A SUDDEN, UNEXPECTED DEATH

Basic life support with CPR should be continued and the Advanced Paediatric Life Support asystole algorithm should be followed (see Fig. 98.1).

Figure 98.1 Advanced Paediatric Life Support asystole algorithm. (Reproduced with modifications from APLS manual, with permission from ALSG and Blackwell Publishing.)

Investigations need to be wide ranging, looking into possibilities such as sepsis, metabolic disease and poisoning. A bedside glucose measurement should be done immediately. It is not always possible to get sufficient blood and urine for all the tests:

• Blood tests: full blood count, urea and electrolytes, bone chemistry, liver function tests, glucose, C-reactive protein, blood gas, blood culture, ammonia, lactate, amino acids, toxicology, cross-match 

• Urine tests: microscopy, culture and sensitivity, amino acids, organic acids, toxicology

• Nasopharyngeal aspirate for virology and bacteriology.

• Chest X-ray and any other imaging as indicated. The likely outcome is death. Cardiac arrest in children is rarely due to cardiac disease and is usually secondary to hypoxia acidosis due to a respiratory illness, e.g. bronchiolitis. Schindler et al. (N Engl J Med 1996; 335: 1473–9) published data on the outcome of out-of-hospital cardiorespiratory arrests. It showed that the absence of any response after 20 min of full hospital resuscitation resulted in 100 per cent mortality. It is conventional to resuscitate infants in hospital for 30 min. An overly prolonged resuscitation can result in the survival of an infant with very severe neurological damage. Rarely, following drowning or poisoning, resuscitation for longer than 30 min is necessary. If the child does not survive, the parents need to be talked to sensitively and told that all sudden unexpected deaths in infancy (SUDI, the new name for the sudden infant death syndrome which was previously also known as cot death) are referred to the coroner and that the baby by law requires a postmortem. The parents also need to be told that it is possible that no cause will be found for the death. They should be told that the police will be automatically informed. The child protection register should be checked. Most hospitals have a list of people who need to be informed after an infant has died, e.g. general practitioner. The family need to be followed up to discuss the results of the postmortem. Bereavement counselling should also be offered.

KEY POINTS

• Cardiac arrest in children is usually secondary to hypoxia due to respiratory disease.

• Following an out-of-hospital cardiac arrest, lack of a response after 20 min of hospital resuscitation almost invariably results in death.

• All cases of SUDI require a referral to the coroner and a postmortem.