Flat line

I worked in the PICU the other night and had a pretty stressful night. My patient was a young preteen boy who fainted on the soccer field. He was brought into the ER twice and admitted once for observation and then sent home, and the second time was admitted (he was just a bit wacky-- yelling that he was going to die, and really really acting out. The admitting diagnosis was mental instability). After some more tests, they diagnosed him with Encephalitis (swelling of the brain-- meningitis is swelling in the outer part of the brain. If it goes into the brain, it's termed encephalitis). After running the full slew of tests, none of which came back conclusive, they will probably just call it "post viral encephalitis" simply because they have not found the mechanism which infected him.
He had to be intubated and was just extubated the afternoon before I came on shift. Anyway, the stressful thing about him was that he would go into asystole, which is the absence of a heart beat. The strange thing was that he was well perfused, his O2 sats would remain above 90%, and he would be "awake" and moving, but just have no heart beat. Asystole is something I have only ever really seen on a simulator, not in real life and here my patient was having it at random times. His heart rate would also get down in the 40's and even 30's. 40's are okay for an elite athlete at rest, but not for a preteen thrashing on the bed.
The compression on the vagal nerve is what caused these as it controls part of the heartbeat. The neurologist stated that the base of his brain was destroyed, but that there are other places that we also control our heartbeat. When the pt fell asleep or coughed however, he would go into a systole, the opinion being that during these times he became more dependent on his brain stem for his heart beat. Most of the episodes were short, lasting less than 5 seconds. We would sometimes apply O2 or stimulate him, but he'd come back up on his own. However, the latter part of my shift he had a few spells where his lips went dusky and he was in asystole for 15 plus seconds. It's just hard to know how long to let him stay without a heartbeat.
I really feel badly for this patient. On the way home I cried. Not knowing this patient, I never knew who he was before this illness. They did have pictures of him on the wall showing a happy kid instead of the unresponsive babbling child with erratic motion from most of his body limbs. One time a neighbor's son who is Heidi's age was in the hospital. I stopped by to see him on my way to work. His nurse was trying to give him some Tylenol. He was crying and didn't want to take it. I was nearly in tears after seeing him. Even though his prognosis was good, it was hard to see someone I was used to seeing riding his bike or rolling down a grass hill being confined to a hospital bed. I thought about some of the boys in my neighborhood who I've had in scouts and who are the same age as this boy. It was hard to picture these things without crying. I'm hoping for a miracle for this boy. They don't really know his prognosis.