Editorial 271

Outcomes of Dead on Arrival Children:

Is it time to teach everybody PBLS?
Dead on arrival (DOA) outcomes pose a major human being found in ventricular fibrillation; (3) the interval
health problem worldwide, and several factors that predict between call for and arrival of the ambulance being brief;
successful cardiopulmonary resuscitation (CPR) in adults and (4) cardiac arrest occurring outside the home.4 These
have been discussed.1,2,3 Among patients who experience findings are compatible with the results obtained by Lin
out-of-hospital cardiac arrest, only a small proportion et al. They stated that successful initial CPR was related
are children, and the pathophysiology of non-trauma to the following: (1) initial cardiac rhythm; (2) emergency
DOA in children is different from that in adults, with medical technician (EMT) transportation; (3) presence
the most common etiology in infants being sudden infant of pre-hospital basic life support (BLS); (4) a shorter
death syndrome (SIDS). 4 Although the etiology of period from the scene to the hospital and a longer
cardiopulmonary arrest in children is different from that duration of pre-hospital BLS. Lin et al. also reported
in adults, the immediate goal is the same: to immediately that age and the possible etiology were not statistically
reestablish cardiac output and tissue delivery of oxygen significant factors. Among the patients for whom
through the use of artificial ventilation, external chest information on initial cardiac rhythm was known, only
compression, and the administration of pharmacologic 17% were found in ventricular fibrillation, consistent with
agents. Currently, the optimal predictor of out-of-hospital previous studies in which the proportion of such patients
non-trauma DOA in children remains controversial, and has varied between 4 and 23%.6,7,8
insufficient data exist to provide guidance on therapy. Children suffering from ventricular fibrillation and
In this issue of Acta Paediatrica Taiwanica, Lin and pulseless ventricular tachycardia (so called “shockable
colleagues presented data on the characteristics among rhythm”) have an overall survival rate of 17-20% which
patients aged less than 18 years who experienced non- is significantly higher than adults (7-10%). 4,9,1 0,11
trauma DOA in Taiwan5. Although the patients studied Consequently, it is worthwhile to review the major
were from only a single city instead of the entire area changes of the algorithm to treat “shockable rhythms”.
or nation, as one of the largest DOA pediatric patient According to the new guideline of pediatric advanced
cohorts ever reported, this article revealed many life support (PALS), 12 ventricular fibrillation (VF) or
important arguments. The authors retrospectively pulseless-hypotensive ventricular tachycardia (VT) are
reviewed the management of 120 DOA children (59 were treated with a SINGLE direct current (DC) shock at 2 J/
non-trauma and 61 were trauma DOA patients) over a kg instead of the previous 3-shock sequence. The 1-
5-year period. They found that initial cardiac rhythm, shock should be followed by immediate resumption of
pre-hospital basic life support, mode of transportation, chest compressions for 2 minutes. Rescuers should not
length of time from the scene to the hospital, and interrupt chest compressions to check circulation.
duration of pre-hospital basic life support were significant Subsequently, refractory or recurrent VF or VT is treated
factors related to initial successful CPR in non-trauma with single DC shocks at 4 J/kg with intervals of 2 minutes
DOA children. of chest compression.
The underlying conditions and diseases affecting the In the study by Lin et al., the age distribution of
non-trauma DOA children varied. Most fit into the non-trauma childhood DOA was skewed toward infancy,
classifications of respiratory (pneumonia, apnea, with about 50% of patients younger than 1 year; this
bronchiolitis, asthma, submersion, aspiration, is consistent with previous studies in which infants
epiglottitis, smoke inhalation, suffocation, anaphylaxis), accounted for the highest percentage of non-trauma
infectious (septic shock, meningitis), cardiovascular childhood DOA,4,7,8 and agrees with evidence that the
(congenital heart disease, arrhythmia, myocarditis, most frequent cause of non-trauma DOA is SIDS.
congestive heart failure, pericarditis, shock), or central Equipment and skills preparedness for this young age
nervous system (hemorrhage/edema, shaken baby range by all emergency medical services (EMS)
syndrome, seizures, meningitis, hydrocephalus with responders and those caring for pediatric emergencies
shunt malfunction, tumor) diseases. Cardiovascular is crucial for achieving the best outcomes.7,8
disease and SIDS accounted for one-third to two-thirds The mode of transportation was also a predictor of
of all pediatric non-trauma DOA, in good agreement with successful CPR. Another important predictor of good
previous research. 4,6 outcome was the length of time from the scene to the
Many factors have been associated with an increased hospital. Lin et al. further reported that 45 non-trauma
chance of survival in non-trauma DOA children. J. Herlitz DOA children were brought to the emergency room by
and colleagues reported the following in order of their families, but basic life support (BLS) was performed
importance: (1) the etiology not being SIDS; (2) patients on only 6 of them (13.33%) at the scene. In contrast,
272 Vol. 47, No. 6, 2006

13 non-trauma DOA children were transported by EMTs, REFERENCES

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Children’s Hospital, Chang Gung University,
Kweishan, Taoyuan, Taiwan, R.O.C.