Unusual case - any thoughts / comments?

[Charles Brault]

I do not see why Commotio cordis could not be caused by a fall
And would be the best expalnation for finding the kid in V-Fib
Hey maybe the V-fib caused the fall in the first place (highly unlikekly) 
V-Fib in a child is more likely caused by a respiratory arrest
- LOC due to head injury causing airway obstruction (how long from fall to discovery to initiation of CPR ?)
- Respiratory arrest due to hit on "plexus solaire" (epigastric region)
CPR on a patient with a pulse is not a good thing
But I do not think it is likely to CAUSE V-Fib
Their is a lot more chance that WE assume that it did
And that the kid was not initialy in cardiac/respiratory arrest 
Interesting case
Charles


----- Original Message ----
From: Steve Walker <walkersteve at bigpond.com>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Friday, July 25, 2008 11:19:16 AM
Subject: Re: Unusual case - any thoughts / comments?

Thanks for the thoughts.

Child went home yesterday - well apart from some minor facial soft tissue 
injuries and a couple of missing teeth. Still a complete mystery - a fairly 
comprehensive workup didn't turn up any suggestion of an underlying cause.

So maybe commotio cordis - either from fall, or from CPR (we know how 
difficult it is for lay people to differentiate loss of consciousness from a 
cardiac arrest). Not that I would want to suggest this to the mother.

Maybe a primary cardiac arrhythmia. No proof - but of course absence of 
proof does not equate to proof of absence.

Maybe VF secondary to hypoxia - thanks for that information Neil. I do now 
have a very vague recollection of this, but had long since forgotton it. 
Might did that paper out. The prevailing wisdom is that kids do all go 
brady-asystolic and that VF is very rare.

Guess we will never know for sure.

Cheers

Steve Walker


----- Original Message ----- 
From: "Bjorn, Pret" <pbjorn at emh.org>
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Sent: Thursday, July 24, 2008 4:46 AM
Subject: RE: Unusual case - any thoughts / comments?


> 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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