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cardiac arrest

Etiology: 1) ventricular fibrillation, primary or secondary to disorders below 2) coronary artery disease (CAD) a) most common cause of cardiac arrest b) cardiac arrest is the initial manifestation in 20-25% of patients with CAD c) chronic ischemia with or without underlying myocardial scarring d) myocardial infarction: 1] 20% of out-of-hospital cardiac arrests are associated with myocardial infarction (MI) 2] attribute cardiac arrest to MI only if large, trans- mural or Q-wave infarction e) within 48 hours of acute Q-wave MI 3) left ventricular hypertrophy 4) obstructive hypertrophic cardiomyopathy 5) congestive heart failure 6) prolonged QT interval a) congenital (long QT syndrome) b) drug-induced 1] antiarrhythmics 2] psychotropics 7) Wolf-Parkinson-White syndrome 8) Brugada syndrome 9) commotio cordis 10) toxic, metabolic or electrolyte disturbances a) alcohol b) illicit drugs 11) proarrhythmic agents a) ecainide f) flecainide 12) pulmonary embolism 13) vigorous exercise heightens risk of cardiac arrest [2,5] (see sudden death in competitive sports) Epidemiology: 1) 300,000/year in the US 2) 1/3 of survivors die within 1 year Pathology: 1) cardiac ischemia 2) reperfusion injury 3) heart failure 4) metabolic abnormalities 5) cardiogenic shock Clinical manifestations: 1) prodomal symptoms occur in 50% of patients within 4 weeks of cardiac arrest [14] - may occur months prior to cardiac arrest - chest pain - palpitations - dyspnea - fatigue - lightheadedness 2) signs of cardiac arrest a) unresponsiveness b) no pulse c) apnea or agonal respirations d) pallor or cyanosis 3) gasping during CPR after cardiac arrest is associated with increased 1-year survival with good neurologic outcome [22] - do NOT terminate chest compressions prematurely Laboratory: 1) arterial blood gas (ABG) a) hypoxia b) acidosis 2) electrolytes a) hypokalemia or hyperkalemia b) hypomagnesemia 3) drug levels 4) addition of long QT syndrome genotyping to autopsy identifies probable cause of death in 13% of young people with sudden cardiac death [16] 5) serum neurofilament light chain at 24 hours after cardiac arrest predicts long-term poor neurologic outcome [25] 6) other genetic testing ? Special laboratory: 1) electrocardiogram a) ventricular tachycardia (VT) or ventricular fibrillation (VF) b) pulseless electrical activity (PEA) c) asystole 2) echocardiogram a) structural heart disease b) LV dysfunction c) cardiomyopathy 3) electrophysiology study a) indications - survivors of sudden cardiac death - suspected ventricular arrhythmias - syncope - structural heart disease b) see management (follow-up) 4) coronary angiography - no difference in survival between immediate vs delayed coronary angiography without ST-segment elevation [27] Differential diagnosis: 1) aspiration of a foreign body 'cafe coronary' 2) vasovagal syncope 3) seizure Complications: - pulmonary aspiration & aspiration pneumonia resulting from cardiopulmonary resuscitation, especially bag-mask ventilation & endotracheal intubation [26] - neurologic impairment in survivors of cardiac arrest generally does not affect ability to live independently [8] - return of spontaneous circulation in out-pf-hospital cardiac arrest lower during the COVID-19 pandemic [32] Management: 1) basic life support - early & effective bystander CPR is the goal for witnessed out-of-hospital cardiac arrests [12] - cardiopulmonary resuscitation at the site of cardiac arrest with better ourcomes than immediate transport & resuscitation attempts on the way to the hospital [31] 2) defibrillation 1) electrocardiography to identify cardiac arrhythmia 2) defibrillation for ventricular fibrillation & other shockable rhythms prior to epinephrine [36] 3) public access defibrillators for out-of-hospital cardiac arrest [17] 4) a prearrest protocol is proposed for at-home use of fully automated external defibrillators reducimg arrest-to-shock interval to < 1 minute [43] - defibrillator placed upon initial symptoms of acute coronary syndrome the defirillator senses & delivers shock autonomously if appropriate [43] 3) advanced cardiac life support (see ACLS) a) combined vasopressin-epinephrine & methylprednisolone during CPR & stress-dose hydrocortisone in postresuscitation shock may improve survival to hospital discharge with favorable neurological status [9] b) vasopressin + methylprednisolone increases likelihood of return to spontaneous circulation in patients with in-hospital cardiac arrest [35] c) epinephrine every 3 to 5 minutes (guideline) - intervals shorter than 3 minutes may increase odds of survival with favorable neurologic outcome [28] d) epinephrine for out-of-hospital cardiac arrest - may be of no benefit [10] - early epinephrine associated with better survival outcomes in adults with shockable & nonshockable out-of-hospital cardiac arrest [34] e) other ACLS medications: amiodarone ... - see ventricular fibrillation for persistent or recurrent VF/VT (i.e. 2nd shock) - of no benefit for out-of-hospital cardiac arrest [11] f) intravenous or intraosseous infusion of calcium no better than saline for sustained return of spontaneous circulation [37] 4) ventilation & oxygen for out-of-hospital cardiac arrest - bag mask ventilation vs endotracheal intubation - results of comparison inconclusive [23] - laryngeal tube insertion vs endotracheal intubation - 72-hour survival 18.3% vs 15.4% [24] - oxygen saturation target of 98%-100% better than or equal to target of 90%-94% in out-of-hospital resuscitation for cardiac arrest [39] 5) targetted temperature management a) standard of care for patients who remain unconscious after cardiac arrest (MKSAP, NEJM) [2,42] b) mild induced hypothermia may (or may not) improve outcomes [2,6,40] c) targetted temperature of 33 C no better than 36 C or 37.5 C [15,33] - may benefit patients with non-shockable rhythms - targetted temperature management = prevention of hyperthermia [42] d) targetted temperature management for at least 12 hours in patients who remain unconcious after out-of-hospital cardiac arrest from ventricular arrhythmia e) may improve neurologic outcomes, survival - no difference in neurologic outcome or mortality 33 C vs 37.5 C [33] - hypothermia does not improve mortality vs normothermia [38] f) 48 hours vs 24 hours of induced hypothermia not associated with better neurologic outcomes [21] g) prophylactic antibiotics prevents pneumonia with hypothermia after cardiac arrest but does not effect mortality, duration of mechanical ventilation, or length of intensive care stay [30] h) no benefit in neurological outcomes or mortality for maintenance of mild hypothermia for out-of-hospital cardiac arrest [40] i) hypothermia does not improve survival or function after out-of-hospital cardiac arrest with initial nonshockable rhythm [44] 6) prognosis: - see cardiopulmonary resuscitation - mortality, brain damage, & nursing home admission at 1 year lower if bystanders had jumped in to help in out-of-hospital cardiac arrest [20] 7) follow-up a) stabilization of cardiac rhythm & hemodynamics b) diagnose & treat underlying etiology c) within 48 hours of acute Q-wave MI - prognosis is good - standard post-MI management d) cardiac arrest not associated with acute MI - coronary angiography - no difference in survival between immediate vs delayed coronary angiography without ST-segment elevation [27] - echocardiography e) electrophysiologic testing - inducible VT or VF - antiarrhythmics if suppress VT/VF - automatic implantable cardioverter defibrillator (AICD)* - empiric amiodarone - 600 mg TID for 9 days, then - 400 mg QD - sotalol 160 mg BID - non-inducible VT or VF - AICD if left ventricular dysfunction (LVEF < 40%) - patient may only need treatment of reversible causes of cardiac arrest - electrophysiologic testing generally not required for reversible causes of cardiac arrest f) 50% recurrence of ventricular tachycardia within 2 years g) indications for AICD* a) cardiac arrest without a reversible cause - includes cardiac arrest without an identifiable cause b) hemodynamically significant, inducible, sustained VT/VF c) MI with LVEF < 40% & inducible VT/VF d) non-sustained VT, cardiomyopathy, LVEF 35% e) high-risk hypertrophic cardiomyopathy h) for patients receiving AICD after cardiac arrest - all-cause mortality: 22% - hospitalization: 65% - heart-failure hospitalization: 19% - skilled nursing facility admission: 22% - patients > 80 years have higher risks [19] 8) prevention [7] a) do not smoke b) maintain BMI > 25 kg/m2 c) exercise at least 30 minutes/day d) adhere to Mediterranean diet e) screen for family history of sudden cardiac death [20] - one 1st degree relative or >= 2 2nd degree relatives - assess left ventricular function if positive history f) for patients hospitalized with high-risk cardiovascular conditions (MI, heart failure), refer family members to CPR & automated external defibrillator education g) implantable cardioverter-defibrillator for patients with heart failure & LVEF < 35% expected to survive > 1 year - effective for prevention of sudden cardiac death [2] h) ACE inhibitor or ARB for patients with heart failure & reduced LVEF (LV systolic dysfunction) [20] * treatment of choice * cardiac magnetic resonance imaging helpfuk to assess myocardial infiltration prior to ICD pacement

Interactions

disease interactions

Related

cardiopulmonary resuscitation (CPR) sudden death in competitive sports

General

heart disease (cardiac disease)

References

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