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Cardiac arrest

A cardiac arrest is the cessation of normal circulation of the blood due to failure of the ventricles of the heart to contract effectively during systole. The resulting lack of blood supply results in cell death from oxygen starvation. Cerebral hypoxia, or lack of oxygen supply to the brain, causes victims to lose consciousness and stop breathing. more...

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Cardiac arrest is a medical emergency that, if left untreated, invariably leads to death within seconds to minutes. The primary first-aid treatment for cardiac arrest is cardiopulmonary resuscitation (commonly known as CPR).

Etiology

Coronary heart disease (commonly known as coronary artery disease, or CAD) is the predominant disease process associated with sudden cardiac death in the United States. The incidence of CAD in individuals who suffer sudden cardiac death is between 64 and 90%. Other causes of cardiac arrest include electrocution and near-drowning, as well as other cardiac conditions such as the cardiomyopathies.

In children, cardiac arrest is typically caused by hypoxia from other causes such as near-drowning. With prompt treatment survival rates are high.

Every fatal injury or illness ultimately terminates in cardiac arrest, which is a natural part of the processes of death.

Treatable causes

There are 8 reversible causes of cardiac arrest, known as the "4Hs and 4Ts". They are looked for and treated by ambulance technicians/paramedics or by medical staff at the hospital while undertaking advanced life support, protocols for which will be used alongside any specific treatments for each of the causes. Lay rescuers performing basic life support can generally neither identify or treat them (with the exception of hypovolemia due to external bleeding), and so can offer only supportive treatment pending the arrival of emergency medical services.

4 Hs:-

  • Hypoxia - A lack of oxygen to the brain and other vital organs. This is treated by providing the patient with oxygen, either through a bag-valve-mask device, or by inserting an endotracheal tube (intubation)
  • Hypovolemia - A lack of circulating body fluids, principally blood. This is usually (though not exclusively) caused by some form of bleeding. Peri-arrest treatment includes giving IV Fluids and blood transfusions, and controlling the source of any bleeding - direct pressure for external bleeding, or emergency surgery (usually an immediate emergency thoracotamy on the ward, to clamp off the descending aorta and achieve haemostasis, the bleed is then repaired properly once the patient has regained circulation) for internal bleeding
  • Hypo/Hyper-metabolic disorders - An abnormally high or low level of electrolytes such as potassium and calcium circulating the body. An arterial blood gas and blood electrolyte test are performed to find the problem, then IV crystalloids are given to correct it.
  • Hypothermia - A low core body temperature, defined clinically as a temperature of less than 35 degrees celsius. The patient is re-warmed either by using a cardiac bypass or by irrigation of the body cavities (such as thorax, peritoneum, bladder) with warm fluids; or warmed IV fluids. CPR only is given until the core body temperature reached 30 degrees celsius, as defibrillation is ineffective at lower temperatures. Patients have been known to be successfully resuscitated after periods of hours in hypothermia and cardiac arrest, and this has given rise to the often quoted medical truism "You're not dead until you're warm and dead"


4 Ts:-

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Vasopressin vs. epinephrine for patients in cardiac arrest
From American Family Physician, 8/1/04 by Bill Zepf

Concerns have been raised about ventricular arrhythmias and myocardial dysfunction following epinephrine treatment in patients with cardiac arrest, and laboratory studies of vasopressin have demonstrated some beneficial effects in cardiopulmonary resuscitation CPR). Wenzel and colleagues report on a study for the European Resuscitation Council comparing vasopressin and epinephrine in patients with cardiac arrest.

This multinational trial initially screened 5,967 adult patients with out-of-hospital cardiac arrest. After excluding patients who were successfully defibrillated without need for a vasopressor and patients with terminal illness, lack of intravenous access, or several other clinical variables, 1,186 patients remained in whom vasopressin and epinephrine could be compared. Patients needing vasopressor drugs during CPR were randomly assigned to receive 1 mg of epinephrine or 40 IU of vasopressin; the dose was repeated in three minutes if spontaneous circulation had not been restored. After two doses of the assigned study drug, an injection of epinephrine could be given at the discretion of the resuscitating physician (the median dose given was 5 mg).

There were no significant differences between the medications in overall rates of spontaneous circulation recovery (24.6 percent versus 28.0 percent), survival to hospital discharge (9.9 percent versus 9.9 percent), or good neurologic outcome in survivors 32.6 percent versus 34.8 percent). Patients with a witnessed cardiac arrest and those in whom CPR was begun within 10 minutes of arrest had improved chances of survival to hospital admission, as did patients who received amiodarone or fibrinolysis in the resuscitation regimen. The only subgroup with a significant difference in outcome between vasopressin and epinephrine represented patients with asystole as the presenting rhythm (44.5 percent of arrest patients overall). More patients with asystole who were treated with vasopressin survived to hospital discharge than those assigned to receive epinephrine. The discretionary dose of epinephrine helped improve outcomes in patients who were randomized to vasopressin but not in patients who had already received epinephrine.

The authors conclude that vasopressin and epinephrine have similar efficacy in patients with out-of-hospital cardiac arrest, and that vasopressin is advantageous in the subgroup of patients with asystole as a presenting rhythm.

REFERENCE

(1.) McIntyre KM. Vasopressin in asystolic cardiac arrest [Editorial]. N Engl J Med January 8, 2003;350:179-81.

Wenzel V, et al. A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med January 8, 2003;350:105-13.

EDITOR'S NOTE: The authors mention in their discussion of the study that the outcome data did not confirm earlier studies that showed an advantage to use of vasopressin in cardiac arrest patients with ventricular fibrillation and pulseless electrical activity. An accompanying editorial (1) by McIntyre speculates on the reasons that the survival advantage of vasopressin may be limited to patients with asystole. Epinephrine and other catecholamines appear to be less effective vasopressors in the hypoxic, acidotic cardiac environment of asystole. He notes that the increased myocardial oxygen consumption occurring with epinephrine may have harmful effects in patients with asystolic cardiac arrest.

COPYRIGHT 2004 American Academy of Family Physicians
COPYRIGHT 2004 Gale Group

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