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
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
eating”) bacterial skin infection (“flesh 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
What Do People Fear?
1.
2.
Public speaking 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 stimuli 2.
3.
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”
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.
2.
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.
3.
No response to verbal/tactile stimulation No pupillary light reflex (pupils fixed and dilated) 4.
5.
Absence of breath sounds 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
1.
2.
3.
4.
5.
6.
7.
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
1.
2.
3.
4.
5.
6.
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
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 EMS provider available the death senior confirms
the Lazarus Phenomenon
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 1/20/10 Over 9,000 implants to date
HM II
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:
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.
2.
3.
4.
Sternotomy scar Attached equipment Caregivers 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 BE PERFORMED ON VAD PATIENTS
NOT
UNLESS DIRECTED
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.
NO CPR 4.
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
1.
Cooling
2.
Rigor mortis
3.
Livor Mortis (lividity)
4.
Decomposition
Cooling Rules 1.
2.
3.
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
• •
“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 remain after 60 min.
•
Lividity fixed after 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 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
• • •
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 RIGHT
Thanks! mikemcevoy.com