15 y.o. cardiac arrest

7/27/2019 15 y.o. Cardiac Arrest

1/22

Morning Report

Erin Fuchs

July 23, 2014


2/22

Case

15 year old previously healthy female

Visiting from Seattle, Washington

Spent the last week at camp in Provo Finished camp Friday

Saturday swimming with family (mom and 3

sibs) at local pool Sat down in the shade by her family and laid

down


3/22

Case contiuned

After a few minutes (?) twin brother noted her

to be drooling

On further exploration -> unresponsive

CPR started at the scene

Per mom estimatesthought to be ~2

minutes prior to CPR initiation


4/22

Case continued

AED placed, advised shock -> given

CPR resumed

Next cycle, shock not advised therefore CPRcontinued

EMS arrived, placed their defibrillator, shock

advised -> given (200 J) Return of Sinus Rhythm

Intubated and transported to OSH


5/22

Case continued Outside Hospital

OSH:

1L NS (cold)

>6PVCs/min on rhythm strip

Propofol started

Foley placed

Transported to PCH

Continued PVCs during transport


6/22

History PMHx:

Twin conception, induced at 41 weeks

Heart murmur that resolved during childhood

No prior hospitalizations

PSurgHx:

Negative

MEDS:

None regularly


7/22

ALLERGIES: NKDA

IMMS: Needs MMR

DEVELOPMENT: Normal growth and development per mom

FHx: Dad with Protein S Deficiency

Cousin drowned at age 3

Maternal aunt w/ arrhythmia during stress test


8/22

SHx:

Lives in Seattle with parents, twin brother, 2

siblings (all healthy)

Involved in schoolreceives great grades

Wants to become a nutritionist

Main extracurricular activity is vocal lesions

Per momno drugs and not sexually active


9/22

PHYSICAL EXAM

Vitals: T 36, HR 103, RR 21, BP 111/77 (85), SaO2 100% on

SIMVWeight: 52kg (42%ile)

Height: 165cm (65%ile)

Gen: well nourished, well developed, intubated, sedatedHEENT: NCAT, Pupils 3mm and briskly reactive B/L to light,no EOM, anicteric sclera, TMs not assessed, NP w/odischarge, OP with MMM, otherwise intubated

NECK: in c-collar, no carotid bruits, no palpable masses orlymphadenopathy

LUNGS: Vesicular breath sounds in all lung fields, noincreased WOB, symmetric aeration to bases w/o

wheezing or crackles


10/22

CV: Regular rate and rhythm, no murmurs, no gallop or

rub, 2+ dorsalis pedis and radial pulses B/L, cap refill

>5sec

ABD: Scaphoid, soft, nontender, nondistended, no HSM,

no masses

GU: Normal external genitalia, Tanner stage 5

EXT: no clubbing, cyanosis, or edema. No gross

deformities

SKIN: Pale, no rashes, jaundice, or cyanosis

NEURO: Spontaneously moving UEnonpurposeful,

clenching hands B/L, inc tone in all extremities (LE>UE),

unable to follow commands, no spontaneous eye

opening, reflexes not assessed, GCS 4T


11/22

15 year old previously healthy

female with sudden cardiac arrest


12/22

Differential Diagnosis CV:

Aortic Stenosis

Cardiomyopathy Dilated

Hypertrophicobstructive

Arrhythmogenic Rventricular (ARVC)

Ebstein Anomaly

Coronary arterydisease:

MI

Congenital CAanomaly

CA embolism

Coronary arterities Myocardial ischemia

Tetralogy of Fallot

Arrythmias Torsades

V. Fib PVCs

V. Tach

WPW Syndrome

Channelopathies Prolonged QT

syndrome BrugadasSyndrome

Ruptured aorticaneurysm (i.e.Marfans)

ID Myocarditis

Endocarditis

Kawasakis

Meningitis

Encephalitis

PULM

PE

Asthma

NEURO Epilepsy

Intracranialhemorrhage

MISC Disordered eating

Trauma

Simulant/Drug intake DKA


13/22

Work-Up OSH

Serum Tox and Urine Tox: NEGATIVE

CMP: Na 133, K 1.9, Cl 84, CO2 17, Gluc 378, BUN 9, Cr 0.94,Ca 9.8, Prot 7.2, Alb 4.4, Tbili 0.6, Alk Phos 69, ALT 73, AST101

Coags: PT 14.9, INR 1.2, PTT 23

CBC: WBC 10 (N52%, L45%, M1%, E1%), Hct 38, Plts 286 UA: Sp Gr 1.015, pH 7.5, Trace hgb, 1+ prot

ABG @ 1919: 7.47/35/551/25.5

Lactate 9.9

CXR: hyperinflated lungs, no fx, no pneumo, noconsolidation or effusion

CT brain w/o contrast: Normal

CT Angio chest: No evidence of PE. Symmetric groundglassopacities and bronchial thickening.

PCH


14/22

PCH ECHO:

Mild TV regurg

Trivial MV regurg

Normal RV size, mildly dec systolic func Normal LV size, mildly dec systolic func

EKG: Sinus rhythm w/ occasional PVCs

Nonspecific T-wave abnormality

Prolonged QT (524 -> 703 -> 583 -> 600 -> 498 -> 445)

Phos:


15/22

Diagnosis? .

DISORDERED EATING


16/22

Sudden Cardiac Arrest

0.5-20 per 100,000 youth

Higher risk (2-2.5x) of SCA during athletic

competition/exercise.

CDC estimates that ~2000 people


17/22

Warning Signs or symptoms (i.e. chest pain,fatigue, and syncope/lightheadedness)

Noted by at least 40-70% of individuals prior to SCAor SCD

MC symptoms:

Chest pain

Actual or near syncope Others: Dizziness, palpitations, or dyspnea

Preceding symptoms of dizziness, chest pain,syncope, palpitations, or dyspnea and a familyhistory of premature, unexpected sudden deathwere noted in 25% to 61% of the studypopulation. Deaths were exertion-related in 8%

to 33% of cases


18/22

Studies

Out-of-Hospital Pediatric Cardiac Arrest: AnEpidemiologic Review and Assessment ofCurrent Knowledge

Articles from 1966-2004 (41 articles) Outcomes for children 18 or younger

Pediatric Utstein outcome report guidelines:

Cessation of cardiac mechanical activity,determined by the inability to palpate a centralpulse, unresponsiveness, and apnea


19/22

Age (when reported = 15 of 41 studies):

Range of median age: 1-7 years

Range of mean age: 7.9 mo5.9 yrs

22 of 41 studies reported number of pts


20/22

Outcomes: (Total of 5,363 patients)

ROSC: 751/2,438 (30.8%)

Sustained ROSC: 165/594 (27.8%) Survival to admit: 340/1,423 (23.9%)

Survival to discharge: 647/5,363 (12.1%) -> 6.7%

Neurologically intact survival: 131/3,272 (4%) -> 2.2%

Witnessed arrest: (532 of 1,725 = 30.8%)

Survived to discharge: 13%

Unwitnessed arrest:

Survived to discharge: 4.6%

Bystander CPR associated with survival todischarge (although inconsistent result amongst

studies)


21/22

Neurologic status post-cardiac arrest

Bystander CPR (ROSC prior to EMS arrival)

Largely under-represented in studies published


22/22

Resources

Berger, S. Sudden cardiac arrest and death in

children. UpToDate. June 30, 2014.

Donoghue, A., Nadkami, V., Berg, R., et al. Out-

of-hospital pediatric cardiac arrest: anepidemiologic review and assessment of currentknowledge. Annuals of Emergency Medicine.

2005; 46, 512-522.

Google images Pediatric sudden cardiac arrest. Policy

statement. Pediatrics Vol. 129 No. 4 April 1, 2012

15 y.o. cardiac arrest

Documents