Age-based centiles for diastolic blood pressure among children in the out-of-hospital emergency setting

Objective: To compare Pediatric Advanced Life Support (PALS) diastolic blood pressure (DBP) criteria to empirically derived DBP criteria for the prediction of out-of-hospital interventions in children. Methods: We performed a retrospective study of pediatric (<18 years) encounters from the ESO Data Collaborative, which includes approximately 2000 Emergency Medical Services agencies in the United States. We developed age-based centile curves for DBP using generalized additive models for location, scale, and shape. We compared the proportion of encounters with a low DBP when using empirically derived and PALS criteria and calculated their associations with the delivery of out-of-hospital interventions (advanced airway management, cardiopulmonary resuscitation, cardiac epinephrine, any systemic epinephrine, defibrillation, and bolus intravenous fluids). Results: We included 343,129 encounters. When using PALS criteria, 155,564 (45.3%) were classified as having abnormal DBP, including 120,624 (35.2%) with high DBP and 34,940 (10.2%) with low DBP. When using empirically-derived criteria, 18.6% had an abnormal DBP (ie, a DBP <10th or >90th centile). The accuracy of low DBP for out-of-hospital interventions between the two criteria was similar. Conclusion: PALS criteria for DBP classified a high proportion of children as having abnormal vital signs, particularly with diastolic hypertension. Empirically derived DBP thresholds more accurately predict the delivery of key out-of-hospital interventions. If externally validated, correlated to in-hospital outcomes, and combined with thresholds for other vital signs, these may better predict the need for out-of-hospital interventions.