The picture of the grieving emergency physician who “couldn’t save” a patient went viral in common media. However emergency physicians know that their emotions run even higher after we “couldn’t save” someone because we are the “final call”, the decision maker, the one that says “stop…right now.” That responsibility in itself can make what might have been already a futile case feel gut-wrenching – especially when it involves a child. As pediatric emergency medicine physicians, we will all be faced with the decision to terminate a resuscitation following cardiac arrest. Clinically, this may be an obvious decision. However, this decision emotionally and ethically looms like an elephant in the resuscitation room, until it is the last one at the bedside…and then it will often follow you home.
Knowing the facts about pediatric cardiac arrest gives perspective to an emergency department resuscitation. A prospective multi-center study of 283 children reported that cardiac arrest at the scene is associated with a higher mortality rate as compared to those with arrest occurring in the emergency department or hospital (73% vs. 65%). A retrospective PECARN study in 2009 evaluated 493 children that suffered either out-of-hospital or in-hospital cardiac arrest. This study demonstrated that the incidence of past medical history, baseline neurologic ability, etiologies of arrest, and post arrest outcome vary between both groups. Also, time courses of survival and live discharge between children with out-of-hospital versus in-hospital cardiac arrest were different. In the out-of-hospital arrest group, children were far more likely to sustain neurological injury as well as subsequently die from it.
Regardless of the setting, overall survival to ultimate hospital discharge following cardiac arrest in children is poor (13%) with good neurologic outcome occurring in only 62% of this small fraction of children. A pediatric study in 2004 reported that the best indicator of mortality was a duration of cardiopulmonary resuscitation of over 20 min (odds ratio: 10.35; 95% CI 4.59-23.32). The same authors also reported in 2005 that other risk factors for mortality following pediatric cardiac arrest included: out-of-hospital arrest; more than 8 min elapsed from arrest to resuscitation attempts; and asystole/slow initial rhythms/pulseless electrical activity. Regardless of our best efforts, mortality following cardiac arrest in children is high and prolonged efforts rarely have successful outcomes. Knowing this, it is still difficult to make the final decision to stop resuscitation.
The American Heart Association, the Neonatal Resuscitation Program, and the European Resuscitation Guidelines (Pediatric) all describe discontinuing support in the newborn without signs of heart rate after 10 min of resuscitation. However none of these organizations describe specifics for discontinuation of support in children. A 2015 study in the Annals of the American Thoracic Society addresses this issue in children and adults with the concept of “CEASE.” CEASE stands for: Clinical features that predict survival; Effectiveness of resuscitation efforts; Ask the other clinicians present; Stop resuscitation efforts; Explain what has happened to the family.” Though this article is vague in its recommendations, the value in it is the mantra like pneumonic. In the hectic setting of a pediatric resuscitation, reviewing the CEASE mnemonic can provide a framework for discontinuing resuscitation.
In the Part 2 follow-up post, I will discuss evidence based recommendations as well as personal experience following the termination of resuscitation in a pediatric patient.
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