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Concurrent Block #4

911, EMS, Fire & Law Enforcement

Best Practices for Caring for Rare but High-Risk Patients in Sudden Cardiac Arrest

Time of Death: The Case of a Pediatric Patient who Defied the Death Evaluation Protocol

Thursday, November 30, 2023
4:45 PM – 5:00 PM PST
Location: Town and Country Ballroom B

    Primary Presenter(s)

  • Audra N. Iness, MD, PhD, CCRP

    Resident Physician
    Baylor College of Medicine
    Houston, TX, United States

    Disclosure(s): No financial relationships to disclose

    • Co-Presenter(s)

  • Andrea De Jesús Martínez, MD (she/her/hers)

    Pediatric Emergency Medicine Fellow
    Baylor College of Medicine/Texas Children's Hospital
    HOUSTON, TX, United States

    Disclosure(s): No financial relationships to disclose

  • Rachel M. Ausmus, RN, MSN, CPEN

    Staff Nurse, Texas Children's Hospital Emergency Department
    Texas Children's Hospital
    Angleton, TX, United States

    Disclosure(s): No financial relationships to disclose

  • Ted Tanner, MD, MPH, MA (he/him/his)

    Assistant Professor of Pediatric Emergency Medicine
    Dayton Children's Hospital and Wright State University Boonshoft School of Medicine
    Dayton, OH, United States

    Disclosure(s): No financial relationships to disclose

    • Moderator(s)

  • Loralee Olejnik, MA, EMT-B

    Public Health Educator
    Not representing current agency
    San Diego, California, United States

    Disclosure information not submitted.

Disclosure(s):
Audra N. Iness, MD, PhD, CCRP: No financial relationships to disclose
Andrea De Jesús Martínez, MD: No financial relationships to disclose
Rachel M. Ausmus, RN, MSN, CPEN: No financial relationships to disclose
Ted Tanner, MD, MPH, MA: No financial relationships to disclose
Summary: A healthy teen with cardiac arrest who was pronounced deceased after 90 minutes of resuscitation had return of spontaneous circulation four minutes later and eventual recovery of baseline mental status, demonstrating the importance of a thorough death evaluation.

Synopsis: A 16-year-old healthy male presented to the emergency department with CPR in progress 90 minutes after a witnessed cardiac arrest at a rock climbing gym. At the gym, bystander CPR was started immediately. Upon EMS arrival, initial rhythm analysis showed ventricular fibrillation. The patient received five rounds of epinephrine and defibrillation along with amiodarone, lidocaine, and sodium bicarbonate and epinephrine drip with brief return of spontaneous circulation (ROSC). CPR was resumed in the ED and the patient’s rhythm showed pulseless electrical activity. Cardiac activity was assessed twice during pulse checks with bedside ultrasound. Shortly after arrival, the patient progressed to asystole with no evidence of cardiac activity. Of note, the patient had an intact gag reflex. After 30 minutes of resuscitation in the ED and no palpable pulse with three points of contact, time of death was called.

Four minutes later, the patient had agonal breathing and carotid pulsations. Heart rate was 20 on the monitor and resuscitation was resumed. ROSC was achieved and CPR stopped 16 minutes later. The patient was transferred to the Intensive Care Unit on norepinephrine and epinephrine drips. Twelve doses of epinephrine, four doses of sodium bicarbonate, and two doses of calcium chloride were administered over approximately 2.25 hours of resuscitation.

The patient was later diagnosed with catecholaminergic polymorphic ventricular tachycardia by genetic testing with history of sudden death in a sibling. He returned to baseline mental status over the course of his recovery. This case demonstrates the importance of thorough death evaluation and need to revisit prognostic indicators when high quality CPR is available.

Learning Objectives:

  • Describe how potential personalization of resuscitation protocols may be implemented based on patient history and prognostic factors.
  • Reflect on death evaluation in the Emergency Department setting and how it can be optimized for standardization and rigor.
  • This presentation will describe one or more survivor / rescuer stories that can be used to illustrate an effective chain of survival for cardiac arrest.