Pediatric Cardiac Arrest: A Story of Hypothermia, Transport, and 300 Minutes of CPR

Introduction: Less than 10% of children survive out-of-hospital cardiac arrest (OHCA), often with poor neurologic outcomes. Neurologically favorable survival has been reported after hypothermic OHCA from cold water submersion and environmental exposures. Prolonged resuscitations are rarely successful outside of this setting and transport options are poorly described.

Case Description: A 40 kg 14 year-old male was found cold and unresponsive by his father, who initiated cardiopulmonary resuscitation (CPR). EMS continued CPR en route to the nearest hospital where he was found to be 23°C. No environmental exposure explained his hypothermia. The underlying rhythm was ventricular fibrillation. He remained in cardiac arrest despite multiple defibrillations, but with CPR had intermittent movements, so transfer was requested to a pediatric center 75 miles away. CPR was continued with a LUCAS® device during ground and air transport. On arrival, CPR had been ongoing three hours, his temperature was 31°C, and rhythm was asystole. Lack of explanation for his hypothermia raised concern for a prolonged downtime and poor prognosis. However, he demonstrated intermittent eye opening and upper extremity movements, prompting extracorporeal life support initiation. In total, he received nearly five hours of continuous CPR. He was rewarmed slowly and decannulated on hospital day three after recovery of cardiac function. He was extubated on day six and renal replacement therapy was discontinued by day nine. His mental status returned to pre-arrest baseline with new lower extremity paralysis. MRI revealed a T10 spinal infarct. Despite extensive work-up, no etiology was found for his profound hypothermia. After prophylactic placement of a LifeVest® defibrillator, he was discharged to inpatient rehabilitation where he has recovered some lower extremity movement.

Discussion: In 2012, Wanscher et al. described the survival of seven teenagers following a boating accident in which they were submerged in 2°C water, resulting in profound hypothermia and circulatory arrest for as long as 2.5 hours. While lacking an environmental etiology for his hypothermia, our patient’s severe hypothermia, successful extracorporeal rewarming, and largely positive neurologic outcome were similar. A 2019 meta-analysis by Liu et al. reported no difference between mechanical CPR devices and manual CPR for adult OHCA in terms of return of spontaneous circulation and survival to admission or hospital discharge. Yet similar data is lacking for pediatric OHCA. In fact, feasibility of prolonged, high-quality manual CPR during pediatric transport has not been established, and currently, mechanical CPR devices are not an approved alternative.

Conclusion: Despite prolonged resuscitation and complex transport logistics, this case suggests that pediatric hypothermic OHCA has the potential for favorable neurologic outcomes with delivery of high-quality CPR and access to extracorporeal support. Furthermore, while mechanical CPR devices are not approved for children, this case may support their use in adult-size patients thought to benefit from lengthy transports.