Life-saving automated external defibrillation in a teenager: a case report

Abstract

Adolescent sudden death during sport participation is commonly due to cardiac causes. Survival is more likely when an automated external defibrillator (AED) is used soon after collapse.

Case presentation
We describe a case of sudden death in a 14 year old boy with two remarkable points, successful resuscitation at school using an AED and diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC). Bystander cardiopulmonary resuscitation (CPR) was immediately started by a witness and 5 minutes after the event the child was placed on an AED monitor that determined he was in a non shockable rhythm, therefore CPR was continued. Two minutes later, the AED monitor detected a shockable rhythm and recommended a shock, which was then administered. One minute after the shock, a palpable pulse was detected and the child began to breathe by himself. Four days after cardiac arrest, the boy was conversing and self-caring. Cardiac magnetic resonance imaging was suggestive of ARVC.

Conclusion
Ventricular fibrillation secondary to ARVC may be a devastating event and places young patients and athletes at high risk of sudden death. Immediate CPR and AED have been demonstrated to be lifesaving in such events. Therefore, we suggest that schools should have teachers skilled in CPR and accessible AEDs.

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Background
Automated external defibrillators (AEDs) have been used to treat sudden cardiac arrest in the adult patient population for over 20 years. Until recently, the use of AEDs in children was not recommended. Therefore, when a paediatric patient suffered a cardiac arrest with a shockable rhythm in an out-of-hospital setting, the only available treatment was manual defibrillation that should be administered by the emergency advanced life support team on arrival, with consequent delay in treatment [1,2]. The incidence of athlete sudden deaths appears to be in the range of 1:200.000 young people of high school per year [3]. Although relatively unfrequent, such deaths are more common than previously thought and represent a substantive health problem [4]. Sudden death during sport participation is commonly due to cardiac causes. Hypertrophic cardiomyopathy, coronary artery anomalies and myocarditis are the more frequent [3]. Therefore, survival is more likely when bystander cardiopulmonary resuscitation (CPR) and AED are initiated soon after collapse. However, and despite the new international CPR guidelines that reinforce this message, few cases of successful AED in children have been reported and it seems that paediatric staff remains unaware of the potential impact of this therapy.

Case presentation
A 14-year-old boy collapsed while playing a football match at school. Bystander CPR, including both chest compressions and mouth-to-mouth resuscitation, was immediately started by a witness who was trained in basic life support (BLS), while the emergency medical system was activated by another layperson. A paramedic BLS ambulance arrived 5 minutes after the event and immediately placed the child on an AED monitor (Heartstart FR2, Philips). Initially, the child was determined to be in a non shockable rhythm, therefore CPR was continued. Two minutes later, the AED monitor detected a shockable rhythm and recommended a shock, which was then administered at 150 joules. Chest compressions and bag-mask ventilation were resumed and one minute after the shock, a palpable pulse with a rate of 85 bpm was detected and the child began to breathe by himself. Fifteen minutes after collapse, the emergency advanced life support team arrived. At that time, heart rhythm was sinus rhythm with premature ventricular beats. Because of respiratory distress, the boy was intubated and transported to a paediatric intensive care unit (PICU) for further treatment. On admission physical examination revealed normal range HR with frequent ventricular extra-systoles, normal blood pressure and adequate peripheral perfusion. Amiodarone continuous IV infusion was started. A first echocardiogram exam revealed a structurally intact heart with adequate biventricular function. Cardiac index measured by pulse contour analysis was also within normal limits. His initial laboratory evaluation revealed a serum troponin level of 0.02 (normal: 0.01 ├óÔé¼ÔÇ£ 0.04 ng/mL) that five hours later increased to 1.17 ng/mL, returning to normal ranges 3 days after PICU admission. After cardiac evaluation, oral beta blocker therapy was started. He was on mechanical ventilation during two days and he was weaned without events. Four days after cardiac arrest, the boy was conversing and self-caring. Brain computed tomography and electroencephalogram revealed no abnormalities. Cardiac magnetic resonance imaging was suggestive of arrhythmogenic right ventricular cardiomyopathy (ARVC) (Figures 1, 2) and consequently a cardioverter-defibrillator was implanted in order to prevent a new episode of sudden death. He has subsequently returned to school with the advice to not perform vigorous exercise or engage in competitive sports.

Published online 2007 September 3. doi: 10.1186/1752-1947-1-76.
Copyright ├é┬® 2007 Rey et al; licensee BioMed Central Ltd.]\">
  Figure 1
Cardiac magnetic resonance. Cardiac magnetic resonance showing an area of increased signal intensity compatible with myocardial fatty substitution.

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