Published online July 27, 2009
PEDIATRICS Vol. 124 No. 2 August 2009, pp. 500-508 (doi:10.1542/peds.2008-1967)

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ARTICLE

Mortality and Functional Morbidity After Use of PALS/APLS by Community Physicians

Joseph A. Carcillo, MD^a, Bradley A. Kuch, RRT-NPS^a, Yong Y. Han, MD^b, Susan Day, MD^c, Bruce M. Greenwald, MD^d, Karen A. McCloskey, MD^e,, Anthony L. Pearson-Shaver, MD^e, Richard A. Orr, MD^a

^a Departments of Pediatrics and Critical Care Medicine, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
^b Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor, Michigan
^c Department of Pediatrics, University of Wisconsin School of Medicine, Milwaukee Children's Hospital, Milwaukee, Wisconsin
^d Division of Pediatric Critical Care Medicine and Department of Pediatrics, Weill Cornell Medical College, New York, New York
^e Department of Pediatrics, Medical College of Georgia, Georgia Children's Hospital, Augusta, Georgia

OBJECTIVES: To test the hypothesis that pediatric shock is a common cause of death and functional morbidity and that pediatric advanced life support (PALS)/advanced pediatric life support (APLS) resuscitation in the community hospital setting improves child health outcomes.

METHODS: This study included all children consecutively transported to 5 regional, tertiary care children's hospitals over 4 years, and is a prospective cohort study comparing outcomes in children who did or did not receive PALS/APLS resuscitation in the community hospital.

RESULTS: Shock occurred in 37% of the patients transferred to the tertiary centers. Regardless of trauma status, children with shock had an increased mortality rate compared with those without shock (all patients: 11.4% vs 2.6%), trauma patients (28.3% vs 1.2%), and nontrauma patients (10.5% vs 2.8%). Early shock reversal was associated with reduced mortality (5.06% vs 16.37%) and functional morbidity (1.56% vs 4.11%) rates. Early use of PALS/APLS-recommended interventions was associated with reduced mortality (8.69% vs 15.01%) and functional morbidity (1.24% vs 4.23%) rates. After controlling for center, severity of illness, and trauma status, early reversal of shock and use of PALS/APLS-recommended interventions remained associated with reduced morbidity and mortality rates.

CONCLUSIONS: Shock is common in children who are transferred for tertiary care. Pediatric shock recognition and resuscitation in the community hospital improves survival and functional outcome regardless of diagnostic category. The development of shock/trauma systems for children with and without trauma seems prudent.

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Key Words: tachycardia • capillary refill time • hypotension • PALS/APLS • emergency medical services for children

Abbreviations: PALS—pediatric advanced life support • APLS—advanced pediatric life support • bpm—beats per minute • OR—odds ratio • CI—confidence interval

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Accepted Jan 22, 2009.

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