Pediatric CPR: When to Stop?

Nothing probably tugs at the heartstrings more than thinking about a child dying. It’s not the way things are supposed to happen. We expect life to follow the natural order of things— the old die first. Parents should never bury their children.

Sadly, we know this reality is not true. The pediatric nurse understands and confronts this reality more often than most. Particularly nurses who work critical care, ER, oncology, and hospice.

A reader of this blog posed this question to me: How long will a nurse or doctor perform chest compressions on a pediatric patient? Is forty-five minutes too long or would they try longer?

This is a tough question and not so easily answered. There are really no hard and fast rules as to when CPR should be stopped and it depends a lot on the reason for the code (if known) and what types of signs the patient is giving us. For instance, just because a patient doesn’t have a pulse, doesn’t mean they don’t have electrical activity in the heart muscle. Some causes of a code are reversible, but it takes time to do so. Hypothermia might be a good example of this.

I’ve worked in both adult and pediatric critical care. What I’ve found generally is providers will run pediatric codes longer than adult codes even when chances are small to get a pulse back. No one wants to see a kid die— health care providers are no different. Plus, culturally, we resist death at every turn even though it is the course each of us will journey to.

However, I did come across this article that begins to address this concern. If we can teach how to resuscitate patients— should we also not teach providers when it is reasonable and ethical to stop such efforts?

1. Are there clinical features present prior to the code that are predictive of poor survival? For instance, in the adult patient some of these from the article included pneumonia, metastatic cancer, and low blood pressure. For pediatric patients, kidney failure and use of a continuous infusion of epinephrine are mentioned.

In the emergency department setting, we want to know what the patient’s initial heart rhythm was. If there was no electrical activity in the heart (terms such as asystole, flat-line, ventricular standstill) then chances of getting back organized electrical activity AND contraction of the heart muscle are low.

2. Is the patient receiving high quality CPR? This might seem like a no brainer. Of course, if the patient codes in the hospital, they must be receiving excellent CPR. What research shows is that this is not true and it is a big drive of many institutions to simply improve the quality of CPR. If I can ease your mind, many hospitals are improving CPR basics through high fidelity code labs, more frequent CPR check-offs, mock codes, and computer based CPR training that measures effectiveness of CPR and coaches the participant on how to improve .

What are some CPR pitfalls? Initiating CPR in a timely manner. Compressing deep enough and at the right rate. Not over or under ventilating the patient (both can actually cause problems). CPR is what we call a high risk, low yield procedure— meaning we don’t do it very often, but when we do we have to do it right. What you don’t practice frequently you don’t become adept at. CPR is no different.

Considering this, we look at how long the patient’s down time was. This refers to the time when the patient’s heart stopped beating to the time they got CPR. Trouble is, this might be relatively hard to determine. When was the patient last seen? Is the patient cold to the touch? Are their pupils fixed and dilated?

The good news for the writer is there is a lot of leeway in this area as far as how long a medical team might “work” on a patient. Factors can be given for both short and long resuscitation times.

The most important part is getting those factors medically correct.

What about you? Have you written a resuscitation scene into a work of fiction?


Author Question: Unconscious Teen Struck in Head by Baseball Bat

Ari Asks:

Hello and thank you for this blog. It’s a brilliant resource and I’m grateful to have the opportunity to reach out to a professional in this setting.

I have two scenarios in a novel I’m writing that I could use your help with.

First, a teenage boy is struck in the head with a baseball bat. He is knocked unconscious and falls into a coma. When he arrives in the ER, I would like some compelling dialogue between the first responders to convey his condition, rather than just typing it out in the slug lines. What are some of the measures that nurses and/or doctors would take in responding to this injury? Also, what type of jargon or verbiage would make this scene convincing to someone in the field?

Second, is the scenario where the doctor informs the parents of the same boy about his condition. In what setting would he/she do this? Or for that matter, who would be the person to inform the parents to begin with?

Thank you for taking the time to help writers do your profession justice.

Jordyn Says:

Hi, Ari. Thanks for reaching out and all your compliments regarding the blog. I’m glad you’ve found it helpful.

Typically, when a patient arrives to the ER via EMS, they give a report on their patient when they get to the assigned room. In this case, it might be something like this:

“This is John Doe, age 17, struck in the head with a baseball bat at 1600 today. Pt with immediate LOC (loss of consciousness). Was unconscious upon our arrival. Responds only to pain. We started an IV, drew labs, and started normal saline TKO (to keep vein open). His Glasgow Coma Score is eight (this is bad). Vitals signs are as follows: Heart rate 100. BP 124/62. Respirations 16. Pulse ox 100% on 100% non-rebreather. Parents are here. No chronic illnesses. No drug allergies.” 

The ER team will place him on a monitor, assess the status of his IV, and do a thorough physical exam of the patient including an extensive neurological exam. I would follow the link above and do some reading on the Glasgow Coma Scale and how it’s scored.

A Glasgow coma score of eight or less will likely lead to the patient being intubated because there is concern that he would not be able to maintain his airway.

Taking into consideration this patient’s mechanism of injury and the fact that he is unconscious, he would receive an expedited CT scan of his brain to look for injury— likely bleeding in this case.

Past this, it would be hard for me to talk to you about all the things the medical team would say. It’s your scene. If it is a compelling scene in the novel, I’d have a medical person review it.

Keep in mind the POV character you’re writing the scene from. If it comes from a medical person’s perspective, then the use of technical terms, etc is more warranted because they should sound like they know what they’re talking about. If the scene is from a lay person’s POV— then you can write more generally about the medical things being done.

Who informs the parents about their son’s condition? These days, parents are generally not separated from their child, even in instances where the child has lost their heartbeat. The parents likely followed the ambulance and would be updated upon arrival in the patient’s room. A nurse or a doctor can update the parents and give them the medical plan of care as outlined by the physician.

Hope this helps and happy writing!

Author Question: Pediatric Near-Drowning

Carol Asks:

I’m writing a scene that involves a child approximately eighteen-months-old. She was submerged for an unknown period of time (no more than a couple of minutes) on a beach after being struck by a rogue wave that knocked her down.

When found, she has a pulse, but is not breathing. Rescue breathing is started within thirty seconds of rescuers reaching her. She coughs up water shortly thereafter and is breathing on her own by the time the ambulance arrives.

This is the outcome I’ve written. Would this be correct?

A couple of days in the hospital for observation. She’s a princess so they insist on whatever tests CAN be done even if they normally wouldn’t be (X-ray, CT to check brain function.)

Neurologist tells the family that given the length of time in the water, how quickly she was given CPR, and the total length of time not breathing, she will likely suffer only minor cognitive issues at worse, and those may will not present until she starts school.

I’m presuming oxygen via nasal cannula or mask as well as an IV started in the ER.

This does not take place in the US, but I’m presuming standard procedure would be an investigation to find out how she ended up unattended long enough to make it to the waterfront. It’s truly an accident– the first time the child escaped from the house. Is this acceptable? Particularly if there was supporting video evidence?

Jordyn Says:

The scenario you have outlined is reasonable.

Here are a few of my thoughts.

This is a patient we would probably admit into the hospital– at least for a day. More depending on what happens in the first twenty-four hours would determine the need for a more lengthy stay.

For instance. as long as the child has an oxygen requirement with this type of mechanism, they can’t go home. Even if they have normal oxygen levels, any type of increased work of breathing would also probably keep them in the hospital until that resolved. However, if the child’s oxygen levels are normal and they exhibit no signs of respiratory distress for twenty-four hours then we might be hard pressed to keep them in the hospital. Remember, you have to be really sick to stay in the hospital these days.

Of course, with her position as princess, it could be easily foreseen that everyone operates with a greater degree of caution.

Chest x-ray would be reasonable and expected in this case. Paramedics starting an IV and oxygen, particularly in the case where the child received rescue breathing, also good. However, one of the first things that will happen when the child get’s to the hospital is that we will remove the oxygen to see where she settles out on room air. This would be an important piece for us to know. She’d be placed on an oxygen and heart monitor with frequent assessments of her breathing.

As far as doing other testing, particularly a CT scan to determine if there’s been any brain damage, I would argue against this. Now, do physicians “cave” sometimes to pressure by royalty. Of course— I’m sure this has happened. Just as here, if it were the president, some testing might be done that might not be necessary to “cover your . . . “.

Medically, however, if she never lost her pulse and was quickly revived, I think the risk of brain damage is extremely low. As long as your heart is beating, your brain is receiving some oxygen. Your blood does have a reserve volume of oxygen molecules on your blood cells for situations just as this. Children are very oxygen sensitive, and it doesn’t take long for them to lose their pulse in an oxygen deprived state. Knowing she still had a pulse when she was pulled from the water, especially considering her age, would mean to me that her down time was probably very little.

Also, the CT scan will likely not show any injury. Absence of injury also doesn’t mean she may not have learning difficulties in the future. So, I don’t think there’s much to be gained by that test— and the subsequent exposure to radiation which is something we balance a lot in pediatrics.

As far as the investigation, I think what you outline is reasonable, particularly if there is supporting video evidence of her slipping from the castle.

Thanks so much for your question. Good luck with your story!

Take Me First: The Triage System

Often times, when I read a medical scene in a fiction novel it generally covers treatment of a character’s injury/illness. That can be the extent of the scene. What other factors inherent to the ED can increase conflict for the character?

One of the first people you’ll come into contact with if you go to the emergency department is the triage nurse. Triage is a process of sorting patients so the sickest are seen first. Can anyone see potential areas of conflict during the triage process?

When I screen a patient in triage, I take their complaint, a set of vital signs, medical history, allergies, and current medications. For pediatrics, we get a weight because every drug dosage is based on their weight. Most likely, the parent explains why they brought their child in. I then assign them a level based on my assessment of how emergency they need to be seen. Different emergency departments will use different scoring systems but all ED’s have them. Some are three levels. The hospital I work for uses a five level triage system.

If I “level” you a one then you’re dying and need immediate resuscitation. A level two patient might be a fracture with obvious deformity that may have to be set using sedation or an infant that needs a septic work-up. A level three patient would be those requiring a work-up for their issue— like abdominal pain. A level four patient is generally a simple laceration repair or concern for fracture but not an obvious deformity. If I assign you a level five, then you could likely be seen by your doctor the next day without suffering any ill effects. This would cover things like getting a test for strep throat or having a doctor look at a rash. You can see as the “acuity” goes down (level one is the highest acuity), so do the number of tests and procedures. ED nurses are very good at anticipating what tests and procedures the doctor will likely preform.

If bed space is not an issue, patients are generally taken in order of arrival. People in the waiting room are excellent at keeping track of what order they’re in and they expect this to be maintained. However, when bed space becomes limited, then I want the doctor to see the patients who have the highest acuity first.

However, when you begin to pull people out of order, this is when tension begins to rise in the waiting room. At first, it may be subtle. I call a patient back and the ones that signed in before that one give me what I affectionately call the “evil eye”. The longer the wait, the more restless people/children become. Sometimes, sicker patients do have to wait. As a nurse, this is not an ideal situation but I also can’t place more than one patient/family in a room.

Often times, it is presumed that a patient that arrives by ambulance will automatically get a room in the department. However, if beds are tight and the patient’s acuity is low, I have triaged them to the waiting room. How happy do you think that patient is? I know this may come as a shock, but some people who call an ambulance are not having a medical emergency.

In the comments section, write a triage scenario that has high conflict in no more than five sentences. Can you do it?

***Contest reposted from February 9, 2011.***

Author Question: Treatment of the Burn Patient

Jennie Asks:

What happens when someone gets burned? What do the EMT’s do on the scene? The story line involves the explosion of a crosswired electrical box.  Two individuals are burned.

First, the man who threw the switch is thrown onto the floor and sparks are showering down on him and his clothes.  He is pinned beneath a shelf that he knocked over.  The second man takes his jacket and tries to put out the flames while others pull the shelf off the man on the floor.  The second man’s arm and hand are burned trying to put out the fire, and keep the sparks from falling on the man on the floor.

I have the paramedics taking the first man to the hospital. I describe very little about his condition. However, the hero is attended by the heroine who is an EMT. His burns are secondary. Would he have to go to the hospital?  Get a tetanus shot if he needs one?

Jordyn Says:

The first distinction to make is that there are several different types of Emergency Medical Service (EMS) providers and their level of responsibility to this patient will be different. An emergency medical technician (EMT) generally provides basic first aid, CPR, can administer oxygen and can assist the patient in giving some of their own medications (like an asthma inhaler or nitroglycerin tablets.) A paramedic does more advanced medical procedures and gives drugs. The level of your provider will need to be clear in the medical care they can provide.

For EMT’s, in general, burn care is as follows:

1. Remove clothing from the burn that is non-adherent.

2. Remove any constricting items. For instance, if the burn is on the ring finger, you would try and take the ring off.

3. Cover burn with a cool, wet, clean dressing. This will help control pain.

If you have a paramedic responding— it is possible that an IV could be started and the patient could get an IV narcotic for pain (something like morphine or fentanyl.)

If the character is burned by the electrical current, this poses a whole new set of problems. I get the feeling he is burned by the electricity because you mention that he has been thrown back. Electrical burns typically have an entrance and an exit wound like the hand and foot. The electricity enters one part but has to exit somewhere.

The other problem with electrical burns is that your heart pumps based on an electrical conduction system. An electrical burn can injure the electrical conduction system of the heart and we will look very closely at whether or not the heart sustained injury. This could be evaluated initially by a 12-Lead ECG and lab work that measures muscle breakdown specific to the heart. The issue with electrical burns is that the damage is often unseen because the electricity will injure you internally but we can’t see it externally except and the entrance and exit sites.

The other thought was the extent of your patient’s burns and this would make a difference in their medical care. Burns are generally calculated based on the percentage of skin that is affected. You can find examples of these tables by clicking this link. Adults and kids are calculated differently.

Burns <15% body surface area (BSA) would get cool, moist compresses. However, burns > 15% would get dry, sterile dressings. The reason for this is that burn patients have lost their skin integrity. Your skin helps your body maintain its temperature. Some consider it the largest organ in the body. When you burn >15% and apply cool, wet dressings, this can pull enough heat away from the patient to cause them to become hypothermic. We actually have to help burn patients maintain their body temperature by cranking up the heat in the room or using other warming techniques.

Your patient will have to go to the hospital. Initial ED treatment would be IV placement, fluid resuscitation (there is a formula we use for this and is dependent on the burn percentage), pain medication (like morphine), and likely consulting with a burn center to help determine his course of treatment. Tetanus shot would be updated if he hasn’t had one in the last five years.

Did you know that paramedic protocols are relatively easy to find online? For instance, this link shows all of the Denver Metro Prehospital Protocols. Referencing these will be one of the best sources for researching what type of prehospital care your character would receive for their given ailment.

***This content originally posted December 10, 2010.***

Author Question: Management of Unusual Patients

Amy Asks:

I hope you can address this. Or, if not, point me at a resource that can. I am writing a short horror story in which a patient complains about not being able to get clean. She washes and then within an hour, she’s dirty again. And if she doesn’t wash, the dirt just accumulates. She’s a magnet for dirt. The patient is not complaining of Morgellons and has no history of drug abuse. Neither does she have a history of (or current problems with) OCD behavior.

My assumption is that the doctor would review proper hygiene with herand then find a tactful way to make a referral to a psychiatrist or psychologist. Is that correct?

What questions would the doctor ask? What language would she use when documenting this meeting? And what would she do when more patients start presenting with the same complaint?

In my story, the complaint becomes a pandemic. With this illness, it’s always possible to wash away the dirt, you just can’t keep it away. What are the long-term health consequences of not being able to remain clean? I know that it will increase the possibility of local infections but can you become ill from simply being dirty? (This hypothetical illness would only attract dirt, not pests. But would being dirty make it easier to attract and harbor fleas, ticks and lice?)

Thank you for any help you may be able to provide me!

Jordyn Says:

Wow, Amy. This is a very intriguing question.

I’ll have to take it from an ER nurse’s standpoint. A patient who presents with a complaint of dirt accumulation despite showering definitely raises some eyebrows. If the patient is not expressing wanting to kill themselves or others—then there’s no immediate need to involve psychiatric services. The doctor may say something akin to, “I don’t think this has a medical cause. I think it might be best to follow-up with your regular physician for a referral to a mental health professional.”

Mental health evaluations are rarely done in the ED by an ER physician. These services are likely contracted out or handled by someone else other than the ER physician. You may have heard this phrase about ER docs, “Knowledge of all. Master of none.”—Meaning they have a significant knowledge base but are not specialists. Their job entails identifying a true medical emergency and managing that—so in absence of that, they’ll refer on.

I would say localized infection from open wounds is the biggest risk. As far as attracting other pests—what kind of environment do they live in? Just because you have extra dirt on you doesn’t mean you’ll have lice, etc.

I also ran you question by friend, author and ER physician Braxton DeGarmo.

Braxton says:

I cannot think of a single scientific way that someone could become a dirt “magnet.” As such, the idea of a pandemic in which people can’t keep clean would very much require some sort of fringe science explanation and to pull the plot off you’d have to build that idea in bits and pieces to make it believable—much like Crichton did for re-building ancient DNA from amber to clone dinosaurs.

Now, as a psychiatric condition, this is very plausible. I’ve taken care of people who thought they were shrinking and that snakes were under their skin. All of these were manifestations of a psychotic break. So, yes, a tactful referral to psych would be warranted. It would be easier to come up with something that causes such a psych pandemic than one where people keep attracting dirt and grime.

The problem, though, is that everyone’s psychotic break would be different. So, again, you’d have to build some case where they all share OCD or the opposite, an attraction to dirt to where they purposefully seek to get dirty. Both scenarios will require some work to build scientifically plausible causes.

Perhaps, there could be an illness that leads to a specific deficiency and the dirt they instinctively “collect” somehow fills this need and is absorbed through the skin. To the casual observer, they just look dirty, but a closer look finds common mineral “X” or whatever, within everyone’s grime. And it’s the only common factor, thus leading the protagonist or someone to figure it out.

Most folks have heard of people with certain deficiencies sharing a common trait, such as pica to fill an iron deficiency. So, this might be an easier way to build plausibility.

As for the specific questions, yes, local skin infections might become more of a problem, but not necessarily any systemic issues. Likewise, with fleas and such. Degree of skin cleanliness has nothing really to do with such infestations. 

Best of luck with this novel! Very intriguing idea.