PEMCoR Mega Code

5-year-old male comes by EMS in cardiac arrest to your ED. EMS states that the patient was found down while in his uncle’s care. The only history they have is that he is a healthy male and takes no medications. He had bystander CPR initiated immediately in the field because he had no pulses. His total time for CPR before EMS arrival is 10 minutes and EMS has been performing CPR for an additional 7 minutes before arrival to your ED.

What do you want to do? Continue CPR with 100% O2 via BVM, Hook him up to the monitor, check a rhythm, {and consider intubation}—note: we’d defer this decision to whether the rhythm is shockable—if so, continue BVM/CPR until charged to shock, if not, you’d then intubate.

You hook him up to the monitor and hold CPR for a rhythm check, which shows the following rhythm

(V.fib)….what do you want to do now? Shock

What voltage do you want to shock assume he is 20kg? 40J (2J/kg)

After you shock what do you want to do? Rotate compressors and Restart CPR

You do another 2 minutes of CPR now what do you want to do? Rhythm check

Your rhythm shows the following

(NSR but no pulses/PEA)…what do you want to do now? Does he have pulses? No, so resume CPR until ready to intubate and give Epi

He has now been receiving CPR for a total of 25 minutes since he went down what should you start thinking of? Hs & Ts!, obtain an iSTAT, intubate, give epi

What size tube do you want to intubate with? 5.5 tube using a size 2 straight blade and insert to approximately 16.5

What dose of epi do you want to use? 0.01mg/kg of 1:10,000 conc.

Its time for another rhythm check and you see the following

(asystole)… what do you want to do now? Rotate Compressors and Resume CPR

You do another 2 minutes of CPR and its time for a rhythm check and you see the following rhythm

(pulseless V. tach)… what do you want to do now? Does he have a pulse? No, so shock

What voltage do you want to use to shock? 2J or 4J/kg so 40-80J

Then what do you want to do? Rotate Compressors and Resume CPR

You do another 2 minutes of CPR and do a rhythm check and see the following rhythm

(Torsades de pointes)… what do you want to do? Give Magnesium 25-50mg/kg to a max of 2 g IV bolus and restart CPR.

You do another round of CPR and this time when you do a rhythm check you see the following rhythm

(sinus tachycardia)…what do you want to do now? Check for pulses.

He has pulses now what do you want to do? Start on epi drip, grab an EKG and start ROSC protocol and get the patient to the PICU.

What dose do you start your epi drip? 0.1mcg/kg/min

You get your EKG and it shows the following, what do you think this kid could have?

Brugada Syndrome.

Brugada Syndrome:

It is a genetic disease that is characterized by abnormal EKG findings and an increased risk of sudden cardiac death. Because of the genetic defect causing a mutation in a gene that encodes in the cardiac sodium ion channel it can precipitate the patient to ventricular tachycardia and/or ventricular fibrillation that often results in sudden cardiac death. It is known as a sodium channelopathy. This condition is inherited in an autosomal dominant pattern and manifests itself more commonly in males, due to a higher penetrance. In addition it has a higher prevalence in most Asian populations. Treatment is implantation of an implantable

cardioverter-defibrillator (ICD). EKG shows the following: a right bundle branch block patten and ST elevation in leads V1-V3.