1. Incidence, Causes and Outcome of Out-of-Hospital Cardiac Arrest in Children A Comprehensive, Prospective, Population-Based Study in The Netherlands Abdennasser Bardai, MD,* Jocelyn Berdowski, MSc, MSE,* Christian van der Werf, MD,* Marieke T. Blom, MA, Manon Ceelen, PhD, Irene M. van Langen, MD, PhD, Jan G.P. Tijssen, PhD, Arthur A.M. Wilde, MD, PhD, Rudolph W. Koster, MD, PhD, Hanno L. Tan, MD, PhD Amsterdam and Groningen, The Netherlands * These authors contributed equally

2. Background  There is a paucity of complete studies on incidence, causes and outcome of pediatric out-of-hospital cardiac arrest (OHCA)  Previous large studies only included OHCA cases that involved emergency medical services (EMS)  Few studies reported the single (groups of) causes of pediatric OHCA J Am Coll Cardiol 2011;57:1822-8

3. Objective  To comprehensively determine:  The incidence of pediatric OHCA  The contribution of OHCA to total pediatric mortality,  The causes of pediatric OHCA  The outcome of resuscitation of pediatric OHCA patients J Am Coll Cardiol 2011;57:1822-8

4. Setting  Prospective population-based study of children suffering OHCA between October 1, 2005 and February 1, 2010 in the North- Holland province of The Netherlands  Population: 2.4 million people, including 588,389 aged <21 years J Am Coll Cardiol 2011;57:1822-8

5. Assessment of cardiac and non-cardiac cause of OHCA  OHCA was non-cardiac when EMS rescuers, hospital physicians or coroners identified a natural, non-cardiac cause or non-natural cause  All other cases had a (presumed) cardiac cause and were termed cardiac OHCA J Am Coll Cardiol 2011;57:1822-8

6. Death certificate data  We retrieved death certificate data from Statistics Netherlands, a Dutch governmental institution that collects age/gender-specific statistics of all deaths in The Netherlands to:  Establish the contribution of OHCA to total mortality in pediatric age groups  Gain insight into the completeness of our data collection J Am Coll Cardiol 2011;57:1822-8

7. Survival analysis  We analyzed only truly resuscitatable OHCA cases by excluding OHCA victims who were found dead by EMS personnel upon arrival  Survival status at hospital discharge obtained by contacting the designated hospital  The pediatric Cerebral Performance Category (CPC) of each patient was estimated by reviewing the hospital charts J Am Coll Cardiol 2011;57:1822-8

8. Patient characteristics  233 pediatric OHCA cases  83 EMS-only, 100 coroners-only cases, 50 cases registered by both sources  24% of total pediatric mortality  We registered 90 (87%) of the 103 potential pediatric cardiac OHCA cases according to the death certificate data, and 143 (99%) of the 144 potential pediatric non-cardiac OHCA cases J Am Coll Cardiol 2011;57:1822-8

9. Incidences of pediatric OHCA All causes (n=233) Cardiac causes (n=90) Non-cardiac causes (n=143) Overall9.0 (7.8-10.3)3.2 (2.5-3.9)5.8 (4.9-6.8) Age <1 years33.8 (23.1-44.5)25.8 (16.4-35.2)8.0 (2.8-13.2) Age 1-11 years4.8 (3.6-6.0)1.6 (0.9-2.3)3.2 (2.2-4.2) Age 12-20 years11.7 (9.5-13.8)2.7 (1.7-3.7)9.0 (7.1-10.8) Data are expressed as number per 100,000 pediatric person-years (95% confidence interval). Adjusted by age/sex to the European Union population J Am Coll Cardiol 2011;57:1822-8

10. Causes of out-of-hospital cardiac arrest J Am Coll Cardiol 2011;57:1822-8

11. Survival and neurologic outcome  CPR was initiated in 69 OHCA victims, but only 51 were truly resuscitatable  Of 51 resuscitated patients, 12 (24%) survived  29% [4/14] in infants, 12% [2/17] in children, 30% [6/20] in adolescents (NS)  10/12 (83%) had a neurologically-intact outcome  83% (75% [3/4] in infants, 100% [2/2] in children, 83% [5/6] in adolescents J Am Coll Cardiol 2011;57:1822-8

12. Operational characteristics of resuscitated victims of OHCA from cardiac causes AllAge <1 year Age 1-11 years Age 12-20 years P-value Variable(n=69)(n=29)(n=18)(n=22) Witnessed collapse, n (%)41 (59)11 (38)14 (78)16 (73)0.03 Bystander CPR, n (%)52 (75)19 (66)14 (78)19 (86)0.53 Collapse at home, n (%)48 (70)28 (97)11 (61)9 (41)<0.001 AED connected, n (%)9 (13)1 (3)1 (6)7 (32)0.02 Time between emergency call and arrival, min, median (25 th to 75 th percentile) 12.1 (8.8-14.8) 12.2 (9.8-13.9) 11.1 (8.4-15.3) 12.0 (9.0-15.6) 0.99 Shockable initial rhythm, n (%)25 (36)1 (3)6 (33)18 (82)<0.001 J Am Coll Cardiol 2011;57:1822-8

13. Conclusions  OHCA accounts for a significant proportion of pediatric mortality  Cardiac causes are the most prevalent causes of OHCA  The vast majority of OHCA survivors have a neurologically-intact outcome J Am Coll Cardiol 2011;57:1822-8