DISCONTINUATION OF LIFE SUPPORT IN CHILDREN If well-executed resuscitative measures fail to achieve ROSC, discontinue resuscitative efforts unless the patient is deemed to be a good candidate for ECPR There is good evidence to support that there is little chance for meaningful survival in patients with unwitnessed arrest who remain unresponsive to airway intervention, chest compressions, and two doses of epinephrine Thus, a brief, well-executed resuscitation is indicated for the child who arrives to the ED with cardiopulmonary arrest During this time, the leader can review the history and complete the primary and secondary survey Prolonged resuscitation efforts past 20 minutes, without ROSC, are usually futile unless other treatable problems exist such as hypothermia, drug overdose, or VT/VF Prolonged resuscitation may be indicated for witnessed collapsed arrest, with short onset of effective BLS/ACLS, especially if a cardiac etiology is suspected Ultimately, the diagnosis of death and subsequent discontinuation of resuscitative efforts is a judgment that is made by the team leader in conjunction with the team A decision not to begin resuscitation is generally not made in the ED unless there is a written do-not-resuscitate (DNR) document provided by the child’s parent or guardian A well-prepared ED should consider and have a plan in place for issues such as advanced directives, palliative care, bereavement measures and postmortem care, survivor follow-up, and request for autopsy and organ donations as outlined in the AAP guidelines Proper documentation of a death is essential, as is notification of medical legal authorities, donor programs, and referring physicians and consultants CEREBRAL RESUSCITATION Cerebral injury remains the leading etiology for morbidity in those who survive cardiopulmonary arrest Permanent brain damage following arrest is determined by many factors and includes arrest time (no-flow state), CPR time (low-flow state), and temperature Cardiopulmonary–cerebral resuscitation is needed to prevent brain injury Oxygen stores are depleted within 20 seconds following arrest, and glucose and adenosine are depleted within minutes During no-flow states, multiple complex chemical derangements occur that contribute to the death of neurons With ROSC, there is impaired cerebral blood flow Therapeutic interventions to prevent postanoxic brain injury have yielded disappointing results to date, outside of prevention of pyrexia Hypothermia