Maayke Hunfeld

16 Chapter 1 Early prediction of outcome In children with an optimal Glasgow Coma Scale (GCS) after OHCA, it is clear that the gross neurological outcome is favorable, at least at short-term. On the other hand, when a child is brain death, there is no doubt that the prognosis is futile. However, when a child remains comatose in the first days after OHCA, prediction of long-term neurological outcome becomes a challenge. Early identification of those children who have a poor long-term neurological prognosis is crucial. An accurate individualized outcome prediction model would help clinicians in making important decisions regarding treatment (or WLST) and in counseling families on their child’s prognosis/future prospects. It would help limit the so intense emotional period of uncertainty for the families. Furthermore, it could reduce health care costs (also on the long-term) when medical professionals are accurately informed on a disastrous patient outcome early after hospital admission. In contrast to adult literature, no prognostic guidelines exist for children post-CA. The adult guidelines combine findings on neurological exam together with ancillary tests (electroencephalography (EEG), somatosensory evoked potentials (SSEP) and cerebral plasma biomarkers) in order to predict gross outcome within a few days after CA (46, 47). It is inappropriate to extrapolate these adult guidelines to children, because children have age-dependent anatomy and physiology relevant to central nervous system injury and its repair (48). Many factors will influence the long-term outcome varying from pre-arrest to post-CA arrest factors, which makes prediction even more complex (figure 2): 1) Pre-CA: Pre-arrest neurocognitive functioning and already existing co- morbidities may play a role in outcome after OHCA. E.g., a child with already a developmental delay (e.g. due to a genetic disease) would be expected to have a more unfavorable outcome than a normal developing child. However, on this specific topic no studies could be found. Furthermore, socioeconomic status (SES) may contribute to outcome; a lower SES is associated with a risk for developmental problems/lower intelligence scores (49, 50). The relationship between age and neurocognitive outcome received much attention in brain injured children, in particular traumatic brain injured children (51, 52). The immature brain appears to be more vulnerable to injury. Further, the phenomenon of growing into deficit causes more significant long-term neurocognitive deficits in infants and young children than in school-age children (51-54) . 2) CA: Known factors associated with favorable outcome after CA are etiology of CA, initial arrest rhythm of ventricular fibrillation or tachycardia, witnessed arrest, shorter duration of CPR, and BLS quality (55).