CARDIAC ARREST

INTRODUCTION
 Cardiopulmonary arrest is the cessation of
adequate heart function and respiration and
results in death without reversal. Often this
condition is found in patients with coronary
artery disease.
 This activity reviews the management and
prevention of cardiopulmonary arrest and
highlights the role of the healthcare team in
treating patients with this condition.
 Cardiopulmonary arrest (CPA) is the cessation of effective
ventilation and circulation. It is also known as cardiac arrest or
circulatory arrest. In adults, it is most likely to be caused by a
primary cardiac event. The most common electrical mechanism
which is responsible for 50 to 80% of cardiopulmonary arrest is
ventricular fibrillation (VF). While, 20^% to 30% which represents
the less common causes of dysrhythmias involve Pulseless
electrical activity (PEA), and asystole.
 Pulseless sustained ventricular tachycardia (VT) is a less common
mechanism. This condition could progress to sudden death if it not
treated promptly. Nevertheless, a cardiopulmonary arrest (CPA)
could be reversed by cardiopulmonary resuscitation and/or
cardioversion or defibrillation, or cardiac pacing.
 ETIOLOGY
 There are various causes for
cardiopulmonary arrest in adults which varies by
age and population. However, patients diagnosed
with cardiac disease are more susceptible to
having a cardiac arrest.
 Furthermore, it can be classified into different
categories, which include
 cardiac, respiratory, and traumatic causes. But
75% of cardiac arrest incidents are believed to be
due to coronary artery diseases.
 Cardiac Causes

 Coronary Artery Disease

 Coronary artery abnormalities:

1Anomalous coronary artery anatomy.
2Acute lesions (platelet aggregation, plaque
fissuring, acute thrombosis).
3Chronic atherosclerosis.
4coronary artery spasm
 Myocardial Infarction:
 Acute
 Healed

 Myocardial Hypertrophy
 Secondary

Hypertrophic cardiomyopathy
1Nonobstructive
2Obstructive
 Valvular Heart Disease

 Infiltrative and Inflammatory Disorders

1Infiltrative diseases
2Noninfectious inflammatory diseases
3Myocarditis
 Heart Failure
 Ejection fraction less than 35%

 Congenital disease
 Tetralogy of Fallot

 Respiratory Causes

 Airway obstruction:
• Bronchospasm due to (pulmonary edema, pulmonary hemorrhage, and
pneumonia)
• Severe asthma or Chronic Obstructive Pulmonary Disease (COPD).
 Pulmonary Embolism

 Respiratory Muscle Weakness: due to spinal

cord injury.

 Traumatic Causes
 Overall, the prevalence of cardiac causes is around
50% to 60%. Whilst, the second most common
cause that is respiratory insufficiency is around
15% to 40%.
 EVALUATION
History and Physical examination:
The physical examination will help to diagnose
the cardiopulmonary arrest as well as provide
the most important information regarding the
possible cause and the prognosis. While, the
history will help to delineate at what time the
event took place, what the victim was doing,
and the involvement of drugs.
 ECG
 INVESTIGATIONS
 Cardiopulmonary resuscitation should not be
interrupted for doing blood or radiological
investigation. However, point of care testing,
like blood glucose or serum potassium may be
done if it doesn't interfere with cardiopulmonary
resuscitation efforts. Point of care ultrasound
can also be used to evaluate the activity of the
heart during cardiopulmonary resuscitation
which has proved beneficial in many studies.
 Treatment / Management

 Five stages in the management of the patient

with confirmed cardiopulmonary arrest are:

 Initial evaluation plus Basic Life Support

 Defibrillation
 Advanced Life Support
 Post-resuscitation care
 Long-term management
CPR
 Initial Evaluation and BLS

 CIRCULATION:

 Confirming cardiopulmonary arrest need careful

examination of the patient's level of consciousness, skin
color, breathing movement, and arterial pulse either in
the carotid or femoral artery. Just after confirming the
arrest, the immediate responsibility of the rescuer is to
call Emergency Medical Services and start CPR.
 AIRWAY
 Maintaining a patent airway is necessary for
successful cardiopulmonary resuscitation.
Maneuvers like chin lift, head tilt, and jaw thrust
can be used to keep the airway patent. Any visible
foreign bodies like displaced dentures should be
removed from the oropharynx. Ventilatory aids
like oropharyngeal airway (OPA) and
the nasopharyngeal airway (NPA) may be used if
the rescuer is experiencing difficulty in ventilating
the patient.
 BREATHING
 Mouth to mouth respiration
 Bag and mask
 Airways
 Endotracheal tubes
 Laryngeal mask airways
 The AHA guideline suggested certain recommendation for doing high-quality CPR:

 Compression should start within 10 seconds of diagnosing cardiopulmonary arrest.

 Two breaths to be given after 30 compressions. Excessive ventilation should be

avoided.

 Every effort should be made to reduce the interruption while changing the rescuer or
while checking the rhythm.

 The rate of compression should be between 100 to 120 per minute

 The depth of compression should be between 2 to 2.4 inches for adults.

 Adequate time should be given for chest recoil

 Advanced Cardiac Life Support
 ADVANCED CARDIAC LIFE SUPPORT (ACLS) is
designed to deliver adequate ventilation, stabilize the
blood pressure along with the cardiac output, control
cardiac arrhythmias, and restore organ perfusion.
 Maneuvers needed to accomplish these goals include-

 Defibrillation and pacing.

 Endotracheal tube intubation and mechanical ventilation

 Intravenous line insertion.

DEFIBRILLATOR
 The rapidity by which defibrillation is performed is an essential element for improving
patient outcomes. The AHA guideline suggested certain recommendation for defibrillation-

 Cardiopulmonary resuscitation should be carried out whilst the AED is being charged

 Immediate early defibrillation should be given preference over intubation and intravenous
line insertion

 A defibrillator with a biphasic waveform is preferred over monophasic.

 Manufacturers recommended energy dose should be used for the first shock. If this is not
mentioned, then the maximum dose should be used for defibrillation.

 Fixed versus escalating energy for subsequent shock should depend on manufacturers'
recommendations. If the machine has the capability to escalate the energy, then higher
energy should be used for a subsequent shock.

 A single shock strategy should be preferred to stacked shock.

 After failed defibrillation, epinephrine, 1mg I/V, should
be given. Furthermore, the dose of this drug may be
repeated after periods of three to five minutes. Additionally,
vasopressin has been recommended as an alternative.

 After 2 or 3 failed attempts, immediate intubation and

arterial blood gas analysis should be carried out. Those
patients who still remain acidotic even after intubation and
successful defibrillation should be given 1 new/ kg of
NaHCO3 initially, and further 50 percent of the dose may be
repeated after 10 minutes.
 COMPLICATIONS
 Various complications can occur during
cardiopulmonary resuscitation. AED failure is
the most common complication. Other
complications include the inability to obtain
venous access, rib fracture, pneumothorax,
pneumomediastinum, hemothorax, lung
laceration, pulmonary hemorrhage, injury to
the major vessel, and cardiac tamponade.