Cardiac arrest.

A cardiac 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]

"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. 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. 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) to provide circulatory
support until availability of medical treatment.

[edit] Etiology

People experiencing cardiac arrest are often transported to a hospital via ambulance

Ventricular fibrillation (VF) constitutes the most common electrical mechanism in

cardiac arrest, and is responsible for 65 to 80% of occurrences. Another 20-30% is caused
by severe bradyarrhythmias, pulseless electrical activity (PEA) and asystole. Other
conditions are associated with impaired circulation due to a state of shock. [1]

Among adults ischemic heart disease is the predominant cause.[6] At autopsy 30% of
victims show signs of recent myocardial infarction. Other conditions include structural
abnormalities, arrhythmias and cardiomyopathies. Secondary cardiac arrest may be
elicited by non-cardiac conditions such as hypoxia from a variety of causes,[7]
overwhelming infection (sepsis), massive pulmonary embolus, arrythmias, cardiac
tamponade, shock, pneumothorax, ventricular rupture, as well as other conditions such as
electrocution and near-drowning. Non-cardiac conditions constitute the principal cause of
cardiac arrest in in-hospital patients.[8]
Coronary heart disease (CHD) -also known as coronary artery disease, or (CAD)- is the
predominant disease process associated with sudden cardiac death in the United States
and elsewhere in the developed world. The incidence of CHD in individuals who suffer
sudden cardiac death is between 64 and 90%.

In children , cardiac arrest is typically caused by hypoxia from other causes such as near-
drowning. With prompt treatment survival rates are high.

[edit] Treatable causes

The most important treatable cause of cardiac arrest is ventricular fibrillation. The only
definitive treatment is defibrillation, although the entire chain of survival must be intact if
a victim of out-of-hospital cardiopulmonary arrest is to survive. The chain of survival
consists of 1. early access to emergency medical services, 2. early CPR, 3. early
defibrillation, and 4. early advanced care. The efficacy of defibrillation is time dependent,
and the odds of successful resuscitation decline rapidly from the onset of
cardiopulmonary arrest. However, current research suggests that 1.5 to 3 minutes of CPR
prior to the first shock may increase survival rates when down times exceed 4 minutes
and no CPR has been performed prior to the defibrillator's arrival.

For other causes of cardiac arrest, the best treatment is prevention. Aggressive therapy
innitiated in the peri-arrest period may prevent cardiac arrest and subsequent death.
Reversible causes of asystole and pulseless electrical activity include the "Hs and Ts."[9]
[10][11]

[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
esophagogastroduodenoscopy (i.e. esophageal varices) and thoracotomy for
internal bleeding.

• Hypoxia - A lack of oxygen to the heart, brain and other vital organs. This can be
identified through a careful assessment of breath sounds and tuble placement.
Treatment may include providing oxygen, proper ventilation, and good CPR
technique.

• Hydrogen ions (Acidosis) - An abnormal pH in the body as a result of shock,

DKA, renal failure, or tricyclic antidepressant overdose. This can be treated with
proper ventilation, good CPR technique, and buffers like sodium bicaronate.

• Hyperkalemia or Hypokalemia - The most life threatening electrolyte

derangement is hyperkalemia (too much potassium). The classic presentation is
 the chronic renal failure patient who has missed a dialysis appointment and
presents with weakness, nausea, and broad QRS complexes on the
electrocardiogram. The most important initial therapy is the administration of
calcium, either with calcium gluconate or calcium chloride. Other therapies may
include nebulized albuterol, sodium bicarbonate, glucose, and insulin. The
diagnosis of hypokalemia (not enough potassium) can be suspected when there is
a history of diarrhea or malnutrition. Loop diuretics may also contribute. The
electrocardiogram may show depressed 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.

• Hypothermia - A low core body temperature, defined clinically as a temperature

of less than 35 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 insulin reactions,

DKA, nonketotic hyperosmolar coma. This condition can be suspected when the
patient is known to be a diabetic. The treatment may include fluids, potassium,
glucose (for hypoglycemia), and insulin (for hyperglycemia).

[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.

• 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
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
an emergency thoracotomy 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. This is relieved in an emergency 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 intervention.

• Thrombosis (Pulmonary embolism) - Usually diagnosed at autopsy. Patients in

asystole or pulseless electrical activity have a poor prognosis. If this can be
detected early, the patient may receive dopamine, heparin, and thrombolytics.

• 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.

In addition to the specific treatments for the causes of cardiac arrest, full resuscitation
(using advanced life support protocols) is offered to patients as soon as possible, and
continues until the patient is either declared dead or regains a pulse and stable heart
rhythm.

Checking respiration.

Checking carotidian pulse.

Insulfation mouth-to-mouth.

[edit] 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] In many cases, lack of carotid pulse is the gold standard for
diagnosing cardiac arrest, but pulselessness (particularly in the peripheral pulses) may be
a result of other conditions (i.e. shock, or other conditions leading to poor circulation)

In a hospital or ambulance, cardiac arrest is identified by the lack of a pulse (or lack of
heartbeat if listened to through a stethoscope), and advanced life support is given.

Out of hospital, lay rescuers are now being taught to identify cardiac arrest in as simple a
manner as possible. With the latest standard as set by the ILCOR, lay rescuers are taught
that a lack of normal breathing is evidence of cardiac arrest, and they begin CPR without
checking a pulse.

An ECG clarifies the heart rhythm and guides therapy, but basic life support should begin
without awaiting an ECG. The ECG may reveal:

• Asystole (known colloquially as a flatline) - a complete stoppage of the heart

• Pulseless electrical activity - The ECG shows electrical activity that could be
consistent with a palpable pulse but no pulse is palpable. It can be because of
electromechanical dissasociation(EMD) or because the cardiac output is so poor
as to not be palpable.
• ventricular fibrillation - A quivering of the ventricles
• ventricular tachycardia - The ventricles contract so rapidly that they do not refill
fully between beats, so they do not pump enough blood to maintain circulation.

[edit] Treatment
[edit] First aid

First aid treatment of cardiac arrest varies from country to country, but the general
principles of the guidelines in all locales are to summon help (in the form of an
ambulance) and then begin CPR.
[edit] Other prehospital care

In many situations in the UK and USA, lay people are trained in the use of an automated
external defibrillator, which analyzes the heart rhythm and delivers a controlled electric
shock to the heart if indicated.

Jurisdictions are beginning to purchase automated CPR machines, such as AutoPulse, to

assist first responders. Such machines are proving superior in cardiac arrest support over
manual CPR, providing for greater circulation and, thus, lower rates of morbidity and
mortality when used in a timely fashion. The ASPIRE Trial - a multicenter
investigational trial of the AutoPulse - published its results and stated that the AutoPulse
resulted in worse neurological outcome than manual compression CPR.

[edit] Hospital treatment

Treatment within a hospital usually follows advanced life support protocols. 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.

[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).[7]

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.[6][12]

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. [13]

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%). [14]

Several high profile organisations (such as St John Ambulance and the British Heart
Foundation) have promoted the "Chain of Survival", which is made up of 4 links, as a
way to maximise prognosis following arrest:

• Early Access - Identifying patients at risk of cardiac arrest early is the best way of
improving prognosis, as it is often possible to prevent the arrest. Similarly, if the
arrest is witnessed there is a much greater chance of survival, as treatment can
begin straight away before tissue hypoxia sets in.

• Early CPR - CPR is unlikely to revive the patient, but it does buy some time by
keeping a (limited) circulation going until it is possible to reverse the arrest,
thereby increasing the chances of this reversal being successful, and minimising
the risk of cerebral hypoxia (which can lead to neurological impairment following
return of circulation).

• Early defibrillation - Patients who present with VF/VT can be defibrillated, and
the earlier this happens the better, as VF/VT often degenerate into asystole (which
is unshockable).

• Early hospital care - Many patients suffer further arrests within the first 24 hours
of admission, so it is better that they are in hospital where their chances of
survival are a little higher.

[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. Internal cardiac massage, an ACLS procedure performed by
emergency medicine physicians requires splitting open the rib cage, which is painful
during the weeks of recovery. While such treatment is worthwhile when it saves a life, it
is sometimes perceived as undignified and adding to the suffering of a victim with a
terminal illness who wishes to die peacefully.

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.

It is also important that these views are written down somewhere in the medical record.
In the event of cardiac arrest, health professionals need to act quickly on the information
that is available to them. As cardiac arrest often happens out of regular hours, the
resuscitation team rarely includes anybody who actually knows the patient.

A patient may ask their doctor to record 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] References
1. ^ a b c d Harrison's Principles of Internal Medicine 16th Edtion, The McGraw-Hill
Companies, ISBN 0-07-140235-7
2. ^ Safar P (1986). "Cerebral resuscitation after cardiac arrest: a review". Circulation 74:
IV138-153. Retrieved on 2007-01-05.
3. ^ Holzer M, Behringer W (2005). "Therapeutic hypothermia after cardiac arrest".
Current Opinion in Anaestesiology 18: 163-168. Retrieved on 2007-01-03.
4. ^ Safar P et al (1996). "Improved cerebral resuscitation from cardiac arrest in dogs with
mild hypothermia plus blood flow promotion". Stroke 27: 105-113. Retrieved on 2007-
01-07.
5. ^ Irwin and Rippe's Intensive Care Medicine by Irwin and Rippe, Fifth Edition (2003),
Lippincott Williams & Wilkins, ISBN 0-7817-3548-3
6. ^ a b Cardiac Resuscitation Mickey S. Eisenberg, M.D., Ph. D., and Terry J. Mengert,
M.D. New England Journal of Medicine, Volume 344:1304-1313, April 26, 2001
7. ^ a b The Oxford Textbook of Medicine Edited by David A. Warrell, Timothy M. Cox and
John D. Firth with Edward J. Benz, Fourth Edition (2003), Oxford University Press,
ISBN 0-19-262922-0
8. ^ European Resuscitation Council Guidelines for Resuscitation 2005 Section 4. Adult
advanced life support, by Jerry P. Nolan, Charles D. Deakin, Jasmeet Soar, Bernd W.
B¨ottiger, Gary Smith
 9. ^ ACLS: Principles and Practice. p. 71-87. Dallas: American Heart Association, 2003.
ISBN 0-87493-341-2.
10. ^ ACLS for Experienced Providers. p. 3-5. Dallas: American Heart Association, 2003.
ISBN 0-87493-424-9.
11. ^ "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care - Part 7.2: Management of Cardiac Arrest." Circulation
2005; 112: IV-58 - IV-66.
12. ^ Long-Term Outcomes of Out-of-Hospital Cardiac Arrest after Successful Early
Defibrillation T. Jared Bunch, M.D., Roger D. White, M.D., Bernard J. Gersh, M.B., Ch.
B., Ryan A. Meverden, B.S., David O. Hodge, M.S., Karla V. Ballman, Ph. D., Stephen
C. Hammill, M.D., Win-Kuang Shen, M.D., and Douglas L. Packer, M.D., New England
Journal of Medicine, Volume 348:2626-2633, June 26, 2003
13. ^ Survival of 1476 patients initially resuscitated from out of hospital cardiac arrest Stuart
M Cobbe, Kirsty Dalziel, Ian Ford, Andrew K Marsden, British Medical Journal
1996;312:1633-1637 (29 June)
14. ^ Recent advances: Cardiopulmonary resuscitation Kenneth A Ballew, British Medical
Journal 1997;314:1462 (17 May)

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