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Case #153 “Make-em-Naked!″ by Charlene Babcock Irvin, MD, FACEP

December 14th, 2010 · No Comments · Trauma

A 4 y/o female presents in cardiac arrest.  According to the EMS report called in, they found the child in asystole, with no bystander CPR.  Patient is already intubated.  When EMS arrives, they provide more information.  They state that the child was playing outside and fell down (that’s where the cut on the chin came from).  She was home from preschool as they had a funeral to go to, and the mother told her to go get dressed.  One hour later they found her sitting in her bedroom rocking chair unconscious.  EMS was called.  When EMS arrived, they found her still sitting in the chair with all the family members hysterical and crying.  No one was doing CPR.

As the small patient is limply transferred to the cot, a quick look with the paddles confirms asystole.  CPR is continued and the patients breath sounds are checked, and are equal end tidal CO2 is put on the end of the ET tube. Pupils are fixed and dilated.  There is a small laceration on the chin, which looks a few hours old.  Patient is fully dressed and there is no history to suggest hypothermia or drowning.

Ultrasound of the heart confirms no cardiac activity, no tamponade.  End tidal C02 is not registering. 
EMS started ACLS protocol 40 minutes ago.  Total estimated down time is more than 55 minutes.

1. What should you do?  Call the code?

This is always a challenge, as the death of a child is emotional to everyone, even those of us who see it on a regular basis.  While everyone has his or her own approach, the important thing to remember is that the prognosis is grim (child found in asystole, no quickly reversible cause (i.e. no tension pneumothroax, cardiac tamponade), child had prolonged down time (at least 55 minutes) and no CPR for at least 15 minutes).  It usually takes me a few minutes to check the tube placement, ultrasound the heart, check for pulses, and assess the rhythm, so I usually end up giving one last round of meds before I call it, but I usually call time of death after one last round of meds (unless the patient is hypothermic or has some other reason to suspect they are salvageable). 

In one study of 150 consecutive out of hospital adult cardiac arrest victims, there were no survivors if end tidal CO2 was less than 10 after 20 minutes of ACLS (100% sensitivity, specificity, positive predictive value, and negative predictive value for an end tidal CO2 level of less than 10 after 20 minutes of ACLS). (1)  While this study was done in adults, it supports the theory that there needs to be some evidence of life (some generation of carbon dioxide, that hopefully in 20 minutes and with appropriate CPR can make it back to the lungs to be exhaled) after 20 minutes to survive cardiac arrest. 

For non-traumatic cardiac arrests, a recent study published in Circulation found that children (age 1-11) were twice as likely as adults to survive out of hospital cardiac arrest. (9% in age 1-11yrs, compared to 4.5% survival in adults).  (2) 

A more recent systematic review published in 2005 found only 1.1% of children suffering cardiac arrest after trauma survived, and only 0.3% survived neurologically intact. (3)(full manuscript available if you click on the link for reference #3).

So, I did call the arrest, but while I had the ultrasound, I did ultrasound the belly and found a large fluid collection.

2. What is the most likely cause of death?  The police officer wants to know if they will need to secure the scene (i.e. if you think this might be a homicide).  What do you    tell him?

I told him yes, absolutely.

Based on a study from 2004, unexpected death in the pediatric patient is usually due to trauma, sudden infant death syndrome, respiratory causes or submersion. (4)  In this study of children under age 12, researchers found 23% died of SIDS, and the next most common cause was trauma (20%).  Also, in this study, they suggested that administration of >3 doses of epinephrine or prolonged resuscitation (>31 minutes) was futile. (4)

So, it’s doubtful there was submersion (her hair was not wet), there is no history to suggest respiratory problem, so you’re left with trauma.  The old laceration on the chin supports this. Additionally, the fluid in the belly also confirms this.  This child was killed by someone.

I showed the detective the abdominal fluid, most likely blood, and as we undressed the child, we also found multiple cigarette burns to the perineum, whip scars (some recent) to the buttock (yes, you could see the buckle marks too), and two recent burns to the dorsum of the hand from what appeared to be a hot curling comb.   On both upper arms, there were bruises consistent with grab marks.  

This was somewhat of a strange case as the forensic team actually showed up at the hospital to take pictures.  I showed them how the pattern on the upper arms were consistent with someone (actually with hands my size) likely grabbed the child very hard. 

The detective came back and told me that the person EMS thought was the mother was the dad’s girlfriend (the mom was in jail).  She explained that the child was burned when she brushed up against her curling comb.  He asked if I thought that was possible.

Absolutely not!  While the pattern is consistent with a burn from a curling comb, no child would ‘accidentally’ brush up against it to get burned twice.  While this didn’t imply she killed the child, she clearly was lying about the curling comb injury as there were two, not one burns.

A skeletal survey was also done, but no old fractures were seen. 

Outcome:

The news reported a few days later that the dad’s girlfriend was arrested, and charged with child abuse.  The dad was also arrested with child endangerment.  About 1 year later I happened to come across an article tucked in the back of section one of the newspaper.  She was found guilty and sentenced to life in prison.  Of note, the final autopsy report noted the little girl had suffered a ruptured liver and actually a transected pancreas.  She died of hemorrhagic shock.  I never heard what happened to the dad.

So the point of this case is that if this child had not been beaten to death, and only presented with the chin laceration, a clinician could easily have missed the tell-tale marks of abuse if they didn’t undress the patient.  So, even that simple chin laceration deserves a quick look to the buttocks, perineum (quick undo the diaper and check!), back and extremities.  Just remember:  ‘make-em-naked!’  You will miss 100% of the diagnosis’ you fail to consider.

References:
1. Levine RL, Wayne MA, Miller CC.  End-Tidal Carbon Dioxide and Outcome of Out-of-Hospital Cardiac Arrest. N Eng J Med 1997;337:301-306.  Accessed at: http://www.nejm.org/doi/full/10.1056/NEJM199707313370503
2.  Atkins, DL, Everson-Stewart S, Sears GK, Daya M, Osmond HH, Warden CR, Berg R.  Epidemiology and Outcomes from Out-of-Hospital Cardiac Arrest in Children.  Circulation March 9, 2009.  Accessed at: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.108.802678v1
3.  Donoghue AJ, Nadkarni V, Berg RA, Osmond MH, Wells G, Nesbitt L, Stiell IG for the CanAm Pediatric Cardiac Arrest Investigators. Out-of-Hospital Pediatric Cardiac Arrest:  An Epidemiologic Review and Assessment of Current Knowledge.  Ann Emerg Med, 2005 46(6):512-522.  Available at: http://ers4kids.com/files/resus2.pdf
4.   Young KD, Gausche-Hill M, McClung CD, Lewis RJ. A Prospective, Population-Based Study of the Epidemiology and Outcome of Out-of Hospital Pediatric Cardiopulmonary Arrest. Pediatrics. 2004;114:157-164
Accessed for free at: http://www.ncbi.nlm.nih.gov/pubmed/15231922

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