127 - Prone CPR achieves ROSC in a 9-year-old with a large anterior mediastinal mass: A case report

Publication Number: 127.6133

Victoria Quinn, The Warren Alpert Medical School of Brown University, Providence, RI, United States; Daniel H. Choi, Hasbro Children’s Brown University Health, Providence, RI, United States; Edward Suh, Hasbro Children's Hospital at Rhode Island Hospital, Providence, RI, United States; Robyn Wing, The Warren Alpert Medical School of Brown University, Wrentham, MA, United States

Background: While prone CPR has garnered some attention in adult populations, there are no studies on prone CPR in pediatric patients with anterior mediastinal masses (AMM’s), making this topic a largely unexplored therapeutic intervention. We present a case of a 9-year-old girl with an AMM who decompensated into a witnessed arrest. She remained pulseless after five rounds of supine CPR, but had return of spontaneous circulation (ROSC) after transitioning to prone CPR.

Objective: This case report aims to contribute to the growing body of evidence regarding prone CPR, underscore the need for innovative approaches in the resuscitation of pediatric patients with large AMM’s, and highlight how further studies are warranted to establish protocols and validate the efficacy of prone CPR in this vulnerable population.

Design/Methods: This is a detailed case report highlighting clinical, diagnostic and therapeutic insights relevant to critical care regarding prone CPR in a pediatric patient. Prone CPR was performed by compressors placing their hands over the T7-T10 vertebrae, which corresponds to the largest left ventricular cross-sectional area. After 8 rounds of prone CPR, return of spontaneous circulation (ROSC) was achieved.

Results: We propose several reasons why prone CPR was vital to obtaining ROSC in our patient. First, initial attempts at supine CPR exacerbated the obstruction from her AMM, as compressions on her sternum displaced the mass posteriorly onto her airway and major vessels. While in the prone position, we suspect gravity allowed the AMM to lift off those structures and alleviate the obstruction. Additionally, the significant size of her AMM made her chest wall rigid and difficult to compress with supine CPR. When transitioned to prone CPR, feedback from the cardiac defibrillator monitor confirmed that the depth and rate of compressions improved and reached traditional high-quality standards. While supine, we also noted that the patient had persistent hypoxemia with an undetectable end-tidal CO2. We hypothesize that this was due to dead space ventilation from compression of the airways as well as ventilation perfusion mismatching due to compression of her pulmonary arteries. Once prone however, her SpO2 improved to 93% and the first end-tidal CO2 reading (88mmHg) was obtained, confirming that we had been unable to oxygenate or ventilate her while supine.

Conclusion(s): In conclusion, prone CPR in pediatric patients with AMM’s is a novel concept that has not yet been reported or studied, and our case suggests it may offer significant advantages in the resuscitation of critically ill pediatric patients.