Objective:  To determine the frequency and causes of ED deaths despite active management, in a tertiary care centre of a low-income country.

Methods:  We conducted a retrospective chart review over a 2 year period (January 2001–December 2002) for all patients who died despite active management in an ED in Karachi, Pakistan.

Results:  Of the 78 418 patient visits, 601 patients (0.7%) were pronounced dead. Of these, 577 patients had complete records. Seventy per cent of these were dead-on-arrival, 1% had do-not-resuscitate orders and 29% (n = 166; 95% confidence interval [CI] 25–32%) died despite active management. Initial vital signs were found to be abnormal in almost all cases (98%). The leading causes of death were sepsis (23%; 95% CI 19–26%), myocardial infarction (19.7%; 95% CI 16–22%), cerebrovascular accident (10.7%; 95% CI 8–13%) and pneumonia (8.2%; 95% CI 6–10%) among adults and sepsis (36.4%; 95% CI 32–40%), myocarditis (15.9%; 95% CI 13–18%) and pneumonia (9.1%; 95% CI 6–11%) among children.

Conclusion:  Sepsis is the leading cause of death in patients of all age groups in the ED of this hospital.