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: What Happens to the Child of an ER Patient?

Susan Asks:

I am wondering what happens when a mother is injured and her seven-year-old child is with her. The unconscious woman is discovered by a passer by who calls 911. She wakes up, an ambulance arrives and she is taken to the ER.

I assume the child who is fine would go with them if the police haven’t been called. The woman is from out of town and knows no one in the city so the child can’t be picked up by anyone. The mother has a concussion and is kept overnight for observation. I am most interested in learning what would happen with the child at the point that they arrive at the ER while the mother is being examined.

Jordyn Says:

From the EMS standpoint— yes, they would bring the child with the parent.  As far as in the ER, if the mother is awake, the child would be in the room with her. The ED staff can assist with care of the child until the mother is feeling like she can manage. A child this age could be given activities to keep them entertained (coloring, snacks, a movie, etc).

If the child needs more than that then a member of the staff (like an ED tech or volunteer) could provide some assistance until the mother is feeling better and able to care for the child on her own.

Also, a concussion is not a reason for admission to the hospital. Not even overnight observation. Concussion patients are generally not admitted— even with a loss of consciousness at the scene. Even a minor car accident with loss of consciousness does not require admission if everything else is okay.

You don’t specify her mechanism of injury in your question. For concussion we want to see them alert and oriented and that their concussion symptoms (headache, dizziness, nausea) improve or resolve. CT scanning is more common in the adult population for head injury so if that shows no bleeding then there’s really no reason for her to stay in the hospital. If you need her admitted, I can help you have the character meet admission criteria.

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!

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.***

EMS and ER Response for an Unconscious Female Trauma Patient


Ginger Asks
:

I have a 23-year-old woman with an obvious head wound (she got hit with the butt of a gun, but the first responders don’t know that) who’s been outside in 20’ish degree weather without a coat for an undetermined amount of time. She’s unconscious. Obviously an IV is started, but what else will paramedics do to treat her? Warming blankets? What would happen when she got to the ER?

Jordyn Says:

Thanks for sending me your question.
 
EMS Response:

For an unconscious patient with an obvious head wound, but is unable to tell how her injury happened should be placed in C-spine precautions. That means C-collar and backboard. IV– yes. And warming. They’d get a set of vital signs, put her on a monitor and then do a full assessment to look for other injuries.

Checking her blood sugar is warranted because why is she unconscious? Did the injury to her head happen because she passed out from low blood sugar? Or is it too high? Looking for medical alert bracelets as well. They’d probably key in on a good neuro exam like are her pupils equal and reactive to light? What type of stimulation does she respond to (voice, touch or pain?) They might even give a dose of Narcan to rule out opiate overdose (like heroin.)  


In the ER:

Full assessment as above and we’ll look for other injures. We’ll maintain C-spine precautions. She would be completely undressed (again– looking for other injuries.) We have a better ability to monitor temperature so we’ll know exactly where she’s at and work to rewarm her. This could range from warm blankets to warming lights and heated IV fluids. Full set of vital signs. We’d place her on the monitor as well to watch her HR, breathing and oxygen levels continuously.
 
As far as testing and procedures go, if she remains unconscious, I would say the following:

1. Spine X-rays. 
2. CT of the head (to look for bleeding, stroke, tumor.)
3. Labs: Full metabolic panel (this will check blood sugar again), complete blood counts, alcohol level, aspirin level, Tylenol level. Tylenol and aspirin are drugs people will overdose on that can be very serious.
4. Urine toxicology panel (this would pick up on major substances of abuse but not everything.) Also urine pregnancy test. 
5. ECG. To see if a heart arrhythmia or heart attack could be an explanation for her passing out.
 
Unless we know the exact mechanism of the injury we have to consider both inflicted wounds from another person but also that she might have just passed out and hit her head and what the reason for that might be.

If she’s truly unconscious and doesn’t respond to pain– she’d likely get a tube in every orifice as they say and they’d have to consider whether or not to intubate her (put a breathing tube in) to protect her airway. If that happens, then NG tube (placed probably through the mouth into the stomach) and a Foley catheter which drains your urine into a bag.

If she’s somewhat responsive but immediately drifts off– they could hold off on tube placements, check the tests I’ve listed, and give her some time to see if she wakes up on her own if she’s breathing well on her own.

Allergic Reaction: Dianna Benson

I always love it when friend and author Dianna Benson stops by! Dianna is a talented writer and has two treats for you today– a new novel, Persephone’s Fugitive, is releasing. I was blessed to have the opportunity to read and endorse this novel. Two, she is giving a factually based fictional account of an EMS call dealing with a severe allergic reaction called anaphylaxis.

Welcome back, Dianna!

“EMS 6, allergic reaction, at 123 Main Street.”

At 7:40 Christmas night, my partner and I flip on the lights and sirens and race our ambulance toward 123 Main Street. En route, my partner reads off details of our dispatched call on our dashboard laptop.

“Twenty-year-old female. Respiratory arrest.”

I grab the radio. “This is EMS 6, requesting assistance on our anaphylaxis call. Copy?”

“Copy EMS 6. FD 14 is en route.”
    
Once we roll up on scene, several people wave us into the two-story home, their faces contorted in panic. As we hear sirens from an approaching fire truck, we rush our loaded stretcher inside the front door and toward the young lifeless body lying on the tiled kitchen floor, cyanosis around her lips.

I notice our patient’s chest is motionless, and I don’t feel or hear any air moving out of her mouth or nose.

“What is her name?” I ask no one in particular in the crowd of about a dozen surrounding us.

“Ally,” several voices answer.

“Ally?” I rub my knuckles over her sternum.

“Unresponsive,” I inform my partner, who’s yanking out a BVM (bag-valve mask), other airway equipment, and the med box.

I feel for a carotid pulse on her flushed neck. “Rapid and weak,” I say to my partner. We share a look of understanding—our patient is headed for cardiac arrest. Our interventions must be quick and efficient.

“What happened here?” I again ask the room full of people as I press the mask over my patient’s mouth and nose with my left hand in the E/C formation. With my right, I squeeze the football-sized bag every five seconds to oxygenate the young woman’s system. Her chest rises and falls with every squeeze, indicating her airway isn’t blocked by swelling or any foreign object.

“She was eating and started coughing, and said her chest is all tight,” a hysterical woman answered, suddenly kneeling next to me. “She was itchy all over, had trouble breathing, hives on her back.” 

I face the middle-aged woman, tears flowing out of her eyes and down her cheeks. “Are you her mother?”    

“Yes. She was severely allergic to peanuts when she was little but out grew it or whatever.”

As I continue bagging, my partner pushes epinephrine IM (intermuscular) then inserts an IV into our patient’s left arm for med access and fluid replacement. A fire crew of four men darts into the house.

Without an exchange of words, I hand one of the firefighters the BVM, and two of them take over bagging. One presses a tight seal over the mouth and nose, the other squeezes the bag.
   

“Hand me our monitor,” I ask the firefighter closest to our cardiac monitor. He and the fourth guy assist me in hooking up a twelve led ECG to our patient’s four limbs and chest.

I study the monitor for our patient’s vital signs, looking for indications of imminent anaphylactic shock and cardiac arrest. “BP 80/52. Pulse 134. SPO2 86%. Normal sinus heart rhythm.”

“Uh-huh,” my partner says, letting me know he heard my report of the grave vital signs.

I hand him diphenhydramine and methylprednisolone to administer into the IV line.

“Does Ally have any medical conditions or take any medications for anything?” I ask the mother.

“No. Nothing.” 

We add Benadryl to the line then attach a little bag of Pepcid to the IV set up. Following up with those meds, we add Solu-medrol.

In scanning the kitchen, I spot several whole pies ready to be served, remnants of T-Bone steaks and empty lobster tails on multiple dirty plates. “Did she eat any nuts tonight?” I ask the mother to keep her occupied.  

“Nothing any of us ate tonight contains nuts.” The mother points over her shoulder. “We haven’t eaten any pie yet, but none of them has nuts.”
     
“Has she ever eaten lobster before tonight?” I ask while digging into our airway bag.
 
“Once. Couple of months ago and loved it.”

“It was probably the lobster. The second encounter with an allergen is when an allergic reaction occurs.” I turn to my partner. “Let’s intubate.”

“Uh-huh.”

I’m readying the intubation equipment when Ally jerks to a conscious state, coughing and rolling on to her side, shoving the mask away from her face.

“Guess she didn’t want to be intubated,” one firefighter whispers near my ear, not out of humor but relief, a feeling I share. 

“Ally? Hi.” I grab a non-rebreather mask. “You suffered a severe allergic reaction. You need oxygen.”

She nods, rolling to lie on her back again. Her mother squeezes her hand, pats her forearm.

“Bummer, I know, but we gotta take you to the hospital to be monitored overnight.” After turning the portable O2 tank on to 15 liters per minute, I strap the non-rebreather to Ally’s face. “Just breathe normally and relax. You’re doing fine. We’ve got you, Ally.” I smile at her.

The firefighters lift her weak body onto our stretcher; I study the monitor. “BP 96/60. Pulse 118. SPO2 92%,” I say to my partner.

“That’s what I want to hear,” he responds in a relief matching my wide smile.

You can read more posts done on allergic reactions/anaphylaxis here, here, and here.


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Dianna T. Benson is the award-winning and international bestselling author of The Hidden Son and Final Trimester. Persephone’s Fugitive is her third release. An EMT and a HazMat and FEMA Operative since 2005, Dianna authentically implements her medical and rescue experience and knowledge into all her suspense novels. She lives in North Carolina with her husband and their three children. www.diannatbenson.com