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Guidelines to deal with Sudden Death: Dr. Ashok Raina

M3 India Newsdesk Jan 11, 2019

Dr. Ashok Raina, a noted physician discusses Sudden Death (SD) and Sudden Cardiac Death (SCD), detailing on the guidelines to deal with it.







Sudden death (SD) is a harsh reality of modern times. We know, due to various factors, not only the developed but also the developing world faces the crisis of SD. It is a well-known fact that the developed countries, valuing human life as an asset, have already put in place the mechanisms to prevent SD and are seen diligently investing and upgrading services to combat the menace of SD. 

The saddest part is that in India, we don’t have reliable census data for sudden deaths because it has never been a priority for the healthcare sector to understand and mitigate the cause of SD. And indeed, these deaths are preventable but unfortunately, as usual, we lack the will to address the issue resulting in the loss of many valuable, productive lives.

Sudden Death (SD) and Sudden Cardiac Death (SCD)

SD occurs rapidly and generally unexpectedly; usually from a cardiac dysrhythmia or myocardial infarction, but also from any cause of rapid death, for example, pulmonary embolus, stroke, ruptured aortic aneurysm and aortic dissection

SCD is unexpected death that occurs within 1 hour from symptom onset in witnessed circumstances or within 24 hours from last observed alive and without symptoms in unwitnessed circumstances. According to the World Health Organization, SCD (Sudden Cardiac Death) is defined by the duration of symptoms preceding the terminal event.

SCD occurs when a triggering factor serves as the catalyst in an anatomic or electrophysiological substrate (either genetically determined or acquired); resulting in the final common pathway of ventricular fibrillation (VF) or ventricular tachycardia (VT) degenerating into VF, and results in haemodynamic prodrome of pre-syncopal symptoms before syncope or presents with only syncope depending on the duration of tachycardia.

  • Non-sustained VT (NSVT) is defined as ≥3 beats and terminates spontaneously in <30 s
  • Sustained VT lasts >30 s in duration or requires defibrillation because of hemodynamic compromise in <30 SCD and fatal arrhythmias may have a diurnal, circadian rhythm

Guidelines to deal with SD and SCD

World over, proper guidelines and protocols are well established by the local ministries of health but unfortunately even in the under-review policy document of Government of India of the year 2017, the authorities are still silent about any such guidelines.

The guidelines can broadly be divided into two groups:

  1. IML (Immediate Life Support Systems): IML constitutes two basic components viz:
  • “A”. Availability of basic equipment required for BLS (basic Life Support) 
  • “B”. Availability of person or persons trained in basic life support.
  1. ALS (Advance Life Support Systems): Nationally, availability of ALS (Advance Life Support) systems should be such that they are available in every nook and corner of the city/country and can be used within a few minutes of an episode, with a maximum delay of five to ten minutes.

Though on paper every doctor and paramedic undergo compulsory training for BLS & ALS and a lot many organisations are available to impart it, the training as such is really under-utilised for the benefit of the public at large. The main reason being that no clear-cut policy document exists as a 'National Protocol' as seen in developed countries.

Hospitals, health centres, major assembly points like schools, malls, and public places etc. are ill-equipped to utilise the trained manpower. Millions of lives are saved every year across the globe but unfortunately, in our country, we continue to lose valuable lives due to a lack of policy formation and implementation.

AHA-recommended steps for resuscitation are known as DRS CABCDE

  • Check for Danger
  • Check for a Response
  • Send or shout for help
  1. C directs rescuers to first attend to catastrophic haemorrhage (life-threatening bleeding) and to stop the bleeding if possible.
  2. A directs rescuers to open the airway and look into the mouth for obvious obstruction. Also to apply a 'head tilt-chin lift' or 'jaw thrust' to open the airway.
  3. B directs rescuers to check Breathing for 10 seconds by listening for breath at the patient's nose and mouth and observe the chest for regular rising and falling breathing movements.
  4. C directs rescuers to maintain Circulation which may be through the administration of chest compressions for Cardio Pulmonary Resuscitation (CPR).
  5. D directs rescuers to identify Disabilities (e.g. diabetic or any allergies), Damage (identify broken bones or any minor bleeding), Devices (including use of AED devices available and follow prompts) and Dry (if casualty is very wet, an AED device will pass current through body surface water and will harm the casualty).
  6. E directs rescuers to take the environment into consideration for weather, location and crowds.
    1. If the patient is unresponsive and not breathing, the responder should begin CPR with chest compressions at a rate of 120 beats per minute in cycles of 30 chest compressions to 2 breaths.
    2. If responders are unwilling or unable to perform rescue breathing, they are to perform compression-only CPR, because any attempt at resuscitation is better than no attempt.


Dr. Raina writes..

My experience with sudden death cases in the Middle East

During my stint in Doha Qatar in the late nineties and early 2000, I was witness to many cases of sudden deaths among the expat population of the Middle East, especially in Qatar.

A bulk of the victims were from the Indian sub-continent. Indians were followed by Nepalese, Bangladeshis, Sri-Lankans, and Pakistanis. This ratio may be because of the fact that the population strength of the expats was of the same order. Though we saw sudden death in other communities as well especially Egyptians and Sudanese, it was not as rampant as in the Indian sub-continent group.

Following are a few common characteristics, victims of SD shared:

  1. Most of them were from low socio-economic strata and were workers in the construction industry
  2. They usually hid medical history or were ignorant of any underlying pathologies
  3. They would be either alcoholics or chain smokers or both. Due to the non-availability of alcohol to the group, these people would usually indulge in making and drinking spurious liquor which further worsened their pre-existing conditions, thus leading to sudden deaths.
  4. Healthcare affordability was an issue earlier as government institutions were not ready for the high influx of labour force, private companies, and institutions were not willing to deliver proper health care to the workers due to the cost implications. Private healthcare was scarce and expensive.
  5. Most of the expat force would be under stress and even at times where found working under duress due to either domestic financial constraints or being falsely promised jobs with higher wages or even the failure of employers to provide basic living facilities or pay proper promised wages.

But the scenario started changing in early 2000 when with the initiatives of the state governing agencies, International Institutions like Amnesty, ILO, etc., brought about a drastic change in not only healthcare but also in the working conditions.

With these cohesive initiatives of improving primary health care of the general populace, the governments were forced to implement policies which in turn compelled even the private sector to invest in primary health of their workforce resulting in pre-emptively detecting a lot of cases, identifying them and treating them. This in turn led to the ability to drastically reduce the number of sudden deaths.

It is, therefore, a well-established fact that sudden cardiac arrest can be treated and reversed, but emergency support must be in place and instituted immediately. Survival can be as high as 90% if treatment is initiated within the first a few minutes after sudden cardiac arrest. This rate decreases by about 10% each minute longer it takes to initiate therapy. Those who survive have a better long-term outlook.


Disclaimer-The information and views set out in this article are those of the author(s) and do not necessarily reflect the official opinion of M3 India. Neither M3 India nor any person acting on their behalf may be held responsible for the use which may be made of the information contained therein. 

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