Improving outcomes from paediatric cardiac arrest in low resource setting
Authors: Ahmad F , Lok S K , Jones M F , Yaakop E , Cole S , Sreenivasan R , Ramali M , Bishop P , Cadet B , Chan S T , Cox S V , Sadiq M A , Zainal Abidin I , Kasim S S 
Published: November 2023

Abstract

Introduction
Both out of (OHCA) and in hospital (IHCA) pediatric cardiac arrest has traditionally been considered a futile medical condition with dismal outcomes. This is further magnified by resuscitation protocols are typically articulated from the perspective of ideal resource environment without consideration of applicability in district hospitals or non-tertiary centres.

Purpose
To determine clinical outcomes from both paediatric OHCA and IHCA in low-resource setting and to identify shortcomings in relation to resuscitation in these areas, possible solutions and to suggest future research priorities.

Methods
This was a multicenter retrospective study in a middle sized city (estimated population 390000) served by a single Emergency Medical Services (EMS) system. All records of OHCA and IHCA under 16 years old were reviewed from the Cardiac Arrest Registry from 2017 to 2022. Data collected included demographic profiles, etiology of cardiac arrest, initial cardiac rhythm, time of initiation of cardiopulmonary resuscitation (CPR) and adrenaline administration by EMS team and duration of CPR. Outcomes of interest included return of spontaneous circulation (ROSC) and survival to hospital discharge (STHD).

Results
From the 5-year study period, 68 children (mean age of 5.8±1.2 yrs) were included in this study. 22 (32.4%) were infants (&lt;1 year old) and 7 (10.3%) were neonates (&lt;28 days old). Total mortality was observed at 63.2% (n=43). Return of spontaneous circulation (ROSC) was achieved in 40 (58.8%) patients and 33.8% (n=23) survived to hospital discharge. OHCA was witnessed in 52 (83.8%) children from total OHCA and bystander CPR was delivered only in 19 (30.6%) cases. All IHCA were witnessed. Asystole was the most common (n=39) initial rhythm. A delay in initiating cardiopulmonary resuscitation (CPR) and adrenaline administration was observed in 49 cases of OHCA and 1 in IHCA. The median time from emergency call to CPR and from CPR to first adrenaline administration was 20.9±1.2 min and 2.9±1.3 min for OHCA and 0.4±0.2 min and 1.5±0.7min for IHCA [Table 1]. Longer time to CPR and adrenaline administration was associated with lower chance of achieving ROSC and STHD. Using multivariate analyses, fewer adrenaline doses (p&lt;0.05), witnessed cardiac arrest (p=0.001), initial rhythm of ventricular fibrillation (p&lt;0.05) and shorter CPR duration (p=0.007) were good prognostic factors for ROSC and STHD.

Conclusion
Outcomes from OHCA and IHCA in low resource settings are poor. Unwitnessed arrest, delays in initiation of CPR and adrenaline administration were associated with poor survival. Recognition and identification of at-risk patients, early high-quality CPR and adrenaline administration are imperative to improve mortality. Early recognition and effective resuscitation protocols for children in the community and encouraging bystander CPR should be developed collaboratively with local experts and the EMS team.