Short lecture about the determination of death for EMS providers

1. With Steve and Dave
S1- Ep 11“Dead Man

2. Administrative
• In the chat box, Type your First/ Last name and agency # (i.e. Ada #).
• If multiple people are watching the same session from the same
location, include all.
• If On Duty, include your “unit”, of off duty, note “Off Duty”
• This is essential to help us issue CE
• Example:
• Medic 18, Joe Snuffy (611), Beetle Baily (644) and Olive Oil (613)
This Photo by Unknown Author is licensed under CC BY-NC

3. Objectives
• Discuss Lazarus Phenomena in EMS
• Review ACCESS criteria for “Determining Death”
• Review ACCESS criteria for withholding resuscitation
• Review ACESS criteria for Termination of Resuscitation
• What we are saving for another time:
• POST/DNR/Comfort One/Advanced Directives
• Death Notification to survivors

6. “Life is a Fatal
Condition with
a 100% chance
of Mortality”
-Anonymous
This Photo by Unknown Author is licensed under CC BY-SA-NC

7. When Death is Obvious
Determination of Death

8. Key Point: It may be
“obvious”, but it
always requires an
assessment

13. Detroit: Aug 23rd, 2020

14. The Lazarus Phenomena
• The Lazerus Phenomenon are situations where patients show signs of
life after being declared dead by medical professionals.
• Described as “delayed return of spontaneous circulation (ROSC)” or
“Auto-Resuscitation”
• True Lazarus Phenomena is extremely rare. Only 32 confirmed
cases since 1982.
• Almost all modern examples are not cases miracles or freak occurrences, but
the result of failure to properly and fully assess the patient.
• Most modern examples involve EMS, though occasionally physicians do this
as well
• One case in Spain where a prisoner was examined by three doctors,and
woke up in the morgue right before his autopsy, subsequently made a full
recovery. He is suspected to have been cataplectic.
• 99.9% of these patients eventually succumb, but the damage to
public trust is irreversible

15. 1968 - “The Harvard Criteria”
• Normothermic
• Not dead until warm and dead
• In the original document this was > 90 degrees F.
• Currently accepted as greater than 95 degrees F.
• Unreceptivity and unresponsitivity.
• No movements or breathing.
• No reflexes.
• Absent Heart tones or Asystole on the EKG
This Photo by Unknown Author is licensed under CC BY-NC-ND

16. 1981 – White Paper to Congress on the Determination of Death by
the “President's Commission for the Study of
Ethical Problems in Medicine and
Biomedical and Behavioral Research”

17. 1981 - Uniform Determination of
Death Act (UDDA)
• Federal Statute
• Defines “Death” legally and
Clinically
• “Clinical Death” (absence
of heart beat and
respiration)
• Irreversible cessation of
circulatory and
respiratory functions
• “Brain Death”
• Irreversible cessation of
all functions of the
entire brain, including
the brain stem.
This Photo by Unknown Author is licensed under CC BY

18. The goal:
• Not to determine only if there is
an absence of life, but if signs of
life will return…or be coaxed
back.
• This requires more than a
casual doorway assessment or 5
second visual inspection.

19. What do the protocols say?
• Appendix 26: “IN-FIELD DEATH/POST/DNR”
• Section II: OBVIOUS DEATH / NON-SALVAGEABLE PATIENTS
• Important points often overlooked
• “The determination that a patient is DOA rests with the EMS
provider on scene.” It is not enough to rely on the word of
the local Law Enforcement, Family, or Bystander
• “In the case of a MCI, this responsibility lies with the triage
team or officer.”
• The following may be used as a guideline to support the
determination that the patient is DOA:
• Absence of Respiratory Effort (MCI only)
• Injury Incompatible with Life
• Signs of Decomposition

20. A special note about
“Fresh” traumatic arrest…
• T-06: The American College of Surgeons and the National
Association of EMS physicians recommend withholding
resuscitation in situations where death is inevitable or
established and in trauma patients presenting with apnea,
pulselessness and without organized ECG activity (asystole).
• However, neurologically intact survivors initially
presenting in this state have been reported. These are
patients who survived but whom otherwise may have not.
We therefore recommend the following approach:
• Consider withholding resuscitation in traumatic cardiac arrest in
any of the following conditions:
• No signs of life within the preceding 15 min (down time
best estimate) AND asytolic.
• Massive trauma incompatible with survival (e.g.
decapitation, penetrating heart injury, loss of brain tissue).

21. Street tip:
No single
assessment is
fool-proof
This Photo by

22. “Injuries Incompatible
with life”
• This is the assessment that most
often results in “Lazarus Syndrome”
• Must document exactly what injuries
are incompatible with life.
• If the injuries are severe, but if the
patient is still breathing, then they are
not “incompatible”
• In 2012, two Australian
Paramedics declared a man dead
with incompatible injuries,
despite documentation agonal
respirations at 4/min.

23. Signs of Decomposition –
Rigor Mortis
• Rigor Mortis: (Latin: rigor "stiffness", and
mortis "of death"),
• Result of exhaustion of ATP and leaking
of Calcium from cells.
• Onset 1-4 hours
• May last 12-36 hours
• Where to assess:
• Small muscle groups
• At least TWO locations- The Jaw and the
hands/wrists
• Nystens Law:
• Rigor onsets in a predictable fashion
from the head to the toes
• Most easily appreciable in the face, jaw,
and neck.
• Then Upper extremities, The torso, then
the lower extremities
• It recedes in the reverse order (toes to
head)
• Pitfalls:
• Seizures “Cataplexy”
• Overdoses

24. Signs of Decomposition – Livor Mortis
• Livor mortis” (Latin: livor – "bluish color", mortis – "of death")
• “Lividity”
By goga312 at Russian Wikipedia, CC BY-SA 3.0,
https://commons.wikimedia.org/w/index.php?curid=9749090

25. Signs of Decomposition –
Algor Mortis
• Not mentioned in protocol but very helpful to note
• Algor mortis: (Latin: algor—coldness; mortis—of death),
• Is the change in body temperature postmortem, until the
ambient/environmental temperature is matched.
• Time
• Initially , body temp may rise
• Slow for first 1-3 hours, then accelerates. Should reach
ambient in 24 hours.
• Where to assess:
• Torso
• Back
• Mouth
• Pitfalls
• Make sure to note type of environment in
• Cold Environments
• Heating Blankets
• Obesity
• Clothing/Coverings
This Photo by Unknown Author is licensed under CC BY-SA

26. Other Signs not
mentioned in protocol
• Putrification
Breakdown of tissue
into proteins and
loss of cohesiveness
• Pallor Mortis (almost
immediate onset)

27. Other useful assessments? 1-
minute rule
• Observe and document any respiratory
effort for 1 minute
• Feel and document an absent radial and
carotid pulse for 1 full minute
• Auscultate and document an absent Apical
Pulse for 1 full minute
• IF an EKG is applied, observe and
document asystole for 1 full minute

28. Listening for an
apical pulse
• To listen for an apical pulse, listen over the
left ventricle. This is usually at the 4th/5th IC
space, in between the left sternal margin
and the mid clavicular line .

29. Do you need an EKG?
Trauma Codes:
“Consider withholding resuscitation in
traumatic cardiac arrest in any of the following
conditions:
• No signs of life within the preceding 15 min
(down time best estimate) AND asytolic.
• Massive trauma incompatible with survival
(e.g. decapitation, penetrating heart injury,
loss of brain tissue). “
This Photo by Unknown Author is licensed under CC BY-NC-ND

30. Whenever resuscitative measures (CPR) are instituted, they should be continued
until arrival at a hospital, until directed by a physician to stop the resuscitation,
or other circumstances dictate, unless the above criteria apply

31. Street tip:
Exam
Respectfully
• Avoid sternal Rubs or “nipple
Pinches”
• Useful for the living, disrespectful
and misconstrued in the dead
• If you expose the patient, cover
them up again.
• Be careful what you say and how
you appear, you may be observed
(and recorded) by family or
neighbors
This Photo by Unknown Author is licensed under CC BY-SA

32. When enough is enough
Termination of Resuscitation

33. What do the protocols say?
• Appendix 26: “IN-FIELD DEATH/POST/DNR”
• Section V. PATIENTS WHO ARE REFRACTORY TO FIELD
INTERVENTIONS
• Important points often overlooked
• “After extensive ALS interventions without improvement, the
likelihood of survival is minimal or non-existent..”
• Examples include:
• Patients who have been without any vital signs for at least 20
minutes (confirmed) with ongoing ALS interventions.
OR
• Patients who are in Asystole (confirmed in two leads) for at least
10 minutes and have received appropriate ALS intervention.
OR
• Any other unforeseen circumstances where the likelihood of
survival is minimal or non-existent and aggressive ALS measures
have been attempted.
In this case the paramedic should contact medical control for
permission to stop resuscitation efforts. Document thoroughly.

34. What do the protocols say?
• Protocol C-01
• “Outside of the POST/Comfort One/DNR
situations (see Appendix 26), once ALS
intervention is initiated; Medical Control
should be called prior to ceasing efforts. In
addition, BLS interventions, an advanced
airway, and at least 20 minutes of rhythm-
appropriate therapy should have been
performed prior to considering termination
of efforts. “

35. When should we go
beyond 20 minutes?
• Paramedic discretion. Common
considerations:
• Persistent shockable rhythm
• Good ETCO2
• Quality of CPR performed
• Age < 65
• Quality of life considerations
• Family/Patient’s wishes
• Special Circumstances (i.e.
Hypothermia)
This Photo by Unknown Author is licensed under CC BY-SA-NC

36. Quality of Life?
• “Healthcare professionals generally agree that a person’s quality of
life is at least as important as his mere ability to sustain a pulse”
• Wake County Study:
• The number of survivors dropped after 20 minutes of ACLS, those who did
survive had comparable neurological survival as those in the < 20 minute
group.
• Many of these “prolonged resuscitation” had CPR in excess of 40 minutes.
• Key Point: Wake County adheres to High Performance CPR
concepts and data tracking.
• Real World Impact: In the Wake County Study: In 7 years of data,
100 neurologically intact people would have not survived if
resuscitation had stopped at 25 minutes

37. Wrapping up
• Determination of death requires a consistent, clinically
based approach and assessment.
• The decision to withhold and terminate resuscitation also
requires a consistent, clinically based approach and
assessment.
• Most failures are the result of disregarding these principles