it is thought to be responsible for fatal ventricular tachyarrhythmia that may lead to syncope or out - of - hospital cardiac arrest ( ohca ) in young people without structural heart disease . because arrhythmic events are more common at night and during sleep , it is difficult to diagnose and treat patients with brugada syndrome . here , we report a case of ohca caused by brugada syndrome , which had been successfully treated with  chain of survival  interventions . a 19-year - old man with no markedly past medical history was found lying on the floor , unresponsive , by his colleagues at 09:40 am of october 28 , 2014 . one colleague immediately called the emergency medical services ( emss ) by mobile phone , while another performed bystander cardiopulmonary resuscitation ( cpr ) . the patient arrived at the emergency department of nanjing drum tower hospital 15 minutes after cardiac arrest . he had poor general conditions with glasgow coma scale score 3 ; he had no spontaneous respirations and heart rhythm , no response to verbal stimuli , and had fixed and dilated pupils . the patient was intubated and mechanically ventilated , while cpr was continuously performed using a gas - driven mechanical chest compression ( grand rapids , michigan instruments ; hirtz , koln , germany ) with compression rate 100/min and deepness of chest compression 5  cm ) . ventricular fibrillation was first detected 35 minutes after cardiac arrest by the defibrillator , and 4 defibrillations ( ventricular fibrillation or pulseless ventricular tachycardia ) were performed in all , following injections of adrenaline ( 5  mg in all ) , as well as amiodarone and dopamine infusions . one hundred and twenty minutes after cardiac arrest , he presented successful return of spontaneous circulation ( rosc ) with blood pressure 85/42 mm hg and heart rate 103 bpm . the patient showed hypoxaemia ( pulse oxygen saturation < 90% ; positive end - expiratory pressure 12 mm hg , fio2 100% , 1 hour after rosc ) , although invasive mechanical ventilation was given . the arterial blood gas was ph 7.309 , partial arterial co2 pressure 40.3 mm hg , po2 52.8 mm hg , fio2 100% , and po2/fio2 52.8 , and the chest x - ray showed pulmonary edema ( figure 1 ) . chest x - ray in 1 hour after rosc showed a hazy opacification spreading from the lung hilar regions ( arrows ) . then the patient was moved to the emergency intensive care unit 3.5 hour after the onset , and his vital signs were as follows : temperature 39c , heart rate 110 bpm , blood pressure 83/55 mm hg ( dopamine infusion 12  mcg / kg    min ) , and oxygen saturation 95% ( mechanical ventilation , fio2 50% ) , and the serum neuron - specific enolase ( nse ) was significantly elevated ( 75.05  ng / ml , reference 016.3  ng / ml ) . neurological examination was notable for the following : disappeared spontaneous respiration , fixed and dilated pupils , absent corneal reflexes , and absent motor responses to painful stimuli in all extremities . the repeat electrocardiogram showed a right bundle branch block and st segment elevation in leads v1v2 ( figure 2 ) . the patient 's uncle had experienced the same event and had received implantable cardioverter defibrillator ( icd ) treatment 1 year earlier . electrocardiograms in precordial leads after rosc showed right bundle branch block and st segment elevation in leads v1v2 ( arrows ) . a mild therapeutic hypothermia ( mth ) was started ( 5 hours after cardiac arrest ) by infusing a cold ( 4c ) saline solution ( 1.8  l in all ) . the body temperature decreased to 35.9c ( 24 hours after cardiac arrest ) , and the core temperature was maintained between 34c and 36c for 24 hours in combination with an external cooling mattress ( hico - hypotherm 680 of hirtz and hico - polyurethan water mat ; hirtz , koln , germany ) . shivering appeared in mth ; the shivering was suppressed with lytic cocktail therapy ( chlorpromazine , promethazine , and pethidine ) and high doses of sedatives ( midazolam , fentanyl , and propofol ) . bedside echocardiography showed left heart insufficiency and an ejection fraction of 33% . because of heart dysfunction and unstable circulation ( systolic blood pressure 7683 mm hg ) , the patient received dopamine and an intraaortic balloon pump ( iabp ) , and pulse index continuous cardiac output ( picco ) monitoring system dopamine infusion and iabp were then discontinued because circulatory condition and heart function had improved . the patient 's consciousness improved 58 hours after cardiac arrest ; he was able to open his eyes to command and respond to painful stimuli . the patient was extubated after a successful spontaneous breathing trial on day 4 after cardiac arrest . then he spoke in full sentences , was fully aware of person , place , and time , and accurately exhibited full strength in all his extremities . the repeat nse was 13.77  ng / ml . a noncontrast head computed tomography scan was performed , which showed no evidence of intracranial hemorrhage , mass infarction , or cerebral edema . he was able to ambulate with a walker and independently perform activities of daily life on day 5 after the cardiac arrest . he completely recovered with 1 point based on the criteria of cerebral performance category on day 8 after cardiac arrest and was then transferred to the cardiology department . the patient was followed up at 1 and 4 months after discharge and he had no noticeable neurological or intellectual deficits ( figure 3 ) . cpr  =  cardiopulmonary resuscitation , ed  =  emergency department , eicu  =  emergency intensive care unit , iabp  =  intraaortic balloon pump , icd  =  implantable cardioverter defibrillator , mth  =  mild therapeutic hypothermia , ohca  =  out - of - hospital cardiac arrest , picco  =  pulse index continuous cardiac output , rosc  =  return of spontaneous circulation . the estimated incidence of ems - treated ohca in the united states is about 40.3 to 86.7/100 000  persons / year , and the overall survival rate is only 3.0% to 16.3% . to improve outcomes of patients after cardiac arrest , the american heart association promotes the concept of the chain of survival . following the new principle , basic life support ( bls ) is the foundation of chain of survival for a higher survival rate . continuous chest compression is a critical component of bls because cardiac output and coronary perfusion depend on compression during cpr . therefore , chest compressions should be the highest priority and the initial action for the patients with ohca . in our case , high - quality cpr that contributed to the successful resuscitation and favorable neurological outcome although the treatment of mechanical chest compression  decompression system in ohca is controversial , at least during prolonged resuscitation , as in our case , it may avoid reducing the quality of cpr . zimmermann et al also found that mechanical cpr improved the outcome of a patient with ohca . early defibrillation is critical to survival from ohca because the most frequent initial heart rhythm in ohca is ventricular fibrillation , which should be immediately defibrillated . however , no defibrillation was performed out of hospital in our case because the initial monitored heart rhythm of the patient was pea , and bystander - performed cpr is more important than defibrillation for patients with a nonshockable rhythm . postcardiac arrest care has significant potential to reduce early mortality caused by hemodynamic instability , and later mortality and morbidity from multiorgan failure and neurological function damage . mth , as a critical component of postcardiac arrest care , is an important resuscitation treatment that improves neurological outcomes and gives a better chance of survival to discharge in survivors with cardiac arrest . our case also showed that mth after rosc greatly improved the neurological outcome in the patient . a difference between our case and earlier studies is that our patient was maintained with a temperature between 34c and 36c . although therapeutic hypothermia ( targeted temperature from 32c to 34c ) is now recommended in international resuscitation guidelines , a recent international multicenter trial demonstrates that a targeted temperature of 36c has comparable survival rate and neurological function of ohca patients , compared with the temperature of 33c . our patient was persistently shivering after rosc and early phrase of mth ; it took us long time with sedation to control and achieve the target temperature . the complex hemodynamic instability , including hypovolemia , myocardial stunning , excessive vasodilation , and pulmonary edema , is common after rosc , which is associated with increased mortality . therefore , it is important to monitor and evaluate hemodynamic variables in patients after rosc under normothermic and hypothermic conditions . in our case , hypotension , heart dysfunction , and pulmonary edema occurred soon after rosc and during the cooling procedure . we monitored cardiopulmonary function and hemodynamic parameters using the picco monitoring system ( table 1 ) , and improved the cardiopulmonary function using iabp and diuretics , all of these measures are very important in goal - directed fluid management patients after ohca . the diagnosis and treatment of the cause of underlying disease is fundamental to the management of ohca . brugada syndrome is diagnosed in our case with typical electrocardiogram findings ( coved st elevation in leads v1v2 ) and family history . an operation of icd implantation was successfully performed for the patient , and he showed complete recovery in the follow - up examinations . in conclusion , our case demonstrates that even after an ohca with prolonged time until rosc , survival with a favorable neurological outcome is possible , provided implementation of an extremely effective rescue chain .
abstractout - of - hospital cardiac arrest ( ohca ) is a crucial public health problem . to improve outcomes of patients after cardiac arrest 
 , the american heart association promotes the concept of the chain of survival.we report a case of a 19-year - old man with no markedly past medical history who suffered from ohca , and he was resuscitated with cardiopulmonary resuscitation , without interruption , during the rescue process for 120 minutes until return of spontaneous circulation ( rosc ) . 
 electrocardiogram on admission showed right bundle branch block and st segment elevation in leads v1v2 , and the patient 's uncle had experienced the same event and had received implantable cardioverter defibrillator ( icd ) treatment . 
 therefore , the patient was diagnosed with brugada syndrome . 
 postcardiac arrest care was performed after rosc , including mild therapeutic hypothermia , hemodynamic monitoring and management , and icd implantation , and then the patient completely recovered without any noticeable neurological or intellectual deficits in the follow - up examinations.our case demonstrates that even after an ohca with prolonged time ( 120 minutes ) until rosc , survival with a favorable neurological outcome is possible , provided implementation of an extremely effective rescue chain .