Age: 0.5
Sex: F
Vaccine: DTAPHEPBIP, FLU3, PNC, RV5
Symptoms: Cardiac arrest, Computerised tomogram normal, Corneal reflex decreased, Crying, Dyspnoea
Clinical narrative: This is a 6-month old white female who was transferred from the emergency room when she came into cardiac arrest on full code, asystole and was resuscitated and the heart rate was brought back after several minutes.  According to the mother, she left the child prone over a blanket that had the four ends secure so it would not fold and left the room.  She had heard the baby cry because, according to her, she didn't like to be prone.  She heard the baby cry 5 minutes before she went back into the room and found her completely unresponsive.  She started CPR and called the paramedics who arrived in another 5 minutes according to her.  They intubated the baby and transferred to the emergency room.  From there, the patient was sent to this PICU.  The physical examination showed the baby to be unresponsive to stimuli with gasping rhythmic chest movements with no effective ventilation.  The pupils were at 5 mm and fixed.  The patient was on the respiratory oxygenating well.  The capillary refill was fair to poor approximately 4-5 seconds.  Air entry was good and the heart was rhythmic with no murmur.  The abdomen was soft.  There were no bruises on the body or head of the infant.  There was no gag reflex.  A CT scan done at the emergency room showed no bleeding or edema with normal ventricles.  The patient was placed on mechanical ventilation.  A femoral line was placed.  The baby was also started on Dopamine and Dobutamine for low blood pressure and poor perfusion and responded well to it.  The baby also received albumin 5%.  Due to the fact there was no cerebral edema, no Mannitol or 3% saline was given.  The venous blood gases showed normal oxygenation and ventilation.  The next day, repeat CT scan still did not show any brain edema or hemorrhage.  An EEG was nearly flat that day with no significant cortical activity.  Over the next 24 hours, the patient had at one point, according to some nurses, some very sluggish pupil reaction and even very mild response to deep pain in the lower extremities only.  In my examination, basically the pupils were nonreactive and there was no response to pain.  Over the next 24 hours, the agonal respirations disappeared.  The EEG became completely flat and there were no signs of any brain activity.  At that point, the situation was discussed with the parents and they agreed to an apnea test which showed the patient to have no spontaneous respirations despite the PCO2 going up to 77 and the oxygen saturation dropping to below 70.  Also, at that point, there was no corneal reflex.  The ocular vestibular reflex was negative.  There was no gagging or coughing reflex, and there was no response to deep pain in any form including unchanged heart rate and blood pressure.  The baby had a brain flow scan shortly after she came to the PICU, and it showed blood flow to the brain.  After the apnea test and the rest of the examination for brain death was done, the mother requested a second brain flow study.  The brain flow study was equivocal but still showed flow.  Despite that, I explained to the mother that the criteria was still met for brain death, especially if the patient had not received any narcotics or any medications that could be impairing the cortical brain stem activity.  At that point, I placed a call to another doctor who came and examined the patient and concurred there was brain death.  The mother discussed the case with organ donation personnel and decided to donate the daughter's organs.  The care was then transferred to organ donation on 12/24/07.  Final diagnosis: 1. acute life threatening event, 2. anoxic encephalopathy, 3. brain death.  9/9/06 Autopsy report states COD as probable apneic event w/history of anoxic encephalopathy, unresponsiveness, resuscitation & hospitalization, neuro delay & no evidence of trauma or injury.