Talk:Cardiac arrest

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This is the talk page for discussing improvements to the Cardiac arrest article.

I think there is a slight difference between "clinical death" and "cardiac arrest".
Cardiac arrest inevitably leads to clinical death but clinical death is the period when circulation ceases and oxygen etc supply is cut from vitally important tissues, namely brain and heart muscle. The consequence is shift into anaerobic metabolism, acidosis and cell disintegraton.
This period is variable and depends on many factors for instance age and surroundings temperature.
There have been examples of successful resuscitation of people drowned for half and hour in ice-cold water.

I agree.


Anyone care to have a look at the "Ethical Issues" section? While the author seems to have tried to advance a possibly valid point (that of terminal patients not willing to prolonge their suffering), the way it is currently written kind of seems to imply that one should not provide emergency care to an arrested patient because of the risk of (non-serious, given the circumstances) injury or pain.--81.42.163.238 01:14, 20 Apr 2005 (UTC)

Contents

[edit] Make it simple

Isn't this basically when the heart stops beating? If so, please include that in the intro sentence. Twilight Realm 00:00, 3 November 2005 (UTC)

Ah, if but it were! A cessation of heartbeat is a type of cardiac arrest (known as asystole or PEA), but there are other types of cardiac arrest where the heart doesn't stop (VFib/VTach). In all cases of cardiac arrest, the carotid pulse is absent, but there are other conditions (hypovolaemia being one) where the pulse may be absent but the heart beating. The best definition is of an inneffective heart beat, but even that produces problems - sinus rhythm is the only heart rhythm which is optimally effective, so where do you draw the line? Atrial Fibrillation is not a totally effective heart beat, but neither is it a cardiac arrest. I think that medically, the definition given on the page is about as good as we're likely to get, even if it is a little long winded. --John24601 16:20, 7 January 2006 (UTC)

[edit] Causes of arrest

I don't know why it was changed from 4H/4Ts... that is the commonly accepted list in the UK at least, and is published by the UK resuscitation council. Acidosis from Hydrogen ions comes under hypo/hyper metabolic causes; and the two thromboses are dealt with together. I've changed the article back to reflect this. --John24601 12:56, 8 January 2006 (UTC)

[edit] Cardiogenic Shock

Have reverted edits by User:Nescio which deleted the page and reverted it to cardiogenic shock. Please don't do it again - alot of us have put alot of hard work into this page, we don't want to see it subsumed into another (irrelevant) topic without even so much as a discussion. Cardiac Arrest is not the same thing as cardiogenic shock.--John24601 07:32, 30 March 2006 (UTC)

Although I appreciate many have done alot of work, and I should have discussed this, much of what is mentioned is chaotic, incorrect, or irrelevant. Cardiac arrest means no circulation, and that is what cardiogenic shock is. It is not equivalent to sinus arrest: the lack of electrical activity from the sinus node. Furthermore, all causes that are mentioned in the article you want to preserve, describe shock. Maybe you could point out the difference between cardiac arrest and cardiogenic shock. Technically (semantics) arrest rapidly (sec-min) transforms into shock. However, that is no reason not to discuss the conditions in the same article, i.e. merge.
As the two terms describe the same situation, rapid depletion of oxygen in vital organs due to inadequate cardiac function, I'll have to revert.Holland Nomen Nescio 12:59, 30 March 2006 (UTC)
Errr... no. Cardiac arrest is not cardiogenic shock. Cardiac Arrest is a cessation of any circulation (although not nescessarily a stoppage of the heart); Cardiogenic shock is one condition where there may be a undereffective circulation. Cardiogenic shock may lead to cardiac arrest, but so may alot of other things. Comments anyone? --John24601 14:43, 30 March 2006 (UTC)

Elaborate please:

Cardiac Arrest is a cessation of any circulation. This is circulatory arrest is it not?

Cardiogenic shock is one condition where there may be a undereffective circulation. From Irwin and Rippe:

In cardiogenic shock, the underlying defect is primary pump failure. The causes ... include: (a) myocardial infarction .... (b) .... cardiomyopathy (c) ventricular outflow obstruction [AoS, aortic dissection] (d) ventricular filling anomalies (atrial myxoma, mitral stenosis) (e) acute valvular failure ...(f) cardiac dysrhythmias (g) ventriculoseptal defects.

This constitutes circulatory arrest and insufficient circulation does it not?

As I pointed out semantics-wise there is a difference but they are very similar and the current form I think explains that. At least it does not warrant two articles.Holland Nomen Nescio 15:11, 30 March 2006 (UTC)


I think I see where we're getting wires crossed here - you're not a native english speaker. In english, Cardiac Arrest is what you are referring to as Circulatory arrest (I guess). It's not the same thing as cardiogenic shock. If others are in agrrement I'll revert again. --John24601 15:30, 30 March 2006 (UTC)
Before reverting, could you please read the current article to see if what you are saying is not already addressed? IMHO, we have two articles discussing the same. In other words, could you explain the difference between arrest and shock to a non-native?Holland Nomen Nescio 15:36, 30 March 2006 (UTC)
Cardiogenic Shock = shock which is cardiac in origin (eg/ could be a result of cardiomyopathy, left ventricular failure, large accute MI). Shock (of which there are many types - the most common being cardiogenic and hypovolemic [diminished circulating volume ie/ after bleeding or burn]) is a condition where there is inneffective perfusion of the tissues, resulting in a mechanism to try and raise the blood pressure. A Cardiac arrest is a sudden cessation of cardiac function (ie/ it either stops [Asystole or PEA] or it goes but fails to pump blood because of its speed/rhythm [VF/VT]), which is treated with (amongst other things) CPR, Intubation, Defibrillation, and consideration of the reversible causes (Which were listed on the page - Hypoxia, Hypovolaemia, Hypothermia, Hypo/Hyper-metabolics, Toxins, Tension Pneumothorax, Tamponade or Thrombosis). They are most definitely not the same thing (although of course cardiogenic shock has the potential to degenerate into cardiac arrest).—The preceding unsigned comment was added by John24601 (talk • contribs).
At the risk of being stubborn, Irwin and Rippe is my guide and I quoted it above. You'll notice that Asystole or PEA (dysrhythmias) are mentioned as cause of cardiogenic shock. Furthermore, inneffective perfusion of the tissues is seen in shock and in cardiac arrest. Please read the well-referenced shock for a better understanding of all the conditions you name as cause of cardiac arrest.
Regarding, although of course cardiogenic shock has the potential to degenerate into cardiac arrest, shock through hypoperfusion may cause cardiac arrest but cardiac arrest may lead to shock as well. SincerelyHolland Nomen Nescio 18:55, 30 March 2006 (UTC)
I'm sorry, but you're simply wrong - I don't know how else I can put it. Yes they share some of the same pathological end-points, but they are not the same thing. Can somebody back me up here?!--John24601 20:06, 30 March 2006 (UTC)

I'm a layperson, not a health care professional, but here's my 2 cents. I don't personally care whether cardiac arrest and cardiogenic shock are one page or two, and leave that up to people in the medical project. As a reader, though, I would like someone to clear up the following questions, either on the current cardiogenic shock page or on the combination of the two pages:

    • What are the formal definitions of cardiogenic shock and cardiac arrest?
    • Given that they have different diagnosis codes, under what circumstances should a HCP diagnose one, the other or both.
    • How are they related? Is it possible to experience cardiogenic shock but not cardiac arrest? Is it possible to experience cardiac arrest but not cardiogenic shock?

If someone could expand the article(s) to answer those questions for a lay reader like me, I think it would clarify the article(s) somewhat, and maybe resolve the debate here. TheronJ 21:16, 30 March 2006 (UTC)

Definition:

  • Cardiac arrest: Abrupt cessation of cardiac pump function which may be reversible by a prompt intervention but will lead to death in its absence. From Harrison's.
  • Cardiogenic shock: the underlying defect is primary pump failure. The causes ... include: (a) myocardial infarction .... (b) .... cardiomyopathy (c) ventricular outflow obstruction [AoS, aortic dissection] (d) ventricular filling anomalies (atrial myxoma, mitral stenosis) (e) acute valvular failure ...(f) cardiac dysrhythmias (g) ventriculoseptal defects. From Irwin and Rippe.

Diagnosis:

  • In the acute setting it is not always possible to differentiate between the two. As in most cases, diagnosis is seldom black and white.

Related:

Holland Nomen Nescio 18:14, 31 March 2006 (UTC)

I have only one clarification to make to that - it is eminently possible to distinguish between the two - most easily by noting that somebody in cardiogenic shock has a pulse (and heart sounds on auscultation), and somebody in cardiac arrest does not.--John24601 18:57, 31 March 2006 (UTC)

[edit] Too BOLD

Realize I was a bit too enthousiastic, therefore I will revert awaiting this discussion. Ans added tag because it needs at least a rewrite.Holland Nomen Nescio 18:14, 31 March 2006 (UTC)

To explain my edits there are several problems:

  • Hypoxia - A lack of oxygen to the brain and other vital organs. This is treated by providing the patient with oxygen, either through a bag-valve-mask device, or by inserting an endotracheal tube (intubation)
This is myocardial infarction
  • Hypovolemia - A lack of circulating body fluids, principally blood. This is usually (though not exclusively) caused by some form of bleeding. Peri-arrest treatment includes giving IV fluids and blood transfusions, and controlling the source of any bleeding - direct pressure for external bleeding, or emergency surgery (usually an immediate emergency thoracotomy on the ward, to clamp off the descending aorta and achieve haemostasis, the bleed is then repaired properly once the patient has regained circulation) for internal bleeding.
This of course is shock
  • Hypo/Hyper-metabolic disorders - An abnormally high or low level of electrolytes such as potassium and calcium circulating the body. An arterial blood gas and blood electrolyte test are performed to find the problem, then IV crystalloids are given to correct it.
This refers to arrhytmia (asystole, VT, et cetera) and potassium, magnesium or calcium disturnances may warrant more than IV crystalloids.
  • Hypothermia - A low core body temperature, defined clinically as a temperature of less than 35 degrees celsius. 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."
I have been told that no sensible thing can be said before the patient has normal temperature. But indeed the heart has stopped.
  • Tension pneumothorax - A rush of air into one of the pleural cavities which is not able to escape compresses the lungs and causes the trachea to deviate away from the mid-line, often putting pressure on the heart so it is not able to beat effectively. This is relieved in an emergency by inserting a needle into the 2nd intercostal space at the mid-clavicular line, releasing the air and the pressure on the thoracic organs.
This is obstructive shock
  • Tamponade (Cardiac) - Blood or other fluids building up in the pericardium can put pressure on the heart so that it is not able to beat. 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.
This is obstructive shock.
  • Toxins - Toxic substances which have been ingested or injected into the body can lead to cardiac arrest. This can be evidenced by items found on or around the patient, 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 is mainly supportive, unless there is an antidote which can be administered.
This refers to arrhytmia (asystole, VT, et cetera) and certain drugs require aggressive treatment.
  • Thrombosis - Blood clots in the heart (myocardial infarction) or lungs (pulmonary embolism) are both well known causes of cardiac arrest. Treatment includes thrombolysis, and possibly surgical interventions such as angioplasty] or surgical embolectomy.
This is obstructive shock, or myocardial infarction.

IMHO, listing types of shock and arrhythmias as different causes is inaccurate. Beyond that anemia is a cause of infarction I missed in the list.Holland Nomen Nescio 19:10, 31 March 2006 (UTC)

It may be innacurate in your opinion, but it is an integral feature of the UK Resuscitation Council's guidelines for Advanced Life Suppport. They are the people who set the standards for resuscitation throughout the UK, based closely on evidence and recommendations from the European Resuscitation Council and the International Liason Committee on Resuscitation; and therefore it is astonishing, considering that you claim to be a doctor in internal medicine, that not only can you not distinguish between cardiac arrest and cardiogenic shock, but that you have not heard of the 4Hs and 4Ts. Thank goodness that you're not likely to be treating me any time soon! For your information, the guidelines can be found at [1], and if you look on page 48 you will see the section pertaining to reversible causes of arrest, which is almost exactly what is written in the article. --John24601 09:35, 1 April 2006 (UTC)
Edited to add - just incase you think it's still just us crazy brits who do it this way, take a look at the European Resuscitation Council standards (which, as you are in the Netherlands, I assume you work by!), which also mention it - [2] --John24601 09:47, 1 April 2006 (UTC)
I thought I reverted the page in light of your concerns, to react this way is at least rather harsh if not uncalled for. Thank you for those links. And unfortunately the FCCS does not use that classification and still have to do the ACLS, my mistake. Regarding your comments: pulse in shock may also be absent, to state that that is the difference is not correct. At least not always. Although I do not disagree with your list, they all boil down to 1 arrhythmia, 2 circulatory arrest diue to obstruction, 3 infarction (following 2?). On top of that I still miss anemia as cause, you must agree this can elicit myocardial infarction and arrest and should be listed.Holland Nomen Nescio 13:57, 1 April 2006 (UTC)

Added references and additional info. Hope you allow me to redeem myself.Holland Nomen Nescio 15:19, 3 April 2006 (UTC)

So you have accepted now that cardiac arrest exists as a seperate condition from cardiogenic shock? Good. Updates/referencing is much appreciated, thankyou. I have taken onboard some of your concerns re/ the style of the article, and am doing some work on this myself - for instance I've expanded and referenced the prognosis section. --John24601 16:22, 3 April 2006 (UTC)

Definitely separate. I agree with John24601 that these are two clearly distinct (although related) conditions that should not be combined. The Cardiac arrest page looks good to me (and the U.S. teaching is similar to U.K.). The Cardiogenic shock page is a tad muddled...I wonder if in fact it should just be merged into Shock, since it is useful to compare it to the other forms of shock. -- JVinocur 22:19, 11 April 2006 (UTC)

[edit] Peri-arrest arrythmias

MI does not show itself on the ECG of someone who is actually in arrest. It may reveal itself after the arrest, or be present before, but during arrest only VF/VT/PEA/asystole can be seen. Someone who has had an arrest secondary to MI usually develops a tachyarrythmia then goes into VT, then VF, then asystole. Resuscitation Council (UK) guidance on peri-arrest arrythmias --John24601 19:17, 3 April 2006 (UTC)

  • Wouldn't you think that if a 2nd infarction causes a total occlusion of the LCA there still is rhythm but no output? In other words, why can't the PEA be having signs of ischemia?Holland Nomen Nescio
Hmmmm, you make a good point. I've been treating Cardiac arrest for over 15 years, and teaching about it for the last 8, and have never, ever come across a situation like you describe; but I guess it could be possible. Do you have a reference for it anywhere? Still though, if we listed everything which PEA might reveal.... maybe that (if you do have a reference for it) has its place on the PEA or MI pages, but not on here...--John24601 19:43, 3 April 2006 (UTC)

[edit] Why?

Why are these more recent studies deleted and your much older studies from BMJ (certainly not superior to the NEJM) are not?

The out of hospital cardiac arrest (OHCA) has a worse suvival 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 asystole or PEA (as they are sensitive to defibrillation, whereas asystole and PEA are not).[1] 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 defribrillator increases survival rate to that of patients that did not have a cardiac arrest.[2][3]

Furthermore, it now says that figures are not known. That is not what this text says. IMHO there is no reason to leave this out while it is better sourced and provides figures to the survival rate.Holland Nomen Nescio 13:15, 11 April 2006 (UTC)

In the absence of reasons for deleting this I will restore the clearly well-sourced part on survival rate.Holland Nomen Nescio 16:39, 12 April 2006 (UTC)

True survival rate is not really known, as it depends on an almost infinite number of factors (the patient, their age, their location, underlying cause, co-morbidities, response time, local protocols for treatment, skills of medical staff blah blah...). There are hundreds of studies about, and whilst they all broadly agree qualititavely(ie/ in-hospital is better than out-of-hospital, younger is better than older etc etc etc), none of them have anything like the same quantitative results. For that reason, your studies were probably just as mine, I agree - was actually planning to incorporate them more into the flow of the text (the studies I cited were arranged into in-hospital and out-of-hospital, which is the biggest determinant of survival; whereas yours were just plonked at the beginning) rather than totally delete them, sorry about that - I got a little sidetracked, will get back to it sometime over the next couple of days. --John24601 19:04, 13 April 2006 (UTC)

[edit] cardiac embarrassment

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[edit] Recent reversion.

I've just reverted a recent series of edits, as they generally added nothing and in some cases were misinformed to say the least. A few points:

  • There is no contraction during diastole, so you can't say that the heart is not contracting properly in this phase
  • "The single most treatable cause to prevent cardiac arrests is the early diagnosis and management of acute coronary syndromes (ACS) (also commonly called coronary heart disease) which includes all types of heart attacks and angina. By having ACS signs and symptoms recognised and treated early most cardiac arrests could be prevented." I don't necessarily disagree with the thrust of what is being said here, but it needs to have better grammar and referencing. Furthermore, ACS includes myocardial infarction and unstable angina, but not stable angina.
  • "Other less common causes, most often associated with one particular classification of cardiac arrest called pulseless electrical activity (PEA), are known as the 5 H's and the 5 T's." There are 4Hs and 4Ts in all published literature, not 5. These describe ALL the causes of cardiac arrest (ACS/CHD comes under Thrombosis), and they can just about all lead to any rhythm (not just PEA)
  • Lay rescuers are taught to commence CPR in the presence of abnormal breathing under the 2005 ILCOR guidelines, movement of skeletal muscle (or any other signs for that matter) doesn't come into it.
  • "(a study end point of no value is the return of a pulse and admission alive to the hospial, the only good end point is the patient surviving to leave the hospital functioning and intact- "survivability to discharge")" Not sure that adds anything useful. Especially as that is not an end point of the study. It is for the readers to make up their own mind which figures they give value to. Other little comments throughout the article also add nothing.--John24601 09:35, 1 November 2006 (UTC)
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