Amanda Levin, MD
Assistant Professor
Johns Hopkins University, United States
Disclosure information not submitted.
David Stockwell, MBA, MD
Associate Professor
Johns Hopkins Hospital, United States
Disclosure information not submitted.
Corina Noje, MD
Assistant Professor Pediatrics
Johns Hopkins Hospital, United States
Disclosure information not submitted.
Title: Pediatric Cardiac Arrest: A Story of Hypothermia, Transport, and 300 Minutes of CPR
Introduction: Less than 10% of children survive out-of-hospital cardiac arrest (OHCA), often with poor neurologic outcomes. Neurologically favorable survival has been reported after hypothermic OHCA from cold water submersion and environmental exposures. Prolonged resuscitations are rarely successful outside of this setting and transport options are poorly described.
Description: A 40 kg 14 year-old male was found cold and unresponsive by his father, who initiated cardiopulmonary resuscitation (CPR). EMS continued CPR en route to the nearest hospital where he was found to be 23°C. No environmental exposure explained his hypothermia. The underlying rhythm was ventricular fibrillation. He remained in cardiac arrest despite multiple defibrillations, but with CPR had intermittent movements, so transfer was requested to a pediatric center 75 miles away. CPR was continued with a LUCAS® device during ground and air transport. On arrival, CPR had been ongoing 3 hours, his temperature was 31°C, and rhythm was asystole. Lack of explanation for his hypothermia raised concern for a prolonged downtime and poor prognosis. However, he demonstrated intermittent eye opening and upper extremity movements, prompting extracorporeal life support initiation. In total, he received nearly 5 hours of continuous CPR. He was rewarmed slowly and decannulated on hospital day 3 after recovery of cardiac function. He was extubated on day 6 and renal replacement therapy was discontinued on day 9. His mental status returned to pre-arrest baseline with new lower extremity paralysis. MRI revealed a T10 spinal infarct. Despite extensive work-up, no etiology was found for his profound hypothermia. After prophylactic placement of a LifeVest® defibrillator, he was discharged to inpatient rehabilitation where he has recovered some lower extremity movement.
Discussion: Pediatric hypothermic OHCA has the potential for favorable neurologic outcomes with delivery of high-quality CPR and access to extracorporeal support. The feasibility of prolonged, high-quality manual CPR in transport has not been established; while mechanical CPR devices are not approved for children, this case supports their use in adult-size patients thought to benefit from lengthy transports.