Cardiac arrest

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For other uses, see Cardiac arrest (disambiguation).

Cardiac arrest

Classification and external resources

CPR being administered during a simulation of cardiac arrest.

ICD-10 I46

ICD-9 427.5

DiseasesDB 2095

MeSH D006323

Cardiac arrest, also known as cardiopulmonary arrest or circulatory arrest, is a sudden stop in
effective blood circulation due to failure of the heart to contract effectively or at all. Medical
[1]

personnel may refer to an unexpected cardiac arrest as a sudden cardiac arrest (SCA).
A cardiac arrest is different from (but may be caused by) a heart attack, where blood flow to the
muscle of the heart is impaired. It is different from congestive heart failure, where circulation is
[2]

substandard, but the heart is still pumping sufficient blood to sustain life.
Arrested blood circulation prevents delivery of oxygen and glucose to the body. Lack of oxygen and
glucose to the brain causes loss of consciousness, which then results in abnormal or absent
breathing. Brain injury is likely to happen if cardiac arrest goes untreated for more than five
minutes. For the best chance of survival and neurological recovery, immediate and decisive
[3][4][5]

treatment is imperative. [6]

Cardiac arrest is a medical emergency that, in certain situations, is potentially reversible if treated
early. Unexpected cardiac arrest can lead to death within minutes: this is called sudden cardiac
death (SCD). The treatment for cardiac arrest is immediate defibrillation if a "shockable" rhythm is
[1]

present, while cardiopulmonary resuscitation (CPR) is used to provide circulatory support and/or to
induce a "shockable" rhythm.

Contents
[hide]

1 Classification
2 Signs and symptoms
3 Causes
o 3.1 Coronary heart disease
o 3.2 Non-ischemic heart disease
 o 3.3 Non-cardiac
o 3.4 Risk factors
o 3.5 Hs and Ts
4 Diagnosis
5 Prevention
o 5.1 Code teams
o 5.2 Implantable cardioverter defibrillators
6 Management
o 6.1 Cardiopulmonary resuscitation
o 6.2 Defibrillation
o 6.3 Medications
o 6.4 Therapeutic hypothermia
o 6.5 Do not resuscitate
o 6.6 Chain of survival
o 6.7 Other
7 Prognosis
8 Epidemiology
9 References
10 External links

Classification[edit]
Clinicians classify cardiac arrest into "shockable" versus "nonshockable", as determined by
the ECG rhythm. This refers to whether a particular class of cardiac dysrhythmia is treatable
using defibrillation. The two "shockable" rhythms are ventricular fibrillation andpulseless ventricular
[7]

tachycardia while the two "nonshockable" rhythms are asystole and pulseless electrical activity. [8]

Signs and symptoms[edit]

Cardiac arrest is an abrupt cessation of pump function in the heart (as evidenced by the absence of
a palpable pulse). Prompt intervention can usually reverse a cardiac arrest, but without such
intervention it will almost always lead to death. In certain cases, it is an expected outcome to a
[1]

serious illness. [9]

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 ofcirculation; however, there
are a number of ways of determining this. Near death experiences are reported by 10-20% of people
who survived cardiac arrest. [10]

Causes[edit]
Coronary heart disease is the leading cause of sudden cardiac arrest. Many other cardiac and non-
cardiac conditions also increase one's risk.
Coronary heart disease[edit]
Approximately 6070% of SCD is related to coronary heart disease. Among adults, ischemic
[11][12]

heart disease is the predominant cause of arrest with 30% of people at autopsy showing signs of
[13]

recent myocardial infarction. [citation needed]

Non-ischemic heart disease[edit]

A number of other cardiac abnormalities can increase the risk of SCD
including: cardiomyopathy, cardiac rhythm disturbances, hypertensive heart disease, congestive
[11]

heart failure. [14]

In a group of military recruits aged 1835, cardiac anomalies accounted for 51% of cases of SCD,
while in 35% of cases the cause remained unknown. Underlying pathology included: coronary artery
abnormalities (61%), myocarditis (20%), and hypertrophic cardiomyopathy (13%). Congestive heart
[15]

failure increases the risk of SCD by 5 fold. [14]

Many additional conduction abnormalities exist that place one at higher risk for cardiac arrest. For
instance, long QT syndrome, a condition often mentioned in young people's deaths, occurs in
1/5000-1/7000 newborns and is estimated to be responsible 3000 deaths each year compared to the
approximately 300000 cardiac arrests seen by emergency services . These conditions are a
[16]

fraction of the overall deaths related to cardiac arrest, but represent conditions which may be
detected prior to arrest, which may be treatable.
Non-cardiac[edit]
About 35% of SCDs are not caused by a heart condition. The most common non-cardiac causes
are trauma, bleeding (such as gastrointestinal bleeding, aortic rupture, or intracranial
hemorrhage), overdose, drowning and pulmonary embolism. Cardiac arrest can also be caused by
[17]

poisoning (for example, by the stings of certain jellyfish).

Risk factors[edit]
The risk factors for SCD are similar to those of coronary heart disease, and include smoking, lack
of physical exercise, obesity and diabetes, as well as family history.[18]

Hs and Ts[edit]
Main article: Hs and Ts
"Hs and Ts" is the name for a mnemonic used to aid in remembering the possible treatable or
reversible causes of cardiac arrest.[7][19]

Hs

Hypovolemia - A lack of blood volume

Hypoxia - A lack of oxygen
Hydrogen ions (Acidosis) - An abnormal pH in the body
Hyperkalemia or Hypokalemia - Both excess and inadequate potassium can be life-threatening.
Hypothermia - A low core body temperature
Hypoglycemia or Hyperglycemia - Low or high blood glucose
Ts

Tablets or Toxins
Cardiac Tamponade - Fluid building around the heart
Tension pneumothorax - A collapsed lung
Thrombosis (Myocardial infarction) - Heart attack
Thromboembolism (Pulmonary embolism) - A blood clot in the lung
Traumatic cardiac arrest

Diagnosis[edit]
Cardiac arrest is synonymous with clinical death.
A cardiac arrest is usually diagnosed clinically by the absence of a pulse. 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 result from 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 or lay persons.
[20] [21]

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, have [19]

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.[7]

Various other methods for detecting circulation have been proposed. Guidelines following the 2000
International Liaison Committee on Resuscitation (ILCOR) recommendations were for rescuers to
look for "signs of circulation", but not specifically the pulse. These signs included coughing,
[19]

gasping, colour, twitching and movement. However, in face of evidence that these guidelines were
[22]

ineffective, the current recommendation of ILCOR is that cardiac arrest should be diagnosed in all
casualties who are unconscious and not breathing normally. [19]

Prevention[edit]
With positive outcomes following cardiac arrest unlikely, an effort has been spent in finding effective
strategies to prevent cardiac arrest. With the prime causes of cardiac arrest being ischemic heart
disease, efforts to promote a healthy diet, exercise, and smoking cessation are important. For
people at risk of heart disease, measures such as blood pressure control, cholesterol lowering, and
other medico-therapeutic interventions are used. [1]

Code teams[edit]
In medical parlance, cardiac arrest is referred to as a "code" or a "crash". This typically refers to
"code blue" on the hospital emergency codes. A dramatic drop in vital sign measurements is referred
to as "coding" or "crashing", though coding is usually used when it results in cardiac arrest, while
crashing might not. Treatment for cardiac arrest is sometimes referred to as "calling a code".
Extensive research has shown that patients in general wards often deteriorate for several hours or
even days before a cardiac arrest occurs. This has been attributed to a lack of knowledge and skill
[7][23]

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 and can often change up to 48 hours prior to a
[7]

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 (or 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. This
usually involves a specialized cart of equipment (including defibrillator) and drugs called a "crash
cart" or "crash trolley".
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.
In some medical facilities, the resuscitation team may purposely respond slowly to a patient in
cardiac arrest, a practice known as slow code, or may fake the response altogether for the sake of
the patient's family, a practice known as show code. This is generally done for patients for whom
[24]

performing CPR will have no medical benefit. Such practices are ethically controversial, and are
[25] [26]

banned in some jurisdictions.

Implantable cardioverter defibrillators[edit]
A technologically based intervention to prevent further cardiac arrest episodes is the use of
an implantable cardioverter-defibrillator (ICD). This device is implanted in the patient and acts 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. An accompanying editorial by Simpson explores
[27]

some of the economic, geographic, social and political reasons for this. Patients who are most
[28]

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. [29]

Management[edit]
Sudden cardiac arrest may be treated via attempts at resuscitation. This is usually carried out based
upon basic life support (BLS) / advanced cardiac life support (ACLS), pediatric advanced life
[19]

support (PALS) or neonatal resuscitation program (NRP) guidelines.

[30]

Cardiopulmonary resuscitation[edit]
Cardiopulmonary resuscitation (CPR) is a important part of the management of cardiac arrest. It is
recommended that it be started as soon as possible and interrupted as little as possible. The
component of CPR which seems to make the greatest difference in most cases is the chest
compressions. Correctly performed bystander CPR has been shown to increase survival; however, it
is performed in less than 30% of out of hospital arrests as of 2007. If high quality CPR has not
[31]

resulted in return of spontaneous circulation and the person's heart rhythm is

in asystole discontinuing CPR and pronouncing the person death is reasonable after 20
minutes. Exceptions to this include those with hypothermia or who have drowned. Longer
[32] [32]

durations of CPR may be reasonable in those who have cardiac arrest while in hospital. [33]

Tracheal intubation has not been found to improve survival rates in cardiac arrest and in the [31]

prehospital environment may worsen it. A 2009 study found that assisted ventilation may worsen
[34]

outcomes over placement of an oral airway with passive oxygen delivery. [35]

CPR which involves only chest compressions results in the same outcomes as standard CPR for
those who have gone into cardiac arrest due to heart issues. A 2013 review found some evidence
[36]

that mechanical chest compressions (as performed by a machine) are better than manual chest
compressions while a 2011 and 2012 review considered the evidence insufficient.
[37]
It is unclear if [38][39]

a few minutes of CPR before defibrillation results in different outcomes than immediate
defibrillation.[40]

Defibrillation[edit]
Shockable and nonshockable causes of cardiac arrest is based on the presence or absence
of ventricular fibrillation or pulseless ventricular tachycardia. The shockable rhythms are treated with
CPR and defibrillation.
In addition, there is increasing use of public access defibrillation. This involves placing automated
external defibrillators in public places, and training 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. Some defibrillators even provide feedback on the quality of CPR
compressions, encouraging the lay rescuer to press the patient's chest hard enough to circulate
blood. In addition, it has been shown that those who have arrests in remote locations have worse
[41]

outcomes following cardiac arrest. [42]

Medications[edit]
Medications, while included in guidelines, have been shown not to improve survival to hospital
discharge post out of hospital cardiac arrest. This includes the use of epinephrine, atropine,
and amiodarone. Vasopressin overall does not improve or worsen outcomes but may be of
[43][44]

benefit in those with asystole especially if used early. [45]

Epinephrine does appear to improve short term outcomes such as return of spontaneous
circulation. Some of the lack of long term benefit may be related to delays in epinephrine use.
[46] [47]

The 2010 guidelines, from the American Heart Association has removed its recommendation for
using atropine in pulseless electrical activity and asystole due to the lack of evidence for its
use. Evidence is insufficient for lidocaine and amiodarone may be considered in those who
[48]

continue in ventricular tachycardia or ventricular fibrillation despite

defibrillation. Thrombolytics when used generally may cause harm but may be of benefit in those
[49]

with a pulmonary embolism as the cause of arrest. [50]

Therapeutic hypothermia[edit]
Main article: Therapeutic hypothermia
Cooling a person after cardiac arrest with return of spontaneous circulation (ROSC) but without
return of consciousness may or may not improve outcomes. This procedure is called therapeutic
[51][52]

hypothermia. People are cooled over a 24 hour period, with a target temperature of 3234 C (90
93 F). Death rates in the hypothermia group were initially believed to be 35% lower with generally
mild complications. A November 2013 trial, however, called this idea into question with findings
[51][53]

that a temperature of 36 C (97 F) results in the same outcomes as 33 C (91 F). And a second[52]

trial looking at earlier versus later cooling found no difference. [54]

Do not resuscitate[edit]
Some people choose to avoid aggressive measures at the end of life. A do not resuscitate order
(DNR) in the form of an advance health care directive makes it clear that in the event of cardiac
arrest, the person does not wish to receive cardiopulmonary resuscitation. Other directives may be
[55]

made to stipulate the desire for intubation in the event of respiratory failure or, if comfort measures
are all that are desired, by stipulating that healthcare providers should "allow natural death". [56]

Chain of survival[edit]
Several organisations promote the idea of a chain of survival. The chain consists of the following
"links":

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 stays in cardiac arrest, their chances of
survival drop by roughly 10%. [7]

Early CPR - improves the flow of blood and of oxygen to vital organs - an essential component
of treating a cardiac arrest. In particular, by keeping the brain supplied with oxygenated blood,
chances of neurological damage are decreased.
Early defibrillation - is effective for the management of ventricular fibrillation and
pulseless ventricular tachycardia [7]

Early advanced care

Early post resuscitation care
If one or more links in the chain are missing or delayed, then the chances of survival drop
significantly.
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. [citation needed]

Other[edit]
Resuscitation with extracorporeal membrane oxygenation devices has been attempted with better
results for in-hospital cardiac arrest (29% survival) than out of hospital cardiac arrest (4% survival) in
populations selected to benefit most. Cardiac catheterization in those who have survived an out of
[57]

hospital cardiac arrest appears to improve outcomes. [58]

The precordial thump may be considered in those with witnessed, monitored, unstable ventricular
tachycardia (including pulseless VT) if a defibrillator is not immediately ready for use, but it should
not delay CPR and shock delivery or be used in those with unwitnessed out of hospital arrest. [59]

Prognosis[edit]
The survival rate to hospital discharge of people who receive initial emergency care by ambulance is
2%, with 15% experiencing return of spontaneous circulation. However, with defibrillation within 3
[60]

5 minutes, the survival rate increases to 30%. Since mortality in case of out-of-hospital cardiac
[61][62]

arrest is high, programs were developed to improve survival rate. Although mortality in case of
ventricular fibrillation is high, rapid intervention with a defibrillator increases survival rate. [13][63]

A 1997 review into outcomes following in-hospital cardiac arrest found a survival to discharge of
14% although the range between different studies was 0-28%. In those over the age of 70 who
[64]

have a cardiac arrest while in hospital, survival to hospital discharge is less than 20%. How well [65]

these individuals are able to manage after leaving hospital is not clear. [65]

Survival is mostly related to the cause of the arrest (see above). In particular, people 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. [citation needed]

A study of survival rates from out of hospital cardiac arrest found that 14.6% of those who had
received resuscitation by ambulance staff survived as far as admission to hospital. Of these, 59%
died during admission, half of these within the first 24 hours, while 46% survived until discharge from
hospital. This gives us an overall survival following cardiac arrest of 6.8%. Of these 89% had normal
brain function or mild neurological disability, 8.5% had moderate impairment, and 2% suffered major
neurological disability. Of those who were discharged from hospital, 70% were still alive 4 years
later.
[66]

Epidemiology[edit]
Based on death certificates sudden cardiac death accounts for about 15% of all death in Western
countries (330,000 per year in the United States). The lifetime risk is three times greater in men
[11] [31]

(12.3%) than women (4.2%) based on analysis of the Framingham Heart Study. However this [67]

gender difference disappeared beyond 85 years of age. [11]