EM Forum Case #102 "4 Year Old in Cardiac Arrest - 2 Minutes Out" by Charlene Babcock Irvin, MD, FACEP  

The small child arrives intubated, with CPR in progress. She is quickly transferred to the ED bed, and as you check for a pulse, she is put on the monitor. No pulse palpated, and CPR is restarted. Equal breath sounds are appreciated, and end tidal CO2 is 4. Pupils fixed and dilated. She is fully dressed (shirt pulled up for chest compressions), and she has a 3 cm laceration (open) that looks a few hours old on her chin.

You ask the paramedics what happened. They note that they were called for an unconscious child, arrived to find the child propped up in a rocking chair in her bedroom, in complete cardiac arrest, asystole on monitor. All the family was just standing by, no bystander CPR. EMS started CPR, intubated, gave ACLS meds, and transported. The only history was that the girl was outside playing, and was then told to get inside and get dressed to go to a family function. A family friend went to her bedroom to check on her, and found her unresponsive in the chair. No one knew how she got the chin laceration.

ACLS is continued for 1 more round of meds. FAST (ultra sound) exam reveals no cardiac activity, but substantial fluid in Morrison’s pouch. Code is called after next round of drugs is not successful (down time with no signs of life was > 30 minutes per EMS).

Child is undressed and multiple whip marks and cigarette burns are noted to buttocks and inside thighs. Two different curling comb burns are noted on the dorsum of one hand. Hand grasp bruising is noted on the upper arms bilaterally.

Questions:

1. The police want to know what you think caused the child’s death. They want to know if you think they need to preserve the scene for a potential crime.

2. What is the difference between child abuse and child neglect? Is child neglect criminal behavior?

3. What fractures suggest child abuse?

4. Is the perpetrator likely male or female?

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