Death

Make the Diagnosis: Death

Prior Probability

A poor neurologic outcome (severe neurologic disability, vegetative state, or death) occurs in 77% of victims after a nontraumatic cardiac arrest.

Assessing the Likelihood of a Poor Outcome

See Table 17-6.

• Individual examination findings work better than scales in predicting the likelihood of death or a poor neurologic outcome.

• The examination results at 24 hours and then at 72 hours are more important than the findings immediately after resuscitation.

• The presence of normal findings does not guarantee a good outcome.

• Seizures at 72 hours have minimal effect on predicting the outcome.

Reference Standard Tests

Although death can be defined with traditional biological criteria, there are also cultural and legal definitions of death. A patient who is unaware of his or her surroundings and who has no cognition of or verbal or psychological interaction with the environment characterizes a comatose or vegetative state. No existing tests for recent postcardiac arrest serve as a reference standard for predicting the clinical outcome. When decisions about coma or vegetative states are required, clinicians must often resort to panels of experts to agree on the patient's condition. Other categories of outcomes are described in the Glasgow-Pittsburgh Cerebral Performance Categories.¹

Original Article: Is This Patient Dead, Vegetative, or Severely Neurologically Impaired? Assessing Outcome for Comatose Survivors of Cardiac Arrest

Clinical Scenarios

Case 1

A 65-year-old man experienced a witnessed ventricular fibrillation cardiac arrest at home 24 hours ago. A neighbor had performed cardiopulmonary resuscitation for 5 minutes until the paramedics arrived and performed successful defibrillation. His electrocardiogram revealed a large anterior myocardial infarction, for which he underwent urgent coronary angioplasty. Although still unresponsive, he withdraws from a painful stimulus and his pupillary and corneal reflexes are present. The family asks you about his chance of meaningful recovery.

Case 2

A 26-year-old woman presented to the emergency department with severe pleuritic chest pain and dyspnea. While ...