Unusual case - any thoughts / comments?

[Bjorn, Pret]

There is a case report in the April edition of Resuscitation
(77(1):139-41) reported out of Melbourne, strikingly similar to this
scenario in all respects, and also attributed to Commotio cordis.  Is
this coincidental, or contagious?

Have to say, though, that I'm unconvinced of the diagnosis in either
case.  This smells like over-convenient pseudo-exclusion.  

For starters, the mechanism is hard to swallow: swan-diving directly
onto your sternum is an odd decision and a neat trick, even for a
toddler.  And classic Commotio cordis is usually triggered by a blunt
missile -- a baseball or hockey puck -- not a floor.

Brugada or LQT take a lot of time and effort to rule out.  A single
cardiogram won't do.  

It's at least as plausible to suggest that the child seized or otherwise
lost control of his airway, brady'd down to pulselessness, and the heart
fibbed in lieu of waving good-bye.  Or maybe somebody over-reacted, and
the chest compressions actually triggered the fibrillation: iatrogenic
Commotio cordis.  

Likely as not, you'll never know for certain.  Be happy the child's
well, and map out all the AED's in the community.

Pret Bjorn, RN
Bangor, ME USA



-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of
walkersteve at bigpond.com
Sent: Monday, July 21, 2008 10:16 PM
To: Trauma &amp, Critical Care mailing list
Subject: Unusual case - any thoughts / comments?

Had an interesting case yesterday that had an unexpectedly good outcome,
but I am not really sure what went on.

I am an emergency physician working part-time on a helicopter in Sydney
Australia. We are currently part way through a study (HIRT - head injury
response trial) looking at whether aggressive early management of
patients following severe head injury results in reduced secondary brain
injury, and whether this translates into improved long term outcomes.

Yesterday, we responded to a 2 yr old boy who had fallen from a top
bunk, and was unconscious when his mother contacted EMS at 12:22. The
mother commenced CPR - perhaps assisted by the EMS dispatcher.

Ground paramedics arrived at 12:29. Found child vital signs absent, and
in VF (!) when they attached a monitor. Delivered one shock, and child
reverted into sinus tachycardia with a femoral pulse. Paramedics then
assisted ineffective spontaneous resp effort pending our arrival - we
were < 5 min away by this time. The alternative was for them to go -
approx 10-15 min from a small community hospital, 20-30 min from an
adult trauma centre, and maybe 35 min from a tertiary pediatric centre. 

We arrived at 12:41. Child GCS 5 (E1,M3,T1). Copious vomit, and airway
still not cleared despite suctioning. Oral airway in situ, and IPPV via
bag/mask given. Signs of minor head trauma (eg cut lip). Spontaneous
flexing movements of upper limbs (which made IV access challenging -
thought we might need to go IO), and impossible to obtain a BP
pre-intubation

Paramedic quickly got IV access, and I intubated the child - thiopentone
(small dose) and rocuronium. Lots of vomit around larynx, but intubation
otherwise easy. IPPV - fairy high pressures required, but otherwise OK.

Transported to tertiary childrens hospital by helicopter.  

CT head, Cx spine and abdomen all NAD.  CXR - collapse right upper lobe,
otherwise clear.  ECG normal - no prolonged QT, no Brugada etc. Bloods
essentially normal - other than significant metabolic acidosis
consistent with post-arrest. Troponin stayed normal.

Admittd to PICU. Echo that afternoon was also normal.

Several hours post-admission, child vomited (must have been a big lunch)
and was then crying. Not re-intubated as adequate spontaneous resp
effort, and child conscious to the point he could recognize his parents.


Appears perfectly normal today, and being transferred to ward.

Considering EPS to help further exclude a primary cardiac arrhythmia -
but less likely now given normal ECG and echo.

All very odd. It will obviously never be possible to 100% exclude a
primary arrhythmia - all we can say at this point is that there is no
evidence pointing towards it. VF very unusual post-trauma (especially in
kids). Head trauma was obviously minor (normal CT, and awake several
hours later), and so maybe the mechanism was loss of consciousness,
vomiting, airway obstruction, hypoxia ..... - although brady-asystole
far more likely than VF in this setting. And very rare to survive
cardiac arrest following blunt trauma - especially given the unavoidable
delay until defibrillation was available. 

Any one ever seen something like this? Any thoughts?

Cheers

Steve Walker
CareFlight 
Sydney Australia

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