Table of Contents
Washington University Experience | VASCULAR | Infarct, watershed | 2A0 Case 2 History
Case 2 History ---- The patient was a 7-year-old boy with a history of epilepsy, a radiologically-diagnosed brain tumor, and Chiari type 1 malformation. A brain MRI performed in July of 2011 demonstrated abnormal T2 / FLAIR focus over the left posterior parietal lobe which eventually proved to be an angiocentric glioma at autopsy. He presented again in April 2014 in status epilepticus and his medications were adjusted. In August 2014, the patient felt unwell the morning of presentation and went on to have a generalized tonic-clonic seizure. His father activated EMS and gave him 10 mg of Diastat per rectum. On EMS arrival, he continued to have tonic-clonic movements and received intranasal Versed. He had respiratory depression and bag-mask ventilation was initiated by EMS. On arrival to the outside hospital, he had ongoing seizure activity and was receiving bag-mask ventilation. He subsequently vomited, aspirated, and developed bradycardia with arrest. CPR was initiated, and he received several doses of epinephrine, following which he had evidence of pulseless electrical activity. CPR continued and his rhythm transitioned to ventricular tachycardia. He received lidocaine and electrical shock followed by amiodarone and finally return of spontaneous circulation and sinus rhythm approximately 30 minutes after the initiation of CPR. He was placed on a ventilator at the outside hospital, and was noted to have a marked lactic acidosis. He was then transferred to St. Louis Children's Hospital. On arrival to the SLCH intensive care unit, he was unresponsive. His pupils were dilated and fixed without a doll's eye reflex, cough, or gag. His distal lower extremities were very mottled and poorly perfused with a capillary refill greater than 6 seconds. Initial labs demonstrated a profound metabolic acidosis and coagulopathy. Over the next several hours, resuscitation was continuously attempted with epinephrine and norepinephrine as well as multiple doses of sodium bicarbonate, calcium gluconate, and a stress-dose hydrocortisone.. Coagulopathy was attempted to be corrected with multiple units of packed RBCs, FFP, cryoprecipitate, and platelets in addition to a 1-time dose of factor VII. His prognosis was grim with the likelihood that he would have very poor neurological function following his prolonged arrest, if he had any chance of survival at all. His family elected to proceed forward with redirection of care. ---- The brain showed evidence of watershed infarcts, particularly in the territories of the anterior cerebral and middle cerebral arteries, and eosinophilic neuronal necrosis, related to the terminal course of cardiac arrest, prolonged efforts at resuscitation and noted poor perfusion.
