when is dead really dead? mike mcevoy, phd, nrp, rn, ccrn ems coordinator, saratoga county, ny...
TRANSCRIPT
When is Dead Really Dead?
Mike McEvoy, PhD, NRP, RN, CCRN
EMS Coordinator, Saratoga County, NY
Resuscitation Committee Chair – Albany Medical Center
EMS Editor – Fire Engineering magazine
EMS Section Board Member – International Association of Fire Chiefs
Disclosures• I have no financial relationships to
disclose.• I am the EMS technical editor for Fire
Engineering magazine.• I do not intend to discuss any unlabeled
or unapproved uses of drugs or products.
Outline• EMS: Bringing out the dead
– Field pronouncements– Why we screw it up
• Criteria for death• How to stay out of hot water
– Standard practice for field pronouncement– Dealing with difficult cases
• Delivering death notifications• Cases
How many of you?
• Pronounce death?• Declare death?• Honor DNR?• Decide not to initiate resuscitation?• Stop resuscitation someone else
started?• Terminate field resuscitation?
Case # 1• R-10, A-15 sent to MVC w/ entrapment• PD @ scene report single vehicle into
concrete bridge abutment, lone occupant appears deceased
• R-10 EMT-FF’s find approx 16 yo ♂ lying across front floor of compact car– Obvious bilat open femur fx– Rigid, distended belly– Blood with apparent CSF from both ears– No observable resps, no palpable pulses
Case # 1 (continued…)• R-10 officer cancels ambulance
– Advises police that driver is dead– Requests Medical Examiner to scene
• ME arrives one hour later– Finds patient breathing, barely palpable pulse
• EMS recalled– Patient resuscitated, xpt to trauma center
• Dies 2 days later from massive head inj• Family calls news media, files complaint
with State EMS office
Case #2
• EMS dispatched to reported obvious death in low income housing project
• Arriving medics find elderly ♀ supine on kitchen floor– Apparent advanced stage of decomposition– Large areas of skin grotesquely peeled from arms
and torso– Overwhelming foul odor throughout apartment
• Coroner contacted to remove body
Case #2 (continued…)
• Later that evening, hospital morgue attendant summon resuscitation team– Supposedly deceased patient moaning for help
• Patient admitted to ICU– Massive Streptococcus pyrogenes (“flesh
eating”) bacterial skin infection
• Dies 3 days later• CNN, national news media prominently
carry the story
Death
• 2.4 million Americans die annually– Most deaths are in hospitals (61%)– Or nursing homes (17%)
• Smallest # die in community (22%)• Why does EMS lead news stories
on mistaken pronouncements?
Fear of live burial
• 1800’s – coffins equipped with rescue devices
• 1899 – NY State enacted legislation requiring a physician pronounce death
• 1968 – Uniform Anatomic Gift Act authorized organ donation: worries about premature pronouncements
Premature Pronouncement• 1968 – Harvard Ad Hoc Committee on Brain Death published definition of “irreversible coma”:1. Unresponsive – no awareness/response
to external or painful stimuli
2. No movement or breathing
3. No reflexes – fixed & dilated pupils, no eye movement when turned or cold water injected into ear, no DTRs
• Currently called “brain death”
1981:• 170+ pages• Became death
criteria for all 50 states
• Basis for UDDA (Uniform Determination
of Death Act)
Why?• Technology• Pulselessness and apnea
no longer identified death:– Mechanical ventilation– Artificial circulatory support– ICU patients who would never recover could
be kept “alive” indefinitely
• Main goal = standardize criteria for irreversible loss of all brain function
Brain Death
• EMS doesn’t pronounce brain death
• Neither does a lone doc, NP, or PA• Such decisions require:
– Time– Specialized testing– Brain specialists such as neurologists
Who does EMS pronounce?
1. People we find dead
2. People we cease resuscitating
So, what’s the book say?
Dead=irreversible cessation
“An individual with irreversible cessation of circulatory and respiratory function is dead. Cessation is recognized by an appropriate clinical exam,” whereas, “Irreversibility is recognized by persistent cessation of functions for an appropriate period of observation and/or trial of therapy.” (p. 133)
“Appropriate Clinical Exam”ABSOLUTE MINIMUM REQUIREMENTS:
1. General appearance of body
2. No response to verbal/tactile stimulation
3. No pupillary light reflex (pupils fixed and dilated)
4. Absence of breath sounds
5. Absence of heart sounds
“Appropriate Clinical Exam”• Deep, painful stimuli inappropriate– Nipple twisting, sternal rubs…
• Some suggest testing corneal reflexes– Duplicates pupillary reaction to light; both
require some intact brainstem function
• When more sophisticated monitors are available, they should be used!
Death Traps: Red Flags
• Patients found dead• Death not observed or expected• Death was sudden• Resuscitation not provided• Termination of field resuscitation
Death Documentation1. Describe your exam
2. Location/position where found
3. Physical condition of body
4. Significant medical hx or trauma
5. Conditions precluding resus
6. Any medical control contact
7. Person body left in custody of
Clinical Exam for Death1. Time (this is the time of death)
2. No response to verbal or tactile stimulation
3. No pupillary light reflex (pupils fixed and dilated)
4. Absence of breath sounds
5. Absence of heart sounds
6. AED or EKG = no signs of life
Employ every available tool
• ALS if available– Record 15 second EKG in 2 leads– Attach AED if no ALS available– Leave electrodes/pads on the body
• Use ultrasound, stethoscope, etc.• Make certain that the most senior
EMS provider available confirms the death
the Lazarus Phenomenon • Autoresuscitation (AR)
• Spontaneous ROSC after failed resuscitation attempt
• Uncommon, theorized due to:– Delayed effects of resuscitation meds– Intrathoracic pressure change once PPV
discontinued
• Warrants prolonged observation
AR: Is He Dead Jim?• Never reported without CPR
– Unless patient not properly pronounced
• No reported cases in children• No single AR >7 minutes following
termination of CPR– When proper times were recorded
• Current best practice is 10 minute observation following termination
Hornby K, Crit Care Med, 2010, 38: 1246-1253
Death Traps• Massive internal injuries
– Torn aorta, ruptured pulmonary artery…– Lack invasive testing to confirm– Tendency to leap to conclusions
Death Traps• Massive head trauma or Explosive
GSW to the head– Often lack experience with these injuries
Death Traps
• Pediatric patients
– Immediate onset central cyanosis– Much more rapid rigor and livor mortis– Psychosocial rationale favors resuscitation
Death Traps• Drowning
– Less than 2 hours may be survivable
• Hypothermia– Can’t pronounce until > 90°F
Death Traps• Isolated fatal injuries – Case # 3
– 0730, having breakfast at local diner– Dispatched to one-car rollover around the
corner from diner, reported ejection, one patient, laying in roadway, not moving
Isolated Fatal Injuries• Arrive to find approx. 17 yo male
patient, apparent operator of vehicle, thrown some 30 feet, occiput touching thoracic spine
• No resps, pulse 30 & weak, no other injuries apparent
Potential Organ Donor?• DHHS contracts with UNOS to list
potential recipients– United Network for Organ Sharing
• Local Organ Procurement Organizations (OPOs) – Approved by HCFA and UNOS– Identify donors, evaluate potential donors,
confirm brain death, consent, manage donor, remove organs, preserve/package
Trauma = 30% of donors
Circumstances of clinical brain death in organ donors, 1999-2009. Source: United Network for Organ Sharing (UNOS), 2009.
Mechanism of donor death
Mechanism of death in organ donors, 1999-2009. Source: United Network for Organ Sharing (UNOS), 2009.
Organ Donation
• Potential to save multiple lives– Organs, tissue, bone, corneas
• Donor criteria vary betweens OPOs• All hospitals required by federal
law to screen prospective donors
•www.organdonor.gov
Back to Case # 3• C-spine straightened, OPA inserted,
BVM initiated, HR to 0• CPR started, ROSC in 30 sec, intubated• Transported to trauma center• Brain death protocol initiated• Donated heart, lungs, kidneys, liver,
bone, tissue next day• Parents thanked EMS for opportunity
to turn tragedy into multiple miracles
Death Like Appearances• Drug overdose
• Massive infections• Total paralysis• Hepatic coma• VAS (Ventricular Assist Systems)
Ventricular Assist Devices• Mechanical circulatory assist– “artificial heart”– Usually L ventricular assist device/system
• Currently about 6,000 outpatients in US.
Ventricular Assist Systems
• LVAS, RVAS or “artificial heart”• Earlier devices were air driven
– Pulsatile pumps
• Next gen devices are centrifugal– Magnetically levitated impeller propels
blood– Non-pulsatile flow
How to ID a VAS Patient:
1. Sternotomy scar
2. Attached equipment
3. Caregivers
4. Medical alert identification
VAD Emergency Management ALL VADs are:
Preload-dependent (consider fluid bolus) EKG-independent (but require a rhythm) Afterload-sensitive (caution with pressors) Anticoagulated (bleeding risk) Prone to:
• infection• thrombosis/stroke• mechanical malfunction
Key difference: pulsatile vs. non-pulsatile
VAD Resuscitation Measures1. DO NOT unplug / remove equipment
2. Assess vitals (C-A-B) Non-pulsatile flow requires doppler MAP 70-80, keep < 90 mmHg Pulse oximetry, NIBP likely inaccurate
3. NO CPR
4. Obtain immediate trained assistance Family / caregivers are highly trained Immediately contact VAD center OLMC unlikely to be helpful, wastes time
Cooling Rules
1. Core temp remains relatively static for1 – 2 hours
2. Then decreases 1.4°F per hour
3. Reaches environmental temp in 20 – 30 hours
Rigor Mortis
• “Temporary muscular stiffening”• Believed muscle cell cytoplasm
– Liquid in life gel (solid) liquid (ATP)
• 2 ways rigor useful to police:– Follows typical pattern and time– If position not consistent with scene, then
body has been moved
Typical Rigor Mortis
• Apparent in 2 – 4 hours• Complete in 12 – 18 hours• Goes away in 24 – 36 hours• Gone in 48 hours
Pattern of Rigor Mortis
• Begins in face & jaw– Initially in eyelids, then face, then jaw
• Spreads downwards• Glycogen store related (sick,
young, exercising )
Livor Mortis (Lividity)
• Blood pools in dependent capillaries• Onset 20 – 30 min or earlier• No coagulation
factors remainafter 60 min.
• Lividity fixedafter 10 – 12 hrs.
Lividity• Depends on position after death• Most common when supine (butt,
calves, shoulders pressing down)• Pressure areas devoid of lividity
Rigor and Algor together:
• Warm and flaccid = dead < 3 hours• Warm and stiff = dead 3-8 hours• Cold and stiff = dead 8-36 hours• Cold and flaccid = dead > 36 hours
Decomposition
• Putrefaction• Mummification• And beyond…
Death Notifications
• Have you ever received any training on death notification?
• GRIEV_ING is a structured communication model for death notification
Hobgood C, Mathew D, Woodyard DJ, Shofer FS, Brice JH. Death in the field: teaching paramedics to deliver effective death notifications using the educational intervention “GRIEV_ING.” PEC 2013;17:501-510.
Death NotificationG – gather Gather everyone, be sure all present
R – resources Call for support
I – identify Identify yourself/deceased (names), assess knowledge of days events
E – educate Educate the family on the events
V – verify Verify that the family member has died (words)
_ - space Give the family personal space
I – inquire Ask if any questions, answer them
N – nuts & bolts
Organs, funeral home, belongings, view body
G - give Your contact info