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For the chapter in the Wells Handbook, please go to Chapter 7. Cardiac Arrest.



  • image High quality cardiopulmonary resuscitation (CPR) with minimal interruptions in chest compressions should be emphasized in all patients following cardiac arrest.

  • image The AHA algorithm for basic life support following cardiac arrest emphasizes circulation, airway, and breathing forming the pneumonic “CAB” versus the historic pneumonic “ABC.”

  • image The purpose of using vasopressor therapy following cardiac arrest is to augment low coronary and cerebral perfusion pressures encountered during CPR.

  • image Vasopressin appears to offer no benefit as a substitute over epinephrine.

  • image Amiodarone remains the preferred antiarrhythmic during cardiac arrest with lidocaine considered as an alternative.

  • image Successful treatment of both pulseless electrical activity (PEA) and asystole depends almost entirely on diagnosis of the underlying cause.

  • image Intraosseous administration is the preferred alternative route for administration if IV access cannot be achieved.


Cardiac arrest is defined as the cessation of cardiac mechanical activity as confirmed by the absence of signs of circulation (eg, a detectable pulse, unresponsiveness, and apnea).1 While there is wide variation in the reported incidence of cardiac arrest, it is estimated that there are more than 320,000 people in the United States who experience emergency medical services (EMS)-assessed out-of-hospital cardiac arrest.2 Survival to hospital discharge following out-of-hospital cardiac arrest is only 10.6% and survival with good neurologic function is only 8.3%.2 While there has been minimal improvement in survival over the past 40 years, recent data have shown some progress from 2005 to 2012 (adjusted rate ratio = 1.47 [1.26-1.7]).3 This improvement was attributed to both improved pre-hospital and in-hospital survival.

In-hospital cardiac arrests occur in roughly 200,000 patients in the United States annually and this rate may be increasing.4 Similar to out-of-hospital arrests, some progress has been made over the past decade with survival rates to hospital discharge being 13.7% in 2000 and 22.3% in 2009.5 Survival rates are substantially higher in victims with a shockable first documented rhythm as one study reported survival rates of 49% with ventricular fibrillation/pulseless ventricular tachycardia (VF/PVT) versus 11% with pulseless electrical activity (PEA)/asystole.6


In adult patients, cardiac arrest usually results from the development of an arrhythmia.7 Historically, VF and PVT have been the most common initial rhythm accounting for 40% to 60% of out-of-hospital arrests but their incidence now is estimated to be only about 24%.8,9 In fact, data from the Cardiac Arrest Registry to Enhance Survival (CARES) project reported asystole to be the most common presenting rhythm (45%) which is similar to other registry data whereby nonshockable rhythms were more prevalent.8,10,11 The reason for this change has not been firmly established. Possible explanations include the influence of ...

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