Resuscitate of SIDS

[vs-eh?]

Obviously I agree, you don't attempt resuscitation on anyone who is "obviously dead" or "beyond resuscitation".

That being said I hope that nobody is putting leads on these kids or adults for "their form" or to "confirm asystole".

Coming to the conclusion that a patient is obviously dead is used by your five senses and will take no more than 30 secs from patient contact.

[Ridryder 911]

My medial director would have a head bleed if we hooked up leads on an "obvious dead" patient. Her theory is .. if you have to hook them up to determine death.. you should work them. Our policy is to declare death with obvious clinical signs :

Of course no pulse & apical

post mortem hemostasis (levidity)

confirmation of no resuscitation over >30 minutes. (* does not include hypothermic conditions, electrocution)

other include the usual : obvious mortal wounds incompatible with life, rigor mortis, an decomp..

Not that I agree.. but; I do understand the rationale..

R/R 911

[Ace844]

My medial director would have a head bleed if we hooked up leads on an "obvious dead" patient. Her theory is .. if you have to hook them up to determine death.. you should work them. Our policy is to declare death with obvious clinical signs :

Of course no pulse & apical

post mortem hemostasis (levidity)

confirmation of no resuscitation over >30 minutes. (* does not include hypothermic conditions, electrocution)

other include the usual : obvious mortal wounds incompatible with life, rigor mortis, an decomp..

Not that I agree.. but; I do understand the rationale..

R/R 911

"Rid,"

Good point and I agree with you, but here is a sticky area in which each clinician must be thoroughly familiar OF ALL THEIR PRACTICE GUIDELINES. For example I practice in New England and this last Nov. Mass OEMS published their "CESSATION OF RESUSCITATION" protocol. Unfortunatly it doesn't recognize established tort or case law supporting the standards you posted above which your Med Con. uses. It compels us to do things like apply the monitor, etc...

Commonwealth of Massachusetts 5.1 Official Version OEMS

APPENDIX C - CESSATION OF RESUSCITATION (1/01/2004) - Page 1

APPENDIX C: CESSATION OF RESUSCITATION

(Effective 2/1/05)

PURPOSE: 1) TO CLARIFY FOR EMS SERVICES AND THEIR EMTS WHEN RESUSCITATIVE

MEASURES MAY BE WITHHELD FOR PATIENTS IN CARDIAC ARREST AND 2) TO DEFINE

WHEN EMTS CAN CEASE RESUSCITATIVE MEASURES ALREADY INITIATED.

Background and EMS Services’ Training/Support Services Obligations:

Emergency Medical Technicians must begin or continue resuscitative measures for all patients in

cardiac arrest except as indicated in this Protocol (also issued as Administrative Requirement (A/R) 5-

515). If in doubt, begin resuscitative efforts.

All EMS services must provide appropriate training on management of death in the field, including

legal, procedural, and psychological aspects; and access to support services.

EMS services and EMS personnel should be aware that the nursing staff of a health care facility, such

as a skilled nursing facility, may need a physician order (including a medical control physician’s order, if

allowed by nursing home policy) to halt resuscitation attempts, even in the case of patients meeting

EMS “obvious death” criteria, as set out below. Nursing staff and EMS personnel should come to a

cooperative decision on continuation or termination of resuscitation; this process may include obtaining

physician input and orders. If the medical professionals at the bedside are unable to reach agreement

on attempting or terminating efforts, the presumption should be to continue resuscitative efforts and

transport the patient to an emergency department.

I. EXCEPTIONS TO INITIATION OF RESUSCITATION

Other than in overriding circumstances such as a large mass-casualty incident or a hazardous scene,

the following are the only exceptions to initiating and maintaining resuscitative measures in the field:

1. Current, valid DNR, verified per the Comfort Care Protocol.

2. Trauma inconsistent with survival

a. Decapitation: severing of the vital structures of the head from the remainder of the

patient’s body

b. Transection of the torso: body is completely cut across below the shoulders and

above the hips

c. Evident complete destruction of brain or heart

d. Incineration of the body

e. Cardiac arrest (i.e. pulselessness) documented at first EMS evaluation when such

condition is the result of significant blunt or penetrating trauma and the arrest is

obviously and unequivocally due to such trauma, EXCEPT in the specific case of

arrest due to penetrating chest trauma and short transport time to definitive care (in

which circumstance, resuscitate and transport)

Commonwealth of Massachusetts 5.1 Official Version OEMS

APPENDIX C - CESSATION OF RESUSCITATION (1/01/2004) - Page 2

APPENDIX C: CESSATION OF RESUSCITATION (con’t)

3. Body condition clearly indicating biological death.

a. Complete decomposition or putrefaction: the skin surface (not only in isolated

areas) is bloated or ruptured, with sloughing of soft tissue, and the odor of decaying

flesh.

b. Dependent lividity and/or rigor: when the patient’s body is appropriately examined,

there is a clear demarcation of pooled blood within the body, and/or major joints

(jaw, shoulders, elbows, hips, or knees) are immovable.

Procedure for lividity and/or rigor: All of the criteria below must be established and

documented in addition to lividity and/or rigor in order to withhold resuscitation:

i. Respirations are absent for at least 30 seconds; and

ii. Carotid pulse is absent for at least 30 seconds; and

iii. Lung sounds auscultated by stethoscope bilaterally are absent for at

least 30 seconds; and

iv. Both pupils, if assessable, are non-reactive to light.

II. Cessation of Resuscitation by EMTs

Emergency Medical Technicians must continue resuscitative measures for all patients in cardiac arrest

unless contraindicated by one of the exceptions below.

1. EMTs, certified at the Basic, Intermediate and Paramedic levels, may cease resuscitative

efforts at any time when any “Exception to Initiation of Resuscitation” as defined in I.,

above, is determined to be present.

2. EMTs certified at the Paramedic level only may cease resuscitative efforts in an adult

patient 18 years of age or older, regardless of who initiated the resuscitative efforts,

without finding “obvious death” criteria only by the following procedure, and only if the

EMS system’s Affiliate Hospital Medical Director has approved of use of this procedure,

as follows:

a. There is no evidence of or suspicion of hypothermia; AND

b. Indicated standard Advanced Life Support measures have been successfully

undertaken (including for example effective airway support, intravenous access,

medications, transcutaneous pacing, and rhythm monitoring); AND

c. The patient is in asystole or pulseless electrical activity (PEA), and REMAINS SO

persistently, unresponsive to resuscitative efforts, for at least twenty (20) minutes while

resuscitative efforts continue; AND

d. No reversible cause of arrest is evident; AND

e. The patient is not visibly pregnant; AND

f. An on-line medical control physician gives an order to terminate resuscitative efforts.

Commonwealth of Massachusetts 5.1 Official Version OEMS

APPENDIX C: CESSATION OF RESUSCITATION (con’t)

III. Special Considerations and Procedures:

1. In all cases where a decedent is left in the field, procedures must include notification of

appropriate medical or medico-legal authorities.

2. EMS documentation must reflect the criteria used to determine obvious death or allow

cessation of resuscitative efforts.

[web:7f7fb85356]http://www.mass.gov/dph/oems/protocol/appendix5_1.pdf[/web:7f7fb85356]

As always YMMV...

out here,

ACE844

[Guest DELETED]

DELETED

[jmac]

ridrider, not trying to be smart but look up the word syndrome, if you want to be specific, the infants were resussed, they showed more then one of the S&S of SIDS and that is why they are under constant monitor and telemetry, and i am not putting the label on them myself, this came from a consultancy team that is running the study, there is nothing that i can put up here as no results have been published, sorry about that.

my reason for bringing up "signs of life" is that under AHA BLS protocols, if there are not any signs of life you begin CPR as opposed to "signs incompatible with life", and we all know what they are, i am in a different country and our clinical guidelines state that if there are no incompatible signs you attempt resus and transport as it is always difficult to determine time the infant is down.

it is well and good having this poll and discussion if you are willing to accept other points of view, there are SIDS guidelines, they may differ from place to place, but my thoughts are always on the PT's, infant or parents and every case is different, there were even comments on sparing the parents the cost of transport, we are a statutory body so that does not come into it where i come from.

to finish, i do know the difference between signs of life and signs incompatible and would treat the situation as is fit, but if there is a slim chance that the infant may survive, even for a short time so the parents can say their goodbyes i will transport, maybe its different countries or cultures but hey, i am sure we all do the job to the best of our abilities and as was said at the start this is a poll and discussion to get peoples views and discuss.......not a way to say my way is better then yours,

keep safe.

PS: our clinical guidelines state that we need two 30 sec strips showing asystole to cease resus.

[TalkEMS]

Okay, to prevent another post from being hijacked.

Should resuscitation measures be made on obvious SIDS case with conclusive death findings ?

No.

[hfdff422]

It is odd that there are so many "yes" responses but so few persons willing to state their point of view in the forum.

[Ridryder 911]

Jmac not trying to be smart either.. but look up the definition of SIDS. The diagnosis can be made ONLY after a autopsy has been performed. And since most people are usually dead when an autopsy is performed (or I at least hope so), resuscitation did not occur.

If they treated the patient for respiratory failure or apnea, or high vagalytic response causing bradycardia or prone position or even the theory it is caused from bacteria or maybe viral... that is what they treated them for not SIDS. Each could possibly or have a high potential risk for SIDS, but not SIDS itself.. thus SIDS stand for Silent Infant DEATH Syndrome. One has to be DEAD & remain so for it to be a true case of SIDS. Not a potential SIDS canidate...

R/R 911

[vs-eh?]

PS: our clinical guidelines state that we need two 30 sec strips showing asystole to cease resus.

I find this extremely interesting...

Is this only for patients with whom you have run an arrest, or this is ALL patients who are pulseless and apneic regardless of when/how it happened..

It either means that...

1) You cannot get a pronouncement in any rhythm besides asystole? This is regardless of downtime, duration of ACLS measures, etc...So if they are in a PEA for a known time of say 45 mins and you have gone through all differentials and thrown the kitchen sink at them you won't get a pronouncement? Do you transport? Keep giving them epi q 3-5 until they finally go aystole? I don't gets...

2) You put leads on obviously dead people. I don't mean putting them on a fresh blunt (or perhaps penetrating) trauma that looks "ok", to get a pronouncement. I mean putting leads to confirm asystole on people who are "obviously dead"

Obviously dead again = rigor mortis, algor mortis, livor mortis, injury incompatible with life (decap, transection, gross head injury with displacement of brain matter), gross charring, or gross decomposition.

You put leads on these patients? I honestly hope that is not what you mean by "showing asystole to cease resus". Where do you draw the line? Well buddy is cold, rigored and with lividity BUT he looks "ok" and he was seen 2 hours ago so lets just make sure? The 5 day old stinker in the bachelor apartment with his face one with the couch?

I seem to remember discussing the ridiculousness of this in some other thread so I apologize if people may recognize some verbatim. I believe Asys said (paraphrasing) "If you are putting the leads on a person who is "obviously dead" then you have doubts...if you have doubts about resuscitation then maybe you should start it".

Asystole on the monitor should not be your decision maker if you are on the fence with an "obviously dead" patient.

[cdemt5710]

:tweety: I agree with medibrat. And no one wants to be lied to if their loved one is deceased. When one of my daughters was critically injured (she survived), I wanted the straight goods. No lies. No false hopes. Just the truth. I think we're the ones who need to feel that we did everything possible. And in the case of definite death, everything possible is making sure the parents get what they need to deal with the loss of their child.