The acuity of the pediatric emergency department at St. Louis Children’s Hospital is the highest I have encountered. While this has been an excellent experience for me as a junior faculty member, those instances requiring me to terminate resuscitation in a child have been difficult clinically and emotionally – driving me to analyze the process and sit with the “elephant in the room” previously introduced in the PEMNetwork’s Termination of Pediatric Resuscitation PART 1.
I cared for Child A that sustained a gun shot wound to the head. The child arrived to my care within 30 min of the injury and our resuscitation with trauma and neurosurgery went smoothly in the emergency department, in the operating room, and in the PICU. That child walked out of the hospital a month later. Shortly thereafter, I cared for Child B who also sustained a gun shot wound to the head. That child arrived to my care within 4 hours of injury and in cardiac arrest. Initial resuscitation provided a return of spontaneous circulation, but that child ultimately died in the emergency department after prolonged efforts. While there were clear differences in the presentation and course of resuscitation for Child A and Child B despite similar injuries, they had vastly different outcomes. My positive experience with Child A made it even more emotionally difficult to ultimately terminate resuscitation in Child B.
I utilized the CEASE method published in 2015 in the Annals of the American Thoracic Society to aid in termination of resusucitation. CEASE represents a loose guide for the termination of resuscitation efforts evaluating: Clinical features that predict survival; Effectiveness of resuscitation efforts; Ask the other clinicians present; Stop resuscitation efforts; Explain what has happened to the family. It was clear that Child B had many clinical predictors of increased risk of mortality described by a 2005 Resuscitation publication. Child B had: an out-of-hospital cardiac arrest; had undergone resuscitation longer than 8 min, and had pulseless electrical activity.
Initial resuscitative measures with epinephrine and vasopressor infusions as well as hypertonic saline were effective and Child B had return of spontaneous circulation. However, cardiac arrest recurred. I continued resuscitative efforts for more than 20 min – such prolonged efforts were one of the best indicators of mortality following pediatric cardiac arrest in a 2005 study.
At this point, I reviewed the course with the trauma team and asked our trauma attending what he thought of terminating resuscitation at that point – he agreed that the resuscitation was no longer effective.
I generally invite caregivers to be present during resuscitations, and prior to terminating efforts, I updated Child B’s caregiver of our plan to discontinue resuscitation. I have found that when the caregiver is present during the resuscitation, there is less of a shock when I have this conversation with them. A 2014 multicenter randomized controlled trial published in the New England Journal of Medicine showed that families who were present during (adult) cardiopulmonary resuscitation had positive results on psychological variables and did not interfere with medical efforts, increase stress in the health care team, or result in medico-legal conflicts. A prospective pediatric trauma study showed that family presence during pediatric trauma resuscitation did not prolong time to CT imaging or to resuscitation completion, and families believed that their presence was helpful to their child and themselves.
I told our team we were stopping resuscitation efforts and noted the time of death. We ensured that Child B was clean, without ET tube/stickers/lines in place, while the family grieved and I explained the course of events to them.
I followed this resuscitation with a debriefing of my emergency department team later during our shift when time permitted. A 2014 study demonstrated that 88% of pediatric ED nurses, fellows, and attendings believed that debriefing was an important process, but half of respondents reported that it occurred less than 25% of the time at their institution.
Stopping a code always feels strangely anti-climatic after the intensity of resuscitative measures. Most of the ED team seems to leave the room within seconds to care for the 20 other patients that have been waiting. I recently read an article that described “The Pause” which is essentially taking a moment with the ED team to acknowledge the efforts of the resuscitation and the passing life of the patient. This silent pause could represent a meditative, spiritual, or simply quiet moment following a clinically and emotionally intense experience to those who partake. I think a pause would have been helpful following the termination of resuscitation in Child B – and I plan to initiate this practice into my future clinical care.
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- Termination of Pediatric Resuscitation – the Elephant in the Room, Part 1 - September 29, 2015