Cardiac Arrest

IN TER N ATIO N A L S P EC IA LIZ ATIO N C O U R S E O N A D U LT H EA LTH N U R S IN G JU LY 25, 2013

CARDIAC ARREST RESOURCE SPEAKER: JOEL C. ESTACIO, RN, RM, MANc

W h at is card iac arrest?  abrupt loss of heart function in a person who

may or may not have diagnosed heart disease.  The time and mode of death are unexpected.

It occurs instantly or shortly after symptoms appear.  Each year, nearly 360,000 emergency

medical services-assessed out-of-hospital cardiac arrests occur in the United States.

Is h eart attack th e sam e as card iac arrest?

 No.  Heart attacks are caused by a

blockage that stops blood flow to the heart. A heart attack (or myocardial infarction) refers to death of heart muscle tissue due to the loss of blood supply, not necessarily resulting in the death of the heart attack victim.

Cardiac arrest  the heart's electrical system malfunctions.  death results when the heart suddenly stops

working properly.  may be caused by abnormal, or irregular, heart rhythms  A common arrhythmia in cardiac arrest is  ventricular fibrillation. This is when the heart's lower chambers suddenly start beating chaotically and don't pump blood. Death occurs within minutes after the heart stops.  Cardiac arrest may be reversed if CPR  (cardiopulmonary resuscitation) is performed and a defibrillator is used to shock the heart and restore a normal heart rhythm within a few minutes.

C lassif c iation SHOCKABLE

NON-SHOCKABLE

 VENTRICULAR

FIBRILLATION  PULSELESS VENTRICULAR TACHYCARDIA

 ASYSTOLE  PULSELESS

ELECTRICAL ACTIVITY

W h at are th e C au ses?

C oron ary h eart d isease  Coronary heart disease is the leading

cause of sudden cardiac arrest  Related to approximately 60–70% of SCD  Among adults, ischemic heart disease is the predominant cause of arrest with 30% of people at autopsy  showing signs of recent  myocardial infarction.

N on -isch em ic h eart d isease  cardiomyopathy,   cardiac rhythm disturbances,   hypertensive heart disease,   congestive heart failure.

N on -card iac  SCDs is unrelated to heart problems

in 35% of cases. The most common non-cardiac causes: trauma, nontrauma related bleeding (such as gastrointestinal bleeding,  aortic rupture, and  intracranial hemorrhage), overdose,  drowning and pulmonary embolism.

H s and Ts  "Hs and Ts" is the name for a

mnemonic used to aid in remembering the possible treatable or reversible causes of cardiac arrest

Hs  Hypovolemia - A lack of blood volume  Hypoxia - A lack of oxygen  Hydrogen ions (Acidosis) - An abnormal pH

in the body  Hyperkalemia or Hypokalemia - Both excess and inadequate potassium can be life-threatening.  Hypothermia - A low core body temperature  Hypoglycemia or Hyperglycemia - Low or high blood glucose

Ts  Tablets or Toxins  Cardiac Tamponade - Fluid building

around the heart  Tension pneumothorax - A collapsed lung  Thrombosis (Myocardial infarction) Heart attack  Thromboembolism ( Pulmonary embolism) - A blood clot in the lung

U nderstand Your R isk for C ardiac A rrest

Scarring from a prior heart attack or other causes  A heart that's scarred or

enlarged from any cause is prone to develop lifethreatening ventricular arrhythmias. The first six months after a heart attack is a particularly high-risk period for sudden cardiac arrest in patients with atherosclerotic  heart disease.

A  thickened heart m uscle (cardiom yopathy) 

 from any cause (typically high blood

pressure or valvular heart disease) — especially if you also have heart failure — can make you more prone to sudden cardiac arrest.

H eart m edications:  Paradoxically, antiarrhythmic drugs used

to treat arrhythmias can sometimes produce lethal ventricular arrhythmias even at normally prescribed doses. This is called a "proarrhythmic" effect.  Regardless of whether there's organic heart disease, significant changes in blood levels of potassium and magnesium (from using diuretics, for example) also can cause life-threatening arrhythmias and cardiac arrest.

Electrical abnorm alities  Certain electrical abnormalities

such as Wolff-Parkinson-White syndrome and long QT syndrome may cause sudden cardiac arrest in children and young people.

B lood vessel abnorm alities  Less often, inborn blood vessel

abnormalities, particularly in the coronary arteries and aorta, may be present in young sudden death victims. Adrenaline released during intense physical or athletic activity often acts as a trigger for sudden cardiac arrest when these abnormalities are present.

R ecreational drug use  In people without organic heart

disease, recreational drug use is a cause of sudden cardiac arrest.

D iag n osis

 Cardiac arrest is synonymous with clinical death.  Usually diagnosed clinically by the absence of a

pulse.  In many cases lack of carotid pulse is the  gold standard for diagnosing cardiac arrest,  lack of a pulse (particularly in the peripheral pulses) may result from other conditions (e.g. shock), or simply an error on the part of the rescuer.  Studies have shown that rescuers often make a mistake when checking the carotid pulse in an emergency, whether they are healthcare professionals or lay persons.

 The Resuscitation Council (UK), in

line with the ERC's recommendations and those of the American Heart Association, have suggested that the technique should be used only by healthcare professionals with specific training and expertise, and even then that it should be viewed in conjunction with other indicators such as agonal respiration.

 With positive outcomes following cardiac

arrest unlikely, an effort has been spent in finding effective strategies to prevent cardiac arrest. With the prime causes of cardiac arrest being  ischemic heart disease, efforts to promote a healthy diet, exercise, and  smoking cessation are important.  For people at risk of heart disease, measures such as blood pressure control,  cholesterol lowering, and other medicotherapeutic interventions are used.

Prevention

 Extensive research has shown that

patients in general wards often deteriorate for several hours or even days before a cardiac arrest occurs.   This has been attributed to a lack of knowledge and skill amongst ward based staff, in particular a failure to carry out measurement of the  respiratory rate, which is often the major predictor of a deterioration and can often change up to 48 hours prior to a cardiac arrest.

 In response to this, many hospitals

now have increased training for ward based staff. A number of "early warning" systems also exist which aim to quantify the risk which patients are at of deterioration based on their vital signs and thus provide a guide to staff.  In addition, specialist staff are being utilised more effectively in order to augment the work already being done at ward level.

These include:  Crash teams (or code teams) - These

are designated staff members who have particular expertise in resuscitation, who are called to the scene of all arrests within the hospital. This usually involves a specialized cart of equipment (including defibrillator) and drugs called a "crash cart".

 Medical emergency teams - These

teams respond to all emergencies, with the aim of treating the patient in the acute phase of their illness in order to prevent a cardiac arrest.

 Critical care outreach - As well as providing

the services of the other two types of team, these teams are also responsible for educating non-specialist staff.  They help to facilitate transfers between  intensive care/high dependency units and the general hospital wards. This is particularly important, as many studies have shown that a significant percentage of patients discharged from critical care environments quickly deteriorate and are re-admitted - the outreach team offers support to ward staff to prevent this from happening.

Im plantable cardioverter defi brillators  A technologically based intervention

to prevent further cardiac arrest episodes  This device is implanted in the patient and acts as an instant defibrillator in the event of arrhythmia.  but they can be combined with a  pacemaker, and modern versions also have advanced features such as

M anagem ent Sudden cardiac arrest may be treated via attempts at  resuscitation

Cardiopulm onary resuscitation  a critical part of the management of

cardiac arrest  should be started as soon as possible and interrupted as little as possible. The component of CPR which seems to make the greatest difference is the chest compressions

D efi brillation  there is increasing use of public

access defibrillation. This involves placing  automated external defibrillators in public places, and training staff in these areas how to use them. This allows defibrillation to take place prior to the arrival of emergency services, and has been shown to lead to increased chances of survival.

D efi brillation  Some defibrillators

even provide feedback on the quality of CPR compressions, encouraging the lay rescuer to press the patient's chest hard enough to circulate blood

M edications  while included in guidelines, have

been shown not to improve survival to hospital discharge post out of hospital cardiac arrest. This includes the use of epinephrine, atropine, and amiodarone. Vasopression  overall does not improve or worse outcomes but may be of benefit in those with asystole especially if used early

Therapeutic hypotherm ia  Cooling a person after cardiac arrest with

return of spontaneous circulation (ROSC) but without return of consciousness improves outcomes. This procedure is called therapeutic hypothermia. People are cooled over a 24 hour period, with a target temperature of 32–34 °C (90– 93 °F). Death rates in the hypothermia group were 35% lower. While associated with some complications these are generally mild

D o not resuscitate  Some people choose to avoid aggressive

measure at the end of life. A  do not resuscitate (DNR) in the form of an  advance health care directive makes it clear that in the event of cardiac arrest the person does not wish cardiopulmonary resuscitation . Other directive may be made to stipulate the desire forintubation in the event of  respiratory failure or if comfort measures are all that are desired by stipulating "allow natural death".

C hain of survival Several organisations promote the idea of a "chain of survival". The chain consists of the following "links":

 Early recognition - If possible,

recognition of illness before the patient develops a cardiac arrest will allow the rescuer to prevent its occurrence. Early recognition that a cardiac arrest has occurred is key to survival - for every minute a patient stays in cardiac arrest, their chances of survival drop by roughly 10%.

 Early CPR - improves the flow of

blood and of oxygen to vital organs an essential component of treating a cardiac arrest. In particular, by keeping the brain supplied with oxygenated blood, chances of neurological damage are decreased.

 Early defibrillation - is effective for

the management of  ventricular fibrillation and pulseless  ventricular tachycardia[7] If defibrillation is delayed the rhythm is likely to degenerate into asystole for which outcomes are worse.

 Early advanced care - Early 

Advanced Cardiac Life Support is the final link in the chain of survival.

PrecordialThum p  The  may be considered in those with

witnessed, monitored, unstable ventricular tachycardia (including pulseless VT) if a defibrillator is not immediately ready for use, but it should not delay CPR and shock delivery or be used in those with unwitnessed out of hospital arrest

W arn in g S ig n s for C ard iac A rrest

 It strikes suddenly and without warning  Sudden loss of responsiveness

               No response to tapping on shoulders                Does nothing when you ask if he is okay     No normal breathing                The victim does not take a normal breath when you tilt the head up                 Check for at least five seconds

If these signs of cardiac arrest are present:  Call 9-1-1 for emergency medical services. 



 

  Get an automated external defibrillator (AED)               If one is available   Begin CPR immediately               Continue until professional emergency medical services arrive   Use the AED as soon as it arrives. If two people are available to help, one should begin CPR immediately while the other calls 9-1-1 and finds an AED.

C ardiac arrest is reversible in m ost victim s if it's treated w ithin a few m inutes  This first became clear in the early 1960s with the development

of coronary care units.  Electrical devices that shocked the heart were discovered to turn an abnormally rapid rhythm into a normal one.  Before then, heart attack victims had a 30 percent chance of dying if they got to the hospital alive; 50 percent of these deaths were due to cardiac arrest.  In-hospital survival after cardiac arrest in heart attack patients improved dramatically when the DC defibrillator and bedside monitoring were developed. Later, it also became clear that cardiac arrest could be reversed outside a hospital by properly staffed emergency rescue teams trained to give CPR and defibrillate.

Im m ediate treatm ent is essentialto survivalof cardiac arrest

The American Heart Association supports implementing a "chain of survival" to rescue people who suffer cardiac arrest.

The chain consists of:  Early recognition of the emergency and activation of the emergency medical services (EMS).     Early defibrillation when indicated.     Early bystander CPR (cardiopulmonary resuscitation).     Early advanced life support followed by postresuscitation care delivered by healthcare providers

Sym ptom s & Em ergency Treatm ent of Cardiac A rrest

While it's estimated that more than 95 percent of cardiac arrest victims die before reaching the hospital, death from sudden cardiac arrest is not inevitable.

Long-Term Treatm ent for C ardiac A rrest

PCAS-Related Conditions  While it's estimated that more than

95 percent of cardiac arrest victims die before reaching the hospital, death from sudden cardiac arrest is not inevitable.  Survivors of sudden cardiac arrest may face a variety of complex medical issues known as PostCardiac Arrest Syndrome (PCAS):

B rain Injury  Can begin hours to days after cardiac arrest.  Too much or too little oxygen delivered during

initial treatment can affect outcome.  Fever, increased blood sugar levels (hyperglycemia) and seizures can affect severity of brain injury and outcome.  Signs include coma, seizures, varying degrees of cognitive dysfunction from memory deficits to persistent vegetative state, movement impairments and brain death.

H eart D ysfunction  Can be detected within minutes of return

of spontaneous circulation (ROSC) with appropriate monitoring.  Heart rate, ejection fraction, heart rhythm and BP may be extremely variable after ROSC.  Dysfunction is transient and can resolve to normal by 72 hours after arrest.  Underlying heart disease that caused the arrest must also be treated.

System ic Ischem ia/R eperfu sion R esponse  During arrest, the body goes into

severe shock. The internal processes for taking in and removing necessary and harmful blood chemicals is stopped.  Lack of oxygen in the blood can cause organ damage or failure and increase susceptibility to infection.

C onditions that cause or ar e caused by cardiac arrest  Acute Coronary Syndrome (acute myocardial

infarction, acute coronary occlusion)  Arrhythmias  Lung conditions (pulmonary embolism, chronic obstructive pulmonary disease, asthma, pneumonia)  Hemorrhage caused by trauma  Infection (including pneumonia)  Drug or alcohol overdose  Accidental hypothermia All of these conditions must be monitored, treated and managed by the survivor's healthcare team.

IM PO RTAN T PO IN TS TO CO N SID ER  Once the patient's basic heart and

respiratory functions have been restarted through emergency care, teams of healthcare providers should evaluate the patient's condition and create a care plan that's as comprehensive as resources allow.  The care plan must be prioritized and executed in the proper order to optimize the patient's outcome and help prevent premature withdrawal of care.

IM PO RTAN T PO IN TS TO CO N SID ER  Variation in patient condition —

ranging from awake, aware and stable to comatose and unstable with ongoing conditions that caused the arrest — means that every patient's care plan will be different and determined by that patient's healthcare team.

TH AN K YO U FO R LISTEN IN G