When to declare an infant dead after cardiac arrest?

When to Declare an Infant Dead After Cardiac Arrest

According to the 2015 American Heart Association guidelines, in infants with an Apgar score of 0 after 10 minutes of adequate resuscitation, if the heart rate remains undetectable, it may be reasonable to stop resuscitative efforts. 1

Assessment of Death in Infants

• The American Heart Association recommends that healthcare providers may take up to 10 seconds to attempt to feel for a pulse (brachial in an infant) to determine if CPR is needed 1
• If within 10 seconds you don't feel a pulse or are not sure if you feel a pulse, begin chest compressions 1
• ECG can be used to provide a rapid and accurate estimation of heart rate in babies requiring resuscitation 1
• The absence of a detectable heart rate for 10 minutes after birth despite continuous and adequate resuscitative efforts is a strong predictor of mortality and severe morbidity 1

Decision-Making Framework for Terminating Resuscitation

• An Apgar score of 0 at 10 minutes is a strong predictor of mortality and morbidity in late-preterm and term infants 1
• Among infants with an Apgar score of 0 at 10 minutes who were successfully resuscitated, studies show approximately 50% died and 24% survived without major or moderate disability at 18-24 months 1
• The decision to continue or discontinue resuscitative efforts should consider the following factors:
  • Whether the resuscitation was considered optimal 1
  • Availability of advanced neonatal care, such as therapeutic hypothermia 1
  • Specific circumstances before delivery (e.g., known timing of the insult) 1
  • Wishes expressed by the family 1

Special Considerations

• For infants with cardiac arrest, multiple variables should be used when attempting to prognosticate outcomes 1
• In intubated patients, failure to achieve an ETCO2 of greater than 10 mm Hg by waveform capnography after 20 minutes of CPR may be considered as one component of a multimodal approach to decide when to end resuscitative efforts 1
• This recommendation should not be used in isolation and does not apply to non-intubated patients 1
• For infants and children with in-hospital cardiac arrest, negative predictive factors include age over 1 year and longer durations of cardiac arrest 1

Resuscitation Protocol Prior to Death Declaration

• Follow the Pediatric Basic Life Support Algorithm for Healthcare Providers 1
• Ensure high-quality CPR with minimal interruptions in chest compressions 1
• For infants, perform cycles of 30 compressions and 2 breaths if single rescuer; when second rescuer arrives, perform cycles of 15 compressions and 2 breaths 1
• Use AED/defibrillator as soon as available and check rhythm to determine if shockable 1
• Continue resuscitation efforts until advanced life support providers take over or the infant starts to move 1

Important Caveats

• The absence of spontaneous breathing or an Apgar score of 1-3 at 20 minutes of age with a detectable heart rate are strong predictors of mortality or significant morbidity 1
• After 10 minutes of continuous and adequate resuscitative efforts with no signs of life, discontinuation of resuscitation may be justified 2
• Studies have shown that infants without signs of life (no heartbeat and no respiratory effort) after 10 minutes of resuscitation show either high mortality or severe neurodevelopmental disability 2

The decision to declare an infant dead after cardiac arrest requires careful consideration of multiple factors, but the strongest evidence supports that after 10 minutes of adequate resuscitation with no detectable heart rate, termination of efforts is reasonable.