Friday, April 1, 2016

Resuscitation of a Pediatric Drowning in Hypothermic Cardiac Arrest

Title: Resuscitation of a Pediatric Drowning in Hypothermic Cardiac Arrest
Authors: Dragann B, Melnychuk E, Wilson C, Lambert R, Maffei F
Journal: Air Medical Journal, March-April 2016

This article describes a fairly impressive case of prolonged submersion and severe hypothermia.  As with many similar cases recently described in the literature, the role of ECMO is described.  The unique thing about this case is that the patient regained a pulse while on the OR table to be cannulated for ECMO, and the procedure was never started.

Here are the case details

  • 22 month old missing in a snow storm in Pennsylvania
  • Found 30 minutes later submerged in 1.1 C water
  • Carried by neighbor to meet EMS crew
  • Ground EMS
    • Warm blankets, BVM, CPR
    • Initial rhythm PEA
    • IO access obtained, Epi given
  • Helicopter EMS (HEMS) dispatched to meet at hospital
    • CPR continued
    • Additional Epi and atropine given
    • Initial rectal temp 25 C (77 F)
    • HEMS team intubated on arrival
    • HEMS called nearby tertiary center with ECMO for transport
  • Arrived in Resus Bay 73 Minutes after initiation of CPR
    • Active rewarming
    • CPR continued
    • PEA rhythm
    • Initial pH 6.5
    • Additional Epi and bicarb given
    • End tidal CO2 12-20
  • Sent to OR for ECMO
    • Return of spontaenous circulation (ROSC) before cannulation
    • Total 101 minutes of CPR
    • Spontaneous respirations and some extremity movement
  • Transported to PICU
    • Continued active rewarming
    • Purposeful movements 8 hours after ROSC
    • Weaned from ventilation day 3
    • Discharged day 4
    • Day 9 follow up showed normal neuro status
This is quite an amazing case for many reasons: (1) very long CPR time before ROSC, (2) extremely acidotic (may be the lowest recorded pH in a survivor), (3) many many points in along the way where all efforts could have justifiably been aborted.  Currently, our best evidence (still not that great) says that there is little point in resuscitating patients who have been submerged > 30 minutes, although this to specific to water > 6 C.  In addition, the risk/benefit of flying a patient who has been in prolonged cardiac arrest greatly favors keeping the helicopter on the ground and ceasing efforts.  In addition, the patient's downtime, PEA rhythm, and severe acidosis all are very poor prognostic factors.  The few things working in the patient's favor were: very young and small, fall in very cold water with rapid cooling, surprisingly low initial potassium (studies show K > 10 poor prognosis), and fairly good end tidal CO2 (for a dead person) during resuscitation.

As with all cases of this nature, what happened with this patient is the exception, not the rule.  Most patients in this condition would likely have not survived or would have had nothing done to them given the poor chance of survival with good neurologic outcome.  And if some one survives it, they will likely have significant neurologic sequelae. A lot of things working for and against him, and obviously a very dedicated team and medical system. Very interesting case.