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INTRODUCTION

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

PATHOPHYSIOLOGY

  • Coronary artery disease is the most common finding in adults with cardiac arrest and causes ∼75% of sudden cardiac deaths. In pediatric patients, cardiac arrest typically results from respiratory failure, asphyxiation, or progressive shock.

  • Noncardiac causes include drowning, choking, asphyxia, electrocution, trauma, poisoning, severe asthma, pneumonia, drug overdose, and sudden infant death syndrome.

  • Two different pathophysiologic conditions are associated with cardiac arrest:

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

    • ✔ Secondary: respiratory failure with 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. Recent data indicate that nonshockable rhythms (ie, asystole, pulseless electrical activity [PEA]) are now more prevalent. This change is of concern because survival rates to hospital discharge are higher after shockable rhythms like VF and PVT than with nonshockable rhythms like asystole and PEA.

CLINICAL PRESENTATION

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

  • Signs include apnea; hypotension; no detectable pulse; cyanosis; cold, clammy extremities; and unresponsiveness.

DIAGNOSIS

  • Rapid diagnosis is vital to success and is made by observing clinical manifestations consistent with cardiac arrest.

  • 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 occurs when there is no electrical activity in the heart, indicated by a flat line on the ECG.

TREATMENT

  • 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 cardiopulmonary resuscitation (CPR) by return of spontaneous circulation (ROSC) with effective ventilation and perfusion quickly to minimize hypoxic damage to vital organs. After successful resuscitation, the primary outcome is survival to hospital discharge with good neurologic function.

General Approach

  • The American Heart Association (AHA) guidelines for CPR and emergency cardiovascular care (ECC) are now updated annually (published online) and emphasize timely implementation of the “chain of survival”:

    • ✔ For out-of-hospital arrests: (1) immediate recognition of cardiac arrest and activation of the emergency response system, (2) immediate high-quality CPR, (3) rapid defibrillation, (4) effective advanced cardiac life support (ACLS), and (5) integrated post-arrest care.

    • ✔ For in-hospital arrests: (1) surveillance and prevention of cardiac arrest, (2) prompt notification and response by a multidisciplinary team of ...

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