CARDIAC ARREST-BASKETBALL 1553

Abstract

HISTORY--A previously healthy 11 year-old male collapsed on court during a basketball game. Initially tonic-clonic activity was noted. He then became flaccid, unresponsive, apneic and pulseless. CPR was initiated. Upon EMS arrival he was intubated and found to be in ventricular fibrillation. Epinephrine administration and defibrillation resulted in conversion to sinus rhythm. Intermittent tonic-clonic seizure activity and posturing was subsequently noted. PHYSICAL EXAMINATION-- Initial examination upon hospital admission demonstrated an intubated, non-responsive hemodynamically stable child. The predominant rhythm was sinus with intermittent single PVCs. Pupils were reactive and fundi sharp. There were no focal neurologic signs. Breath sounds were course. Cardiovascular exam revealed a regular rhythm with a II/VI long systolic murmur at the apex. Peripheral capillary refill was 3-4 seconds. Muscle mass was normal. Hypertonicity of the extremities was present. He was admitted to the pediatric intensive care unit. DIFFERENTIAL DIAGNOSIS Ruptured cerebral aneurysm or arteriovenous malformation Cerebrovascular accident (thrombotic or embolic) Ruptured aortic aneursym Drug ingestion Primary dysrhythmia (long QTc, ventricular tachycardia, WPW with a-fib/flutter) Hypertrophic cardiomyopathy Aortic stenosis Coronary artery anomaly (Kawasaki disease, anomalous origin or course of left coronary artery) TESTS AND RESULTS CT scan of head: hypoxic ischemic encephalopathy without bleed or aneurysm. Urine drug screen: negative. ECG: sinus rhythm with QRS prolongation, diffuse ST changes, T-wave inversion. Echocardiogram: dyskinetic left ventricular apex with reduced ejection fraction; probable anomalous origin of the left coronary artery. Cardiac catheterization: anomalous origin of the left coronary artery from the posterior sinus of the pulmonary artery. FINAL/WORKING DIAGNOSIS: Anomalous origin of the left coronary artery from the pulmonary artery Cardiac arrest secondary to #1 with resulting hypoxic-ischemic encephalopathy TREATMENT: Initial stabilization and ventilatory/cardiac/nutritional support. Trachetomy/gastrostomy tube. Re-implantation of left coronary artery. Comprehensive rehabilitative care (physical, occupational, speech therapy).