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Clinical death is the medical term for cessation of blood circulation and breathing, the two criteria necessary to sustain the lives of human beings and of many other organisms. It occurs when the heart stops beating in a regular rhythm, a condition called cardiac arrest. The term is also sometimes used in resuscitation research.
Stopped blood circulation has historically proven irreversible in most cases. Prior to the invention of cardiopulmonary resuscitation (CPR), defibrillation, epinephrine injection, and other treatments in the 20th century, the absence of blood circulation (and vital functions related to blood circulation) was historically considered the official definition of death. With the advent of these strategies, cardiac arrest came to be called clinical death rather than simply death, to reflect the possibility of post-arrest resuscitation.
At the onset of clinical death, consciousness is lost within several seconds, and in dogs, measurable brain activity has been measured to stop within 20 to 40 seconds. Irregular gasping may occur during this early time period, and is sometimes mistaken by rescuers as a sign that CPR is not necessary. During clinical death, all tissues and organs in the body steadily accumulate a type of injury called ischemia.
The brain, however, appears to accumulate ischemic injury faster than any other organ. Without special treatment after circulation is restarted, full recovery of the brain after more than 3 minutes of clinical death at normal body temperature is rare. Usually brain damage or later brain death results after longer intervals of clinical death even if the heart is restarted and blood circulation is successfully restored. Brain injury is therefore the chief limiting factor for recovery from clinical death.
Although loss of function is almost immediate, there is no specific duration of clinical death at which the non-functioning brain clearly dies. The most vulnerable cells in the brain, CA1 neurons of the hippocampus, are fatally injured by as little as 10 minutes without oxygen. However, the injured cells do not actually die until hours after resuscitation. This delayed death can be prevented in vitro by a simple drug treatment even after 20 minutes without oxygen. In other areas of the brain, viable human neurons have been recovered and grown in culture hours after clinical death. Brain failure after clinical death is now known to be due to a complex series of processes called reperfusion injury that occur after blood circulation has been restored, especially processes that interfere with blood circulation during the recovery period. Control of these processes is the subject of ongoing research.
In 1990, the laboratory of resuscitation pioneer Peter Safar discovered that reducing body temperature by three degrees Celsius after restarting blood circulation could double the time window of recovery from clinical death without brain damage from 5 minutes to 10 minutes. This induced hypothermia technique is beginning to be used in emergency medicine. The combination of mildly reducing body temperature, reducing blood cell concentration, and increasing blood pressure after resuscitation was found especially effectiveallowing for recovery of dogs after 12 minutes of clinical death at normal body temperature with practically no brain injury. The addition of a drug treatment protocol has been reported to allow recovery of dogs after 16 minutes of clinical death at normal body temperature with no lasting brain injury. Cooling treatment alone has permitted recovery after 17 minutes of clinical death at normal temperature, but with brain injury.
Under laboratory conditions at normal body temperature, the longest period of clinical death of a cat (after complete circulatory arrest) survived with eventual return of brain function is one hour.
Patients supported by methods that certainly maintain enough blood circulation and oxygenation for sustaining life during stopped heartbeat and breathing, such as cardiopulmonary bypass, are not customarily considered clinically dead. All parts of the body except the heart and lungs continue to function normally. Clinical death occurs only if machines providing sole circulatory support are turned off, leaving the patient in a state of stopped blood circulation.
Controlled clinical death has also been proposed as a treatment for exsanguination to create time for surgical repair.
Clinical death that occurs unexpectedly is treated as a medical emergency. CPR is initiated. In a United States hospital, a Code Blue is declared and Advanced Cardiac Life Support procedures used to attempt to restart a normal heartbeat. This effort continues until either the heart is restarted, or a physician determines that continued efforts are useless and recovery is impossible. If this determination is made, the physician pronounces legal death and resuscitation efforts stop.
If clinical death is expected due to terminal illness or withdrawal of supportive care, often a Do Not Resuscitate (DNR) or "no code" order is in place. This means that no resuscitation efforts are made, and a physician or nurse may pronounce legal death at the onset of clinical death.
A patient with working heart and lungs who is determined to be brain death can be pronounced legal death without clinical death occurring. However, some courts have been reluctant to impose such a determination over the religious objections of family members, such as in the Jesse Koochin case.Appel, JM. Defining Death: When Physicians and Families Differ" Journal of Medical Ethics Fall 2005 Similar issues were also raised by the case of Mordechai Dov Brody, but the child died before a court could resolve the matter.
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