In-hospital cardiac arrests

Nearly 1% of all hospital admissions result  in an in-hospital cardiac arrest with an estimated survival of 20%.

Unexpected events that are difficult to predict with certainty.

Involves heterogeneous patients.

Mean age is 66 years, 58% of patients are men, in the presenting rhythm is most often nonshockable, that is asystole for pulseless electrical activity (Andersen L).

In the above study the causes of the cardiac arrest is,most often cardiac, 50-60%, followed by respiratory insufficiency, 15-40%.

Approximately 25% of patients survive to discharge.

Managed by a variety of of specilaties, hospital sites, allied personnel to provide resuscitation efforts.

The primary elements of treatment include: chest compressions, ventilation, early defibrillation, when applicable, and immediate attention to potentially reversible causes, such as hyperkalemia or hypoxemia.

Cardiac arrest survival is affected by immediate recognition of the arrest, performance of high quality chest compression with minimal interruptions, rapid defibrillation for shockable rhythms i.e., ventricular fibrillation or pulseless ventricular tachycardia, and prompt use of medication such as epinephrine.

Epinephrine augments coronary perfusion pressure by increasing aortic pressure.

Increased coronary perfusion pressure is associated with increased rates of return of spontaneous circulation, the first critical target necessary for survival.

Survival after IHCA has improved over the last decade.

Lowered survival associated with delay in defibrillation, unwitnessed events, after hour events, and black race.

Variation in survival across hospitals.

Delay in treatment associated with lower survival rate and worse neurological outcomes (Chan).

Many patient who experience such events have physiologic deterioration hours before the event (Hillman).

In a study of hospitalized Medicare patients undergoing cardiopulmonary resuscitation from 1992-2005 there was no significant change in survival to discharge (Ehlenbach WJ et al).

Among 84,625 hospitalized patients with cardiac arrest 79.3% with initial asystole or pulseless electrical activity and 20.7% with ventricular fibrillation or pulseless ventricular tachycardia: risk adjusted survival rates to discharge increased from 13.7% in 2000 to 22.3% in 2009 due to improved acute resuscitation survival and post resuscitation survival Get with the Guidelines -Resuscitation Investigators).

In the above study significant neurologic disability among survivors decreased over time from an adjusted rate of 32.9% in 2000 and 28.1% in 2009.

Among patients with in-hospital cardiac arrest administration of vasopressin and methylprednisolon compared with placebo,significantly Increased the likelihood of return of spontaneous circulation, but uncertainty remains whether the treatment results in benefit or harmful long-term survival (Andersen, L).