systematic review added. Categorisation unchanged (unknown effectiveness).
Targeted temperature management after out-of-hospital arrest Two systematic reviews added. One RCT in adults and one RCT published after the search date of this review were added to Comment section. Categorisation unchanged (unknown effectiveness).
INTRODUCTION: Cardiorespiratory arrest outside hospital occurs in approximately 1/10,000 children per year in resource-rich countries, with two-thirds of arrests occurring in children under 18 months of age. Approximately 45% 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 overview, aiming 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 November 2014 (BMJ Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS: At this update, searching of electronic databases retrieved 192 studies. After deduplication and removal of conference abstracts, 81 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 68 studies and the further review of 13 full publications. Of the 13 full articles evaluated, three systematic reviews were added at this update. We have also added eight studies to the Comment section. We performed a GRADE evaluation for three PICO combinations. CONCLUSIONS: In this systematic overview, we categorised the efficacy for nine interventions based on information about the effectiveness and safety of airway management and ventilation (bag-mask ventilation and intubation), bystander cardiopulmonary resuscitation, direct-current cardiac shock, high dose and standard dose intravenous adrenaline (epinephrine), intravenous sodium bicarbonate, intubation versus bag-mask ventilation, targeted temperature management, and training parents to perform resuscitation.
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