Page 111 - PJ MED OPS Handbook 8th Ed

Determination of Death/Discontinuing Resuscitation

SPECIAL CONSIDERATIONS:
1. Immediate determination of death is appropriate in a trauma patient without pulse or
respirations in the setting of multiple casualties when resuscitative efforts would hinder
the care of more viable patients.
2. Patients who are struck by lightning, have hypothermia, cold-water drowning, or intermit-
tent pulses may require extended cardiopulmonary resuscitation.
3. It is assumed that personnel do not have access to ECG, or other monitoring equipment
to evaluate heart rhythm, or deliver countershocks.
Signs and Symptoms:
Obvious Death – Persons who, in addition to absence of respiration, cardiac activity, and neurologic
reflexes, have one or more of the following:
1. Decapitation
2. Massive crushing and/or penetrating injury with evisceration of the heart, lung or brain
3. Incineration
4. Decomposition of body tissue
5. Rigor mortis or post-mortem lividity
Management:
1. In the setting of obvious death, resuscitative efforts should not be initiated.
2. In trauma patients, particularly combat trauma, perform bilateral needle decompression before
calling Vital Signs Absent (VSA).
3. If resuscitative efforts have been initiated, consider termination of resuscitation:
a. After 15 minutes (if the cause is unknown or due to trauma) or after 30 minutes (when the
cause is due to hypothermia, electrical injury, lightning strike, cold water drowning, or other
cause known to require a prolonged resuscitative effort) when:
i) There is persistent absence of carotid and other pulses, and respirations despite assuring
airway patency and effective ventilation as well as administration of resuscitative fluids
in hypovolemic patients and medications.
ii) Pupils are fixed and dilated. This is not applicable in the setting of lightning strikes or in
the presence of drugs that cause pupil dilatation.
iii) No response to deep pain above or below the clavicles.
iv) Absence of end-tidal CO2, (either colorimetric or wave form) from a correctly placed
endotracheal tube or alternative airway.
v) Document all four items: 1. pulseless, 2. apneic, 3. unresponsive, 4. pupils fixed and di-
lated. Have a second PJ double check findings and co-sign patient treatment card. If there
is a monitor, document end tidal CO2 and asystole.
4. If there is any question as to the discontinuation of resuscitative efforts, then a medical officer
should be contacted for guidance.
5. If CPR is prolonged and it is the decision of the team leader or medic that it is no longer effective
or resources do not permit continuation, then document the reason and discontinue CPR.

DISPOSITION:
1. Evacuation of the remains when tactically feasible.
2. Always cover the head and torso at least with space blanket or other item, use flag when
able, protect the Hero with dignity.
3. In the event of return of spontaneous circulation, Urgent evacuation.

Chapter 8. Tactical Medical Emergency Protocols (TMEPs) n 109