A 23-year-old boy with no prior history of illness suffered CPA (cardiopulmonary arrest) while playing soccer at the university. His previous electrocardiogram at age 12 showed no abnormality. He had no prodromal symptoms before the event. His coach immediately initiated cardiopulmonary resuscitation (CPR). Emergency medical services (EMS) arrived at the scene 10 min after the boy collapsed and confirmed cardiac arrest. EMS personnel continued CPR with bag–mask ventilation and chest compression. The patient was defibrillated twice with an automated external defibrillator (AED) by the EMS personnel en route to the hospital. Ventricular fibrillation was the initial recorded rhythm in the patient. Sinus tachycardia with sustained circulation was achieved after second rescue shock. A review of the patient's pre-hospital records showed that he returned to spontaneous circulation 23 min after the collapse.

• Upon arrival at the emergency department (ED), the patient's blood pressure (BP) was 72/54 mmHg, pulse was 155 beats/min, and temperature was 37.2°C via a rectal thermometer.


• Initial neurological examination in the emergency department indicated coma (Glasgow coma scale score [GCS] was 3), sluggish pupillary light reflex, and diminished respiratory effort.


• Cardiovascular examination was normal.


• Patient was intubated immediately upon arrival at the emergency department.

• Serum aspartate aminotransferase, 253 U/L
• Alanine aminotransferase, 356 U/L
• Lactate dehydrogenase, 604 U/L
• Creatine phosphokinase, 4382 U/L
• Myocardial bands of 554 U/L
• Troponin I, 3.50 ng/mL
• Lactate, 108.9 mg/dL
• Serum glucose, 200 mg/dL

• Chest radiograph showed no congestion
• Cardiothoracic ratio was 54% (maximal horizontal cardiac diameter/ maximal horizontal thoracic diameter) normal < 50% - x-ray
• Echo-cardiogram demonstrated normal ventricular function with no effusion, ventricular hypertrophy, or organic heart disease.
• Computed tomography (CT, non-contrast) of the brain was unremarkable
• 12-lead electrocardiogram - sinus tachycardia

After discussion of the risks and benefits of treatment with therapeutic hypothermia, the family agreed to begin therapy.

• Ice packs and a surface cooling system with sedative measures and infusion of neuromuscular blockers were used to induce hypothermia. I.V.
insulin infusion was also initiated.
• Target temperature of 34°C was reached approximately 5 h after the collapse.
• Rectal temperature was maintained between 33°C and 34°C for the next 24 h.
• On day 1, verapamil hydrochloride was infused for treating paroxysmal supraventricular tachycardia.

• Over the next 48 h, the patient was slowly rewarmed until his temperature reached 36°C.
• Sedation measures and neuromuscular blockers were discontinued.
• Subsequently, the patient responded to pain.
• On day 5, he was extubated.
• Physical examination - no neurological abnormalities.
• EEG and MRI (magnetic resonance imaging) of the brain – normal
• Cerebral Performance Category (CPC) score at 1 month and at 3 months after the event were both CPC 1.

Enhanced CT confirmed the course of the left coronary artery (LCA) originating with a separate ostium (small opening) from the right coronary sinus. The LCA subsequently coursed between the aorta and the pulmonary artery. Enhanced CT also showed no evidence of atherosclerotic coronary artery disease. To reduce the risk of future episodes of myocardial ischemia and sudden cardiac death (SCD), surgical intervention with coronary artery bypass grafting was performed. The left internal mammary artery was anastomosed to the left anterior descending artery. The LCA was ligated at the left main trunk to avoid competitive flow. No coronary spasm or arrhythmia was noted at 6 months after the surgery.

Note: If patient is anesthetized, paralyzed, or intubated, use “as is” clinical condition to calculate scores.

CPC 1. Good cerebral performance: conscious, alert, able to work, might have mild neurologic or psychologic deficit.

CPC 2. Moderate cerebral disability: conscious, sufficient cerebral function for independent activities of daily life. Able to work in sheltered environment.

CPC 3. Severe cerebral disability: conscious, dependent on others for daily support because of impaired brain function. Ranges from ambulatory state to severe dementia or paralysis.

CPC 4. Coma or vegetative state: any degree of coma without the presence of all brain death criteria. Unawareness, even if appears awake (vegetative state) without interaction with environment; may have spontaneous eye opening and sleep/awake cycles. Cerebral unresponsiveness.

CPC 5. Brain death: apnea, areflexia (absence of neurologic reflexes e.g., ‘knee jerk’), EEG silence, etc.

Safar P. Resuscitation after Brain Ischemia, in Grenvik A and Safar P Eds: Brain Failure and Resuscitation, Churchill Livingstone, New York, 1981; 155-184.

Click at the link below to learn more:
Clinical Values for Case Study Problem-Solving

Abbreviations

Click at the link below to learn more:
Abbreviations