Cardiac arrest


Refers to the cessation of the effective pump mechanism of the heart.

In the US 38 people have an out of hospital cardiac arrest every hour, and fewer than one of 10 survive.

Up to 1/3 of all patients with acute manifestations of heart disease do not reach the hospital after cardiac arrest.

The survival to hospital discharge following out of hospital cardiac arrest, due to any cause, is as low as 10%.

Cardiac arrest associated with the survival rate of 10 to 12% for out of hospital cardiac arrest and 25 to 30% for in-hospital cardiac arrest.

Outcomes are particularly poor for patients with cardiac arrest who are not responsive to initial treatment.

Approximately 600,000 people in the United States experience cardiac arrest each year.

Estimated incidence of out-of-hospital cardiac arrest is 140.7 per 100,000 persons per year.

About 28% of individuals have a return of spontaneous circulation, and of these only 10% survive to 30 days or hospital discharge.

About 1000 adults suffer out of hospital cardiac arrest each day in the US.

Sudden cardiac death, including out of hospital cardiac arrest, accounts for nearly half of all years of life lost due to cardiac disease, and is the leading cause of death among men.

Of the patients who are most likely to survive cardiac arrest are those who present with ventricular fibrillation, that is responsive to defibrillation.

Lay individuals play a major role in the resuscitation of people with out of hospital cardiac arrest.

Pre-arrival care refers to basic medical interventions initiated by bystanders before train medical providers arrive on the scene of out of hospital cardiac arrest.

In patients with coma,  after out-of-hospital cardiac arrest, targeted hypothermia did not lead to a lower incidence of death by six months than  targeted normothermia.

Among patients with coma who had been resuscitated from cardiac arrest with a non-shockable rhythm, moderate therapeutic hypothermia at 33°C for 24 hours lead to a higher percentage of patients who survive with a favorable neurologic outcome at day than was observed with target normothermia  (Lascarrou JB).

Among individuals with out-of-hospital cardiac arrest, shockable initial rhythms noted in 7.7-32% of patients, occur significantly less often than nonshockable rhythms and are associated with a better prognosis than mon shockable rhythms.

Pre-arrival care is associated with increased chance of survival and improved neurologic status.

Bystander initiated CPR significantly increases the chance of survival.

Bystander application of automated external defibrillator markedly increases the chance of survival.

It is recommended that bystanders should suspect cardiac arrest and begin CPR whenever a person is unresponsive and not breathing normally.

The delivery of prearrival care and its effect on neurologic outcomes is time sensitive, that is for every minute that a person with out of hospital cardiac arrest goes without CPR and defibrillation, the chance of survival decreases by 7-10%.

May manifest as sudden collapse or loss of consciousness.

In most cases it is the direct complication of heart disease.

Diagnosis is confirmed by the absence of a detectable pulse, unresponsive state, and apnea or agonal respirations.

Failure of the pumping mechanism of the heart to generate enough pressure for the perfusion of vital organs.

The brain and heart of the organs most susceptible to decreased blood perfusion.

The complete or near complete cessation of perfusion to the CNS leads to unconsciousness within seconds.

In hospital survival 10.9%-30%.

Only a minority of cardiac arrest patients survive to hospital discharge intact neurologically.

Only half of out of hospital cardiac arrests are witnessed1, a situation associated with substantially better outcomes

Neurologically favorable survival is different from overall survival among cardiac arrest survivors as the prevalence of severe cerebral disability or a vegetative state ranges from 25 to 50%.

About 200,000 adults have hospitalizations complicated by a cardiac arrest annually.

In hospital cardiac arrests incidence 1-5 per 1000 patient admissions, with a 20% discharge survival rate.

Hospitals with exceptional rates of survival for in-hospital cardiac arrest are better at preventing cardiac arrests as well (Chen LM et al).

Survival after refractory cardiac arrest including refractory ventricular fibrillation, pulse less ventricular tachycardia, asystole or pulseless electrical activity, ranges from 5-15%.

There are 4 main underlying cardiac rhythms during cardiac arrest: asystole, ventricular fibrillation, ventricular tachycardia, and pulseless electrical activity.

Asystole refers to absence of detectable electrical activity of the heart.

Ventricular fibrillation refers to a disordered electrical activity of the ventricles producing rapid unsynchronized contractions.

Ventricular tachycardia refers to a rapid synchronized heart contractions originating from the ventricles.

Pulseless electrical activity refers to organized electrical signals that do not result in sufficient mechanical activity to produce a detectable BP.

IN pulseless electrical activity electrical signals may be normal, but there is no palpable pulse.

Out of hospital cardiac arrest leads to an estimated 330,000 deaths each year in the United States and Canada.

Out of hospital cardiac arrest approximately 420,000 cases in the US annually.

Out of hospital cardiac arrest survival rates are typically low and largely related to location of the arrest event.

In 2016 less than 10% of patients with out of hospital cardio pulmonary arrest survived to hospital discharge.

There has been little improvement in the rate of survival from out of hospital cardiac arrest in the last 30 years.

Survival for cardiac arrest out of the hospital can be improved by early notification of emergency response agencies, bystander cardiopulmonary resuscitation, and application of early defibrillation.

Bystander CPR is providing less than 50% of out of hospital cardiac arrests.

Automatic external defibrillators are used in out of hospital cardiac arrests no more than 25% of of the time in appropriate patients, even though they are frequently available.

The rate of survival to hospital discharge among patients with an out of hospital cardiac arrest treated by emergency medical services ranges from 3 to 16.3% (Nichol G et al).

Out of hospital cardiac arrest survival is low and this is especially true in patients who do not have a response to advanced cardiac support by paramedics.

Rate of survival in out of hospital cardiac arrests attributed to five key aspects: rapid EMS access, early CPR, early defibrillation, early advanced cardiac life support, and effective care after resuscitation.

Out of hospital arrest 92%-93% die and 2%-3% have neurological impairment.

Out of hospital cardiac arrests have an overall survival at 7-9% annually for the last 30 years.

Out of hospital cardiac arrest survival varies significantly across geographic regions.

75% of patients with out of hospital cardiac arrest who achieve return of spontaneous circulation in the field die before hospital discharge.

Patients with out of hospital cardiac arrest are vulnerable to poor outcomes due to post-resuscitation syndrome which is a combination of processes including systemic ischemia/reperfusion response, neurologic injuries, myocardial dysfunction, and the underlying cause of their cardiac arrest.

Every one minute delay in initiating CPR is associated with a 10% decrease in survival.

Rates of bystander CPR among out of hospital cardiac arrest ranges from 10-65% with the lowest rates in rural, minority, and low income communities.

The immediate institution of cardiopulmonary resuscitation by a bystander may double an individual’s likelihood of surviving a cardiac arrest.

Less than half of the persons with cardiac arrest receive a bystander initiated CPR.

CPR be performed before the arrival of EMS is associated with a 30 day survival rate after Avenue cardiac hospital after an out of hospital cardiac arrest that is more than twice as high as that associated with no CPR before EMS arrival (Hasselquist-Ax, I et al).

In a comparison of EMS management of a brief period of manual chest compressions and ventilations with prompt initiation of rhythm analysis and defibrillation versus a longer period of compressions andventilations before the first analysis of cardiac rhythm in patients with Al of hospital cardiac arrest: no differences were noted in outcomes ( Resuscitation Outcomes Consortium).

Among patients with cardiac arrest that require vasopressors, combinations of vasopressin-epinephrine and methylprednisolone during CPR and stress dose hydrocortisone in post resuscitation shock compared with epinephrine/saline placebo resulted in improved survival to hospital discharge with favorable neurologic status (Mentzelopoulos SD et al).

In the above study patients were assigned to receive 30-60 seconds of EMS administered CPR and those in the later analysis group assigned to receive 180 seconds of CPR, before initial electrocardiographic analysis- both groups had a primary outcome of survival to hospital discharge of 5.9%.

Advanced airway management such as with endotracheal intubation or insertion of a supraglottic airway has been standard airway management of patients with out of hospital cardiac arrest, however any type of advanced airway management is associated with decreased odds of neurologically favorable survival compared with conventional bag-Valve-mask ventilation (Hasegawa K et al).

Large percentage of cardiac arrests are unwitnessed, approximately 50% and 14% in hospitals.

Of the approximately 250,000 persons who experience an out of hospital cardiac arrest, only about 5% survive to be discharged from the hospital.

In hospital events occur at twice the level of out patient arrests.

Lower cortisol levels are present relative to other stress states.

Approximately 16,000 children in U.S. have a cardiac arrest annually predominantly in a hospital setting.

Childhood cardiac arrest most commonly initially a pulseless electrical activity or asystole carrying significant mortality with 25-40% surviving to hospital discharge.

Bystanders may fail to recognize cardiac arrest, mistaking it for syncope or seizures.

Persons with cardiac arrest may have continued gasping respirations which confuse lay rescuers and delays care.

In the Resuscitation Outcomes Consortium involving 10 studies sites survival to hospital discharge occurred in 4% of patients who underwent intra-arrest transport versus 8.5% who were resuscitated on the scene.
Guidelines for post resuscitation care, recommend active fever prevention for 72 hours in comatose patients who have been resuscitated after an out of hospital cardiac arrest.
Active device-based fever prevention for 36 or 72 hours after cardiac arrest did not result in significantly different percentages of patients dying or having severe disability or coma (Hassager C).

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