Cardiac arrest

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For other uses, see Cardiac arrest (disambiguation).
Cardiac arrest
Classification and external resources
ICD-10 I46.
ICD-9 427.5
MeSH D006323
A cardiac arrest, also known as cardiorespiratory arrest,
cardiopulmonary arrest or circulatory arrest, is the abrupt
cessation of normal circulation of the blood due to failure of the
heart to contract effectively during systole.
[1]

A cardiac arrest is different from (but may be caused by) a heart
attack or myocardial infarction, where blood flow to the still-
beating heart is interrupted.
"Arrested" blood circulation prevents delivery of oxygen to all
parts of the body. Cerebral hypoxia, or lack of oxygen supply to
the brain, causes victims to lose consciousness and to stop normal
breathing, although agonal breathing may still occur. Brain injury
is likely if cardiac arrest is untreated for more than 5 minutes,
[2]

although new treatments such as induced hypothermia have begun
to extend this time.
[3][4]
To improve survival and neurological
recovery immediate response is paramount.
[5]

Cardiac arrest is a medical emergency that, in certain groups of
patients, is potentially reversible if treated early enough (See
"Reversible causes" below). When unexpected cardiac arrest leads
to death this is called sudden cardiac death (SCD).
[1]
The primary
first-aid treatment for cardiac arrest is cardiopulmonary
resuscitation (commonly known as CPR) which provides
circulatory support until availability of definitive medical
treatment, which will vary dependent on the rhythm the heart is
exhibiting, but often requires defibrillation.
Contents
[hide]
1 Characteristics and diagnosis
2 Causes of cardiac arrest
o 2.1 Reversible causes
2.1.1 Hs
2.1.2 Ts
3 Treatment
o 3.1 Out of hospital arrest
o 3.2 Hospital treatment
o 3.3 Therapeutic hypothermia
o 3.4 Peri-arrest period
4 Prognosis
5 Prevention
6 Implantable cardioverter defibrillators
7 Ethical issues
8 See also
9 References
10 External links
[edit] Characteristics and diagnosis
Cardiac arrest is an abrupt cessation of pump function (evidenced
by absence of a palpable pulse) of the heart that with prompt
intervention could be reversed, but without it will lead to death.
[1]

However, due to inadequate cerebral perfusion, the patient will be
unconscious and will have stopped breathing. The main diagnostic
criterion to diagnose a cardiac arrest (as opposed to respiratory
arrest, which shares many of the same features) is lack of
circulation, however there are a number of ways of determining
this.
In many cases, lack of carotid pulse is the gold standard for
diagnosing cardiac arrest, but lack of a pulse (particularly in the
peripheral pulses) may be a result of other conditions (e.g. shock),
or simply an error on the part of the rescuer. Studies have shown
that rescuers often make a mistake when checking the carotid pulse
in an emergency, whether they are healthcare professionals
[6][7]
or
lay persons.
[8]

Owing to the inaccuracy in this method of diagnosis, some bodies
such as the European Resuscitation Council (ERC) have de-
emphasised its importance. The Resuscitation Council (UK), in
line with the ERC's recommendations and those of the American
Heart Association,
[9]
have suggested that the technique should be
used only by healthcare professionals with specific training and
expertise, and even then that it should be viewed in conjunction
with other indicators such as agonal respiration.
[10]

Various other methods for detecting circulation have been
proposed. Guidelines following the 2000 International Liaison
Committee on Resusciation (ILCOR) recommendations were for
rescuers to look for "signs of circulation", but not specifically the
pulse
[9]
. These signs included coughing, gasping, colour, twitching
and movement.
[11]
However, in face of evidence that these
guidelines were ineffective, the current recommendation of ILCOR
is that cardiac arrest should be diagnosed in all casualties who are
unconscious and not breathing normally.
[9]

Following initial diagnosis of cardiac arrest, healthcare
professionals further categorise the diagnosis based on the
ECG/EKG rhythm. There are 4 rhythms which result in a cardiac
arrest. Ventricular fibrillation (VF/VFib) and pulseless ventricular
tachycardia (VT) are both responsive to a defibrillator and so are
colloquially referred to as "shockable" rhythms, whereas asystole
and pulseless electrical activity (PEA) are non-shockable. The
nature of the presenting hearth rhythm suggests different causes
and treatment, and is used to guide the rescuer as to what treatment
may be appropriate
[10]
(see Advanced life support and Advanced
cardiac life support, as well as the causes of arrest below).
[edit] Causes of cardiac arrest
Cardiac arrest is synonymous with Clinical death. All disease
processes leading to death have a period of (potentially) reversible
cardiac arrest: the causes of arrest are, therefore, numerous.
However, many of these conditions, rather than causing an arrest
themselves, promote one of the "Reversible causes" (see below),
which then triggers the arrest (e.g. choking leads to hypoxia which
in turn leads to an arrest). In some cases, the underlying
mechanism cannot be overcome, leading to an unsuccessful
resuscitation.
Among adults, ischemic heart disease is the predominant cause of
arrest.
[12]
At autopsy 30% of victims show signs of recent
myocardial infarction
[citation needed]
. Other cardiac conditions
potentially leading to arrest include structural abnormalities,
arrhythmias and cardiomyopathies. Non-cardiac causes include
infections, overdoses, trauma and cancer, in addition to many
others.
[edit] Reversible causes
Cardiopulmonary resuscitation (CPR), including adjunctive
measures such as defibrillation, intubation and drug administration,
is the standard of care for initial treatment of cardiac arrest.
However, most cardiac arrests occur for a reason, and unless that
reason can be found and overcome, CPR is often ineffective, or if
it does result in a return of spontaneous circulation, this is short
lived.
[10]
As highlighted above, a variety of disease processes can
lead to a cardiac arrest, however they usually boil down to one or
more of the "Hs and Ts".
[13][14][15]

[edit] Hs
Hypovolemia - A lack of circulating body fluids,
principally blood volume. This is usually (though not
exclusively) caused by some form of bleeding,
anaphylaxis, or pregnancy with gravid uterus. Peri-
arrest treatment includes giving IV fluids and blood
transfusions, and controlling the source of any bleeding
- by direct pressure for external bleeding, or emergency
surgical techniques such as esophageal banding,
gastroesophageal balloon tamponade (for treatment of
massive GI bleeding such as in esophageal varices),
thoracotomy in cases of penetrating trauma or
significant shear forces applied to the chest, or
exploratory laparotomy in cases of penetrating trauma,
spontaneous rupture of major blood vessels, or rupture
of a hollow viscus in the abdomen.
Hypoxia - A lack of oxygen delivery to the heart, brain
and other vital organs. Rapid assessment of airway
patency and respiratory effort must be performed. If the
patient is mechanically ventilated, the presence of
breath sounds and the proper placement of the
endotracheal tube should be verified. Treatment may
include providing oxygen, proper ventilation, and good
CPR technique. In cases of carbon monoxide poisoning
or cyanide poisoning, hyperbaric oxygen may be
employed after the patient is stabilized.
Hydrogen ions (Acidosis) - An abnormal pH in the
body as a result of lactic acidosis which occurs in
prolonged hypoxia and in severe infection, diabetic
ketoacidosis, renal failure causing uremia, or ingestion
of toxic agents or overdose of pharmacological agents,
such as aspirin and other salicylates, ethanol, ethylene
glycol and other alcohols, tricyclic antidepressants,
isoniazid, or iron sulfate. This can be treated with
proper ventilation, good CPR technique, buffers like
sodium bicarbonate, and in select cases may require
emergent hemodialysis.
Hyperkalemia or Hypokalemia - Both excess and
inadequate potassium can be life-threatening. A
common presentation of hyperkalemia is in the patient
with end-stage renal disease who has missed a dialysis
appointment and presents with weakness, nausea, and
broad QRS complexes on the electrocardiogram. (Note
however that patients with chronic kidney disease are
often more tolerant of high potassium levels as their
body often adapts to it.) The electrocardiogram will
show tall, peaked T waves (often larger than the R
wave) or can degenerate into a sine wave as the QRS
complex widens. Immediate initial therapy is the
administration of calcium, either as calcium gluconate
or calcium chloride. This stabilizes the electrochemical
potential of cardiac myocytes, thereby preventing the
development of fatal arrhythmias. This is, however,
only a temporizing measure. Other temporizing
measures may include nebulized albuterol, intravenous
insulin (usually given in combination with glucose, and
sodium bicarbonate, which all temporarily drive
potassium into the interior of cells. Definitive treatment
of hyperkalemia requires actual excretion of potassium,
either through urine (which can be facilitated by
administration of loop diuretics such as furosemide) or
in the stool (which is accomplished by giving sodium
polystyrene sulfonate enterally, where it will bind
potassium in the GI tract.) Severe cases will require
emergent hemodialysis. The diagnosis of hypokalemia
(not enough potassium) can be suspected when there is
a history of diarrhoea or malnutrition. Loop diuretics
may also contribute. The electrocardiogram may show
flattening of T waves and prominent U waves.
Hypokalemia is an important cause of acquired long QT
syndrome, and may predispose the patient to torsades
de pointes. Digitalis use may increase the risk that
hypokalemia will produce life threatening arrhythmias.
Hypokalemia is especially dangerous in patients with
ischemic heart disease.
Hypothermia - A low core body temperature, defined
clinically as a temperature of less than 35 degrees
Celsius (95 degrees Fahrenheit). The patient is re-
warmed either by using a cardiac bypass or by
irrigation of the body cavities (such as thorax,
peritoneum, bladder) with warm fluids; or warmed IV
fluids. CPR only is given until the core body
temperature reached 30 degrees Celsius, as
defibrillation is ineffective at lower temperatures.
Patients have been known to be successfully
resuscitated after periods of hours in hypothermia and
cardiac arrest, and this has given rise to the often-
quoted medical truism, "You're not dead until you're
warm and dead."
Hypoglycemia or Hyperglycemia - Low blood glucose
from overdose of oral hypoglycemics such as
sulfonylureas, or overdose of insulin. Rare endocrine
disorders can also cause unexpected hypoglycemia.
Generally, hyperglycemia is itself not fatal, however
DKA will cause pH to drop, and nonketotic
hyperosmolar coma leads to a severely hypovolemic
state. Hypoglycemia is corrected rapidly by intravenous
administration of concentrated glucose (typically 25 ml
of 50% glucose in adults, but in children 25% glucose
is used, and in neonates 10% glucose is used.)
However, the patient will often require a continuous
intravenous drip until the causative agent is completely
metabolized. In DKA, the goal is correction of acidosis.
In NKH, the goal is adequate fluid resuscitation.
[edit] Ts
Tablets or Toxins - Tricyclic antidepressants,
phenothiazines, beta blockers, calcium channel
blockers, cocaine, digoxin, aspirin, acetominophen.
This may be evidenced by items found on or around the
patient, the patient's medical history (i.e. drug abuse,
medication) taken from family and friends, checking
the medical records to make sure no interacting drugs
were prescribed, or sending blood and urine samples to
the toxicology lab for report. Treatment may include
specific antidotes, fluids for volume expansion,
vasopressors, sodium bicarbonate (for tricyclic
antidepressants), glucagon or calcium (for calcium
channel blockers), benzodiazepines (for cocaine), or
cardiopulmonary bypass. Herbal supplements and over-
the-counter medications should also be considered.
Cardiac Tamponade - Blood or other fluids building up
in the pericardium can put pressure on the heart so that
it is not able to beat. This condition can be recognized
by the presence of a narrowing pulse pressure, muffled
heart sounds, distended neck veins, electrical alternans
on the electrocardiogram, or by visualization on
echocardiogram. This is treated in an emergency by
inserting a needle into the pericardium to drain the fluid
(pericardiocentesis), or if the fluid is too thick then a
subxiphoid window is performed to cut the pericardium
and release the fluid.
Tension pneumothorax - The build-up of air into one of
the pleural cavities, which causes a mediastinal shift.
When this happens, the great vessels (particularly the
superior vena cava) become kinked, which limits blood
return to the heart. The condition can be recognized by
severe air hunger, hypoxia, jugular venous distension,
hyperressonance to percussion on the effected side, and
a tracheal shift away from the effected side. The
tracheal shift often requires a chest x-ray to appreciate
(although treatment should be initiated prior to
obtaining a chest x-ray if this condition is suspected. )
This is relieved in by a needle thoracotomy (inserting a
needle catheter) into the 2nd intercostal space at the
mid-clavicular line, which relieves the pressure in the
pleural cavity.
Thrombosis (Myocardial infarction) - If the patient can
be successfully resuscitated, there is a chance that the
myocardial infarction can be treated, either with
thrombolytic therapy or percutaneous coronary
intervention.
Thromboembolism (Pulmonary embolism) -
hemodynamically significant pulmonary emboli are
generally massive and typically fatal. Administration of
thrombolytics can be attempted, and some specialized
centers may perform thrombolectomy, however,
prognosis is generally poor.
Trauma (Hypovolemia) - Reduced blood volume from
acute injury or primary damage to the heart or great
vessels. Cardiac arrest secondary to trauma, particularly
blunt trauma, has a very poor prognosis.


Checking respiration.


Checking carotid pulse.


Insulfation mouth-to-mouth.
[edit] Treatment
[edit] Out of hospital arrest
Most out-of-hospital cardiac arrests occur following a myocardial
infarction (heart attack), and present initially with a heart rhythm
of ventricular fibrillation. The patient is therefore likely to be
responsive to defibrillation, and this has become the focus of pre-
hospital interventions. Several organisations promote the idea of a
"chain of survival", of which defibrillation is a key step. The links
are:
Early recognition - If possible, recognition of illness
before the patient develops a cardiac arrest will allow
the rescuer to prevent its occurrence. Early recognition
that a cardiac arrest has occurred is key to survival - for
every minute a patient is in cardiac arrest, their chances
of survival drop by roughly 10%
[10]

Early CPR - This buys time by keeping vital organs
perfused with oxygen whilst waiting for equipment and
trained personnel to reverse the arrest. In particular, by
keeping the brain supplied with oxygenated blood,
chances of neurological damage are decreased.
Early defibrillation - This is the only effective
treatment for ventricular fibrillation, and also has
benefit in ventricular tachycardia
[10]
and should be
employed in such cases if the patient has signs of
hemodynamic compromise, or if the patient has
pulseless ventricular tachycardia. If defibrillation is
delayed, then the rhythm is likely to degenerate into
asystole, for which outcomes are markedly worse.
Early advanced care - Early Advanced Cardiac Life
Support is the final link in the chain of survival.
If one or more links in the chain are missing or delayed, then the
chances of survival drop significantly. In particular, bystander CPR
is an important indicator of survival: if it has not been carried out,
then resuscitation is associated with very poor results. Paramedics
in some jurisdictions are authorised to abandon resuscitation
altogether if the early stages of the chain have not been carried out
in a timely fashion prior to their arrival.
Because of this, considerable effort has been put into educating the
public on the need for CPR. In addition, there is increasing use of
public access defibrillation. This involves placing automated
external defibrillators in public places, and training key staff in
these areas how to use them. This allows defibrillation to take
place prior to the arrival of emergency services, and has been
shown to lead to increased chances of survival. In addition, it has
been shown that those who suffer arrests in remote locations have
worse outcomes following cardiac arrest
[16]
: these areas often have
first responder schemes, whereby members of the community
receive training in resuscitation and are given a defibrillator, and
called by the emergency medical services in the case of a collapse
in their local area.
[edit] Hospital treatment
Treatment within a hospital usually follows advanced life support
protocols. In the US, non-traumatic adult resuscitation is described
by ACLS (advanced cardiac life support), pediatric resuscitation is
described by PALS (pediatric advanced life support), and neonatal
resusciation is described by NALS (neonatal advanced life
support.) Depending on the diagnosis, various treatments are
offered, ranging from defibrillation (for ventricular fibrillation or
ventricular tachycardia) to surgery (for cardiac arrest which can be
reversed by surgery - see causes of arrest, above) to medication
(for asystole and PEA). All will include CPR.
While specific details may vary, all hospitals have protocols as to
how resuscitations should be performed in patients, visitors, or
employees who have arrested unexpectedly in the hospital. These
protocols are often initiated by a Code Blue, which usually denotes
impending or acute onset of cardiac arrest or respiratory failure,
although in practice, Code Blue is often called in less life-
threatening situations that require immediate attention from a
physician.
If not already done, a definitive airway will be establish by the
placement of an endotracheal tube which is then attached to a
mechanical ventilator.
Cardiac arrest is generally divided into two cases: presence of
disorganized mechanical cardiac activity, or complete absence of
mechanical cardiac activity.
Disorganized mechanical cardiac activity includes ventricular
fibrillation and hemodynamically unstable or pulseless ventricular
tachycardia. This also includes torsade de pointes. These must all
be treated primarily with defibrillation. Advanced cardiac life
support algorithms also detail the stepwise administration of
epinephrine, vasopressin, the antiarrhythmic agent amiodarone, as
well as attempts to correct possible underlying causes.
Complete absence of mechanical cardiac activity includes asystole
and pulseless electrical activity. This is treated entirely with
pharmacologic agents, specifically epinephrine and atropine.
However, resuscitation is rarely successful without effective
treatment of the underlying cause.
[edit] Therapeutic hypothermia
Main article: Therapeutic hypothermia
In some cases, doctors may choose to induce hypothermia after
return of spontaneous circulation (ROSC). This procedure is called
therapeutic hypothermia. The first study conducted in Europe
focused on people who were resuscitated 5-15 minutes after
collapse. Patients participating in this study experienced
spontaneous return of circulation (ROSC) after an average of 105
minutes. Subjects were then cooled over a 24 hour period, with a
target temperature of 32-34C (89.6-93.2F). 55% of the 137
patients in the hypothermia group experienced favorable outcomes,
compared with only 39% in the group that received standard care
following resuscitation.
[17]
Death rates in the hypothermia group
were 14% lower, meaning that for every 7 patients treated one life
was saved.
[17]
Notably, complications between the two groups did
not differ substantially. This data was supported by another
similarly run study that took place simultaneously in Australia. In
this study 49% of the patients treated with hypothermia following
cardiac arrest experienced good outcomes, compared to only 26%
of those who received standard care.
[18]

[edit] Peri-arrest period
The period (either before or after) surrounding a cardiac arrest is
known as the peri-arrest period. During this period the patient is
in a highly unstable condition and must be constantly monitored in
order to halt the progression or repeat of a full cardiac arrest. The
preventative treatment used during the peri-arrest period depends
on the causes of the impending arrest and the likelihood such an
event occurring.
[edit] Prognosis
The out-of-hospital cardiac arrest (OHCA) has a worse survival
rate (2-8% at discharge and 8-22% on admission), than an in-
hospital cardiac arrest (15% at discharge). The principal
determining factor is the initially documented rhythm. Patients
with VF/VT have 10-15 times more chance of surviving than those
suffering from pulseless electrical activity or asystole (as they are
sensitive to defibrillation, whereas asystole and PEA are not).
[citation
needed]

Since mortality in case of OHCA is high, programs were
developed to improve survival rate. A study by Bunch et al.
showed that, although mortality in case of ventricular fibrillation is
high, rapid intervention with a defibrillator increases survival rate
to that of patients that did not have a cardiac arrest.
[12][19]

Survival is mostly related to the cause of the arrest (see above). In
particular, patients who have suffered hypothermia have an
increased survival rate, possibly because the cold protects the vital
organs from the effects of tissue hypoxia. Survival rates following
an arrest induced by toxins is very much dependent on identifying
the toxin and administering an appropriate antidote. A patient who
has suffered a myocardial infarction due to a blood clot in the left
coronary artery has a lower chance of survival as it cuts of the
blood supply to most of the left ventricle (the chamber which must
pump blood to the whole of the systemic circulation).
Cobbe et al (1996) conducted a study into survival rates from out
of hospital cardiac arrest. 14.6% of those who had received
resuscitation by ambulance staff survived as far as admission to an
acute hospital ward. Of these, 59.3% died during that admission,
half of these within the first 24 hours. 46.1% survived to hospital
discharge (this is 6.75% of those who had been resuscitated by
ambulance staff), however 97.5% suffered a mild to moderate
neurological disability, and 2% suffered a major neurological
disability. Of those who were successfully discharged from
hospital, 70% were still alive 4 years after their discharge.
[20]

Ballew (1997) performed a review of 68 earlier studies into
prognosis following in-hospital cardiac arrest. They found a
survival to discharge rate of 14% (this roughly double the rate for
out of hospital arrest found by Cobbe et al (see above)), although
there was a wide range (0-28%).
[21]

[edit] Prevention
With positive outcomes following cardiac arrest so unlikely, a
great deal of effort has been spent in finding effective strategies to
prevent cardiac arrest.
As noted above, one of the prime causes of cardiac arrest outside
of hospital is ischemic heart disease. Vast resources have been put
into trying to reduce cardiovascular risks across much of the
developed world. In particular schemes have been put in place to
promote a healthy diet and exercise. For people considered to be
particularly at risk of heart disease, measures such as blood
pressure control, prescription of cholesterol lowering medications,
and other medico-therapeutic interventions, have been widely
used. A magnesium deficiency, or lower levels of magnesium, can
contribute to heart disease and a healthy diet that contains adequte
magnesium may help prevent heart disease.
[22]
Magnesium can be
used to enhance long term treatment, so it may be effective in long
term prevention.
Patients in hospital are far less likely to have a cardiac arrest
caused of primary cardiac origin, and hence present in asystole or
PEA, and have bleak outcomes.
[citation needed]
Extensive research has
shown that patients in general wards often deteriorate for several
hours or even days before a cardiac arrest occurs
[10][23]
. This has
been attributed to a lack of knowledge and skill amongst ward
based staff, in particular a failure to carry out measurement of the
respiratory rate, which is often the major predictor of a
deterioration
[10]
and can often change up to 48 hours prior to a
cardiac arrest. In response to this, many hospitals now have
increased training for ward based staff. A number of "early
warning" systems also exist which aim to quantify the risk which
patients are at of deterioration based on their vital signs and thus
provide a guide to staff. In addition, specialist staff are being
utilised more effectively in order to augment the work already
being done at ward level. These include:
Crash teams (also known as code teams) - These are
designated staff members who have particular expertise
in resuscitation, who are called to the scene of all
arrests within the hospital.
Medical emergency teams - These teams respond to
all emergencies, with the aim of treating the patient in
the acute phase of their illness in order to prevent a
cardiac arrest.
Critical care outreach - As well as providing the
services of the other two types of team, these teams are
also responsible for educating non-specialist staff. In
addition, they help to facilitate transfers between
intensive care/high dependency units and the general
hospital wards. This is particularly important, as many
studies have shown that a significant percentage of
patients discharged from critical care environments
quickly deteriorate and are re-admitted - the outreach
team offers support to ward staff to prevent this from
happening.
[edit] Implantable cardioverter defibrillators
A technologically based intervention to prevent further cardiac
arrest episodes is the use of an implantable cardioverter-
defibrillator (ICD). This device is implanted in to the patient.
They act as an instant defibrillator in the event of arrhythmia. Note
that standalone ICDs do not have any pacemaker functions, but
they can be combined with a pacemaker, and modern versions also
have advanced features such as anti-tachycardic pacing as well as
synchronized cardioversion. A recent study by Birnie et al. at the
University of Ottawa Heart Institute has demonstrated that ICDs
are underused in both the United States and Canada.
[24]
An
accompanying editorial by Simpson explores some of the
economic, geographic, social and political reasons for this.
[25]

Patients who are most likely to benefit from the placement of an
ICD are those with severe ischemic cardiomyopathy (with systolic
ejection fractions less than 30%) as demonstrated by the MADIT-
II trial.
[26]

[edit] Ethical issues
Cardiopulmonary resuscitation and advanced cardiac life support
are not always in a person's best interest. This is particularly true in
the case of terminal illnesses when resuscitation will not alter the
outcome of the disease. Properly performed CPR often fractures
the rib cage, especially in older patients or those suffering from
osteoporosis. Defibrillation, especially repeated several times as
called for by ACLS protocols, may also cause electrical burns.
Some people with a terminal illness choose to avoid such measures
and die peacefully. People with views on the treatment they wish
to receive in the event of a cardiac arrest should discuss these
views with both their doctor and with their family. A patient may
ask their doctor to place a do not resuscitate (DNR) order in the
medical record. Alternatively, in many jurisdictions, a person may
formally state their wishes in an advance directive or advance
health directive.
[edit] See also