Pediatric defibrillation doses often fail to terminate prolonged out-of-hospital ventricular fibrillation in children
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A Rat Model of Ventricular Fibrillation and Resuscitation by Conventional Closed-chest Technique
Published on: April 26, 2015
Marc D Berg1, Ricardo A Samson, Robyn J Meyer
1Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ 85724, USA. marcb@peds.arizona.edu
Insights
Pediatric defibrillation doses are ineffective for prolonged out-of-hospital cardiac arrest. The standard 2 J/kg dose failed to terminate ventricular fibrillation (VF) in most cases, highlighting a critical knowledge gap.
Area of Science:
- Pediatric Emergency Medicine
- Cardiology
- Resuscitation Science
Background:
- The current pediatric defibrillation dose (2 J/kg) is based on limited evidence from short-duration ventricular fibrillation (VF).
- Animal models and a prior pediatric study suggest this dose may be insufficient for prolonged out-of-hospital VF.
Purpose of the Study:
- To evaluate the effectiveness of the standard pediatric defibrillation dose (2 J/kg) in terminating ventricular fibrillation (VF) during out-of-hospital cardiac arrest.
- To compare VF termination rates in out-of-hospital pediatric cardiac arrest with historical in-hospital data.
Main Methods:
- Retrospective analysis of pediatric cardiac arrests (<13 years) in Tucson (1998-2003).
- Focused on cases with documented ventricular fibrillation (VF) receiving pediatric dose shocks (2 J/kg ±10 J).
- Compared VF termination rates to a published historical in-hospital pediatric control group.
Main Results:
- Out of 151 pediatric out-of-hospital cardiac arrests, 13 had VF; 11 received 14 shocks at the standard pediatric dose.
- Only 7 of 14 shocks (50%) successfully terminated VF, with most leading to asystole or pulseless electrical activity.
- VF termination failure was significantly higher (7/14) compared to in-hospital data (5/57; OR 10.4, P=0.001).
- No survivors to hospital discharge were observed in this cohort.
Conclusions:
- The standard pediatric defibrillation dose is substantially less effective for prolonged out-of-hospital ventricular fibrillation (VF) compared to short-duration in-hospital VF.
- The optimal defibrillation dose for pediatric out-of-hospital cardiac arrest with prolonged VF remains unknown.
Background:
The recommended dose for pediatric defibrillation is 2 J/kg, based on animal studies of brief duration ventricular fibrillation (VF) and a single pediatric study of short duration in-hospital VF. In a piglet model of out-of-hospital (prolonged) cardiac arrest, this recommended dose was usually ineffective at terminating VF. We, therefore, hypothesized that pediatric dose defibrillation may be less effective for prolonged out-of-hospital pediatric VF.
Methods:
We evaluated retrospectively all cardiac arrests in children less than 13 years old in Tucson from November 1998 to April 2003, with special attention to all children in ventricular fibrillation. We determined the rate of ventricular fibrillation termination after pediatric dose shocks in this cohort, and compared this rate with a published historical pediatric in-hospital defibrillation control group. A pediatric dose shock was defined as 2 J/kg (+/-10 J). All shocks in both groups were provided as monophasic damped sinusoidal waveforms.
Results:
Thirteen of 151 (9%) children with out-of-hospital cardiac arrest had documented VF. Eleven children received a total of 14 pediatric dose shocks. The median minimum untreated dispatch-to-shock time in unwitnessed arrest or collapse-to-shock in witnessed arrest for those 11 children was 11 min (interquartile range 25-75%; 9-15.5 min). Seven of the 14 pediatric dose shocks terminated the VF (six to asystole, one to pulseless electrical activity). Nine children (68%) died in the emergency department and four (31%) in the pediatric intensive care unit; none survived to hospital discharge. Failure to terminate VF after a pediatric dose shock in this study group with prolonged out-of-hospital ventricular fibrillation was substantially more common than the previously reported in-hospital data (7/14 versus 5/57; OR 10.4; 95% CI 2.6-42; P=0.001).
Conclusions:
Termination of VF after a pediatric defibrillation dose is substantially worse for prolonged pediatric out-of-hospital VF cardiac arrest compared with in-hospital (short duration) ventricular fibrillation. The optimal pediatric defibrillation dose for prolonged VF is not known.
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