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Error Slide – Premature Pronouncement

Updated: Thu 11:54 PM, Apr 24, 2014 The Reaper Comes for Thee!

Richard Beebe MS RN RNP

Lesson Road Map

Today we will talk about: • Identification of Death • Field Pronouncements

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What is your FIRST Job?���Recognition of Life Extinction (ROLE)���

•  Massive Cranial Destruction •  Decomposition •  Incineration

•  Massive Truncal Injury

•  Putrefaction •  Hemicorporectomy

EMS Definition “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.”

.McEvoy M. Dead Wrong. Firemedically. 1st July 2007 http://www.ems1.com/ems-products/aeds/articles/290547-Dead-Wrong/7

“Appropriate Clinical Exam”

General Impression Appearance of Body / Position

LOC : No response to verbal & tactile stimulation Airway/Breathing:

Absence of breath sounds Circulation: Absence of carotid pulse Disability: No pupillary light reflex

(pupils fixed and dilated)

“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!

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AED or EKG

Include copy with PCR Leave electrodes on body

Lead Two? Have No Clue!

Classic Death Defined

1.  Algor Mortis 2.  Rigor mortis 3.  Livor Mortis

Algor Mortis

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* * Granny under the electric blanket

Rigor Mortis

•  “Temporary muscular stiffening” •  Believed muscle cell cytoplasm

– Liquid in life è gel (solid) è liquid (ATP)

•  2 ways rigor useful to police: – Follows typical pattern and time – If position not consistent with scene,

then body has been moved

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Evolution of Rigor Mortis

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

Progression of Rigor Mortis

•  Begins in face & jaw – Initially in eyelids, then face, then

jaw – Pupil Checks and Jaw Thrust

•  Spreads downwards •  Glycogen store related (sick,

young, exercising é)

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.

Decision to Terminate?

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AHA OHCA BLS Rule

•  Unwitnessed Cardiac Arrest •  NO ROSC after 3 rounds of CPR

– Including AED Analysis •  NO AED shocks delivered

37% reduction in EMS Transport

Morrison LJ, Visentin LM, Kiss A, Theriault R, Eby D, Vermeulen M, Sherbino J, Verbeek PR. Validation of a rule for termination of

resuscitation in out-of-hospital cardiac arrest. N Engl J Med. 2006;355:478–487

OHCA EMS Study

N = 17,238 patients

Goto Y. et al. CPR for Out-of-Hospital Cardiac Arrest should be conducted for atleast 35 minutes. 30 Aug 2015

Questions? • MedicThink@Gmail.com