Enhancing Pediatric Death Declaration: Role of Cardiac Ultrasound in Confirming Cardiac Standstill

Introduction: Point-of-care ultrasound (POCUS) has emerged as an invaluable tool, providing real-time imaging that supports rapid clinical decision-making. The process of declaring death in pediatric patients is often challenging task, particularly where life-sustaining interventions like ventilators and inotropes were used. A significant concern in pediatric death declaration is the phenomenon of autoresuscitation, studies reported upto 14% of cases exhibit transient cardiac activity post-flatline. This study aimed to evaluate the utility of Cardiac POCUS in enhancing accuracy and timeliness of death declaration.


Methods: An observational study was conducted in the Pediatric Intensive Care Unit of the Sindh Institute of Child Health and Neonatology from September 2023 to April 2024. Patients aged 1 month to 12 years were included if they were considered at the end of life based on clinical criteria. Traditional death declaration was determined by the absence of breathing, pulse, heart sounds, response to painful stimuli, fixed dilated pupils, and a flatline on electrocardiogram. A subcostal view of the heart was obtained, and a 1-minute video recording was taken to confirm the absence of cardiac activity. The time from ECG flatline to the confirmation of akinetic cardiac activity on POCUS was recorded.


Results: Among 1,878 PICU admissions, the mortality rate was 11.7% (220 deaths), of which 60 pediatric patients were included in the study. The median age was 12 months (IQR: 5–23 months), with a male-to-female ratio of 1:1. The two leading causes of death were infectious (30%) and cardiac (23.3%) etiologies. Cardiac POCUS confirmed akinetic cardiac activity in 100% of cases. The median time from ECG flatline to POCUS-confirmed cardiac standstill was 7.5 minutes (0–44). However, the variability in time to confirmation suggests that factors such as body habitus, prior inotropic support, and underlying pathology may influence results.


Conclusions: Cardiac POCUS was found to be a reliable adjunct to traditional clinical assessments for pediatric death declaration, offering real-time confirmation of cardiac standstill. Further multicenter studies are recommended to validate its role in clinical practice.