Corrigendum to “who dies at A&E? The role of forensic pathology in the audit of mortality in an emergency medicine department”

Aetiology of unsuccessful prehospital witnessed cardiac arrest of unclear origin

OBJECTIVES

To determine, by means of autopsy, the cause of death following unsuccessful cardiopulmonary resuscitation of patients with a witnessed prehospital cardiac arrest of unclear origin.

METHOD

Observational study of all prehospital-witnessed cardiac arrest of unclear origin over a period of 19 months in the emergency medical service region of a tertiary care hospital.

RESULTS

During the study period, 211 prehospital cardiopulmonary resuscitation attempts were recorded. In 144 study participants, cardiopulmonary resuscitation was not successful: there was no return of spontaneous circulation. Cardiac arrest of traumatic or other clear origin was not considered, nor were paediatric cases. Thirty out of the 114 remaining patients underwent an autopsy (26.3%). The main aetiology of cardiac arrest in this selected population was ischaemic heart disease in 16 out of 30 patients (53.3%) followed by pulmonary embolism in four patients (13.3%) and vascular disease other than coronary disease in two patients (6.7%). Other causes consisted of hypertrophic obstructive cardiomyopathy (one patient) (3.3%) and poisoning (one patient) (3.3%). The cause of death could not be identified in six cardiac arrest victims (20%).

CONCLUSIONS

Ischaemic heart disease and pulmonary embolism account for 66.6% of all witnessed cardiac arrest with no return of spontaneous circulation.

What do we know about patients dying in the emergency department?

OBJECTIVE

To determine our knowledge in terms of cause of death and quality of death certification about patients who die in the emergency department. To establish the role of autopsy in this matter.

METHODS

Retrospective chart review of all patients dying in an academic emergency department (ED) of a tertiary hospital over a period of 1 year.

RESULTS

One hundred and ninety-six patients died in the ED in 1998. In 141/196 patients the cause of death could be determined on clinical grounds. In 53/196 patients, the antemortem clinical diagnosis was unknown. Twenty-nine out of 53 patients underwent autopsy. In all but one patient autopsy revealed the cause of death. After retrospective analysis of all patient data (notes, biology, radiology and pathological investigation), the major causes of death were cardiac (19.4%), cerebral (non-traumatic) (16.8%), trauma (15.3%) and unknown (13.3%). In the patient group with sudden cardiac arrest of unclear origin, the postmortem cause of death was identified as cardiac (51.7%), non-traumatic bleeding (10.3%), infectious (10.3%) and pulmonary embolism (3.4%). In the group of patients with a clinically clear cause of death, who underwent autopsy, 14 class II findings according to the Goldman's classification of autopsy diagnoses (i.e. major diagnosis whose detection would not have altered therapy nor outcome) were found in 16 patients. No class I findings (i.e. major diagnosis whose detection would have altered therapy or outcome) were noted. Altogether, major discrepancies between the antemortem presumed cause of death according to the notes and the real cause of death was found in 15.3%.

CONCLUSIONS

Autopsy remains a very important tool to establish the cause of death in patients dying in ED. The concordance between the antemortem presumed cause of death recorded in the patient notes and the real cause (all patient data) is poor.