When is Dead Really Dead?

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Transcript When is Dead Really Dead?

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.

Not Suitable for Small Children


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

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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

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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


Streptococcus pyrogenes

eating”) bacterial skin infection (“flesh Dies 3 days later CNN, national news media prominently carry the story

Isolated Events?

April 2, 2012: Australia


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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

What Do People Fear?



Public speaking Live burial

Fear of live burial

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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

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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 No reflexes – fixed & dilated pupils, no eye movement when turned or cold water injected into ear, no DTRs Currently called “brain death”


• •

170+ pages Became death criteria for all 50 states

Basis for UDDA (Uniform Determination of Death Act)


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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

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EMS doesn’t pronounce brain death Neither does a lone doc, NP, or PA Such decisions require:


Specialized testing

Brain specialists such as neurologists

Who does EMS pronounce?



People we find dead 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. appropriate clinical exam,” whereas, “

Cessation Irreversibility

is recognized by an 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 body 2.


No response to verbal/tactile stimulation No pupillary light reflex (pupils fixed and dilated) 4.


Absence of breath sounds Absence of heart sounds

“Appropriate Clinical Exam”

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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 Documentation Describe your exam Location/position where found Physical condition of body Significant medical hx or trauma Conditions precluding resus Any medical control contact Person body left in custody of







Clinical Exam for Death Time (this is the time of death) No response to verbal or tactile stimulation No pupillary light reflex (pupils fixed and dilated) Absence of breath sounds Absence of heart sounds AED or EKG = no signs of life


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 EMS provider available the death senior confirms

the Lazarus Phenomenon

the Lazarus Phenomenon

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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

• •


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?

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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


FDNY * EMS – trial program

Back to Case # 3

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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

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Drug overdose Massive infections Total paralysis Hepatic coma VAS (Ventricular Assist Systems)

Ventricular Assist Devices

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Mechanical circulatory assist

“artificial heart”

Usually L ventricular assist device/system Currently about 6,000 outpatients in US.

Ventricular Assist Systems

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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 1/20/10 Over 9,000 implants to date


Cored into LV Outflow to aorta Percutaneous tube System Controller Batteries

Inside the HM II is a rotor


Blood Flow


Anatomic Placement

Smaller, cleaner profile: Simple Design:


One moving part (rotor)

Distance Traveled

Out for a ride: anywhere

Holding Political Office

How can I identify a VAS?


How to ID a VAS Patient: 1.




Sternotomy scar Attached equipment Caregivers Medical alert identification



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:



mechanical malfunction

Key difference: pulsatile vs. non-pulsatile




VAD Resuscitation Measures 1.

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.


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 Changes




Rigor mortis


Livor Mortis (lividity)



Cooling Rules 1.



Core temp remains relatively static for 1 – 2 hours Then decreases 1.4

°F per hour Reaches environmental temp in 20 – 30 hours

Rigor Mortis

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“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

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Apparent in 2 – 4 hours Complete in 12 – 18 hours Goes away in 24 – 36 hours Gone in 48 hours

Pattern of Rigor Mortis

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Begins in face & jaw

Initially in eyelids, then face, then jaw Spreads downwards Glycogen store related (sick, young, exercising


Livor Mortis (Lividity)

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Blood pools in dependent capillaries Onset 20 – 30 min or earlier No coagulation factors remain after 60 min.

Lividity fixed after 10 – 12 hrs.


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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


• • •

Putrefaction Mummification And beyond…

Death Notifications

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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 Notification G – gather R – resources I – identify E – educate V – verify G - give Gather everyone, be sure all present Call for support Identify yourself/deceased (names), assess knowledge of days events Educate the family on the events 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 Your contact info

Death Traps

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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


Thanks! mikemcevoy.com