To Resuscitate or Not To Resuscitate

To Resuscitate or Not To Resuscitate

It is very important to perform a good, thorough assessment on every patient, including our cardiac arrest patients.  We must always check cardiac arrest patients for obvious signs of death and attempt to determine the exact time (or range of time) when the patient went into cardiac arrest. It can be difficult to determine the exact time of death, but we must do our best to get the most reliable estimate of when the patient was last seen/known to be alive.  The assessment for obvious signs of death and the decision of whether or not to resuscitate should be completed quickly (ideally, in less than 10 seconds).

When in doubt, resuscitate!  Contact medical control for advice.

What are we looking for?

  • Algor mortis (gradual cooling of the body following death)
    • Following death, bodies can remain warm for several hours
    • Factors affecting algor mortis: amount of clothing, body mass, environment of the body (ambient temperature), etc.
  • Rigor mortis (stiffness of death; this is where the term “stiff” originated when referring to a deceased person)
    • Begins within 2-6 hours of death, starting with the eyelids, neck, and jaw
    • Rigor mortis follows a downward progression that begins in the upper region of the body, around the face and head, and travels in a set pattern down to the rest of body and the extremities.
    • While affecting all muscles in the same way at the same time, rigor mortis becomes noticeable first in small muscle groups, such as those around the eyes, mouth and jaws, and becomes pronounced somewhat later in the larger muscles of the lower limbs.
    • Learning Lesson: check the jaw first. In the absence of pre-existing medical conditions affecting the jaw (temporomandibular joint problems, tetanus, etc.), if the jaw is difficult to open, it could be rigor mortis!
  • Livor mortis, a.k.a. dependent lividity (blood settling)
  • Injuries incompatible with life
  • Valid DDNR (Durable Do Not Resuscitate) or POST (Physician Orders for Scope of Treatment) Forms
  • Time since last seen/known to be alive
    • Per the American Heart Association, for every minute without life-saving CPR and defibrillation, chances of survival decrease 7%-10%[1] . When bystander CPR is provided, the decrease in survival is more gradual and averages 3% to 4% per minute from collapse to defibrillation[2].
      • If the patient has been in cardiac arrest for more than 15 minutes without any bystander CPR, the chances of survival are slim-to-none and, in the absence of extenuating circumstances (e.g., hypothermia), withholding of resuscitation should be considered. Be sure to consider the time when 911 was first called and the estimated amount of time the patient may have been in cardiac arrest prior to that when determining total down time.

[1] Facts: A Race Against the Clock: Sudden Cardiac Arrest: http://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_301793.pdf. 2013.

[2] 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: http://www.circ.ahajournals.org/content/112/24_suppl/IV-19.full

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