Resuscitation 117 (2017) e9–e10
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Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor
Ventricular fibrillation as initial rhythm in
pediatric cardiac arrest by suicidal hanging
Sir,
Hypoxia is the main cause of out of hospital cardiac arrest in
children (OHCAC) with asystole as predominating initial rhythm.
Shockable rhythms are rare in childhood and are mainly found in
patients with underlying cardiac diseases.
We report two cases of ventricular fibrillation as first detected
rhythm in pediatric cardiac arrest due to attempted suicide by
hanging.
An 11 year old boy was admitted to our pediatric intensive care
unit after OHCAC with return of spontaneous circulation (ROSC).
He had no preexisting cardiac disorder. After attempted suicide
by hanging himself with a belt on a built-in cupboard in his room
he was found lifeless by his father approximately 15–20 min later.
Immediate basic life support according to ERC Guidelines was
Fig. 1. Initial ventricular fibrillation and successful conversion to sinus rhythm by the first shock in both patients.
http://dx.doi.org/10.1016/j.resuscitation.2017.04.021
0300-9572/© 2017 Elsevier B.V. All rights reserved.
started [1].A few minutes later the emergency medical service
arrived. The initial on-site ECG-analysis (LP1000, Physiocontrol)
showed ventricular fibrillation (Fig. 1, patient 1). Cardiopulmonary
resuscitation (CPR) was continued and the first shock with 200 J
(6 J/kg) was delivered. After 2 min of CPR reevaluation showed a
conversion to a stable sinus rhythm and palpable pulses (Fig. 1).
The second case is a 13-year old boy admitted to our pedi-
atric intensive care unit after OHCAC with ROSC. The boy had hung
himself with a judo belt clamped in a door. He was found lifeless
after unkown duration of hanging and basic life support according
to ERC Guidelines was started [1]. When the emergency medical
service arrived the on-site ECG-analysis showed ventricular fib-
rillation (Fig. 1, patient 2). CPR was continued and the first shock
with 200 J (3 J/kg) was delivered with successful conversion to sinus
rhythm and palpable pulses.
Major causes of pediatric resuscitation are respiratory or circu-
latory (shock) emergencies. These lead to hypoxia/ischemia which
in pediatric patients typically initiate a sequence of bradycardia
 e10 Letter to the Editor / Resuscitation 117 (2017) e9–e10

and non-shockable rhythms such as asystole or pulseless electric [2].Rajan S, Wissenberg M, Folke F, et al. Out-of-hospital cardiac arrests in children
activity (PEA). and adolescents: incidences, outcomes, and household socioeconomic status.
Resuscitation 2015;88:12–9.
There exist few data on out-of-hospital cardiac arrest in children [3].Kitamura T, Iwami T, Kawamura T, et al. Conventional and chest-compression-
but all studies conclude that shockable rhythms as first docu- only cardiopulmonary resuscitation by bystanders for children who have out-
mented rhythm after OHCA and CPR occur in only 4,8–11,7% of of-hospital cardiac arrests: a prospective, nationwide, population-based cohort
study. Lancet 2010;375:1347–54.
cases [2,3]. In most of these cases a preexisting cardiac disease was [4].Shain B. Committee on adolescence. Suicide and suicide attempts in adolescents.
diagnosed.In children with submersion injuries, 20% showed ini- Pediatrics 2016;138, pii: e20161420.
tially shockable rhythms [5] whereas in the others no data about [5].Donoghue AJ, Nadkarni V, Berg RA, et al. Out-of-hospital pediatric cardiac arrest:
an epidemiologic nreview and assessment of current knowledge. Ann Emerg Med
exact diagnoses exist.
2005;46:512–22.
Suicide is the second leading cause of death in 15–19 years
old adolescents in the U.S. and unfortunately the number of Johanna Wagner
deaths resulting from suicide increased dramatically during recent Karl Reiter
decades [4]. Yet there exist no data about cardiac arrest and pre- Carola Schön
dominating initial rhythm after suicide attempts. Julia Keil
To our knowledge this is the first report of documented ven- Dr. v. Hauner Children’s Hospital, Pediatric Intensive
tricular fibrillation after cardiac arrest by suicidal hanging in two Care Unit, LMU Munich, Lindwurmstr. 4, D-80337
adolescents without underlying cardiac disorders. We speculate Munich, Germany
that catecholamine excess in conjunction with ischemia/hypoxia
might cause ventricular fibrillation in suicidal hanging [1]. Michael Strobelt
Pediatrician’s Office, Bahnhofstr. 16, D-83052
Consent Bruckmühl, Germany
Martin Olivieri
Written parental consent has been obtained for publication by Florian Hoffmann ∗
Dr Hoffmann. Dr. v. Hauner Children’s Hospital, Pediatric Intensive
Care Unit, LMU Munich, Lindwurmstr. 4, D-80337
Conflict of interest statement Munich, Germany

All authors disclose any financial or personal conflict of interest ∗ Corresponding

author.
that could affect objectivity. There was also no financial funding. E-mail addresses:
florian.hoffmann@med.uni-muenchen.de,
Acknowledgement florian.hoffmann@med.uni-muenchen.de
(F. Hoffmann).
There are no sources of funding.
12 April 2017
References
18 April 2017
[1].Maconochie IK, Bingham R, Eich C, et al. Paediatric life support section Collabora-
tors: European Resuscitation Council Guidelines for Resuscitation 2015: Section
6. Paediatric life support. Resuscitation 2015;95:223–48.