When is Dead Really Dead?

Mike McEvoy, PhD, NRP, RN, CCRNEMS Coordinator, Saratoga County, NY

Resuscitation Committee Chair – Albany Medical CenterEMS 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.

Not Suitable for Small Children

www.mikemcevoy.com

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

Isolated Events?

April 2, 2012: Australia

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?

Formal Training• Physicians are taught & practice

death pronouncement• EMS is not

Your name here?

What Do People Fear?1. Public speaking2. Live burial

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 stimuli2. No movement or breathing3. 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

“Appropriate Clinical Exam”ABSOLUTE MINIMUM REQUIREMENTS:

1. General appearance of body2. No response to verbal/tactile

stimulation3. No pupillary light reflex (pupils

fixed and dilated)4. Absence of breath sounds5. 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 found3. Physical condition of body4. Significant medical hx or trauma5. Conditions precluding resus6. Any medical control contact7. Person body left in custody of

Clinical Exam for Death1. Time (this is the time of death)2. No response to verbal or tactile

stimulation3. No pupillary light reflex (pupils

fixed and dilated)4. Absence of breath sounds5. Absence of heart sounds6. AED or EKG = no signs of life

AED or EKG

Include copy with PCR Leave electrodes on body

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 La R

ésurrection de Lazare - Vincent van Gogh

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

Avoid associating this:

With this:

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

Injury? Prognosis?

Broken neck, non-survivable

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

US: Listed, Xplants, Donors

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

FDNY*EMS – trial program

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

HeartMate II LVAD - simple

FDA: BTT 4/21/08, DT 1/20/10Over 9,000 implants to date

Cored into LV

Outflow to aorta

Percutaneous tube

System Controller

Batteries

HM II

Inside the HM II

is a rotor

Blood Flow

Anatomic Placement

Smaller, cleaner profile:Simple Design:

Valveless One moving part

(rotor)

Distance Traveled

Out for a ride: anywhere

Holding Political Office

How can I identify a VAS?

Obvious:

How to ID a VAS Patient:1. Sternotomy scar

2. Attached equipment3. Caregivers4. Medical alert identification

Sternotomy

Sternotomy

External Equipment

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

CPR SHOULD NOT BE PERFORMED

ON VAD

PATIENTSUNLESS DIRECTED

VAD Resuscitation Measures1. DO NOT unplug / remove equipment2. Assess vitals (C-A-B)

Non-pulsatile flow requires doppler MAP 70-80, keep < 90 mmHg Pulse oximetry, NIBP likely inaccurate

3. NO CPR4. Obtain immediate trained assistance

Family / caregivers are highly trained Immediately contact VAD center OLMC unlikely to be helpful, wastes time

Doppler measured BP

Post Mortem Changes1. Cooling

2. Rigor mortis3. Livor Mortis (lividity)4. Decomposition

Cooling Rules1. 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

Livor and Rigor

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 presentR – resources Call for supportI – identify Identify yourself/deceased (names),

assess knowledge of days eventsE – educate Educate the family on the eventsV – verify Verify that the family member has

died (words)_ - space Give the family personal spaceI – inquire Ask if any questions, answer themN – nuts & bolts

Organs, funeral home, belongings, view body

G - give Your contact info

Death Traps• You will never find something that

you don’t look for!• Every mistaken pronouncement:

– Jumping to conclusions– Lack of detailed search for any sign of life

• Don’t be dead wrong; be DEAD RIGHTThanks! mikemcevoy.com