Abstract
Children and young adults tend to have reduced mortality and disability after acquired brain injuries such as trauma or stroke and across other disease processes seen in critical care medicine. However, after out-of-hospital cardiac arrest (OHCA), outcomes are remarkably similar across age groups. The consistent lack of witnessed arrests and a high incidence of asphyxial or respiratory etiology arrests among pediatric and young adult patients with OHCA account for a substantial portion of the difference in outcomes. Additionally, in younger children, differences in pre-hospital response and the activation of developmental apoptosis may explain more severe outcomes after OHCA. These require us to consider whether present practices are in line with the science. The present recommendations for compression-only cardiopulmonary resuscitation in young adults, normothermia as opposed to hypothermia (33°C) after asphyxial arrests, and paramedic training are considered within this review in light of existing evidence. Modifications in present standards of care may help restore the benefits of youth after brain injury to the young survivor of OHCA.
Highlights
Outcomes by age in acute neurologic injuries tend to favor youth
It is well known that vascular disease increases with each decade of life[10] such that one would expect far better cerebral and coronary blood flow assuming that the same quality of cardiopulmonary resuscitation (CPR) was administered
We previously found worsened neurologic outcomes and survival associated with non-cardiac etiology OHCA22, which was likewise noted in the Korean Hypothermia Network (KORHN) registry[23], whereas the opposite association was noted by the ROC24
Summary
Outcomes by age in acute neurologic injuries tend to favor youth. When stratified by age, younger age groups tend to have improved rates of mortality and favorable neurologic recovery in traumatic brain injury (TBI)[1,2,3] and stroke[4,5,6], including both intracerebral[7,8] and subarachnoid[9] hemorrhages. Young adults, who tend to make up the majority of overdose-related OHCA, generally present with non-shockable rhythms[16] It remains uncertain why asphyxial CA confers more severe outcomes, this observation has been consistently made in experimental comparisons of different forms of CA where insult time is matched[31,32]. The AHA’s call to action is intended “for bystanders [and] does not apply to unwitnessed cardiac arrest, cardiac arrest in children, or cardiac arrest presumed to be of non-cardiac origin”, nor does it apply to paramedics who can provide full CPR47 This distinction is not conveyed to the public or appreciated by 911 operators; we routinely care for asphyxial OHCA patients who have received COCPR. Simulation approaches applied systematically across multiple paramedic systems are being evaluated, as is the analysis of the specific errors that are most frequently observed in this setting[61]
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