Bystander CPR in Kids: Add Breaths to Compressions for Best Results

November 12, 2016

NEW ORLEANS, LA — Bystander CPR was associated with higher rates of overall survival and neurologically favorable status after pediatric out-of-hospital cardiac arrest, in a new study. And conventional CPR was associated with better outcomes than compression-only CPR[1].

The study was presented November 12 at the American Heart Association 2016 Scientific Sessions and published online simultaneously in JAMA Pediatrics.

The authors, led by Dr Maryam Naim (Children's Hospital of Philadelphia, PA), state that to their knowledge, this is the first report focused on the association of conventional and compression-only bystander CPR in children from the United States.

There say there are several important findings to highlight from the study:

  • Bystander CPR was provided for 47% of these children after cardiac arrest, which is greater than previously reported.

  • Bystander CPR was associated with a higher survival to hospital discharge and neurologically favorable survival than previously reported from the US.

  • A racial disparity exists in the provision of bystander CPR.

  • Compression-only CPR and conventional CPR were provided in a similar number of arrests, but conventional CPR was associated with better outcomes than compression-only CPR.

  • Both conventional CPR and compression-only CPR were associated with better outcomes than no CPR for children aged 1 to 18 years.

  • Although infants made up the largest age group, bystander CPR was associated with improved outcomes only in infants when ventilations were also performed.

They conclude that public-health efforts to improve the provision of CPR in minority communities and increase the use of conventional bystander CPR may improve outcomes for pediatric out-of-hospital cardiac arrests.

The researchers analyzed information on children 18 years and younger from the Cardiac Arrest Registry to Enhance Survival (CARES) database from January 2013 through December 2015.

Of the 3900 children with out-of-hospital cardiac arrest, 2317 (59.4%) were infants, 2346 (60.2%) were female, and 3595 (92.2%) had nonshockable rhythms. Bystander CPR was performed on 1814 children (46.5%) and was more common for white children (56.3%) than for African American children (39.4%) and Hispanic children (43.3%).

Overall survival was 11% and neurologically favorable survival (defined as a Cerebral Performance Category score of 1 or 2 at the time of hospital discharge) was 9.1%.

On multivariable analysis, bystander CPR was independently associated with improved overall survival vs no bystander CPR (adjusted proportions 13.2% vs 9.5%; adjusted odds ratio 1.57) and neurologically favorable survival (10.3% vs 7.6%; adjusted odds ratio 1.50).

For the 1411 children with data on type of CPR received, 697 (49.4%) received conventional CPR and 714 (50.6%) received compression-only CPR.

On multivariable analysis, only conventional CPR was associated with improved neurologically favorable survival compared with no bystander CPR (adjusted odds ratio 2.06).

There was a significant interaction of bystander CPR with age. Among infants, conventional bystander CPR was associated with improved overall survival and neurologically favorable survival while compression-only CPR had similar outcomes to no CPR.

The authors note that both rates of bystander CPR and survival rates were higher in this study than in previous reports. They suggest that the increase in bystander CPR may be secondary to an increase in compression-only CPR by bystanders unwilling to perform conventional CPR with rescue breaths, which is supported by the observation that an almost equal number of children received conventional CPR and compression-only CPR in the current study. And they suggest the improvement in survival rates is presumably because of the increased bystander CPR noted in this study as well as improvements in management after cardiac arrest.

But they note that the survival rate among infants remains low and as public-health campaigns currently stress the provision of chest compressions over ventilations (a more difficult technique), "alternative public-health strategies may be needed to improve outcomes in this age group."

They also highlight the need for intervention in African American and Hispanic communities, where a public-health strategy could be undertaken to enhance bystander CPR in children.

In an accompanying editorial[2], Drs Sarah E Haskell and Dianne L Atkins (University of Iowa Carver College of Medicine, Iowa City) say this study "affirms that we are making progress," but they stress that to increase bystander CPR rates further and to correct the racial disparity for provision of bystander CPR, national initiatives teaching CPR are needed. "Development of a widespread and effective public response to cardiac arrest across the nation is critical to improving outcomes of an eminently treatable problem," they conclude.

The authors report no relevant financial relationships.Haskell and Atkins receive modest supply support from the Children’s Hospital of Philadelphia for participation in an in-hospital cardiopulmonary resuscitation project.

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