Sequence of Successful Epinephrine or Advanced Airway Interventions in Nontraumatic Pediatric Out-Of-Hospital Cardiac...

The optimal sequence of epinephrine administration and advanced airway management (AAM) successfully delivered during pediatric out-of-hospital cardiac arrest (OHCA) is unclear. Our objective was to determine whether the sequence of first successful epinephrine administration and first successful AAM is associated with survival and functional outcomes in pediatric OHCA.

We performed a secondary analysis of the Resuscitation Outcomes Consortium Epidemiologic Registry-Cardiac Arrest, a prospective database from 10 US and Canadian regions (2011-2015). We included children (age < 18 years) with non-traumatic OHCA who received epinephrine and/or AAM (endotracheal intubation or supraglottic airway). Our exposure was the sequence of first successful epinephrine administration versus first successful AAM (epinephrine-first or AAM-first). The primary outcome was survival at hospital discharge. Secondary outcomes were a favorable functional outcome at discharge (modified Rankin Scale ≤ 3) and return of spontaneous circulation (ROSC) at hospital arrival. We adjusted for group differences using inverse-probability-of-treatment weighting derived from a propensity score and compared outcomes with logistic regression.

Of 886 eligible patients, 297 (33.5%) received AAM as the first successful intervention, 558 (63.0%) received epinephrine as the first successful intervention, and 31 (3.5%) received these at the same recorded second. There was no significant difference in survival at discharge between the epinephrine-first and AAM-first groups (odds ratio [OR], 1.03; 95% confidence interval [CI], 0.69-1.52). Relative to the AAM-first group, the epinephrine-first group was associated with higher odds of ROSC at hospital arrival (OR, 1.38; 95% CI, 1.06-1.80) but lower odds of favorable functional outcome at hospital discharge (OR, 0.32; 95% CI, 0.13-0.76).

In this large observational study of pediatric OHCA, the observed sequence of first successful epinephrine administration and first successful AAM was not associated with survival to hospital discharge.