November-December 2008 299 Abstract Introduction: A 14-year-old boy with cardiorespiratory failure was referred for air medical transport. The complexity of care during air medical transport and subsequent diagnosis of hantavirus war- ranted a post hoc review of the literature to establish optimal trans- port management criteria. Methods: This is a case report and literature review, defining epi- demiology, presentation, cause of pulmonary edema and cardiac failure, management, and outcome. Results: Hantavirus cardiopulmonary syndrome is rare in children. Severe cases have manifestations similar to those seen in adults: atypical pneumonia progresses to respiratory failure with severe pulmonary edema and associated circulatory compromise. Mechanical ventilation, judicious fluid replacement, and early inotropic therapy are central to transport management. Critical care may require extracorporeal membrane oxygenation (ECMO). Mortality remains high, although it appears to be lower in children younger than 14 years. Conclusion: Hantavirus infection commonly progresses to a car- diopulmonary syndrome, in which mortality is high. Optimal man- agement includes: early suspicion/recognition based on characteris- tic clinical course and history; provision of oxygen and comprehen- sive ventilatory support; judicious fluid replacement; early and inten- sive inotropic therapy; prompt referral to an appropriate level of care; skillful interfacility transport. Definitive care can involve ECMO. Introduction Hantavirus cardiopulmonary syndrome (HCPS) is a rare infection transmitted through aerosolized rodent (typically deer mouse) excrement. Infection can result in rapidly pro- gressive cardiopulmonary collapse. The management of these patients, particularly the rapid progression of car- diopulmonary collapse, can pose a significant challenge to the transport team. Transport Referral History and Management A critically ill 14-year-old boy required air medical trans- port from a peripheral tertiary level hospital 240 km away. The information relayed to the receiving hospital during the request for transfer was that the patient had a “flu-like” ill- ness, but that over the preceding 24 hours, his respiratory status had rapidly deteriorated, requiring intubation and of assisted ventilation. The patient had become tired and unwell 6 days earlier but did not have a cough, runny nose, or fever at that time and still felt well enough to attend school. Three days later, he complained of a headache and did not attend school. The next day he had a fever above 39.5ºC, his headache was worse, and he complained of visual disturbance. The following morning he was taken to his local secondary-level regional hospital, where, based on his symptoms and chest x-ray, a diagnosis of atypical pneumonia was made. He was treated with cefuroxime, azithromycin, dimenhydrinate, and aerosolized albuterol and ipratropium. Over the course of that day and night in the hospital, he had increasing oxygen requirements, increasing tachypnea, and his breathing was more labored. By the morning of the second day in hospital, he required 15 L O 2 via face mask, and he had an oxygen saturation of 87% and arterial blood gas (ABG) values of pH = 7.35, partial pressure of oxygen (PaO 2 ) = 27, partial pressure of carbon dioxide (PCO 2 ) = 54, bicarbonate = 14.5, and base deficit = -8.8. That morning he was trans- ported by ambulance to the closest tertiary-level hospi- tal. On arrival he was found to be tachypneic (respiratory rate of 60 breaths/minute) and cyanotic, and he required emergent intubation, fluid resuscitation, and inotropic support. This prompted emergent referral to the provincial pediatric intensive care unit. A pediatric transport team composed of two paramedics and an intensive care unit physician was dispatched by a fixed-wing aircraft that was pressurized to the level of the referring hospital. On arrival, the team obtained additional history. The patient was previously healthy, with no known contact with infected individuals, no known medical condi- tions, no previous hospitalizations, no medications, and no known allergies. His friends confessed that they had smoked marijuana laced with homegrown poppy extract the day before he became unwell. After the transport it became known that the family home had recently devel- oped a mouse infestation, and the patient’s bedroom was in the basement, where the infestation was the worst. Hantavirus Cardiopulmonary Syndrome: Implications for Transport Management and Care Division of Emergency Medicine, BC Children’s & Women’s Hospital, Vancouver, British Columbia, Canada. Address for correspondence: J. Guilfoyle, Division of Pediatric Emergency Medicine, BC Children’s and Women’s Hospital, 4480 Oak Street, Vancouver, BC, Canada V7E 5N7, jguilfoyle@cw.bc.ca. 1067-991X/$34.00 Copyright 2008 by Air Medical Journal Associates doi:10.1016/j.amj.2008.008.003 Jonathan F. Guilfoyle, MD, FRCPC, and Andrew J. Macnab, MD, FRCPC, FRCPCH, FCAHS CASE REPORT