Pediatric emergency medicine trisk 0247 0247

DISCONTINUATION OF LIFE SUPPORT IN CHILDREN
If well-executed resuscitative measures fail to achieve ROSC, discontinue
resuscitative efforts unless the patient is deemed to be a good candidate for ECPR. There is good evidence to support that there is little chance for meaningful
survival in patients with unwitnessed arrest who remain unresponsive to airway
intervention, chest compressions, and two doses of epinephrine. Thus, a brief,
well-executed resuscitation is indicated for the child who arrives to the ED with
cardiopulmonary arrest. During this time, the leader can review the history and
complete the primary and secondary survey. Prolonged resuscitation efforts past
20 minutes, without ROSC, are usually futile unless other treatable problems
exist such as hypothermia, drug overdose, or VT/VF. Prolonged resuscitation may
be indicated for witnessed collapsed arrest, with short onset of effective
BLS/ACLS, especially if a cardiac etiology is suspected. Ultimately, the
diagnosis of death and subsequent discontinuation of resuscitative efforts is a
judgment that is made by the team leader in conjunction with the team. A
decision not to begin resuscitation is generally not made in the ED unless there is
a written do-not-resuscitate (DNR) document provided by the child’s parent or
guardian.
A well-prepared ED should consider and have a plan in place for issues such as
advanced directives, palliative care, bereavement measures and postmortem care,
survivor follow-up, and request for autopsy and organ donations as outlined in the
AAP guidelines. Proper documentation of a death is essential, as is notification of
medical legal authorities, donor programs, and referring physicians and
consultants.

CEREBRAL RESUSCITATION
Cerebral injury remains the leading etiology for morbidity in those who survive
cardiopulmonary arrest. Permanent brain damage following arrest is determined
by many factors and includes arrest time (no-flow state), CPR time (low-flow
state), and temperature. Cardiopulmonary–cerebral resuscitation is needed to
prevent brain injury. Oxygen stores are depleted within 20 seconds following
arrest, and glucose and adenosine are depleted within 5 minutes. During no-flow

states, multiple complex chemical derangements occur that contribute to the death
of neurons. With ROSC, there is impaired cerebral blood flow. Therapeutic
interventions to prevent postanoxic brain injury have yielded disappointing
results to date, outside of prevention of pyrexia.

Hypothermia