Timeline: The Emergency Department – The Resuscitation

Do we always do CPR?

There is no hard, fast rule about whether a resuscitation should be attempted on an infant or child that is found dead out-of-hospital. However, the vast majority of paramedics would start CPR and we need to be mindful of the effect on the paramedic crew, the parents and our own staff members of not being seen to continue with resuscitation efforts.

As with all cardiac arrests, continuing with the resuscitation also gives us the opportunity and time to gather facts and get the whole multi-disciplinary team together to come to a team consensus to stop resuscitation. It also gives the parents the opportunity to have resuscitation attempts stopped and their child “die” in their arms.

What is the outcome in resuscitation of SUDIC cases?

A local audit by Kehler et al.¹¹ found that only very few children gain a cardiac output, and this is often after prolonged resuscitation of over 15 minutes. The neurological outcome is incredibly poor, and these patients often end up having care withdrawn on PICU later down the line.

What do we do in the Emergency Department?

The sequence of actions below is an example of good practice. You should follow your local hospital guidance to ensure all the appropriate local agencies are informed.

1. Alert the Acute Consultant Paediatrician on-call. In most Trusts, the designated paediatrician for child deaths will not be available out of hours, in which case the Consultant Paediatrician on-call should attend.
2. Liaise with police present to ensure that the Senior Investigating Officer (SIO) is en-route or present. If the child has arrived by ambulance, the ambulance service will usually have alerted the police to attend.
3. Allocate a member of staff to remain with the parents and support them through the process. Some hospitals have access to SUDIC Clinical Nurse Specialists specifically for this role. The family must not be left alone with the deceased child.
4. If resuscitation is ongoing, give the family the option of being present. This is best practice and recommended by both the European Resuscitation Council (ERC) and the Resuscitation Council UK (RCUK). If they choose to be present, the allocated staff member should accompany the family throughout this period to explain what is going on.
5. If resuscitation is going to be stopped, inform the parents and give them the option of holding their child as care is withdrawn. Confirm and document the date and time, and document the resuscitation itself, including all activities, interventions and drugs used. You must document all attempts at procedures such as cannulation; not just successful ones.
6. Leave any lines and tubes in place and only remove them following discussion with the police Senior Investigation Officer (SIO). ET tubes must also only be removed after confirmation of correct placement by direct laryngoscopy – by somebody other than the person who placed the tube. This person must be competent to intubate. The local coroner will usually have provided guidance on this and you should follow the local coroner’s advice.

If any equipment was difficult to insert or may have contributed to death, it must be left in situ.

 

 

Learning bites

• It is good practice to offer family-witnessed resuscitation at paediatric resuscitations. Some may want this, others may not.

• In the words of a nurse, “It has been my experience that families deal better with ‘knowns’ than ‘unknowns’. I find that what families actually see is invariably better than their fantasies”¹⁶.

• The time any resuscitation efforts are stopped is not the time of death. The time of stopping of resuscitation and the time of death should both be clearly recorded, with a period of a minimum of five minutes of observation in between, to establish that irreversible cardiorespiratory arrest has occurred.