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INTRODUCTION

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  • Cardiac arrest involves cessation of cardiac mechanical activity as confirmed by absence of signs of circulation (eg, detectable pulse, unresponsiveness, and apnea).

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PATHOPHYSIOLOGY

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  • Coronary artery disease is the most common finding in adults with cardiac arrest and causes ~80% of sudden cardiac deaths. In pediatric patients, cardiac arrest typically results from respiratory failure, asphyxiation, or progressive shock.

  • Two different pathophysiologic conditions are associated with cardiac arrest:

    • ✓ Primary: arterial blood is typically fully oxygenated at the time of arrest.

    • ✓ Secondary: results from respiratory failure in which lack of ventilation leads to severe hypoxemia, hypotension, and cardiac arrest.

  • Cardiac arrest in adults usually results from arrhythmias. Historically, ventricular fibrillation (VF) and pulseless ventricular tachycardia (PVT) were most common. The incidence of VF in out-of-hospital arrests is declining, which is of concern because survival rates are higher after VF/PVT than with cardiac arrest resulting from nonshockable rhythms like asystole or pulseless electrical activity (PEA).

  • Because in-hospital cardiac arrest is typically preceded by hypoxia or hypotension, asystole or PEA occurs more commonly than VF or PVT.

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CLINICAL PRESENTATION

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  • Cardiac arrest may be preceded by anxiety, shortness of breath, chest pain, nausea, vomiting, and diaphoresis.

  • After an arrest, individuals are unresponsive, apneic, and hypotensive without a detectable pulse. Extremities are cold and clammy, and cyanosis is common.

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DIAGNOSIS

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  • Rapid diagnosis is vital to success of cardiopulmonary resuscitation (CPR). Patients must receive early intervention to prevent cardiac rhythms from degenerating into less treatable arrhythmias.

  • Diagnosis is made by observation of clinical manifestations consistent with cardiac arrest. Diagnosis is confirmed by vital signs, especially heart rate and respirations.

  • Electrocardiography (ECG) identifies the cardiac rhythm, which in turn determines drug therapy.

    • ✓ VF is electrical anarchy of the ventricle resulting in no cardiac output and cardiovascular collapse.

    • ✓ PEA is absence of a detectable pulse and presence of some type of electrical activity other than VF or PVT.

    • ✓ Asystole is presence of a flat line on the ECG.

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TREATMENT

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  • Goals of Treatment: Resuscitation goals are to preserve life, restore health, relieve suffering, limit disability, and respect the individual’s decisions, rights, and privacy. This can be accomplished via CPR by return of spontaneous circulation (ROSC) with effective ventilation and perfusion as quickly as possible to minimize hypoxic damage to vital organs. After successful resuscitation, primary goals include optimizing tissue oxygenation, identifying precipitating cause(s) of arrest, and preventing subsequent episodes.

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GENERAL APPROACH

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  • The 2015 American Heart Association (AHA) guidelines for CPR and emergency cardiovascular care (ECC) emphasize timely implementation of the “chain of survival” for out-of-hospital and in-hospital arrests:

    • ✓ Out-of-Hospital Arrests: (1) recognition and activation of the emergency response system, (2) immediate high-quality CPR, (3) rapid defibrillation, (4) basic and advanced emergency medical services, and (5) advanced life support and post-arrest care.

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