Introduction: the Automatic External Defibrillator (AED) pediatric pads are used to calculate the body impedance and thus deliver the appropriate power to a child during CPR and DC shock. We report a case of inappropriate power delivery to a neonate using adult pads.
Case: AB, a healthy two weeks old baby, 3.6 kilos, experienced two days of poor feeding and mild shortness of breath. On the second day the mother noticed the patient was gasping and the local rescue team was called. Upon arrival the patient was found dusky with poor saturation and no pulse. CPR was initiated, AED pads were attached to the body and intra osseous access was established. Due to malfunction of the pediatric pads, adult pads were placed. During the resuscitation the AED recognized the patient was in VF and delivered two shocks after which CPR continued, the patient regained pulse and spontaneous breathing and was transferred safely to our center for further care. For arrhythmia evaluation the original AED strips were retrieved and analyzed. It was discovered the patient during the entire resuscitation was in sinus bradycardia which the device failed to recognize, concluded as VF and two shocks were delivered. Moreover since the patient was treated with adult pads he received 221 J twice though weighing only 3.6 K. Despite the inappropriate shocks the patient has improved during CPR and was transferred in good condition to the hospital and has fully recovered after one week, the patient luckily had no burns and no cardiac sequelae. A Holter monitor recording discovered later the patient had prolonged episodes of supraventricular tachycardia and was started on beta blockers.
Discussion: inappropriate connection of a neonate to adult AED pads during resuscitation way lead to erroneous diagnosis of fatal arrhythmia leading to inappropriate shocks using adult dosage.
