If you have worked long enough in the emergency department (ED), you probably have seen several patients with cardiac arrest on arrival during your shifts. The question is: Would you consider your patient already dead or still alive? It seems an easy enough question but another question follows: Are you sure about that?
I had many night shifts in the ED. I remember a night when an unconscious 55-year-old gentleman came with mydriatic pupils and no pulse. His wife’s cries broke my heart! Suddenly, my mind went so blank that I couldn’t even recall the basic life support! I needed to resuscitate him, but what was next Epinephrine or cardioversion? In my perplexity, I felt to my bones that everything I learnt and memorised was in vain. The nurses were waiting for my instructions, but I was petrified myself. Why couldn’t I think systematically? At that point in time, I swore to myself that I would try again, harder and harder, to learn -and implement- life support better. And, I had to be quick about it, because soon this year, I would be handling patients myself (even though I still have to report each case to the staff).
Long after that moment, I came to realise that death means different things to different people. Even for the same people, it will be different from each perspective -Biologically, spiritually, medically, metaphorically, metaphysically, existentially, chemically, anatomically, ethically, legally, or on a cellular basis. So, now that I am about to take more responsibility of my patients, the fundamental question remains: How do we make sure that the patient without a pulse on arrival is positively dead? Or more importantly, how should we act?
Between 10% and 50% of deaths occur before reaching hospitals (1-2). Death on arrival (DoA) can refer to two different patient groups: those who were declared dead upon arrival to an ED with no resuscitation attempt or those who died after failed resuscitation, usually within the first hour of arrival (3). The studies show that in addition to prehospital and hospital care, basic life support by laypeople plays a crucial role in reducing deaths (4).
Do you know this?
Sometimes, when we put the defibrillator paddles on an arrest patient, the first rhythm we see is ventricular fibrillation (VF). It’s an easy call – which means if we quickly resuscitate the patient, we can save him or her. At other times, the patient arrives with mydriatic pupils, no breathing, and no pulse, and a flat line. This decision is more challenging because the patient might have passed the critical period for resuscitation or what causes pupils to be mydriatic could be a recent amphetamine or cocaine overdose. What is the best course of action in this scenario
- American Heart Association realised that this is a worldwide problem (5). Therefore, they made a statement about this very situation. According to it:
At the time of cardiac arrest, there is no way to assess reliably brain death or neurologic outcome. - From an ethical perspective, withholding resuscitation during resuscitation and discontinuation of life-sustaining treatment after are equivalent.
- If the prognosis is not clear, starting resuscitation without delay is reasonable so that more information can be gathered about the situation to predict the clinical course and the outcome, and learn the patient’s end-of-life preferences.
In other words, not being able to diagnose a patient with DoA at the first glance is OK. Once we don’t feel the pulse, we start CPR! We should learn more about the situation to be sure. In this way, we avoid any adverse outcomes, which might be associated with the delay of treatment.
What steps should we take to save the patient?
My Opinion
Personally, I find pronouncing someone DoA difficult. Dead on arrival diagnosis is an irreversible verdict. Devastating news for families who lost their loved ones forever.
Of course, we can declare someone dead if obvious clinical signs of irreversible death (eg, rigour mortis, dependent lividity, decapitation, transection, decomposition) are present. Otherwise, I feel that we should try and give patients the best possible chance for survival.
The key to a good doctor is three-pronged: comprehensive knowledge, mastery of skills, and proper attitude. Ever doctor, especially those who are dealing with emergencies, must know the process of death, master skills to provide help to those who can benefit, and remain dedicated to serving.
Take-home messages
- Don’t memorise the algorithm, understand it clearly.
- Try not to panic even though it’s your first time. There is a first time for everything.
- Little acts of help can save someone’s life.
References and Further Reading
- Arreola-Risa, Carlos, et al. “Low-cost improvements in prehospital trauma care in a Latin American city.” Journal of Trauma and Acute Care Surgery 48.1 (2000): 119.
- Roudsari, Bahman S., et al. “Emergency Medical Service (EMS) systems in developed and developing countries.” Injury 38.9 (2007): 1001-1013.
- Khursheed, Munawar, et al. “Dead on arrival in a low-income country: results from a multicenter study in Pakistan.” BMC emergency medicine 15.2 (2015): 1-7.
- Calland, James Forrest, et al. “The effect of dead-on-arrival and emergency department death classification on risk-adjusted performance in the American College of Surgeons Trauma Quality Improvement Program.” Journal of Trauma and Acute Care Surgery 73.5 (2012): 1086-1092.
- Panchal, Ashish R., et al. “Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.” Circulation 142.16_Suppl_2 (2020): S366-S468.