Cardiac arrest in a 14-year-old at an overnight camp

Discussion

Overnight summer camps are common in Canada, though a specific census has never been done. Although injury and illness do occur at camp, medical emergencies are exceedingly uncommon across all age groups.1^–4 Nevertheless, preparation for low-frequency, high-acuity emergencies are needed and should account for remote geography and prolonged EMS response times. Pediatric out-of-hospital cardiac arrest is uncommon but may be under-reported owing to inadequate surveillance systems, publication bias or legal concerns.

Survival after pediatric out-of-hospital cardiac arrest is 5%–10%,5^,6 with survival among adolescents (estimated at 8.9%–15.8%) higher than among infants and younger children.7 Modifiable factors — such as early CPR, early AED use, early EMS attendance and quality of hospital care — can improve outcomes. 6^–9 Unmodifiable factors include patient factors (e.g., age, comorbidity, cause of arrest) and features of the arrest (e.g., witnessed v. unwitnessed, initial rhythm).7 Widely available, public access to AEDs has allowed for earlier defibrillation, which is associated with higher rates of survival and better neurologic outcomes.10 Each additional minute of delay to shock is associated with an 8% decrease in 1-month survival.10 For our patient, a number of elements in her care contributed to her successful resuscitation and intact neurologic survival. She had a witnessed arrest by a fellow camper trained in basic life support, who immediately started CPR with good-quality compressions. The bystander was quickly supported by trained medical staff, employed by the camp. Fortunately, the camp was situated close to an EMS station; EMS personnel attended the scene quickly with immediate defibrillation, achieving ROSC within 10 minutes of initial unresponsiveness.

This case highlights the importance of early recognition and prompt initiation of effective compressions in the resuscitation of out-of-hospital cardiac arrest, regardless of age. Bystander CPR increases survival and improves neurologic outcomes by minimizing delays in establishing systemic blood flow.9 Bystander CPR can be supported in a camp by training all staff in basic CPR and maintaining skills through regular simulation.6^,9 Response times can be further shortened by training willing older campers, support staff and other bystanders to perform compression-only CPR, which can be accomplished by watching a 60-second video.11 The societal benefits of widespread CPR training for youth and young adults are exemplified by this case, as the camper who recognized and started the resuscitation had received first aid training previously. Finally, this case offers a positive contrast to previous findings that bystander CPR occurs less frequently in pediatric out-of-hospital cardiac arrest, even when witnessed,6^,9 underscoring the importance of training as many people as possible in CPR, with periodic practising of compressions.

Debriefing after an out-of-hospital cardiac arrest is important both for witnesses’ and providers’ psychological coping, and is vital for optimizing system performance.12 The campers present in the cabin during the time of the arrest underwent an immediate debrief by the camp physician and a camp director, with an appropriate crisis response to support their mental health. Crisis counsellors were made available for camp counsellors and others over the ensuing days. The camp health centre team and camp directors undertook a detailed analysis of system performance, which led to a number of changes. The AED is now stored in a portable bag containing other resuscitation equipment in a conspicuous location at the front of the health centre; this bag is assigned daily to 1 of the health centre staff, to be brought to a medical emergency declared on camp grounds. A second AED was purchased and placed near the cabins where the arrest occurred (a more remote area of the camp), secured against potential use for pranks. A camp policy, “Medical Emergency on Camp Grounds,” was developed to complement the existing health-related policies already in use, detailing roles in the event of an emergency, locations of AEDs and resuscitation equipment, and way-finding to assist EMS arriving at the camp.

Our patient had myocarditis, which is a common cause of out-of-hospital cardiac arrest and unexpected cardiac deaths in children.13 Myocarditis causes dysrhythmias due to cardiac inflammation, triggered primarily from a viral infection and associated cardiac dysfunction. Acute myocarditis has a biphasic presentation, with peaks in early infancy and mid-teenage years.14 Diagnosis can be clinically challenging as symptoms are wide-ranging and often nonspecific. Fulminant myocarditis is diagnosed when patients present with profound shock or acute arrhythmias, which can be fatal in the absence of advanced hemodynamic support.15 Treatment remains largely supportive, with ongoing debate over the benefits of anti-inflammatory therapies such as intravenous immunoglobulin or corticosteroids, and an overall 93% survival without transplant.15 Overall survival and long-term outcomes are highly dependent on both the severity and early recognition and treatment of this condition.