The patient (CF) is a 17-year-old male with a history of bipolar disease and polysubstance abuse. The patient had recently been released from a rehabilitation center and was at home with his mother when he started to become inappropriately aggressive. His mother was concerned for her safety and called the police.
The patient was aggressive and uncooperative when the police arrived and was subdued with a taser. He was hit in the left side of his chest. CF did not suffer any other injury. Twenty minutes after being tasered, CF is noticed to still be on the ground. On further inspection he is unresponsive and the paramedics are called. When they arrive he is apneic and pulseless. CPR is initiated, he is intubated, and IV access is obtained. CF is in pulseless v-tach and receives epinephrine, atropine, and defibrillation X 3 en route to the hospital.
On arrival to the emergency department, the endotracheal tube position is verified and CPR is continued as the patient does not have a pulse. A second IV is established and the patient is placed on the monitor. He is still in pulseless v-tach, and is defibrillated. After defibrillation the patient continues to go between pulseless v-tach and v-fib. He receives epinephrine and amiodarone and multiple defibrillations. After being defibrillated for the third time, the patient has return of spontaneous circulation with a pulse. He is still hypotensive and started on levophed.
The patient is still unresponsive but maintaining a blood pressure on pressors. It is decided to initiate a hypothermia protocol. A right femoral cool line is placed and CF is cooled to 34 degrees and transferred to the ICU for further care. Initial labs show him to be acidotic with an elevated Cr and troponin. His blood alcohol level is in the 230s.
OUTCOME:
The patient codes while in the ICU but promptly regains a pulse. The hypothermia protocol is continued for 18 hour and then CF is passively warmed. He cannot be weaned from the ventilator, but does show signs of neurologic function. Approximately one week after the initial injury, CF receives a tracheotomy and a PEG tube for feeds. He is following commands and able to answer yes or no questions. He is transferred to a step down unit where he continues to receive aggressive therapy. Less than a month after the injury he is transferred to a rehabilitation center. At that time he is able to walk, swallow thickened feeds, and does not have a focal neurologic deficit.
During his inpatient hospitalization, a brain MRI does not show an injury or infarction. He has hypoxic brain injury and cardiovascular damage. Before the event he was healthy but now has an ejection fraction of 25% on repeat echo. This is up from his first echocardiogram that showed an EF of approximately 15%. His troponin while in the ICU peaked at 168.
Recently we have initiated a hypothermic protocol at my hospital. As supported by recent literature, patients initially in pulseless v-tach or v-fib who have a return of circulation, have better neurologic outcomes after initial cooling to 32-34 degrees. While literature includes only those 18 years or older, this is a case report showing a good neurologic outcome in a 17 year old patient who was in pulseless v-tach, resuscitated, and initiated on a hypothermia protocol for 18 hours.