A Tale of Two Cities: Timing of Brain Imaging and Neurophysiologic Assessments Following In-hos- Pital Pediatric Cardiac Arrest

Introduction: Neurologic imaging and physiologic studies may predict functional outcome following Cardiac Arrest(CA). Cross-cultural comparisons of neurodiagnostic assessments have not been described following pediatric in-hospital CA. Hypothesis: Post-resuscitation neurologic assessment in children rarely includes brain imaging or physiologic studies in the first 72 hours and diagnostic approach differs between cultures. Methods: Retrospective review of consecutive in-hospital pediatric CA’s(chest compressions >1 minute) at the Children’s Hospital of Philadelphia (P,3/01 to 7/03) and National Center for Child Health and Development in Tokyo(T,3/02 to 2/04) using the Pediatric Utstein CA report template. Timing of neurologic imaging(CT, MRI scans), and physiologic studies(EEG, BAER) were compared. Analysis by two-tailed Fisher’s exact test with alpha=0.05. Results: Of 122 CA, 64(52%) survived >24 hours: 51/104(49%)P and 13/18(72%)T [p=ns]. Within 24 hours after CA, 25/51(49%)P and 11/13(85%)T were comatose with GCS <8, and 19/51(37%)P and 4/13(31%)T received iatrogenic paralysis; but only 31%(P=T) had any imaging or physiologic studies. Within 72 hours 8%P vs 15%T had both imaging and physiologic studies, 11%P vs 8%T had imaging only, 24%P vs 15%T had physiologic studies only, and 59%P vs 62%T had no studies(p=ns). At 72 hours after CA, 13/49(27%)P and 7/11(64%)T were iatrogenically paralyzed(p<0.05), but only 41%P and 38%T had imaging or physiologic studies(p=ns). 47/64(73%) had either imaging or physiologic study prior to discharge: 36/51(71%)P vs 11/13(85%)T,[p=ns]. Conclusions: In two large international children’s hospitals, early iatrogenic masking of the neurologic exam with paralytics is common <72 hours post-CA, but imaging and physiologic studies are obtained in only 40% of CA survivors <72 hours. Cultural differences in approach to post-CA management suggest that the timing and intensity of neurologic imaging and neurophysiologic assessment may be important.