Masashi Okubo

Objectives: While advanced airway management (AAM) is commonly performed for children with out-of-hospital cardiac arrest (OHCA), the benefit and optimal timing of AAM remains unclear. To determine whether earlier prehospital AAM is associated with patient outcomes compared with later or no AAM in children with OHCA. Methods: Retrospective cohort study of pediatric patients (aged <18 years) with nontraumatic OHCA treated by emergency medical services (EMS), using the Resuscitation Outcomes Consortium Epidemiologic Registry–Cardiac Arrest at 10 sites in the United States and Canada from April 2011 to June 2015. The exposures are early prehospital AAM (defined as successful AAM within 10 minutes of EMS arrival) and any successful prehospital AAM (endotracheal intubation or supraglottic airway placement). The primary outcome was survival to hospital discharge. Children who received successful prehospital AAM at each minute after EMS arrival were matched, using time-dependent propensity scores, to children at risk of AAM in the same minute. Results: Among 954 eligible pediatric patients (median [IQR] age, 1 [0 to 11] years), 521 (54.6%) received prehospital AAM, and 433 (45.4%) did not. Overall, 91 (9.5%) survived to discharge. In the propensity score-matched cohort (922 matched cases), successful AAM ≤10 minutes was associated with higher likelihood of survival to hospital discharge (risk ratio [RR], 1.93; 95% CI, 1.01-3.70) compared with children at risk of receiving AAM. In contrast, when successful prehospital AAM was considered regardless of timing, any successful AAM was not associated with survival (RR, 1.35; 95% CI, 0.75-2.43). Conclusions: In this North American cohort of pediatric OHCA, earlier AAM (successful AAM within 10 minutes) was associated with survival to hospital discharge. However, successful prehospital AAM at any time was not associated with survival to hospital discharge. These findings suggest that performing AAM earlier in the resuscitation may have a potential benefit for children with OHCA.

Background: Survival after in‐hospital cardiac arrest has improved over the past 2 decades, yet prior studies have documented worse outcomes among Black compared with White patients. Although the racial survival gap narrowed through 2014, it remains unclear whether disparities persist in more recent years. Methods: We conducted an observational cohort study using in‐hospital cardiac arrest data from the Get With The Guidelines–Resuscitation registry from 2015 to 2022. Multivariable models using generalized estimating equations evaluated the association between patient race (White versus Black) and survival to hospital discharge, accounting for clustering by hospital. Secondary outcomes included return of spontaneous circulation and favorable neurological survival (ie, survival without severe neurologic disability). Models were adjusted for patient, arrest, and hospital characteristics. Results: Among 156 528 patients, 40 874 were Black and 115 654 were White. Black patients were younger, more often female, and had higher rates of diabetes, renal insufficiency, and respiratory insufficiency, whereas White patients had more prior myocardial infarctions. After adjustment, survival to discharge was similar between races (23.2% versus 20.0%; adjusted odds ratio [aOR], 1.03 [95% CI, 0.99–1.00], P =0.11), as were return of spontaneous circulation rates (68.1% versus 64.4%; aOR, 0.99 [95% CI, 0.97–1.02], P =0.62). However, White patients had higher favorable neurological survival (16.0% versus 12.6%; aOR, 1.10 [95% CI, 1.05–1.14], P <0.001). These findings remained consistent across years and were unchanged when adjusting for hospitals with high versus low proportions of Black patients. Conclusions: Although racial differences in survival to discharge have largely resolved, disparities in favorable neurological outcomes persist, suggesting potentially modifiable differences in postresuscitation care.

Importance: While epinephrine is commonly administered in children with out-of-hospital cardiac arrest (OHCA) via an intraosseous (IO) or intravenous (IV) route, the optimal route of epinephrine delivery is unclear.Objective: To evaluate the association between the route of epinephrine administration (IO or IV) and patient outcomes after pediatric OHCA.Design, Setting, and Participants: Retrospective cohort study of pediatric patients (aged <18 years) with nontraumatic OHCA treated by emergency medical services who received prehospital epinephrine either via an IO or IV route. Patients were included in the Resuscitation Outcomes Consortium Epidemiologic Registry, a prospective OHCA registry at 10 sites in the US and Canada from April 2011 to June 2015. Data analysis was performed from May 2024 to April 2025.Exposure: Epinephrine administration route: IO or IV route.Main Outcomes and Measures: The primary outcome was survival to hospital discharge. The secondary outcome was return of spontaneous circulation (ROSC) before hospital arrival. Propensity scores were calculated and inverse probability of treatment weighting (IPTW) was performed with stabilized weights to control imbalances in measured patient demographics, cardiac arrest characteristics, and bystander and prehospital interventions.Results: Of 739 eligible patients (median [IQR] age, 1 [0-11] years), 449 (60.8%) were male. Epinephrine was administered via an IO route for 535 (72.4%) and via an IV route for 204 (27.6%) patients. In the IPTW pseudopopulation (740 weighted cases), there was no significant difference in survival to hospital discharge (IO epinephrine: 28 of 528 patients [5.3%] vs IV epinephrine: 12 of 212 patients [5.7%]; risk ratio [RR], 0.92; 95% CI, 0.41-2.07) or prehospital ROSC (IO epinephrine: 76 of 528 patients [14.4%] vs IV epinephrine: 46 of 212 patients [21.7%]; RR, 0.66; 95% CI, 0.42-1.03) between the IO and IV epinephrine groups.Conclusions and Relevance: In this retrospective cohort study of pediatric patients with OHCA in the US and Canada, the route of epinephrine administration was not associated with survival to hospital discharge or prehospital ROSC. This may support the practice of administering epinephrine via IO or IV route.

Importance: For pediatric out-of-hospital cardiac arrest (OHCA), emergency medical services (EMS) may elect to transport to the hospital during active cardiopulmonary resuscitation (CPR) (ie, intra-arrest transport) or to continue on-scene CPR for the entirety of the resuscitative effort. The comparative effectiveness of these strategies is unclear.Objective: To evaluate the association between intra-arrest transport compared with continued on-scene CPR and survival after pediatric OHCA, and to determine whether this association differs based on the timing of intra-arrest transport.Design, Setting, and Participants: This cohort study included pediatric patients aged younger than 18 years with EMS-treated OHCA between December 1, 2005 and June 30, 2015. Data were collected from the Resuscitation Outcomes Consortium Epidemiologic Registry, a prospective 10-site OHCA registry in the US and Canada. Data analysis was performed from May 2022 to February 2024.Exposures: Intra-arrest transport, defined as an initiation of transport prior to the return of spontaneous circulation, and the interval between EMS arrival and intra-arrest transport.Main Outcomes and Measures: The primary outcome was survival to hospital discharge. Patients who underwent intra-arrest transport at any given minute after EMS arrival were compared with patients who were at risk of undergoing intra-arrest transport within the same minute using time-dependent propensity scores calculated from patient demographics, arrest characteristics, and EMS interventions. We examined subgroups based on age (P value for the interaction between intra-arrest transport and time to matching = .10). Among patients aged younger than 1 year, intra-arrest transport was associated with lower survival to hospital discharge (RR, 0.52; 95% CI, 0.33-0.83) but there was no association for children aged 1 year or older (RR, 1.22; 95% CI, 0.77-1.93).Conclusions and Relevance: In this cohort study of a North American OHCA registry, intra-arrest transport compared with continued on-scene CPR was not associated with survival to hospital discharge among children with OHCA. However, intra-arrest transport was associated with a lower likelihood of survival to hospital discharge among children aged younger than 1 year.

Objective To quantify time dependent probabilities of outcomes in patients after in-hospital cardiac arrest as a function of duration of cardiopulmonary resuscitation, defined as the interval between start of chest compression and the first return of spontaneous circulation or termination of resuscitation. Design Retrospective cohort study. Setting Multicenter prospective in-hospital cardiac arrest registry in the United States. Participants 348 996 adult patients (≥18 years) with an index in-hospital cardiac arrest who received cardiopulmonary resuscitation from 2000 through 2021. Main outcome measures Survival to hospital discharge and favorable functional outcome at hospital discharge, defined as a cerebral performance category score of 1 (good cerebral performance) or 2 (moderate cerebral disability). Time dependent probabilities of subsequently surviving to hospital discharge or having favorable functional outcome if patients pending the first return of spontaneous circulation at each minute received further cardiopulmonary resuscitation beyond the time point were estimated, assuming that all decisions on termination of resuscitation were accurate (that is, all patients with termination of resuscitation would have invariably failed to survive if cardiopulmonary resuscitation had continued for a longer period of time). Results Among 348 996 included patients, 233 551 (66.9%) achieved return of spontaneous circulation with a median interval of 7 (interquartile range 3-13) minutes between start of chest compressions and first return of spontaneous circulation, whereas 115 445 (33.1%) patients did not achieve return of spontaneous circulation with a median interval of 20 (14-30) minutes between start of chest compressions and termination of resuscitation. 78 799 (22.6%) patients survived to hospital discharge. The time dependent probabilities of survival and favorable functional outcome among patients pending return of spontaneous circulation at one minute’s duration of cardiopulmonary resuscitation were 22.0% (75 645/343 866) and 15.1% (49 769/328 771), respectively. The probabilities decreased over time and were Conclusions This analysis of a large multicenter registry of in-hospital cardiac arrest quantified the time dependent probabilities of patients’ outcomes in each minute of duration of cardiopulmonary resuscitation. The findings provide resuscitation teams, patients, and their surrogates with insights into the likelihood of favorable outcomes if patients pending the first return of spontaneous circulation continue to receive further cardiopulmonary resuscitation.

Out-of-hospital cardiac arrest (OHCA) is an important public health problem, with high mortality rates observed globally.¹ Emergency medical services (EMS) play a pivotal role in providing initial treatment for patients with OHCA as a part of the chain of survival.² Prehospital care entails a multifaceted approach, encompassing simultaneous and sequential resuscitative interventions, such as chest compressions, airway management, ventilation, defibrillation, and medication administration.²