Pediatric cardiac arrest: PEA

1250:  A 10 year old boy is brought to the emergency room by EMS after he struck a tree with his three-wheeler.  On the scene he was conscious,  alert and oriented but in route he began to have increasing shortness of breath and was becoming more lethargic.  The EMTs initiated positive pressure ventilations in route to the hospital.    He is on a spinal board with a C collar in place.   When he is transferred from the EMS stretcher to the hospital stretcher is found to be unresponsive and he no longer has spontaneous respirations. 

1252:  No pulse is detected.  A pediatric code is called and CPR is initiated.  He is placed on the monitor and this is his initial rhythm. 

PEA rhythm

1255: CPR is continued.   A #20 IV is started in his right antecubtial fossa.  Epinephrine 1mg IV is given and and a fluid bolus of 20ml/kg is also started.  Because there is difficulty with providing positive pressure ventilations, the patient is intubated with a 6.5 cuffed ET tube. 

1255:  A review of his medical history is as follows

Symptoms:  no symptoms prior to accident.  A healthy 10 year old male child

Allergies:  allergic to Augmentin which causes a systemic rash

Medications: a daily chidlren's multivitamin

Past medical history: a tonsillectomy 2 years ago, seasonal allergies. 

Last meal eaten:  last oral intake estimated to be at 0800 that morning

Events:   His friends stated that he was driving racing his friend on his three-wheeler and lost control and hit a tree at high speed.  He was wearing a helmet at the time. 

1256:   Physical exam is as follows

Neuro:  unresponsive, Glasgow score of 8

EENT:  pupils nonreactive, no facial or head trauma

Neck: tracheal deviation to the left

Lungs:  Intubated with 6.5 ET tube.  Positive end tidal CO2 indicators.  Difficult to ventilate with positive pressure ventilations.   Auscultation of chest reveals good breath sounds on the right but decreased breath sounds on the left and no gurgling over the epigastrium.  There is asymmetrical chest rise. There is bruising and swelling on the left chest wall.  

Abdomen:  bruising on the left side of the upper abdomen.  Mild stomach distension.

Gentialia:  No bleeding from the urinary meatus.  A urinary catheter is being placed.  

Extremities:  Abrasions to left shoulder and arm.  Left shoulder is posteriorly displaced. Lower extremities unremarkable

Labs:  CBC, comprehensive metabolic panel, type and cross match

Radiology:  CXR, Left shoulder, clavicle, left arm.  CT head, neck, abdomen, and pelvis.  

1259:  CPR is in progress and epinephrine 0.01mg/kg is repeated.  A 2^nd fluid bolus is initiated.    

CPR rhythm

13:01: Because of the tracheal deviation and asymmetrical chest rise, a needle decompression is performed which causes an immediate improvement in the ease of ventilations and the patient also begins to have symmetrical chest rise.   

1305:  CPR continues.  EpInephrine 0.01mg/kg is given.  

CPR rhythm

1308:  A rhythm check reveals a change in the patient’s rhythm

Sinus bradycardia without a pulse

1309:  The patient remains pulseless and apneic.  CPR is continued.

CPR rhythm

1310:  Another dose of epinephrine is given and another fluid bolus of 20mg/kg is ordered.   

1314:  Another rhythm check reveals the following rhythm.

Sinus tachycardia

1315:  At this time a carotid and brachial pulse are detected.   Vital signs:  97.2-120-20.   BP 84/54.   Oxygen saturation 93%.   The patient is beginning to have spontaneous, shallow respirations.   Positive pressure ventilations are continued and another fluid bolus of 20ml/kg is given.   Portable X-ray studies are completed at the bedside and preparations are being made to transport the patient to radiology for the CT studies.

Final diagnosis:

CT head and neck: negative

Left shoulder X-ray:  displaced fracture of the left clavicle and proximal humerus.

Chest x ray:  Pneumothorax and left 9-12 rib fractures. 

CT abdomen:  a splenic hematoma with contrast extravasation and some contrast pooling on delayed images with free fluid in the abdomen.

CBC:  Hgb 9.2 and HCT 10.3

Chemistries:  WNL

Type and Cross match: O positive blood.