Significant factors in predicting sustained Significant factors in predicting sustained ROSC (return of spontaneous circulation) ROSC (return of spontaneous circulation) in paediatric patients with traumatic out-oin paediatric patients with traumatic out-of-hospital cardiac arrest (OHCA) admitted f-hospital cardiac arrest (OHCA) admitted to the emergency department.to the emergency department.

By intern 9001140By intern 9001140

李凱靈李凱靈

TitleAuthor(s): (Chang Hua Hosp.)TitleAuthor(s): (Chang Hua Hosp.)– Yan-Ren Lin, Han-Ping Wu,Chin-Yi Huang, Yu-Jun C

hang,Ching-Yuang Lin, Chu-Chung Chou

Source/Date/Volume/Issue: Source/Date/Volume/Issue: Resuscitation (2007.6.26) 74, 83—89

Study Design : retrospective studyStudy Design : retrospective study

Type : Clinical paperType : Clinical paper

Introduction(1)Introduction(1)

Aim of study: determine Aim of study: determine predicting factorspredicting factors for su for sustained return of spontaneous circulation (ROSstained return of spontaneous circulation (ROSC) in paediatric OHCA patients with trauma. C) in paediatric OHCA patients with trauma.

Major cause of death in OHCA children: Major cause of death in OHCA children: TraumaTrauma (trauma pose challenges in resuscitation)(trauma pose challenges in resuscitation)

evaluate the evaluate the condition and prognosiscondition and prognosis of OHCA p of OHCA paediatric patients with trauma. aediatric patients with trauma. provide approp provide appropriate managementriate managementhigher survival rateshigher survival rates

Introduction (2)Introduction (2)

In adults: initial cardiac rhythm, bystander In adults: initial cardiac rhythm, bystander BLS, a short interval from scene to BLS, a short interval from scene to hospital and early defibrillation. hospital and early defibrillation.

In children: unclearIn children: unclear

Materials and methods(1)Materials and methods(1)

Patient population:115, <18y/o, Jan2000-Dec20Patient population:115, <18y/o, Jan2000-Dec2004 (Chang Hua Hosp.)04 (Chang Hua Hosp.)– Traumatic:56 (traffic accidents, falls, child abuse)Traumatic:56 (traffic accidents, falls, child abuse)– Non-traumatic:59Non-traumatic:59

Methods:Methods:– prehospital info from EMSprehospital info from EMS– Present to EDPresent to EDAPLS (advanced paediatric life suppoAPLS (advanced paediatric life suppo

rt)rt)– Sustained ROSC: when chest compressions were not Sustained ROSC: when chest compressions were not

required for required for 20 consecutives minutes20 consecutives minutes and signs of a ci and signs of a circulation persist rculation persist

Materials and methods(2)Materials and methods(2)

Analysed factors:Analysed factors:– (1) demographic data gathered from the ED sheets in(1) demographic data gathered from the ED sheets in

cluding initial vital signs, age, and sexcluding initial vital signs, age, and sex– (2) mode of transportation (family, EMTs)(2) mode of transportation (family, EMTs)– (3) the period from scene to hospital (call(3) the period from scene to hospital (callarrived Earrived E

D)D)– (4) whether pre-hospital BLS had been performed(4) whether pre-hospital BLS had been performed– (5) initial cardiac rhythm on presentation to the ED (P(5) initial cardiac rhythm on presentation to the ED (P

EA, VF EA, VF include pulses VTinclude pulses VT, asystole), asystole)– (6) the main site of trauma (H&N, T, Abd,multiple)(6) the main site of trauma (H&N, T, Abd,multiple)– (7) type of trauma (blunt or penetrating trauma) (7) type of trauma (blunt or penetrating trauma) – (8) the duration of in-hospital CPR(8) the duration of in-hospital CPR

Materials and methods(3)Materials and methods(3)

Statistical methods:Statistical methods:– %, mean±S.D., median, logistic regression an%, mean±S.D., median, logistic regression an

alysis - alysis - to select independent predictors to dichotomous dependeto select independent predictors to dichotomous dependent variables between sustained ROSC and non-sustained ROSC patientnt variables between sustained ROSC and non-sustained ROSC patient

ss – Log Rank test and 95% CI - Log Rank test and 95% CI - compare the difference betcompare the difference bet

ween trauma and non-trauma groups ween trauma and non-trauma groups

– ROC curve – ROC curve – determined the best duration of in-hospital CPRdetermined the best duration of in-hospital CPR

PP-value < 0.05 -value < 0.05

Results(1)Results(1)sustained ROSC was obtained in 20 OHCA patients, but only one (spleen laceration+massive internal bleeding) eventually discharged from hospital-->percentage of sustained ROSC :35.7%-->total mortality rate:98.2%

Head and neck injury (majority in trauma group), survival rate is very low , but 35.7% regained sustained ROSC -->possible organ donation (sustained ROSC is necessary to prevent organ failure before surgical intervention)-->thus, 2 survey (thorough head-to-toe)should be performed rapidly after 1 survey-->X-ray , CT scan for accurate diagnosis without delay after brief neurologial examination

Results (2)Results (2)Initially cardiac rhythm:asystole>PEA>VFsuccess rate of initial CPR:PEA>VF>asystole

Survival rate of paediatric patients with cardiac arrest secondary to trauma is poor, especially in patients with head an

d thoracic injury.

Results (3)Results (3)

1.Initial cardiac rhythm1.Initial cardiac rhythm and and the duration othe duration of in-hospital CPRf in-hospital CPR were the were the mostmost significa significant factors associated with sustained ROSnt factors associated with sustained ROSC . C . 2.The 2.The success ratesuccess rate of initial CPR was of initial CPR was highigherher in patients with in patients with PEA PEA ( (P P = 0.003) and = 0.003) and VFVF ( (P P = 0.03) than in patients with asysto= 0.03) than in patients with asystole le 3.PEA and VF were better predictors3.PEA and VF were better predictors of s of successful CPR outcome than asystoleuccessful CPR outcome than asystole-->accuracy and speed in reading the EC-->accuracy and speed in reading the ECG and providing the appropriate manageG and providing the appropriate management (for example, CPR in asystole or Pment (for example, CPR in asystole or PEA; early defibrilation in VF or pulseless EA; early defibrilation in VF or pulseless VT)VT)

Results (4)Results (4)

•Two survival curves fell once the period was prolonged, especially in the trauma group(P=0.008).•Decreasing the period from scene to hospital may improve the sustained ROSC rate in the ED, especially in OHCA children with trauma.

Survival analysis: OHCSurvival analysis: OHCA children with A children with traumatrauma h had aad a lower lower chance of chance of susurvivalrvival than non-trauma c than non-trauma children as the interval frhildren as the interval from the scene to the ER om the scene to the ER increased (P=0.008)increased (P=0.008)

Results (5)Results (5)

The best cut-off duration of in-hospital CPR was The best cut-off duration of in-hospital CPR was 25 min25 min (CI:0.769-0.953) (CI:0.769-0.953)Sens : 90%Sens : 90% (patients with sustained ROSC, CPR was performed in-hospital (patients with sustained ROSC, CPR was performed in-hospital for <25min)for <25min)Spec : 86%Spec : 86% ( patients without sustained ROSC do not return to achieve RO ( patients without sustained ROSC do not return to achieve ROSC even after >25min)SC even after >25min)

However, clinically, some patients in the study received >25min of in-hospital CPR and regained sustained ROSCThus, in-hospital CPR may have to be performed for at least 25 min to enable a spontaneous circulation to return

THE END! THANKS!THE END! THANKS!