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Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia
Participants Children aged up to 16 with cardiac arrest and hypothermia after drowning, who presented at emergency departments and/or were admitted to intensive care.
Main outcome measure Survival and neurological outcome one year after the drowning incident. Poor outcome was defined as death or survival in a vegetative state or with severe neurological disability (paediatric cerebral performance category (PCPC) 4).
Results From 1993 to 2012, 160 children presented with cardiac arrest and hypothermia after drowning. In 98 (61%) of these children resuscitation was performed for more than 30 minutes (98/160, median duration 60 minutes), of whom 87 (89%) died (95% confidence interval 83% to 95%; 87/98). Eleven of the 98 children survived (11%, 5% to 17%), but all had a PCPC score 4. In the 62 (39%) children who did not require prolonged resuscitation, 17 (27%, 16% to 38%) survived with a PCPC score 3 after one year: 10 (6%) had a good neurological outcome (score 1), five (3%) had mild neurological disability (score 2), and two (1%) had moderate neurological disability (score 3). From the original 160 children, only 44 were alive at one year with any outcome.
Conclusions Drowned children in whom return of spontaneous circulation is not achieved within 30 minutes of advanced life support have an extremely poor outcome. Good neurological outcome is more likely when spontaneous circulation returns within 30 minutes of advanced life support, especially when the drowning incident occurs in winter. These findings question the therapeutic value of resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia. Many houses are built near to ponds, ditches, or canals. A temperate maritime climate prevails, with mean air temperatures of 3.5C in winter, 9.5C in spring, 10.6C in autumn, and 17.0C in summer and water temperatures ranging from 0 8C in winter, 6 18C in spring and autumn, and 15 28C in summer.19 20
The Dutch emergency medical service has a legally enforced arrival time of less than 15 minutes for medical emergencies.21 All ambulance teams consist of a nurse trained in paediatric basic and advanced life support and allowed to perform intubation and administration of adrenaline (epinephrine) in children and a driver trained in paediatric basic life support. In cases of a cardiac arrest, a second emergency medical team is always called on, and, since 1999, this second team is often the helicopter emergency medical service with a physician on board.
Prehospital treatment is provided by emergency medical service nurses according to Dutch national ambulance protocols. These protocols are in accordance with the guidelines of the European Resuscitation Council. The national ambulance protocols how much is a hermes handbag instruct that all children with cardiac arrest and hypothermia should be transported, under continuous cardiopulmonary resuscitation, to a hospital with facilities for extracorporeal life support. The physicians of the helicopter emergency medical service and the emergency department treat according to the replica hermes birkin handbags guidelines of the Dutch Resuscitation Council and the European Resuscitation Council. All children with return of spontaneous circulation after prolonged resuscitation, whether primarily presented at the emergency department of a general hospital or a university medical centre, are transferred to a paediatric intensive care unit in one of the eight university medical centres.
PatientsWe retrospectively identified eligible patients by using the ICD 9 (international classification of diseases, ninth edition) code for drowning (994.1). For those aged 16 and under, their demographical and clinical data were entered in the database when they were admitted at the emergency department, the general paediatric ward, or the paediatric intensive care unit of one of the eight university medical centres from 1 January 1993 to 1 January 2012. Children who presented at the emergency department of a general hospital and transferred to the paediatric intensive care unit were included in this database.
Inclusion and exclusion criteriaWe included children with cardiac arrest after drowning outside (excluding heated outdoor swimming pools) and an initial core body temperature below 34C. Drowning outside was an inclusion criterion so hermes replica we could use season as a proxy for water temperature. As concurrent traumatic injuries could possibly influence outcome, we excluded children who drowned in a traffic or boating incident.
VariablesThe data collection was based on the Utstein style variables for uniform reporting of data from drowning.22 Data collected at the arrival of the emergency medical service included initial cardiac arrest rhythm, the use of bag and mask ventilation, intubation, duration of chest compressions, and number of doses of adrenaline and attempts at defibrillation. Data collected at the emergency department included initial core body temperature, score on Glasgow coma scale, the use of bag and mask ventilation, intubation, duration of chest compressions, number of doses of adrenaline, use of extracorporeal life support for cardiac arrest, and return of spontaneous circulation or death. Data collected at the paediatric intensive care unit included death or discharge, the cause of death, and, if applicable, the withdrawal of life sustaining treatment. Final disposition was dead or alive at one year after the drowning incident, and, if alive, the neurological status according to the paediatric cerebral performance category score (PCPC).23
DefinitionsThe minimum and maximum durations of submersion were taken from the medical records and were based on estimations by the caretaker(s) of the child at the time of incident. Cardiac arrest was defined as the necessity for chest compressions on arrival of the emergency medical service or and/or helicopter emergency medical service. The start point of the resuscitation time was marked by the initiation of chest compressions by the emergency services and the total duration of resuscitation included prehospital and in hospital advanced life support but excluded bystander cardiopulmonary resuscitation. Prolonged resuscitation was defined as more than 30 minutes of total resuscitation. This cut off was chosen because the mean attempted resuscitation time in many studies concerning resuscitation in children with out of hospital cardiac arrest averaged 30 minutes.24 We defined spring as the period between 1 March and 31 May, summer between 1 June and 31 August, autumn between 1 September and 30 November, and winter between 1 December and 29 February.
Initial cardiac arrest rhythm was the first rhythm visible after connection of the patient to the electrocardiograph of the emergency medical services. Initial temperature was defined as the first body temperature measured within one hour after arrival at the emergency department and concerned measurements of rectal or oesophageal temperature with a low reading thermometer. The initial blood gas analysis was measured within two hours after arrival at the emergency department. The term extracorporeal life support was used to indicate both extracorporeal circulation and extracorporeal membrane oxygenation. In the paediatric intensive care unit a diagnosis of severe neurological damage could lead to withdrawal of further intensive treatment. The severity of the brain damage was assessed by clinical neurological examination, cerebral magnetic resonance imaging and/or electroencephalography, and/or sensory evoked potentials. The combined results could lead to a decision to withdraw further intensive treatment. The paediatric cerebral performance category scale (PCPC)23 was used to qualify neurological outcome. This scale rates the neurological outcome by cognitive impairment in six categories: good neurological performance, mild neurological disability, moderate neurological disability, severe neurological disability, coma or vegetative state, and brain death.23 A good outcome was characterised by a PCPC score 3 at one year after the incident. Although fake hermes leather handbags it can be debated whether patients with a score of 3, who will require assistance in daily activities, really have a good outcome, we chose this conservative cut off point to be able to classify extremely poor outcome beyond discussion. We therefore defined poor outcome as death or survival with severe neurological disability at one year after the incident (score 4).
Statistical analysesContinuous data are presented as medians and interquartile range. Dichotomous and categorical data are presented as proportions, percentages of total, and 95% confidence intervals. We used Fisher's exact test for categorical data and Mann Whitney U test for continuous data. P
ResultsDescription of study populationFrom 1993 to 2012, 784 children were identified by the ICD 9 code for drowning. Two of the eight university medical centres were unable to identify children who died at the emergency department. Medical records were available for 753 children. Seventeen children were misclassified, thus 736 children were retained in the database, of whom 207 (28%) experienced cardiac arrest requiring advanced life support. Of these 207 children, 47 (47/207, 23%) were excluded from the present study: 25 had an initial body temperature of 34C, 14 were involved in a vehicle or boat incident, and eight drowned indoors.
We concentrated on the 160 children who experienced a cardiac arrest with hypothermia after drowning outside, which was not associated with a motor vehicle or boat incident. Figure 1 shows the flow of the 160 included children from the emergency department onwards and their subsequent clinical outcome. Of these children, 104 (65%) had ongoing cardiac arrest on arrival at the emergency department. All 98 children in whom return of spontaneous circulation was not achieved within 30 minutes received prolonged resuscitation. Of these 98 children, 23 children died in the emergency department. The 137 other children, in whom return of spontaneous circulation was achieved, were admitted to the paediatric intensive care unit (137/160, 86%), where 79 died (79/137; 58%, 95% confidence interval 50% to 66%); 30 had a diagnosis of brain death (30/79; 38%, 27% to 49%) and 27 had a diagnosis of severe neurological damage (27/79; 34%, 24% to 44%), the 22 others died of cardiac arrest, acute respiratory distress syndrome, or multi organ failure (22/79; 28%, 18% to 38%). In the original 160 children, the total mortality rate after cardiac arrest with hypothermia was 73% (66% to 80%; n=116). Ten children remained in a vegetative state (10/160; 6%, 2% to 10%), and 17 had severe neurological damage (17/160; 11%, 6% to 16%). One year after the drowning accident 17 children had a PCPC score of 3 (17/160; 11%, 6% to 16%).
Fig 1 flow and clinical outcome of children who drowned with cardiac arrest and hypothermia after presentation at emergency department. Final outcome was one year after drowning incident and categorised with paediatric cerebral performance categories (PCPC). Death, vegetative state, and severe disability were categorised as poor outcome. ROSC=return of spontaneous circulation, PICU=paediatric intensive care unit
Prolonged resuscitationProlonged resuscitation was performed in 98 of the 160 children with a cardiac arrest and hypothermia (61%, 95% confidence interval 54% to 69%). The outcome was not good in any of the children who underwent resuscitation beyond 30 minutes (0% with good outcome, 0% to 3%) (fig 3). Seventeen of the children who did not require prolonged resuscitation survived with a PCPC score 3 after one year (17/62 good outcome; 27%, 16% to 38%). The maximum duration of resuscitation with good outcome was 25 minutes. The outcome of prolonged resuscitation was extremely poor: 87 of the 98 children died (89%, 83% to 95%), and 11 survived in a vegetative state or with severe neurological damage (11%, 5% to 17%). Table 4 shows the characteristics of the children in relation to duration of resuscitation. Extracorporeal life support was performed in 12 children, of whom 11 died and one survived in a vegetative state. Thus, no child who underwent prolonged resuscitation, with or without extracorporeal life support, had a good outcome.
Initial cardiac arrest rhythmWe were able to retrieve data on the initial cardiac arrest rhythm from the medical records in 118 of the 160 children (74%). Asystole was diagnosed in nearly all children (101/118, 86%), followed by bradycardia (15/118, 13%) and ventricular fibrillation (2/118, 2%). Bradycardia correlated strongly with good outcome: six of the 15 children with bradycardia had good outcome versus eight of the 101 children with asystole (40% (95% confidence interval 15% to 65%) v 8% (3% to 13%); odds ratio 7.8 (2.2 to 27.3), P=0.001).
Duration of submersion, doses of adrenaline, and blood gas abnormalitiesIn only 3% of the cases (5/160) was the drowning incident witnessed by an adult, and consequently the duration of submersion was not precisely known in most cases. The typical history of most incidents was a sudden realisation of the child's absence, followed by an immediate search by the caretaker. Though the duration of the search was reasonably well known, it was usually unknown how long the child had been out of sight. The median estimated minimum and maximum durations of submersion correlated negatively with outcome (table 3). The longest estimated duration of submersion with good outcome was 25 minutes. Figure 6 shows the relation between maximum estimated submersion duration and outcome.
The median total number of doses of adrenaline administered was negatively associated with outcome (table 3). The median initial pH and the base excess were significantly lower in children with poor outcome (table 3). All children were manually or mechanically ventilated at the time of the initial blood gas measurement, while some children were still being resuscitated and others already had return of spontaneous circulation. The lowest pH associated with good a outcome was 6.75.
Treatment changesWe performed a subanalysis to determine whether changes in treatment during the study period affected the main outcomes. The percentage of children with good outcome in the first five years of the study period was comparable with the percentage in the last five years (7/51, 14% (95% confidence interval 4% to 23%) v 5/30, 17% (3% to 30%), P=0.75).
DiscussionImplication of key findingsIn children with cardiac arrest and hypothermia after drowning the necessity for resuscitation for more than 30 minutes did not result in good outcome in any child: 89% of children died and 11% survived in a vegetative state or with severe neurological damage. The study used a nationwide database over the period 1993 2012. Most children drowned during spring, summer, or autumn and had a much poorer outcome than those who drowned in winter. These results strongly question the therapeutic value of prolonged resuscitation in drowned children with cardiac arrest and hypothermia.
Participants Children aged up to 16 with cardiac arrest and hypothermia after drowning, who presented at emergency departments and/or were admitted to intensive care.
Main outcome measure Survival and neurological outcome one year after the drowning incident. Poor outcome was defined as death or survival in a vegetative state or with severe neurological disability (paediatric cerebral performance category (PCPC) 4).
Results From 1993 to 2012, 160 children presented with cardiac arrest and hypothermia after drowning. In 98 (61%) of these children resuscitation was performed for more than 30 minutes (98/160, median duration 60 minutes), of whom 87 (89%) died (95% confidence interval 83% to 95%; 87/98). Eleven of the 98 children survived (11%, 5% to 17%), but all had a PCPC score 4. In the 62 (39%) children who did not require prolonged resuscitation, 17 (27%, 16% to 38%) survived with a PCPC score 3 after one year: 10 (6%) had a good neurological outcome (score 1), five (3%) had mild neurological disability (score 2), and two (1%) had moderate neurological disability (score 3). From the original 160 children, only 44 were alive at one year with any outcome.
Conclusions Drowned children in whom return of spontaneous circulation is not achieved within 30 minutes of advanced life support have an extremely poor outcome. Good neurological outcome is more likely when spontaneous circulation returns within 30 minutes of advanced life support, especially when the drowning incident occurs in winter. These findings question the therapeutic value of resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia. Many houses are built near to ponds, ditches, or canals. A temperate maritime climate prevails, with mean air temperatures of 3.5C in winter, 9.5C in spring, 10.6C in autumn, and 17.0C in summer and water temperatures ranging from 0 8C in winter, 6 18C in spring and autumn, and 15 28C in summer.19 20
The Dutch emergency medical service has a legally enforced arrival time of less than 15 minutes for medical emergencies.21 All ambulance teams consist of a nurse trained in paediatric basic and advanced life support and allowed to perform intubation and administration of adrenaline (epinephrine) in children and a driver trained in paediatric basic life support. In cases of a cardiac arrest, a second emergency medical team is always called on, and, since 1999, this second team is often the helicopter emergency medical service with a physician on board.
Prehospital treatment is provided by emergency medical service nurses according to Dutch national ambulance protocols. These protocols are in accordance with the guidelines of the European Resuscitation Council. The national ambulance protocols how much is a hermes handbag instruct that all children with cardiac arrest and hypothermia should be transported, under continuous cardiopulmonary resuscitation, to a hospital with facilities for extracorporeal life support. The physicians of the helicopter emergency medical service and the emergency department treat according to the replica hermes birkin handbags guidelines of the Dutch Resuscitation Council and the European Resuscitation Council. All children with return of spontaneous circulation after prolonged resuscitation, whether primarily presented at the emergency department of a general hospital or a university medical centre, are transferred to a paediatric intensive care unit in one of the eight university medical centres.
PatientsWe retrospectively identified eligible patients by using the ICD 9 (international classification of diseases, ninth edition) code for drowning (994.1). For those aged 16 and under, their demographical and clinical data were entered in the database when they were admitted at the emergency department, the general paediatric ward, or the paediatric intensive care unit of one of the eight university medical centres from 1 January 1993 to 1 January 2012. Children who presented at the emergency department of a general hospital and transferred to the paediatric intensive care unit were included in this database.
Inclusion and exclusion criteriaWe included children with cardiac arrest after drowning outside (excluding heated outdoor swimming pools) and an initial core body temperature below 34C. Drowning outside was an inclusion criterion so hermes replica we could use season as a proxy for water temperature. As concurrent traumatic injuries could possibly influence outcome, we excluded children who drowned in a traffic or boating incident.
VariablesThe data collection was based on the Utstein style variables for uniform reporting of data from drowning.22 Data collected at the arrival of the emergency medical service included initial cardiac arrest rhythm, the use of bag and mask ventilation, intubation, duration of chest compressions, and number of doses of adrenaline and attempts at defibrillation. Data collected at the emergency department included initial core body temperature, score on Glasgow coma scale, the use of bag and mask ventilation, intubation, duration of chest compressions, number of doses of adrenaline, use of extracorporeal life support for cardiac arrest, and return of spontaneous circulation or death. Data collected at the paediatric intensive care unit included death or discharge, the cause of death, and, if applicable, the withdrawal of life sustaining treatment. Final disposition was dead or alive at one year after the drowning incident, and, if alive, the neurological status according to the paediatric cerebral performance category score (PCPC).23
DefinitionsThe minimum and maximum durations of submersion were taken from the medical records and were based on estimations by the caretaker(s) of the child at the time of incident. Cardiac arrest was defined as the necessity for chest compressions on arrival of the emergency medical service or and/or helicopter emergency medical service. The start point of the resuscitation time was marked by the initiation of chest compressions by the emergency services and the total duration of resuscitation included prehospital and in hospital advanced life support but excluded bystander cardiopulmonary resuscitation. Prolonged resuscitation was defined as more than 30 minutes of total resuscitation. This cut off was chosen because the mean attempted resuscitation time in many studies concerning resuscitation in children with out of hospital cardiac arrest averaged 30 minutes.24 We defined spring as the period between 1 March and 31 May, summer between 1 June and 31 August, autumn between 1 September and 30 November, and winter between 1 December and 29 February.
Initial cardiac arrest rhythm was the first rhythm visible after connection of the patient to the electrocardiograph of the emergency medical services. Initial temperature was defined as the first body temperature measured within one hour after arrival at the emergency department and concerned measurements of rectal or oesophageal temperature with a low reading thermometer. The initial blood gas analysis was measured within two hours after arrival at the emergency department. The term extracorporeal life support was used to indicate both extracorporeal circulation and extracorporeal membrane oxygenation. In the paediatric intensive care unit a diagnosis of severe neurological damage could lead to withdrawal of further intensive treatment. The severity of the brain damage was assessed by clinical neurological examination, cerebral magnetic resonance imaging and/or electroencephalography, and/or sensory evoked potentials. The combined results could lead to a decision to withdraw further intensive treatment. The paediatric cerebral performance category scale (PCPC)23 was used to qualify neurological outcome. This scale rates the neurological outcome by cognitive impairment in six categories: good neurological performance, mild neurological disability, moderate neurological disability, severe neurological disability, coma or vegetative state, and brain death.23 A good outcome was characterised by a PCPC score 3 at one year after the incident. Although fake hermes leather handbags it can be debated whether patients with a score of 3, who will require assistance in daily activities, really have a good outcome, we chose this conservative cut off point to be able to classify extremely poor outcome beyond discussion. We therefore defined poor outcome as death or survival with severe neurological disability at one year after the incident (score 4).
Statistical analysesContinuous data are presented as medians and interquartile range. Dichotomous and categorical data are presented as proportions, percentages of total, and 95% confidence intervals. We used Fisher's exact test for categorical data and Mann Whitney U test for continuous data. P
ResultsDescription of study populationFrom 1993 to 2012, 784 children were identified by the ICD 9 code for drowning. Two of the eight university medical centres were unable to identify children who died at the emergency department. Medical records were available for 753 children. Seventeen children were misclassified, thus 736 children were retained in the database, of whom 207 (28%) experienced cardiac arrest requiring advanced life support. Of these 207 children, 47 (47/207, 23%) were excluded from the present study: 25 had an initial body temperature of 34C, 14 were involved in a vehicle or boat incident, and eight drowned indoors.
We concentrated on the 160 children who experienced a cardiac arrest with hypothermia after drowning outside, which was not associated with a motor vehicle or boat incident. Figure 1 shows the flow of the 160 included children from the emergency department onwards and their subsequent clinical outcome. Of these children, 104 (65%) had ongoing cardiac arrest on arrival at the emergency department. All 98 children in whom return of spontaneous circulation was not achieved within 30 minutes received prolonged resuscitation. Of these 98 children, 23 children died in the emergency department. The 137 other children, in whom return of spontaneous circulation was achieved, were admitted to the paediatric intensive care unit (137/160, 86%), where 79 died (79/137; 58%, 95% confidence interval 50% to 66%); 30 had a diagnosis of brain death (30/79; 38%, 27% to 49%) and 27 had a diagnosis of severe neurological damage (27/79; 34%, 24% to 44%), the 22 others died of cardiac arrest, acute respiratory distress syndrome, or multi organ failure (22/79; 28%, 18% to 38%). In the original 160 children, the total mortality rate after cardiac arrest with hypothermia was 73% (66% to 80%; n=116). Ten children remained in a vegetative state (10/160; 6%, 2% to 10%), and 17 had severe neurological damage (17/160; 11%, 6% to 16%). One year after the drowning accident 17 children had a PCPC score of 3 (17/160; 11%, 6% to 16%).
Fig 1 flow and clinical outcome of children who drowned with cardiac arrest and hypothermia after presentation at emergency department. Final outcome was one year after drowning incident and categorised with paediatric cerebral performance categories (PCPC). Death, vegetative state, and severe disability were categorised as poor outcome. ROSC=return of spontaneous circulation, PICU=paediatric intensive care unit
Prolonged resuscitationProlonged resuscitation was performed in 98 of the 160 children with a cardiac arrest and hypothermia (61%, 95% confidence interval 54% to 69%). The outcome was not good in any of the children who underwent resuscitation beyond 30 minutes (0% with good outcome, 0% to 3%) (fig 3). Seventeen of the children who did not require prolonged resuscitation survived with a PCPC score 3 after one year (17/62 good outcome; 27%, 16% to 38%). The maximum duration of resuscitation with good outcome was 25 minutes. The outcome of prolonged resuscitation was extremely poor: 87 of the 98 children died (89%, 83% to 95%), and 11 survived in a vegetative state or with severe neurological damage (11%, 5% to 17%). Table 4 shows the characteristics of the children in relation to duration of resuscitation. Extracorporeal life support was performed in 12 children, of whom 11 died and one survived in a vegetative state. Thus, no child who underwent prolonged resuscitation, with or without extracorporeal life support, had a good outcome.
Initial cardiac arrest rhythmWe were able to retrieve data on the initial cardiac arrest rhythm from the medical records in 118 of the 160 children (74%). Asystole was diagnosed in nearly all children (101/118, 86%), followed by bradycardia (15/118, 13%) and ventricular fibrillation (2/118, 2%). Bradycardia correlated strongly with good outcome: six of the 15 children with bradycardia had good outcome versus eight of the 101 children with asystole (40% (95% confidence interval 15% to 65%) v 8% (3% to 13%); odds ratio 7.8 (2.2 to 27.3), P=0.001).
Duration of submersion, doses of adrenaline, and blood gas abnormalitiesIn only 3% of the cases (5/160) was the drowning incident witnessed by an adult, and consequently the duration of submersion was not precisely known in most cases. The typical history of most incidents was a sudden realisation of the child's absence, followed by an immediate search by the caretaker. Though the duration of the search was reasonably well known, it was usually unknown how long the child had been out of sight. The median estimated minimum and maximum durations of submersion correlated negatively with outcome (table 3). The longest estimated duration of submersion with good outcome was 25 minutes. Figure 6 shows the relation between maximum estimated submersion duration and outcome.
The median total number of doses of adrenaline administered was negatively associated with outcome (table 3). The median initial pH and the base excess were significantly lower in children with poor outcome (table 3). All children were manually or mechanically ventilated at the time of the initial blood gas measurement, while some children were still being resuscitated and others already had return of spontaneous circulation. The lowest pH associated with good a outcome was 6.75.
Treatment changesWe performed a subanalysis to determine whether changes in treatment during the study period affected the main outcomes. The percentage of children with good outcome in the first five years of the study period was comparable with the percentage in the last five years (7/51, 14% (95% confidence interval 4% to 23%) v 5/30, 17% (3% to 30%), P=0.75).
DiscussionImplication of key findingsIn children with cardiac arrest and hypothermia after drowning the necessity for resuscitation for more than 30 minutes did not result in good outcome in any child: 89% of children died and 11% survived in a vegetative state or with severe neurological damage. The study used a nationwide database over the period 1993 2012. Most children drowned during spring, summer, or autumn and had a much poorer outcome than those who drowned in winter. These results strongly question the therapeutic value of prolonged resuscitation in drowned children with cardiac arrest and hypothermia.
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