Understanding Brain Injury After Cardiac Arrest in Children

What is “neurological prognostication”?

The medical team will continuously evaluate the extent of brain injury and your child’s neurologic prognosis. “Neurologic prognosis” means how much the doctors think your child’s brain will recover.

What will my child be like after a cardiac arrest?

During a cardiac arrest, the heart cannot pump blood to the important body organs, particularly the brain. The body’s organs are damaged by lack of oxygen and nutrients. The amount of damage to the body’s organs is different for each child. Your child’s injury may be long-lasting even if they got all the care they needed. 

The recovery after cardiac arrest ranges from full recovery to brain death. The medical team will check your child every day to see how likely they are to recover and determine their “neurologic outcome” or “prognosis.”

When will we try to see if my child will wake up?

Right after a cardiac arrest, your child’s body should be in “rest” mode. When they are receiving treatments during rest mode, it is hard to know what their brain function might be. During this time, you will probably feel restless and anxious, not knowing if your child will recover. However, it is important to give your child’s body this time to rest.  

After a period of rest, the medical team will try to wake up your child. First, they will ensure your child is medically stable before turning off sedation medications. They will then see if your child can breathe, move, or respond to you and the medical team. 

How does the medical team try to wake my child up?

• The medical team will ask your child to do things like: “open your eyes,” “squeeze my fingers,” or “wiggle your toes.” This will give them an idea of your child’s consciousness or awareness. 
• The medical team might try pressing on your child’s fingers or toes to see if your child responds or grimaces to discomfort. 
• The medical team will also check other things like the eyes’ response to light and whether your child can cough.  
• The medical team will also see if your child can breathe on their own without or with the partial help of the ventilator (breathing support machine).

How can the medical team determine my child’s “neurologic prognosis”?

If your child has not awakened after the sedative medications were lowered, the medical team will review specific tests to evaluate the extent of brain injury. 

First, they will do a detailed neurological checkup to see how awake your child is. Together, they will review pictures of your child’s brain – typically a computed tomography (CAT scan or CT) and/or a brain magnetic resonance imaging (MRI). They will also use an electroencephalogram (EEG) to look at the brain waves. Each test will help your team understand how much brain damage there is and what recovery could look like. Not all tests may be needed or done at all hospitals. The medical team, including a neurologist (brain doctor), will decide which ones are needed.  

Based on these tests, the medical team will do their best to estimate what your child’s recovery might be based on the extent of your child’s brain injury. They will help you understand what life with brain injury could look like. They will tell you how your child might depend on you and machines to live (breathing, eating, bathing, toileting). They will help you understand your child’s ability to interact with others, speak and learn.

What happens if the medical team does not think my child will wake up?

Unfortunately, many children do not wake up after cardiac arrest. Each child’s injury and needs may be different. The medical team will meet with you to discuss the next steps for your child and your family. 

What does brain death mean?

Brain death (also known as “death by neurologic criteria”) is when a person no longer has any brain stem function. This means they will not wake up or be able to breathe without support. Brain death is permanent. A person who is brain dead is legally confirmed as dead. To confirm brain death, formal brain death testing is performed. This includes a physical exam to search for any brain function and if they have any spontaneous breaths. In case your child is not safe enough to do these tests, your medical team will talk with you about other tests to confirm the diagnosis of brain death.

Sources

Berg, K. M., Bray, J. E., Ng, K. C., Liley, H. G., Greif, R., Carlson, J. N., Morley, P. T., Drennan, I. R., Smyth, M., Scholefield, B. R., Weiner, G. M., Cheng, A., Djärv, T., Abelairas-Gómez, C., Acworth, J., Andersen, L. W., Atkins, D. L., Berry, D. C., Bhanji, F.,…Nolan, J.P. (2023). 2023 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: Summary from the basic life support; advanced life support; pediatric life support; neonatal life support; education, implementation, and teams; and first aid task forces. Circulation, 148(24), e187–e280. https://doi.org/10.1161/CIR.0000000000001179

Geocadin, R. G., Callaway, C. W., Fink, E. L., Golan, E., Greer, D. M., Ko, N. U., Lang, E., Licht, D. J., Marino, B. S., McNair, N. D., Peberdy, M. A., Perman, S. M., Sims, D. B., Soar, J., Sandroni, C., & American Heart Association Emergency Cardiovascular Care Committee (2019). Standards for studies of neurological prognostication in comatose survivors of cardiac arrest: A scientific statement from the American Heart Association. Circulation, 140(9), e517–e542. https://doi.org/10.1161/CIR.0000000000000702 

Meert, K. L., Telford, R., Holubkov, R., Slomine, B. S., Christensen, J. R., Dean, J. M., Moler, F. W. (2016). Pediatric out-of-hospital cardiac arrest characteristics and their association with survival and neurobehavioral outcome. Pediatric Critical Care Medicine, 17(12), e543–e550. https://doi.org/10.1097/PCC.0000000000000969

Nickson, C. (2015, March 30). Examination of the unconscious patient. https://litfl.com/examination-of-the-unconscious-patient/

Rajajee, V., Muehlschlegel, S., Wartenberg, K. E., Alexander, S. A., Busl, K. M., Chou, S. H. Y., Creutzfeldt, C. J., Fontaine, G. V., Fried, H., Hocker, S. E., Hwang, D. Y., Kim, K. S., Madzar, D., Mahanes, D., Mainali, S., Meixensberger, J., Montellano, F., Sakowitz, O. W., Weimar, C., Westermaier, T., … Varelas, P. N. (2023). Guidelines for neuroprognostication in comatose adult survivors of cardiac arrest. Neurocritical Care, 38(3), 533–563. https://doi.org/10.1007/s12028-023-01688-3

Smith, A. E., & Friess, S. H. (2020). Neurological prognostication in children after cardiac arrest. Pediatric Neurology, 108, 13–22. https://doi.org/10.1016/j.pediatrneurol.2020.03.010

Thank you to our contributors

Megan McSherry & Samantha Fernandez