What to do with an unwitnessed cardiac arrest?

[ASDIC]

hey guys,

A few days ago, my crew responded to an unresponsive man lying in bed. The man was obviously dead with lividity, rigor mortis and no signs of breating. However, the person who called 911, said that she hadnt seen him for days and found him unresponsive when she returned home. So my crew chief and the police decided not to do CPR, even though I wanted to do it.

So what do other EMTs do when they respond to such an unwitnessed cardiac arrest?

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[tkim]

The man was obviously dead with lividity, rigor mortis and no signs of breating.

That's all the answer you need.

 

[beanbean]

Why did you want tod do CPR on a body with rigor and lividity?

Both of these conditions take some time so appear and the person is long past any type of resuscitation.

The conditions to presume death without starting CPR vary from region to region, but you never would start CPR on a body with rigor and lividity. Find a medic or talk to your medical director about the protocols in your area. They are important guidelines you should know (including DNR protocols).

 

[beanbean]

Sorry, I forgot to mention what to do in a situation when your patient has obviously expired....

Call your med control hospital if needed to confirm and record a time of death

Try to not touch or move anything until the police have determined that there is no foul play suspected. Remember you may be standing in a crime scene even if it doesn't appear that way at first glance.

Call for the police if they haven't already been dispatched. They will need to call the medical examiner (at least in my state).

The medical examiner will determine if they need to come out to the scene or if they will release the body to a funeral home as is. In cases where the person is older and no foul play is suggested they will release the body over the phone. Again, this is how it works in my state.

If the body is released the family should be asked if they prefer which funeral home to come pick up the body. If there is no family available the police will call a local funeral home.

When there is nothing medically to do for the dead patient, often the family, friend or unfortunate bystander who found the body may need some assistance. Having someone explain why CPR was not started and explain what the next steps are is very helpful.

 

[OSUdoc08]

hey guys,

A few days ago, my crew responded to an unresponsive man lying in bed. The man was obviously dead with lividity, rigor mortis and no signs of breating. However, the person who called 911, said that she hadnt seen him for days and found him unresponsive when she returned home. So my crew chief and the police decided not to do CPR, even though I wanted to do it.

So what do other EMTs do when they respond to such an unwitnessed cardiac arrest?

You must have missed the part of class where "obvious signs of death" are a positive justification for withholding CPR. Why would you want to do CPR on someone who has begun decomposing?

Livor Mortis, Rigor Mortis, Decapitation, severe trauma to brain/head, and severe trauma to heart are all reasons to withhold CPR in a pulseless, apneic patient.

If someone has Rigor Mortis & Livor Mortis, then they have been dead for several hours. You can only revive someone if they've been dead for approximately 10 minutes or so, unless they are hypothermic (but this precludes onset of L. & R. Mortis)

 

[leviathan]

hey guys,

A few days ago, my crew responded to an unresponsive man lying in bed. The man was obviously dead with lividity, rigor mortis and no signs of breating. However, the person who called 911, said that she hadnt seen him for days and found him unresponsive when she returned home. So my crew chief and the police decided not to do CPR, even though I wanted to do it.

So what do other EMTs do when they respond to such an unwitnessed cardiac arrest?

Hey, ASDIC

If the patient is already presenting signs of rigor mortis, there is no chance of resuscitation. The rigor mortis essentially tells you that this patient has completely utilized 100% of any ATP they may have had in their system either from pre-arrest aerobic metabolism or apneic anaerobic metabolism. Once there is no remaining energy, the Ca++-ATPase pumps fail and Ca++ remains outside the SR causing the permanent muscle contraction/rigor mortis...Without ANY ATP left for the brain/other tissues, the extent of necrosis in the brain tissue is so great that resuscitation is futile.

 

[Oats]

hey guys,

A few days ago, my crew responded to an unresponsive man lying in bed. The man was obviously dead with lividity, rigor mortis and no signs of breating. However, the person who called 911, said that she hadnt seen him for days and found him unresponsive when she returned home. So my crew chief and the police decided not to do CPR, even though I wanted to do it.

So what do other EMTs do when they respond to such an unwitnessed cardiac arrest?

Why in the world would you even consider trying to work this pt.? You say he was obviously dead, with rigor and lividity ( ), so why waste the time and effort on it?
What would I do? Walk in, look at the body, and call him DOA. End of story.

 

[HNS]

Wave.....

 

[dgmedic]

Agree with the above posts....wouldn't even considered starting.

 

[Febrifuge]

Yep... no disrespect intended, but outside of one really fun movie, there's no such thing as "only mostly dead."

(However, the maxim, "don't rush me, sonny. You rush a miracle man, you get rotten miracles" is totally true.)

 

[pushinepi2]

Pushinepi..

^/\^---------^/\^------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Asystole + lividity + rigor = celestial discharge/transfer to literally higher level of care. Jeez.

Talk to your medical director, I believe most EMS systems will have protocols dealing with obvious death. Another alternative is to wait for decomposition to begin.



Pushinepi2

 

[oudoc08]

The service I worked for last, actually had it somewhere in their protocols that if CPR had been started prior to arrival, even if obvious signs of death were present, then we were supposed to continue BLS and call medical control to get orders.
I found out about this asinine protocol when I walked into a nursing home, found the nurse doing compressions (no ventilations) on a patient in bed (yes, in bed) who was so rigored, that their leg was bouncing on the foot rail with each compression.

Of course, I called the code, filled out the necessary paperwork and ensured that the patient's funeral home had been contacted.

On leaving the scene, my dispatcher asked me over the radio which medical control physician had given permission to discontinue the code. I actually laughed on the radio, but then received a phone call from that dispatcher informing me that in fact I had violated protocol. It turns out he had gotten in trouble for doing the same thing awhile back on a street shift. When I asked to see the protocol, it took about an hour to find it, and it was the last sentence of the last obscure paragraph, of the last, (well you get the point). It was buried in the antiquated depths of our protocol book.

So, I made a quick trip to our directors office, and made it well understood that I wasn't intending to follow such a *****ic, outdated protocol that was going to make me, my partner, our company, and EMS in general look like a bunch of blithering idiots.

The protocol changed quickly.

 

[EMResident]

The service I worked for last, actually had it somewhere in their protocols that if CPR had been started prior to arrival, even if obvious signs of death were present, then we were supposed to continue BLS and call medical control to get orders.
I found out about this asinine protocol when I walked into a nursing home, found the nurse doing compressions (no ventilations) on a patient in bed (yes, in bed) who was so rigored, that their leg was bouncing on the foot rail with each compression.

Of course, I called the code, filled out the necessary paperwork and ensured that the patient's funeral home had been contacted.

On leaving the scene, my dispatcher asked me over the radio which medical control physician had given permission to discontinue the code. I actually laughed on the radio, but then received a phone call from that dispatcher informing me that in fact I had violated protocol. It turns out he had gotten in trouble for doing the same thing awhile back on a street shift. When I asked to see the protocol, it took about an hour to find it, and it was the last sentence of the last obscure paragraph, of the last, (well you get the point). It was buried in the antiquated depths of our protocol book.

So, I made a quick trip to our directors office, and made it well understood that I wasn't intending to follow such a *****ic, outdated protocol that was going to make me, my partner, our company, and EMS in general look like a bunch of blithering idiots.

The protocol changed quickly.

Often, if CPR is initiated, the preference is to continue while in public to -- for better or worse -- alleviate anxiety on the part of whomever found the body. That is the case in the City of Chicago.

Having provided medical command, there is often insufficient data provided via the radio to allow cessation of efforts once started especially when cold outside. There are some outstanding studies supporting prolonged resuscitation in hypothermia out of Finland (even after 120 minutes of prolonged CPR 14/16 patients had 100% neuropsychological recovery when taken to cardiopulmonary bypass).

But if they're obviously dead, don't start. Once started, it's difficult to cease efforts.

 

[pushinepi2]

Interesting post re: finland studies. I think everyone would agree that access to CP bypass, especially in the field, is somewhat impractical here in the US. The overwhelming majority of data indicate that neurological survival is exceedingly poor when BLS/ALS care is delayed past 8 or so minutes. Hypothermic cardiac arrest, is of course, an exception. I think these posts deal with the "obviously dead" patient. Legal concerns aside, I am absolutely positive that medical directors and paramedics/EMTs alike can reach consensus on when enough is enough. Speaking from personal experience, it is difficult to work an arrest (virtually by yourself) when transport times are prolonged and you've got less than ideal resources. It did not take me long to find out that when I was over 25 minutes away from the nearest hospital without sufficient help, maintenance of CPR was unrealistic. That being said, EMS is by nature unpredictable. Protocol attempts to deal with the most commonly encountered cases/scenarious. With adequately trained paramedics, there's medical evidence enough to support cessation of efforts in the following scenarios:
1. The obviously dead
2. The elderly asystolic patient down > 15 mins or unresponsive to 20-30 mins of ACLS
3. Victims of prehospital traumatic arrest (not those who stop breathing in the ED).
If in doubt, resuscitate. If there's doubt about the prehospital DNR, resuscitate. Protocols must be in place, however, to assist paramedics in determining when further resuscitative efforts are futile. Perhaps this dialogue must necessarily take place with on-line medical control or with prehospital ALS systems. Whatever the case, death in the field is an absolute reality. It wasn't that long ago when I responded to adjacent counties in rural north florida and was faced with the possibility of transporting an asystolic patient over 30 minutes just to satisfy some outdated SOP. Discussion with online medical control and the, "determination of death" in the field is both a necessary and medically justified strategy to assist our ALS providers in optimizing prehospital cardiac care.

Interesting discussion..

Pushinepi2

 

[Febrifuge]

There are some outstanding studies supporting prolonged resuscitation in hypothermia out of Finland (even after 120 minutes of prolonged CPR 14/16 patients had 100% neuropsychological recovery when taken to cardiopulmonary bypass).

Greetings from Minnesota!

The above is why the rule is, "you're not dead until you're warm and dead."

 

[oudoc08]

Often, if CPR is initiated, the preference is to continue while in public to -- for better or worse -- alleviate anxiety on the part of whomever found the body. That is the case in the City of Chicago.

Having provided medical command, there is often insufficient data provided via the radio to allow cessation of efforts once started especially when cold outside. There are some outstanding studies supporting prolonged resuscitation in hypothermia out of Finland (even after 120 minutes of prolonged CPR 14/16 patients had 100% neuropsychological recovery when taken to cardiopulmonary bypass).

But if they're obviously dead, don't start. Once started, it's difficult to cease efforts.

Exactly, why is it difficult to cease efforts in a nursing home patient that's rigored when some ***** LPN who let her emotions get the better of him/her, decides to start pushing chest?
It's not difficult for the ER doctor to say stop when I bring in a patient that's been coded for an hour, it ought not to be too tough to call a rigored patient. While addressing bystander anxiety is important, it most certainly should not be the overriding factor. This is especially true in someone who works in the medical profession. I care about wasting resources, time, and using an ambulance that somebody could get benefit out of, in order to put on a show. In addition, somebody's going to have to pay for that mess, and I'd be more than a little unhappy if my ambulance was in an accident running emergency status to the hospital for that. In addition, that's a trauma room, ER staff wasted. Not to mention false hope for any family members present. All that for what exactly?

Insufficient information relayed to medical command to terminate resuscitation efforts? How long does it take to say rigor, lividity, pupils fixed and dilated?

Maybe your idea of a good time, but certainly not mine, and I refuse to be a part of it.

I didn't mention anything about hypothermic codes. That's a completely different situation, than being in an warm building, and demonstrating signs of obvious death. And no offense, but if you gave me orders to continue the above code, I'd politely ask to speak to your attending.

In addition, the service I worked for allowed field termination of resuscitation efforts that we had initiated if the patient was initially in asystole and had no rhythm changes during our care (after successful ET intubation, IV access, 1st line meds, fluid challenge, FSBS, and no reversible causes identified) . In my opinion, this is the true role of the EM consult. This decision contains many variables, not the least of which is hope for the family. However, this is the patient that is actively being resuscitated, not the obviously dead. Even so, current ACLS guidelines encourage considering termination of efforts, a trend which many services are moving towards, thank goodness.

 

[12R34Y]

If the code is started by bystanders or LPN's or whoever prior to our arrival. We take over the compressions and bagging (this helps the bystander to feel like we're helping)and hook them up to the monitor. If it is asystole or PEA with obvious signs of death (rigor, cold etc..) then we can call it on our own in the field.

The ED docs love it down here because they aren't constantly getting calls to stop codes that should OBVIOUSLY be stopped.

I'm all for having EMS call codes in the field. It was one of the best protocol changes we ever made at our EMS system.

later

 

[oudoc08]

If the code is started by bystanders or LPN's or whoever prior to our arrival. We take over the compressions and bagging (this helps the bystander to feel like we're helping)and hook them up to the monitor. If it is asystole or PEA with obvious signs of death (rigor, cold etc..) then we can call it on our own in the field.

The ED docs love it down here because they aren't constantly getting calls to stop codes that should OBVIOUSLY be stopped.

I'm all for having EMS call codes in the field. It was one of the best protocol changes we ever made at our EMS system.

later

Exactly. It is nonsensical to be any other way.

 

[Febrifuge]

Agree, 100%.

 

[EMBess]

For the original poster, the first few times you see a dead person and do nothing is hard, but it's a necessary process. There's a reason why you're in the position you're in as a less-experienced EMT - to see those situations and learn how to deal with them appropriately. But I hve to say I still know a few experienced medics who fancy themselves 'cowboys' and think they can save anybody.

That said, I'd like to know where they find Nursing Home LPNs that actually do CPR in the first place , b/c every Nursing Home code I've ever been on
1.) Is not actually called a code until after we get there, and
2.) Has not a soul in the room except the patient, on the infamous 2L NC.

As much as there is a public movement to get AEDs out in the community, you would think that they'd at least have them in Nursing Homes or even, hey, have a code cart and one (?) person who is ACLS certified, or at least willing to do CPR, but not the case where I ride.

I have to say that the protocols for stopping CPR in progress are the same here - if they actually do start it, then we have to call a doc and ask to stop, even if decapitation is a factor, and as silly as that sounds I personally think it is valid.

Most of the ER docs (even if they are IM, which a lot of them here are) know that if the word "rigor" and "dependent lividity" come out of your mouth that you know enough to be darn sure that the patient is past saving. It doesn't take long to do, and the run sheet has an MD's signature on it - in my book any time efforts are ceased this should be the case, if for nothing else than to cover my butt and as a backup for cases where the ALS providers may not be that experienced to allow the docs to ask pertinent questions. As a future doc, I think that's wise too. If I were the OMD, I wouldn't've changed the protocol, because that would leave me signing run sheets that I knew nothing about at the time and for calls in which I wasn't involved at all.

Just my 2 cents.

 

[southerndoc]

Where I used to work, we had standing orders for patients where CPR was not started and a patient was pronounced. Basically downtime of >12 mins without CPR in the abscence of hypothermia was an indication to not start CPR. So basically any patient in asystole without hypothermia was not worked. The outcome is so abysmal that it wasn't even attempted.

Likewise, any traumatic arrest was not worked unless it was witnessed. By witnessed, I don't mean the patient took his last agonal breath while you pulled up onscene. We're talking about a patient is doing fine enroute to the hospital and then codes.

CPR has its indications, but we tend to overly do CPR when there is no hope of survival. (The hospital discharge rate for asystolic cardiac arrests, in the absence of hypothermia, is less than 1 in 5,000.)

Where I'm doing my residency, the paramedics must call to stop a code. Where I worked, we had standing orders to stop a code if we started it (e.g., patient in v-fib, gets worked into asystole, which at that point they receive 2 more rounds of drugs and then it's called).

Many people have problems with this, but if you look at the actual research behind the effectiveness of CPR and ACLS interventions, you soon realize that most of it is a waste of time.