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
• I have no financial relationships to
• I am the EMS technical editor for Fire
Engineering magazine.
• I do not intend to discuss any unlabeled
or unapproved uses of drugs or
Not Suitable for Small Children
• 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
• 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
• 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. Public speaking
2. Live burial
Fear of live burial
• 1800’s – coffins equipped with
rescue devices
• 1899 – NY State enacted legislation
requiring a physician pronounce
• 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”
• 170+ pages
• Became death
criteria for all 50
• Basis for UDDA
(Uniform Determination
of Death Act)
• 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
• 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”
1. General appearance of body
2. No response to verbal/tactile
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
– 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
1. Time (this is the time of death)
2. No response to verbal or tactile
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
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 Résurrection 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
• 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
– 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
Inside the HM II
is a rotor
Blood Flow
Smaller, cleaner profile:
Simple Design:
One moving part
Distance Traveled
Out for a ride: anywhere
Holding Political Office
How can I identify a VAS?
How to ID a VAS Patient:
Sternotomy scar
Attached equipment
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:
• infection
• thrombosis/stroke
• 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
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
Rigor mortis
Livor Mortis (lividity)
Cooling Rules
1. Core temp remains
relatively static for
1 – 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 remain
after 60 min.
• Lividity fixed
after 10 – 12 hrs.
• 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
• Have you ever received any
training on death notification?
• GRIEV_ING is a structured
communication model for death
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
Gather everyone, be sure all present
Call for support
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
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

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