PAEDIATRIC CLINICAL GUIDELINE
Resus /A&E: 1.10
MANAGEMENT OF SUDDEN CHILDHOOD DEATH
Admit to resuscitation room
Initiate/continue CPR if indicated (see text)
Allocate experienced team member to care for parents
in or out of the resuscitation room
Stop CPR
(decision by most senior member of team
after discussion with others)
Confirm death
Inform relatives as soon as possible IN PRIVACY
(most senior member of team)
Detailed history
Full examination and documentation
Investigations
(as per checklist)
Photographs/lock of hair
Inform relevant individuals/agencies
(as per checklist)
Ensure parents have transport home
Arrange follow-up for counselling via A&E Secretary
SUDDEN DEATH IN CHILDHOOD
INTRODUCTION
The death of a child is distressing for all concerned and the impact it has on members of the team should not be underestimated.
Remember KEEP CALM - There is no hurry. Deaths are thankfully rare.
They fall into two broad categories:
EXPECTED
End point of acute or chronic illness eg. oncology, cardiac or neurological problems. There is usually a plan for terminal care in operation involving the Community Nursing Team and G.P. These children may not present to the hospital at all. If they do it is usually better for the consultant responsible for the child’s care (or their team) to issue a death certificate obtained from PICU.
UNEXPECTED (9 at QMC in 2000; 14 in 1999)
These are further subdivided:
Trauma (3 in 2000; 1 in 1999) Cause of death is usually apparent, although there may be suspicious circumstances.
Unexplained (6 in 2000; 13 in 1999) eg undiagnosed cardiac problems, infections, SUDI (sudden unexpected death in infancy)
As the incidence of cot deaths falls, more of these deaths must be regarded as suspicious and managed accordingly. See section 9.4 – Child Protection Guidelines for medical staff
LikelyCauses of Sudden Unexpected Deaths
< 1yr> 1yr
SUDITrauma
InfectionInfection
Congenital AbnormalitiesSudden deterioration in chronic condition
NAINAI
SUDI
The incidence of ‘cot death’ has dropped dramatically since 1989.
Total NoNo per 1000 live birth
198913771.8
19944540.68
19982840.45
The “Back to Sleep” and “Reduce the Risk’s” campaigns in 1991 appear to have been highly effective, but there is still much work to be done especially relating to smoke exposure.
Most sudden unexpected deaths in infancy are in babies between 1 and 6 months and there is still an increased incidence in boys compared with girls. There is a strong association with maternal smoking and smokey atmospheres, and of course with prone sleeping.
Management (Follow guidelines on page 1).
1.Admit to resuscitation room.
Team to include:A&E middle grade +/- paediatric middle grade
paediatric SHO
2 experienced A&E nurses
2.Decision to Resuscitate?
- If CPR is being given by family/ambulance personnel on arrival - CONTINUE until there has been sufficient time for an assessment of the situation.
- If not being given assess:colour (dependent discoloration)
tone (rigor mortis)
temperature (NB it may have been high at time of death; beware immersion hypothermia)
last known breath
IF YOU ARE UNSURE - INITIATE EFFECTIVE CPR
3.When to Stop?
The decision to discontinue resuscitation is a difficult one and should be made by the most senior doctor present. If there is no detectable cardiac output nor any signs of cerebral activity for 20 minutes (including pre-hospital), it is reasonable to withdraw.
4.Parents.
Parents may wish to remain with the child in the resuscitation room. If this is the case an experienced nurse or doctor should be allocated to remain with them explaining procedures throughout. Alternatively they should be taken to a private room nearby and kept informed of events. One of the team should obtain a detailed history from them at this stage.
Once the child has been pronounced dead the responsibility for breaking the bad news to the parents rests with the most senior member of the team. There should be privacy for the initial period of distress. Parents should be encouraged to hold the child and spend as much time as they wish with them.
ANSWER QUESTIONS HONESTLY BUT DO NOT ASSUME A CAUSE OF DEATH. The post mortem may show something unexpected.
NB: Although accusations should not be made at any stage, remember that a proportion of sudden childhood deaths will be due to non-accidental injury.
Siblings
A surviving twin or young sibling may cause the family concern following the death and urgent arrangements should be made for them to be examined and admitted if necessary.
NB If non-accidental injury is suspected, urgent arrangements must be made to examine all vulnerable siblings, especially those < 2 years of age. (This will normally be carried out at the QMC; consult the on-call Consultant Community Paediatrician if sexual abuse is suspected.)
5.Documentation (Complete the forms available in resuscitation room)
History:
As with any paediatric patient this should include:
symptoms prior to event
obstetric problems
gestational age
development
family history
social history (including parents full names and any previous names; names dates of birth and whereabouts of all siblings
usual address and address the family will go to on leaving the hospital
Examination:
Fully undress the child noting particularly:
physical state of the child (vomit, nutrition, hydration, nasal discharge)
clothing and nappy (do not discard - should be put in labelled property bag and stay with child)
general hygiene
rashes
bruises / other marks
rectal temperature
evidence of bleeding
evidence of trauma
evidence of illness
Record the comments of the ambulance personnel regarding their findings on arrival at the scene and during transfer.
Record any resuscitation attempts, (IV lines, cardiac punctures, attempts at suprapubic aspiration etc) on a body chart attached to the notes so that the pathologist knows that these injuries were post-mortem.
The nursing staff will photograph the child and ask the parents if they wish a lock of hair to be taken. If the parents do not want these immediately they will be sent to the liaison health visitor or bereavement centre.
6.Investigations
As per checklist below. Some samples are best obtained as soon as possible after death.
Labelling of request forms:
Trauma deathsPaediatric Pathology with a copy to Miss L Williams (A&E Consultant)
Other deaths Paediatric Pathology with a copy to Dr S Smith (Paediatric Consultant)
In the A&E Department
Cardiac Puncture forblood spot on Guthrie card (for metabolic studies)
blood culture
FBC including Hb
U&E’s Serum for toxicology
Remember correct labelling, ensure chain of evidence
(use pre-typed labels where appropriate)
Throat Swab forbacteriology
virology
Rectal Swab forvirology
Urine fortoxicology
Per nasal swab forbacteriology (? Pertussis)
Nasopharyngeal aspirate forvirology (if any secretions present)
Skin biopsy forchromosomes (if relevant)
(The investigations in bold type are the minimum that should be performed.)
Organise skeletal survey for unexplained deaths in children < 2 years of age, by writing a request form which should stay with the child. If no cause of death is obvious, consider a CT head scan in children< 2 years of age. Write a request form for this and ensure CT department is rung as soon as possible (agreed with Dr Jaspan Nov 1997). If a CT scan is organised it may be appropriate to do a CT chest also to look for occult rib fractures.
7.Follow-Up
Before they leave the department parents must be informed of the legal requirement to inform the coroner and that the police will wish to visit the place of death and take a statement. Death certificates cannot be issued if the cause of death is unknown. If appropriate the need for tissues (eg brain) to be examined in detail should be mentioned to the family. This will delay a final cause of death and therefore the funeral, for 4-6 weeks generally. For infant deaths the local support group should be mentioned at an appropriate time as many families find their early support invaluable.
Parents will be given a concise leaflet (available in the A&E Department) reminding them of the important facts and phone numbers.
The family will be offered an appointment with a consultant to discuss the post mortem report etc. (Trauma deaths – A&E consultant involved/Miss Williams; other deaths - Dr Stephanie Smith who will refer on if family already known to another consultant). This currently happens approximately 4-6 weeks after the event but contact is usually made much earlier.
The CONI (Care of the Next Infant) scheme is available for families who have lost a baby from sudden infant death. The CONI Plus Scheme is available to families of babies who have died suddenly from other causes eg infection. These will be introduced to them at their follow-up appointment.
A copy of the A&E notes should be sent to Ricci Capaldo (A&E Secretary) to arrange.
8. Who To Tell
Doctor (usually middle grade paediatrician). Should inform:
*Coronertel: 0115 9412322
*Local Policetel: 0115 9482999
*G.P. (ensure he knows address the family have gone to)
*Consultant caring for child previously (if applicable)
*Consultant on call
*Child Protection Register – County:tel: 0115 960 5251
City: tel: 0115 915 1900
Inform register clerk that this is a sudden childhood death.
Nursing Staff
*Family members at parents’ request
*Liaison Health Visitor (may be available for support in working hours) (bleep)
*Religious Leader at parents’ request
*Appointments (outpatient department and baby clinic), ext 41210
*A&E Secretary to Miss Williams, ext 41153
Paediatric x-ray reception (they will ensure films are reported ASAP), ext 41244
SUDI office by completing form
Labour suite (it will be documented in mother’s notes if she is still of reproductive
age) ext 41032
*School Nurse/Community Nurses/Nursery
*Nurse Manager on call (if the child’s death is of journalistic value)
Child Protection Team, ext 45516
9.Interagency Strategy Meeting
When contact is made with the child protection register following a sudden unexpected death, the register clerk will alert the nominated Child Protection Manager in either the City or County Social Services Department. The Child Protection Manager will then be responsible for making initial enquiries of social service records, of heath professionals (GP, Health Visitor etc) and of any other agencies involved with the family. If there is significant concern raised by these enquiries, the Child Protection Manager will organise an interagency strategy meeting within 3 working days. The meeting will be chaired by the Child Protection Manager or their nominated deputy and all involved personnel will be expected to attend. A Police Officer will attend and parents will not be invited at this stage. A senior member of the Community Trust child protection team will attend the meeting.
A decision about the level of concern will be made and:
Eitherthere will be no further investigation as the concerns are minimal
Ora decision will be made to proceed to a full child protection conference
The meeting may consider whether or not to recommend to the ACPC that a Child Death (Part 8) review is undertaken.
10.Staff Counselling
Any member of the team involved with the death of a child may be deeply affected. Do not hesitate to consult a senior member of staff to discuss this understandable reaction.
SUDDEN DEATH IN CHILDHOOD
(To be completed by senior attending doctor prior to child’s transfer to the mortuary)
Please affix patient
ID LabelSTAFF PRESENT ...... ………..
...... ……
...... ……
...... ……
DATE: ...... ……
RESUSCITATION
Bag and MaskYN
IntubationYN
Any Problems……...... ………………………………
Cardiac MassageYN
IV CannulationYN
How Many Attempts...... (depict on body chart overleaf)
I NeedleY N
Intracardiac NeedleYN
Suprapubic AspirationYN
Drugs given (circle)Adrenaline
Sodium HCO3
Dextrose
Other (please specify) ......
HISTORY FROM AMBULANCE PERSONNEL
EXTERNAL EXAMINATION – Including fundal examination (for retinal haemorrhages)
Any:bruising
scratchesnoted (depict on body chart overleaf)
rashes
other marks
General state of child e.g. hygiene, vomit, hydration, clothing, nasal discharge:
......
Temperature ...... rectal, axillary (please circle)
Child’s Name:
BODY CHART
INVESTIGATIONS (circle those done in department and specify where necessary).
Those in bold are essential; others when relevant.
Bloods:Blood cultureFBCU&E’sGlucoseViral titres
(cardiac puncture)Serum for toxicologyOther ......
Blood spot Guthrie card (metabolic studies)
Urine:CultureToxicology
CSF:
Throat Swab:BacteriologyVirology
Rectal Swab:Virology
Per nasal swab: Bacteriology (? Pertussis)
Stool sampleNPASkin Biopsy
X-ray:ChestAbdomenHeadCervical Spine Pelvis
Other ......
Signature: ...... Date: ......
Print Name: ......
Dr Stephanie SmithPage 1 of 11Updated February 2001
Please affix patient ID label
This sheet to be completed for
non-traumatic unexpected deaths
HISTORY OF EVENTS (indicate who gave history)
PRE-EXISTING SYMPTOMS (please circle any that apply)
CoryzaYN
DiarrhoeaYN
VomitingYN
DrowsinessYN
CoughYN
Decreased feedingYN
RashYN
Sore throatYN
HeadacheYN
EaracheYN
Crying/UnsettledYN
TemperatureYN
Other……………………………………………………………………………………………..
ON TREATMENTYN
If yes, what?...... …………………………………………………………………
For how long ?...... ………………………………………………
Child’s Name:
SOCIAL AND FAMILY HISTORY
(include parent’s current and previous names; names, dates of birth and whereabouts of all siblings)
PAST MEDICAL HISTORY (including place of birth, obstetric, delivery history and development)
IMMUNISATION RECORD
Arrangements for follow-up via A&E Secretary to Miss Lynn Williams (ext 41153)
A photocopy of this form should be sent with the child to the mortuary. The original to be kept with the A&E record.
Signature: ...... ………………….Date: ......
Print Name: ...... …………………………….
PAEDIATRIC CLINICAL GUIDELINES
ISSUE:VERSION: FINAL
Title: Management of Sudden Childhood Death
Author: Dr Stephanie Smith
Job Title:Consultant Emergency Paediatrician
First Issued:Date Revised:Feb 2001 Review Date: Feb 2004
Document Derivation:Consultation Process:
i.e. References:
Included in document
Ratified By:Paediatric Clinical Guidelines Committee
Chaired By:Dr Kate Armon
Consultant with Responsibility: Dr Stephanie Smith
Distribution:All wards QMC and CHN
Training issues: Included in Induction Programme
Audit:
This guideline has been registered with Nottingham City Hospital NHS Trust and QMC Clinical Guidelines Committee. However, clinical guidelines are ’guidelines’ only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
MANUAL AMENDMENTS RECORD(please complete when making any hand-written changes/ amendments to guideline and not processed through guideline committee)
Date / Author / Description
Dr Stephanie SmithPage 1 of 11Updated February 2001