Cardiac arrest

Cardiac Arrest
Classification and external resources

CPR being administered during a simulation of cardiac arrest.
ICD-10 I46.
ICD-9 427.5
MeSH D006323

Cardiac arrest, (also known as cardiopulmonary arrest or circulatory arrest) is the cessation of normal circulation of the blood due to failure of the heart to contract effectively,[1] and if this is unexpected can be termed a sudden cardiac arrest or 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.[2]

Arrested blood circulation prevents delivery of oxygen to the body. Lack of oxygen to the brain causes loss of consciousness, which then results in abnormal or absent breathing. Brain injury is likely if cardiac arrest goes untreated for more than five minutes.[3][4][5] For the best chance of survival and neurological recovery, immediate and decisive treatment is imperative.[6]

Cardiac arrest is a medical emergency that, in certain situations is potentially reversible if treated early. When unexpected cardiac arrest leads to death this is called sudden cardiac death (SCD).[1] The treatment for cardiac arrest is cardiopulmonary resuscitation (CPR) to provide circulatory support, followed by defibrillation if a shockable rhythm is present. If a shockable rhythm is not present after CPR and other interventions, clinical death is inevitable.

Contents

Classification

Cardiac arrest is classified into "shockable" versus "non–shockable", based upon the ECG rhythm. The two shockable rhythms are ventricular fibrillation and pulseless ventricular tachycardia while the two non–shockable rhythms are asystole and pulseless electrical activity. This refers to whether a particular class of disrhythmia is treatable using defibrillation.[7]

Signs and symptoms

Cardiac arrest is an abrupt cessation of pump function in the heart (as evidenced by the absence of a palpable pulse). Cardiac arrest can usually be reversed with prompt intervention, but without such intervention, it will almost always lead to death.[1] In certain cases, it is an expected outcome to a serious illness.[8]

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.

Causes

Coronary heart disease is the leading cause of sudden cardiac arrest. Many other cardiac and non–cardiac conditions also increase ones risk.

Coronary heart disease

Approximately 60–70% of SCD is related to coronary heart disease.[9][10] Among adults, ischemic heart disease is the predominant cause of arrest[11] with 30% of people at autopsy showing signs of recent myocardial infarction.

Non ischemic heart disease

A number of other cardiac abnormalities can increase the risk of SCD including: cardiomyopathy, cardiac rhythm disturbances, hypertensive heart disease[9], congestive heart failure.[12]

In a group of military recruits aged 18–35, 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%).[13] Congestive heart failure increases the risk of SCD by 5 fold.[12]

Non–cardiac

SCDs is unrelated to heart problems in 34% of cases. The most common non–cardiac causes were: trauma, non-trauma related bleeding (such as gastrointestinal bleeding, aortic rupture, and intracranial hemorrhage), overdose, drowning and pulmonary embolism.[14]

Risk factors

The risk factors for SCD are similar to those seen with coronary heart disease including: smoking, lack of physical exercise, obesity, diabetes, and family history.[15]

Hs and Ts

The Hs and Ts is a mnemonic used to aid in remembering the possible causes of cardiac arrest.[7][16]

Hs
Ts

Diagnosis

Checking for respiration.
Checking carotid pulse.

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 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[17] or lay persons.[18]

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,[16] 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.[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.[16] These signs included coughing, gasping, colour, twitching and movement.[19] 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.[16]

Prevention

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

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.[7][20] 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[7] 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:

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 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.[21] An accompanying editorial by Simpson explores some of the economic, geographic, social and political reasons for this.[22] 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.[23]

Management

Sudden cardiac arrest is treated via attempts at resuscitation. This is usually carried out based upon Basic Life Support(BLS) / Advanced Cardiac Life Support (ACLS)[16], Pediatric Advanced Life Support (PALS)[24] or Neonatal Resuscitation Program(NRP) guidelines.

Chain of survival

Several organisations promote the idea of a "chain of survival" The links are:

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.

Cardiopulmonary resuscitation

Main article: Cardiopulmonary resuscitation

CPR is a critical part of the management of cardiac arrest. It should be started as soon as possible and interrupted as little as possible. The component of CPR which seems to make the greatest difference is the chest compressions.

Ventilation

Endotracheal intubation has not been found to improve survival rates in cardiac arrest cases.[25] A 2009 study has found that assisted ventilation may worsen outcomes over placement of an oral airway with passive oxygen delivery.[26]

Bystander CPR

Correctly performed bystander CPR has been shown to increase survival; it is performed in less than 30% of out of hospital arrests.[25]

Defibrillation

Cardiac arrest is divided into shockable and non–shockable causes based on the presence or absence of ventricular fibrillation or pulseless ventricular tachycardia. The shockable rhythms are treated with CPR and defibrillation.

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 interventions.

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. In addition, it has been shown that those who suffer arrests in remote locations have worse outcomes following cardiac arrest:[27] these areas often have first responders, 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.

Medications

Medications, well included in guidelines, have been shown not to improve survival to hospital discharge post cardiac arrest. This includes the use of epinephrine, atropine, and amiodarone.[28]

Therapeutic hypothermia

Cooling a person after cardiac arrest with return of spontaneous circulation (ROSC) but without return of consciousness improves outcomes. 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 32–34 °C (90–93 °F). 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.[29] Death rates in the hypothermia group were 14% lower, meaning that for every 7 patients treated one life was saved.[29] 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.[30]

Prognosis

Out-of-hospital cardiac arrest (OHCA) has a worse survival rate (2-8% for discharge and 8-22% for admission), than an in-hospital cardiac arrest (15% for discharge). The principal determining factor is the initially documented rhythm. People with ventricular fibrillation or pulseless ventricular tachycardia have 10-15 times greater chance of surviving than those suffering from pulseless electrical activity or asystole.

Since mortality in case of OHCA 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.[11][31]

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.

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.[32]

A review into prognosis following in-hospital cardiac arrest found a survival to discharge of 14% although the range between different studies was 0-28%.[33]

Epidemiology

Based on death certificates sudden cardiac death accounts for about 15% of all death in Western countries[9] (330,000 per year in the United States).[25] The lifetime risk is three times greater in men (12.3%) than women (4.2%) based on analysis of the Framingham Heart Study.[34] However this gender difference disappeared beyond 85 years of age.[9]

Ethical issues

Some people with a terminal illness choose to avoid aggressive measure at the end of life. A do not resuscitate (DNR) order is to make this wish clear. This may be included in an advance health care directive.

See also

References

  1. ↑ 1.0 1.1 1.2 Jameson, J. N. St C.; Dennis L. Kasper; Harrison, Tinsley Randolph; Braunwald, Eugene; Fauci, Anthony S.; Hauser, Stephen L; Longo, Dan L. (2005). Harrison's principles of internal medicine. New York: McGraw-Hill Medical Publishing Division. ISBN 0-07-140235-7. 
  2. ↑ Mallinson, T (2010). "Myocardial Infarction". Focus on First Aid (15): 15. http://www.focusonfirstaid.co.uk/Magazine/issue15/index.aspx. Retrieved 2010-06-08. 
  3. ↑ Safar P (December 1986). "Cerebral resuscitation after cardiac arrest: a review". Circulation 74 (6 Pt 2): IV138–53. PMID 3536160. 
  4. ↑ Holzer M, Behringer W (April 2005). "Therapeutic hypothermia after cardiac arrest". Curr Opin Anaesthesiol 18 (2): 163–8. doi:10.1097/01.aco.0000162835.33474.a9. PMID 16534333. 
  5. ↑ Safar P, Xiao F, Radovsky A, et al. (January 1996). "Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion". Stroke 27 (1): 105–13. PMID 8553385. 
  6. ↑ Rippe, James M.; Irwin, Richard S. (2003). Irwin and Rippe's intensive care medicine. Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-3548-3. 
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 "Resuscitation Council (UK) Guidelines 2005". http://www.resus.org.uk/pages/guide.htm. 
  8. ↑ "Mount Sinai - Cardiac arrest". http://www.mountsinai.org/Other/Diseases/Cardiac%20arrest. 
  9. ↑ 9.0 9.1 9.2 9.3 Zheng ZJ, Croft JB, Giles WH, Mensah GA (October 2001). "Sudden cardiac death in the United States, 1989 to 1998". Circulation 104 (18): 2158–63. doi:10.1161/hc4301.098254. PMID 11684624. 
  10. ↑ Centers for Disease Control and Prevention (CDC) (February 2002). "State-specific mortality from sudden cardiac death--United States, 1999". MMWR Morb. Mortal. Wkly. Rep. 51 (6): 123–6. PMID 11898927. 
  11. ↑ 11.0 11.1 Eisenberg MS, Mengert TJ (April 2001). "Cardiac resuscitation". N. Engl. J. Med. 344 (17): 1304–13. doi:10.1056/NEJM200104263441707. PMID 11320390. 
  12. ↑ 12.0 12.1 Kannel WB, Wilson PW, D'Agostino RB, Cobb J (August 1998). "Sudden coronary death in women". Am. Heart J. 136 (2): 205–12. doi:10.1053/hj.1998.v136.90226. PMID 9704680. 
  13. ↑ Eckart RE, Scoville SL, Campbell CL, et al. (December 2004). "Sudden death in young adults: a 25-year review of autopsies in military recruits". Ann. Intern. Med. 141 (11): 829–34. PMID 15583223. 
  14. ↑ Kuisma M, Alaspää A (July 1997). "Out-of-hospital cardiac arrests of non-cardiac origin. Epidemiology and outcome". Eur. Heart J. 18 (7): 1122–8. PMID 9243146. 
  15. ↑ Friedlander Y, Siscovick DS, Weinmann S, et al. (January 1998). "Family history as a risk factor for primary cardiac arrest". Circulation 97 (2): 155–60. PMID 9445167. 
  16. ↑ 16.0 16.1 16.2 16.3 16.4 ECC Committee, Subcommittees and Task Forces of the American Heart Association (December 2005). "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation 112 (24 Suppl): IV1–203. doi:10.1161/CIRCULATIONAHA.105.166550. PMID 16314375. 
  17. ↑ Ochoa FJ, Ramalle-Gómara E, Carpintero JM, García A, Saralegui I (June 1998). "Competence of health professionals to check the carotid pulse". Resuscitation 37 (3): 173–5. doi:10.1016/S0300-9572(98)00055-0. PMID 9715777. 
  18. ↑ Bahr J, Klingler H, Panzer W, Rode H, Kettler D (August 1997). "Skills of lay people in checking the carotid pulse". Resuscitation 35 (1): 23–6. doi:10.1016/S0300-9572(96)01092-1. PMID 9259056. 
  19. ↑ British Red Cross; St Andrew's Ambulance Association; St John Ambulance (2006). First Aid Manual: The Authorised Manual of St. John Ambulance, St. Andrew's Ambulance Association, and the British Red Cross. Dorling Kindersley Publishers Ltd. ISBN 1-4053-1573-3. 
  20. ↑ Kause J, Smith G, Prytherch D, Parr M, Flabouris A, Hillman K (September 2004). "A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom--the ACADEMIA study". Resuscitation 62 (3): 275–82. doi:10.1016/j.resuscitation.2004.05.016. PMID 15325446. 
  21. ↑ Birnie, David H; Sambell, Christie; Johansen, Helen; Williams, Katherine; Lemery, Robert; Green, Martin S; Gollob, Michael H; Lee, Douglas S; Tang, Anthony SL (July 2007). "Use of implantable cardioverter defibrillators in Canadian and IS survivors of out-of-hospital cardiac arrest". Canadian Medical Association Journal 177 (1): 41. doi:10.1503/cmaj.060730. PMID 17606938. PMC 1896034. http://www.cmaj.ca/cgi/reprint/177/1/41. Retrieved 2007-07-29. 
  22. ↑ Simpson CS (July 2007). "Implantable cardioverter defibrillators work--so why aren't we using them?". CMAJ 177 (1): 49–51. doi:10.1503/cmaj.070470. PMID 17606939. 
  23. ↑ Moss AJ, Brown MW, Cannom DS, et al. (October 2005). "Multicenter automatic defibrillator implantation trial-cardiac resynchronization therapy (MADIT-CRT): design and clinical protocol". Ann Noninvasive Electrocardiol 10 (4 Suppl): 34–43. doi:10.1111/j.1542-474X.2005.00073.x. PMID 16274414. 
  24. ↑ American Heart, Association (May 2006). "2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric advanced life support". Pediatrics 117 (5): e1005–28. doi:10.1542/peds.2006-0346. PMID 16651281. 
  25. ↑ 25.0 25.1 25.2 Mutchner L (January 2007). "The ABCs of CPR--again". Am J Nurs 107 (1): 60–9; quiz 69–70. PMID 17200636. 
  26. ↑ Bobrow BJ, Ewy GA, Clark L, et al. (November 2009). "Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest". Ann Emerg Med 54 (5): 656–662.e1. doi:10.1016/j.annemergmed.2009.06.011. PMID 19660833. 
  27. ↑ Lyon, R.M, Cobbe, S.M., Bradley, J.M., Grubb, N.R. (2004)Surviving out of hospital cardiac arrest at home: a postcode lottery? Emergency Medical Journal Vol. 21 pp. 619-624
  28. ↑ Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L (November 2009). "Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial". JAMA 302 (20): 2222–9. doi:10.1001/jama.2009.1729. PMID 19934423. 
  29. ↑ 29.0 29.1 Holzer, Michael. “Mild Hypothermia to Improve the Neurologic Outcome After Cardiac Arrest.” New England Journal of Medicine. (2002) Vol. 346, No. 8.
  30. ↑ Bernard, Stephen et al. "Treatment of Comatose Survivors of Out-of-Hospital Cardiac Arrest with Induced Hypothermia." N England Journal of Medicine. (2002) Vol. 346, No. 8. http://content.nejm.org/cgi/content/abstract/346/8/557
  31. ↑ Bunch TJ, White RD, Gersh BJ, et al. (June 2003). "Long-term outcomes of out-of-hospital cardiac arrest after successful early defibrillation". N. Engl. J. Med. 348 (26): 2626–33. doi:10.1056/NEJMoa023053. PMID 12826637. 
  32. ↑ Cobbe SM, Dalziel K, Ford I, Marsden AK (June 1996). "Survival of 1476 patients initially resuscitated from out of hospital cardiac arrest". BMJ 312 (7047): 1633–7. PMID 8664715. 
  33. ↑ Ballew KA (May 1997). "Cardiopulmonary resuscitation". BMJ 314 (7092): 1462–5. PMID 9167565. 
  34. ↑ "Abstract 969: Lifetime Risk for Sudden Cardiac Death at Selected Index Ages and by Risk Factor Strata and Race: Cardiovascular Lifetime Risk Pooling Project -- Lloyd-Jones et al. 120 (10018): S416 -- Circulation". http://circ.ahajournals.org/cgi/content/meeting_abstract/120/18_MeetingAbstracts/S416-c?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=lloyd-jones&searchid=1&FIRSTINDEX=10&sortspec=date&resourcetype=HWCIT. 

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