The patient is a 21-month-old male who presented to the emergency department in full cardiac arrest after “choking” on a cookie earlier that day on October 15, 2018. Return of spontaneous circulation (ROSC) occurred after thirty minutes of cardiopulmonary resuscitation (cpr) and three rounds of epinephrine. When the ambulance arrived at the scene they found the child in agonal breathing and were unable to dislodge anything with the Heimlich maneuver.
EMS was told that the mother went into the gas station and the boyfriend was left with the child alone in the car. The boyfriend stated that the child was eating cookies and he noticed that the child was choking and called the ambulance. The crew then proceeded to intubate with a 2.5 endotracheal tube because they could not pass a larger tube. The patient’s Glasgow coma score was a three on arrival to the emergency department with an absence of brain stem reflexes including cough, gag, corneal, with fixed and dilated pupils, and the patient was reintubated with a 3.5 endotracheal tube.
A Glasgow coma score of three is indicative of a deep coma and the patient’s brain function should be tested to ensure that there is no brain death present resulting in death. The mother was questioned about the patient’s medical history and the mother stated that the patient was a “cooling baby” from a nuchal cord complication and a hypoxic event at birth. She states that the patient was discharged from the neonatal intensive care unit after two weeks and they have been following up with a neurologist at Children’s Healthcare of Atlanta every six months to monitor fluid around the brain and the mother states that there have been no complications.
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The mother also stated that the patient was recently diagnosed with tonsillitis and has been taking Amoxicillin as prescribed twice a day. I decided to choose this patient for my case study because it made me emotional which is a tough thing to do after working in the emergency department for over two years. I also had a bad feeling that things were not adding up with the patient’s story and wanted to truly find out what happened to this 21-month-old to cause him to go into cardiac arrest because nowhere in the report did I find where a cookie was found or an object to correlate with the patient having choked to cause the cardiac arrest episode.
Following the resuscitation, the physical exam revealed that the patient’s pupils were 6mm and fixed, normal and clear breath sounds bilaterally, and dried blood at the right external auditory meatus of the patient’s ear. The head CT revealed the following: subdural hematomas at different ages adjacent to the right supratentorial brain and left supratentorial brain as well, but no skull fractures. This finding leads me to believe that this child has been undergoing physical assault which may have led to the cardiac arrest event. This patient underwent the protocols for declaring a patient to be brain dead.
According to Ganapathy brain dead is defined as “Today, brain death is considered equivalent to death of the individual, and death of the brain stem is accepted as death of the brain” (p. 309). These protocols included a brain death test, an apnea test, a brain flow test, another brain death test, and then after all these things have been done can the patient then be declared brain dead. A brain death test consists of many different steps. The first step is to determine if the patient is responsive to any deep pain stimuli. If the patient is unresponsive then the next step is to check brain stem reflexes which Nelson (p. 497) states as follows:
- Pupillary response (cranial nerves II and III): Pupil size does not change in response to bright light. Pupils are generally 4 mm to 6 mm in diameter and nonreactive, but they can be any shape.
- Ocular movements (cranial nerves III, IV, VI, VIII): During oculocephalic testing (commonly called “doll’s eye testing”), no eye movements are noted when the head is briskly rotated horizontally and vertically. During oculovestibular testing (commonly called “cold caloric testing”), no eye movements are noted after 50 mL of ice water is injected into each ear, 5 minutes apart.
- Corneal reflex (cranial nerves V and VII): No eyelid movement occurs when the cornea is pressed with a cotton swab.
- Cough and gag reflexes (cranial nerves IX and X): When the posterior pharynx is suctioned or stimulated with a tongue blade, there is no cough or gag. After that comes the apnea test in which the patient is taken off the ventilator and given supplemental oxygen to see if the patient can take a spontaneous breath.
If the patient cannot do this, then they move on to the brain flow test. The brain flow test is done in nuclear medicine and the patient is given a mild radioactive isotope to help us visualize intracranial blood flow. A tourniquet is placed around the patient’s head and then the test begins, and we wait to see if there is any intracranial blood flow. After this is done, if there is no blood flow, the brain death test is conducted again before declaring the patient officially brain dead.
Typical signs and symptoms of brain death include the patient being unconscious and unresponsive, the patient will score less than a 3 on the Glasgow coma scale, the patient will normally have the bare minimum on vital signs to sustain life, the peripheral pulses and blood flow will be lessened as the body attempts to protect the major organs to keep the patient alive, and the patient will fail all of the test previously mentioned.
This 21-month-old male patient failed all these tests on October 16, 2018 and was pronounced brain dead. A sitter was placed in the patient’s room always to ensure that no one other than a medical employee laid hands on the patient. The patient’s family then agreed to organ donation and the facility began to follow the life link protocols keeping the organs alive until they get accepted to go somewhere. Once it was found that the patient had several subdural hematomas of different ages the authorities were notified and so was a pediatric medical examiner to determine if there was any foul play resulting in the child’s death.
The GBI and medical examiner constantly questioned the family and any visitors while the medical staff concentrated on beginning the life link protocols. These protocols as explained by Silva (p. 54-56), include keeping the patient’s body temperature between 35-37.5 degrees Celsius to maintain organ function, it has to be determined that there was no drug use which was verified in this patient, the patient was also checked for HIV, and any type of cancer or tumor was screened for while we awaited acceptance of different organs.
The physician did everything in his power to find a way for this child to survive. The subdural hematomas caused too much bleeding for the brain to survive and the patient then became brain dead after the cardiac arrest event. The physicians plan was to monitor the patient and try to control the bleeding on the brain to reduce the swelling and see if the patient could wake up. Vasopressors were given to keep the patient’s blood pressure up enough to keep the patient from crashing or having another cardiac episode.
Eventually the physician decided it was time to test for brain death and followed the facilities protocol to the letter, and he constantly explained the situation to the family and what each test was for and how it was going to be done. He also explained to the family that each time the patient failed a test it was leaning more and more towards a negative outcome and that there was a real possibility that the patient would not survive. There are no more recommendations that I can make for this patient at this time. All the current data that I was able to research supports the physician’s decision to pronounce this child brain dead.
After that it is completely up to the family if they want to stop ventilatory support, keep the patient on ventilatory support, or agree to have the patient become a candidate for life link. All we can do as medical professionals is explain each option to the family so that they can make an informed decision. In this position it is mostly important to be a good listener for the family, and to try and comfort them the best you can given the unforeseen circumstances.
A pediatric patient has no control over what goes on in their home life. These patients are one-hundred percent dependent on their parents or legal guardian. Every act of violence or suspicious injuries should be reported to the proper authorities to help protect these children. Maybe if someone had said something or noticed that this child was being abused he would not have gone into cardiac arrest and lost his brain function.
Parents need to be aware of who is spending time with their children. In this case the mother’s boyfriend was arrested for murder in the first degree for abusing this child. It is a heartbreaking scene when someone you love can cause so much damage to someone so innocent and young. Brain death is a final irreversible disease that results in the end of the patient’s life, but hopefully his organs will be able to save others who are in desperate need of organ transplants.
Throughout this case study I have learned a great deal about pediatric and end of life care. Brain death testing is not something I was aware occurred in the manner that it does. I was taken back at actually seeing a patient with “dolls eyes”, and then to see all the deep pain stimuli not have an effect on the patient. The most shocking test to me was the ice water into the ears to try and get a reaction from the patient. I had no idea that this would test a brain stem reflex and is something I will take with me the rest of my life.
Dealing with a pediatric death is something that I did not know I would have to handle going into this clinical and I had always figured if I did come across this it would be something strictly medical that killed the patient. I learned how to put my personal feelings aside and just care for the patient. This experience taught me how to work with individuals who are not hospital personnel and what I can and cannot share with them according to HIPPA. I also learned that choking in children does not cause subdural hematomas like it was once thought to. This case study helped me to grow as a therapist and I hope that I can carry this experience with me throughout my career and use it to guide my thinking about patients in relation to their life outside of the hospital. This will be an experience that I will never forget.
