Cardiac Arrest-Updated.pdf

CARDIAC ARREST
Dr. Nayan Ray
MBBS
Mymensingh Medical College and Hospital

INTRODUCTION
• Cardiac arrest is the cessation of functional cardiac contraction and is the final
common pathway in death from any pathology.
• In the clinical context, cardiac arrest refers to the sudden loss of cardiac output that
prompts an emergency response.
• Pathogenesis, prognosis and management of in-hospital and out-of-hospital cardiac
arrest are subtly different; however, the basic principles of cardiopulmonary
resuscitation (CPR) are to maintain forward flow of oxygenated blood, correct the
causative factor and restore spontaneous circulation.
NYN/DMA/BPL

• Sudden cardiac arrest (SCA): Sudden cessation of normal cardiac activity with
haemodynamic collapse.
• Sudden cardiac death (SCD): Sudden natural death presumed to be of cardiac cause that
occurs within 1 h of onset of symptoms in witnessed cases, and within 24 h of last being seen alive
when it is unwitnessed. SCD in autopsied cases is deﬁned as the natural unexpected death of
unknown or cardiac cause.
• Sudden unexplained death: Unexplained sudden death occurring in an individual older
than 1 year.
NYN/DMA/BPL

• Sudden infant death syndrome (SIDS): Unexplained sudden death occurring in an
individual younger than 1 year with negative pathological and toxicological assessment and
negative forensic examination of the circumstances of death.
• Sudden arrhythmic death syndrome (SADS): Unexplained sudden death occurring in an
individual older than 1 year with negative pathological and toxicological assessment. Note:
Synonymous with ‘autopsy-negative sudden unexplained death’.
NYN/DMA/BPL

EPIDEMIOLOGY
SCD accounts for approximately 50% of all cardiovascular
deaths, with up to 50% being the ﬁrst manifestation of
cardiac disease.
NYN/DMA/BPL

•The incidence of SCD increases markedly with age.
• With a very low incidence during infancy and childhood (1 per 100
000 person- years),
• the incidence is approximately 50 per 100 000 person- years in
middle-aged individuals (in the ﬁfth to sixth decades of life).
• In the eighth decade of life, it reaches an annual incidence of at
least 200 per 100 000 person-years.
NYN/DMA/BPL

At any age, males have higher SCD rates compared with females, even
after adjustment for risk factors of coronary artery disease (CAD).
Ethnic background also seems to have large effects. It is estimated that
10–20% of all deaths in Europe are SCD.
Approximately 300 000 people in Europe have out-of-hospital cardiac
arrest (OHCA) treated by emergency medical systems every year.
NYN/DMA/BPL

SCD IN SPORTS
• Although regular physical activity beneﬁts cardiovascular health,
sport, particularly when practiced vigorously, has been shown to be
associated with SCD during or shortly after exercise in selected
populations.
• Reports have suggested that the majority of sports- related SCD
occurs in a recreational rather than competitive setting, especially
among middle-aged male participants, suggesting that CAD is the
most common underlying cause.
NYN/DMA/BPL

Meiso Hayashi. Circulation Research. The Spectrum of Epidemiology Underlying Sudden Cardiac Death, Volume: 116, Issue: 12, Pages: 1887-1906, DOI:
(10.1161/CIRCRESAHA.116.304521)
ETIOLOGY

Truhlář
A,
Deakin
CD,
Soar
J,
Khalifa
GE,
Alfonzo
A,
Bierens
JJ,
Brattebø
G,
Brugger
H,
Dunning
J,
Hunyadi-Antičević
S,
Koster
RW.
European
resuscitation
council
guidelines
for
resuscitation
2015:
section
4.
Cardiac
arrest
in
special
circumstances.
Resuscitation.
2015
Oct
1;95:148-201.
https://fpnotebook.com/er/exam/RvrsblCsOfCrdplmnryArst.htm
ACLS.com
MA/BPL

Figure 1 Central figure. Genetic risk for VA/SCD, typical triggers for VA/SCD, age at presentation with VA/SCD, sex..

CLINICAL ASSESSMENT AND MANAGEMENT
NYN/DMA/BPL

AWARENESS AND INTERVENTION: PUBLIC
BASIC LIFE SUPPORT, AND ACCESS TO
AUTOMATED EXTERNAL DEﬁBRILLATORS
NYN/DMA/BPL
Bystander cardiopulmonary resuscitation (CPR) and use of
public automated external deﬁbrillators (AEDs) have demon-
started improvement of neurological and functional outcome as
well as survival of OHCA patients.

www.escardio.org/guidelines
©ESC
2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death
(European Heart Journal; 2022 – doi: 10.1093/eurheartj/ehac262)
Recommendations Class Level
It is recommended that public access defibrillation be available at sites where
cardiac arrest is more likely to occur.
I B
Prompt CPR by bystanders is recommended at OHCA. I B
It is recommended to promote community training in basic life support to
increase bystander CPR rate and AED use.
I B
Mobile phone-based alerting of basic life support-trained bystander volunteers
to assist nearby OHCA victims should be considered.
IIa B
Recommendations for public basic life support and access to AED
NYN/DMA/BPL

BASIC LIFE SUPPORT
ABCDE approach
• Prompt assessment and restoration of the Airway,
• Maintenance of ventilation using rescue Breathing (‘mouth-to-mouth’ breathing),
• Maintenance of the Circulation using chest compressions;
• Disability, in resuscitated patients, refers to assessment of neurological status, and
• Exposure entails removal of clothes to enable defibrillation, auscultation of the chest and
assessment for a rash caused by anaphylaxis, for injuries and so on
NYN/DMA/BPL

NYN/DMA/BPL
ALGORITHM
FOR
ADULT
BASIC
LIFE
SUPPORT

ADVANCED LIFE SUPPORT
• Advanced life support (ALS) aims to restore normal cardiac rhythm by defibrillation
when the cause of cardiac arrest is a tachyarrhythmia, or to restore cardiac output
by correcting other reversible causes of cardiac arrest.
• The initial priority is to assess the patient's cardiac rhythm by attaching a
defibrillator or monitor.
• Once this has been done, treatment should be instituted based on the clinical findings.
• Only a minority of patients will have a shockable rhythm at the commencement of
resuscitation.
NYN/DMA/BPL

NYN/DMA/BPL
Algorithm for adult advanced life support
DAVIDSON
24TH
EDITION

NYN/DMA/BPL
DAVIDSON 24TH EDITION

DEFIBRILLATION
• Ventricular defibrillation or pulseless ventricular tachycardia should be treated with
immediate defibrillation.
• Defibrillation is more likely to be effective if a biphasic shock defibrillator is used,
where the polarity of the shock is reversed midway through its delivery.
• Defibrillation is usually administered using a 150 Joule biphasic shock, and CPR
resumed immediately for 2 minutes without attempting to confirm restoration of a
pulse, because restoration of mechanical cardiac output rarely occurs immediately
after successful defibrillation.
NYN/DMA/BPL

• If, after 2 minutes, a pulse is not restored, a further biphasic shock of 150–
200 J should be given. Thereafter, additional biphasic shocks of 150–200 J
are given every 2 minutes after each cycle of CPR.
• During resuscitation, adrenaline (epinephrine, 1 mg IV) should be given every
3–5 minutes and consideration given to the use of intravenous amiodarone,
especially if ventricular defibrillation or ventricular tachycardia re-initiates
after successful defibrillation.
NYN/DMA/BPL

AUTOMATED EXTERNAL DEFRIBILLATOR IMPLANTABLE CARDIOVERTER DEFRIBILLATOR
NYN/DMA/BPL

NYN/DMA/BPL
IMAGING STUDIES
LAB TEST
• CBC ,
• ABG ANALYSIS ,
• SERUM ELECTROLYTE
• CHEST XRAY ,
• MRI ,
• ELECTROCARDIOGRAM ,
• ECHOCARDIOGRAM ,
• CORONARY ANGIOGRAPHY
DIAGNOSTIC EVALUATION

DIAGNOSTIC EVALUATION AT FIRST PRESENTATION WITH
VENTRICULAR ARRHYTHMIA IN PATIENTS WITHOUT
KNOWN CARDIAC DISEASE
NYN/DMA/BPL

SCENARIO 1:
INCIDENTAL FINDING OF A
NON-SUSTAINED VENTRICULAR TACHYCARDIA
NYN/DMA/BPL

©ESC
In patients with newly documented VA (frequent PVCs, NSVT, SMVT), a baseline
12-lead ECG, recording of the VA on 12-lead ECG, whenever possible, and an
echocardiogram are recommended as first-line evaluation.
I C
In patients with newly documented VA (frequent PVCs, NSVT, SMVT) and
suspicion of SHD other than CAD after initial evaluation, a CMR should be
considered.
IIa B
In patients with an incidental finding of a NSVT, a ≥24h Holter ECG should be
considered.
IIa C
Recommendations for evaluation of patients presenting with newly
documented VA
NYN/DMA/BPL

©ESC
Figure 2
Algorithm for the
evaluation of patients
presenting with an
incidental finding of
NSVT
NYN/DMA/BPL

SCENARIO 2:
FIRST PRESENTATION OF SUSTAINED
MONOMORPHIC VENTRICULAR TACHYCARDIA
NYN/DMA/BPL

©ESC
In patients presenting with a first SMVT episode, electrophysiological study,
electroanatomical mapping, and mapping-guided biopsies may be considered
for aetiological evaluation.
IIb C
Recommendations for evaluation of patients presenting with a first
episode of SMVT
NYN/DMA/BPL

©ESC
Figure 4
Typical idiopathic VT
morphologies
NYN/DMA/BPL

©ESC
Figure 4
Algorithm for the
evaluation of patients
presenting with a first
SMVT episode
NYN/DMA/BPL

©ESC
Figure 5
Bundle-branch re-
entrant ventricular
tachycardia
NYN/DMA/BPL

SCENARIO 3:
SUDDEN CARDIAC ARREST SURVIVOR
NYN/DMA/BPL

©ESC
The investigation of a SCA survivor without obvious extra-cardiac cause is
recommended to be overseen by a multidisciplinary team.
I B
In electrically unstable patients after SCA, with suspicion of ongoing myocardial
ischaemia, a coronary angiogram is indicated.
I C
In SCA survivors, brain/chest CT scan should be considered when patient
characteristics, ECG, and echocardiography are not consistent with a cardiac
cause.
IIa C
In SCA survivors, collection of blood samples at presentation is recommended
for potential toxicology and genetic testing.
I B
Retrieval of recordings from CIEDs and wearable monitors is recommended for
all SCA survivors.
I B
Recommendations for evaluation of SCA survivors (1)
NYN/DMA/BPL

©ESC
In SCA survivors, repeated 12-lead ECGs during stable rhythm (including high
precordial lead ECG), as well as continuous cardiac monitoring, are
recommended.
I B
Echocardiography is recommended for evaluation of cardiac structure and
function in all SCA survivors.
I C
Coronary imaging and CMR with LGE, are recommended for evaluation of cardiac
structure and function in all SCA survivors without a clear underlying cause.
I B
Sodium channel blocker test and exercise testing is recommended in SCA
survivors without a clear underlying cause.
I B
In SCA survivors, ergonovine, acetylcholine, or hyperventilation testing may be
considered for the diagnosis of coronary vasospasm.
IIb B
Recommendations for evaluation of SCA survivors (2)
NYN/DMA/BPL

©ESC
Figure 6 Part One
Algorithm for the
evaluation SCA
survivors
NYN/DMA/BPL

©ESC
Figure 6 Part Two
Algorithm for the
evaluation SCA
survivors
NYN/DMA/BPL

SCENARIO 4:
SUDDEN DEATH VICTIM
NYN/DMA/BPL

©ESC
Investigation of unexpected SD, especially in case of suspicion of inherited
disease, should be made a public health priority.
I B
In cases of SD, it is recommended to collect a detailed description of
circumstances of death, symptoms prior to death, the family history, and to
review prior medical files.
I B
A comprehensive autopsy is recommended, ideally, in all cases of unexpected
SD, and always in those under 50 year.
I B
In cases of SCD, it is recommended to retain samples suitable for DNA extraction
and consult a cardiac pathologist when an inherited cause is suspected or the
cause of death unexplained.
I B
Toxicology screens are recommended in SD cases with uncertain cause of death. I B
For SCD where the cause is known or suspected to be heritable, genetic testing
targeted to the cause is recommended.
I B
Recommendations for evaluation of sudden death victims (1)
NYN/DMA/BPL

©ESC
Following SADS, post-mortem genetic testing targeted to primary electrical
disease is recommended when the decedent is young (< 50) and/or the
circumstances and/or family history support a primary electrical disease.
I B
When an autopsy diagnoses possible heritable cardiac disease, it is
recommended to refer first-degree relatives for cardiac assessment in a
specialized clinic.
I B
In non-autopsied cases of SD where inherited cardiac disease is suspected, it is
recommended to refer first-degree relatives for cardiac assessment in a
specialized clinic.
I B
Following SADS, post-mortem genetic testing in the decedent for additional
genes may be considered.
IIb C
Following SADS, hypothesis-free post-mortem genetic testing using exome or
genome sequencing is not recommended.
III B
Recommendations for evaluation of sudden death victims (2)
NYN/DMA/BPL

©ESC
Figure 7
Algorithm for the
evaluation of SD
victims
NYN/DMA/BPL

SCENARIO 5:
RELATIVES OF SUDDEN ARRHYTHMIC DEATH
SYNDROME DECEDENTS
NYN/DMA/BPL

©ESC
Familial evaluation of SADS decedents is recommended:
• for first-degree relatives
• for relatives who must carry a mutation based on analysis of the family history
• for relatives with suspicious symptoms
• when the decedent’s age is < 50 years or if there is other circumstantial data or
family history to suggest heritable disease.
I B
Familial evaluation of SADS decedents is recommended to include genetic testing
when post-mortem genetic testing in a SADS decedent detects a pathogenic mutation
I B
Baseline familial evaluation of SADS decedents is recommended to include taking a
medical history and performing physical examination, standard- and high-precordial
lead ECG, echocardiography, and exercise testing.
I B
In SADS families without a diagnosis after clinical evaluation, follow-up is
recommended for children of decedents until they reach adulthood.
I C
Recommendations for evaluation of relatives of SADS decedents (1)
NYN/DMA/BPL

©ESC
Pharmacological testing with a sodium channel blocker should be considered in
relatives of SADS decedents who are 16 years or older when baseline testing
and/or proband findings increase the suspicion of BrS.
IIa B
Ambulatory cardiac rhythm monitoring and CMR may be considered in relatives
of SADS decedents.
IIb C
Pharmacological testing including epinephrine challenge (if exercise testing is
impractical) and sodium channel blocker challenge may be considered in first-
degree relatives of SADS decedents with normal baseline testing.
IIb B
In SADS families without a diagnosis after clinical evaluation, follow-up is not
recommended for asymptomatic adults who can be discharged with advice to
return if they develop symptoms or if the family history changes.
III C
Recommendations for evaluation of relatives of SADS decedents (2)
NYN/DMA/BPL

©ESC
Figure 8
Algorithm for the
evaluation of
relatives of
unexplained sudden
death decedents
NYN/DMA/BPL

OUT-OF-HOSPITAL CARDIAC ARREST (OHCA)
• This is the sudden and complete loss of cardiac output occurring in the
community.
• The clinical diagnosis is based on the victim being unconscious and pulseless;
breathing may take some time to stop completely after cardiac arrest. Death
is virtually inevitable, unless effective treatment is given promptly.
NYN/DMA/BPL

PATHOGENESIS
• Cardiac arrest may be caused by ventricular fibrillation, pulseless ventricular
tachycardia, asystole or pulseless electrical activity.
NYN/DMA/BPL

PATHOGENESIS
• Myocardial ischaemia is the most common trigger of OHCA. This can be due
to an acute infarct, acute on chronic coronary insufficiency, post-infarct
ventricular scarring or structural cardiac disease (cardiomyopathy, aortic
stenosis).
NYN/DMA/BPL

PATHOGENESIS
• Ventricular fibrillation can occur in the absence of recognised structural
abnormalities, e.g. congenital syndromes such as Brugada syndrome.
• Occasionally, sudden cardiac death can occur from an acute mechanical
catastrophe such as cardiac rupture or aortic dissection.
NYN/DMA/BPL

IN-HOSPITAL CARDIAC ARREST (IHCA)
• Historically, outcomes from IHCA were extremely poor. However, with
appropriate anticipatory care planning and prompt intervention of hospital
resuscitation teams, outcomes can be significantly better than for OHCA.
NYN/DMA/BPL

PATHOGENESIS
• Although primary cardiac causes are the most common cause of IHCA,
additional factors such as organ failure, sepsis or respiratory
decompensation are often more pertinent.
• Correction of hypoxaemia with early tracheal intubation and ventilation is
therefore of higher importance in this group than in OHCA, provided it can
be achieved without interruption of chest compressions.
NYN/DMA/BPL

RISK FACTORS CARDIAC ARREST
• A family history of coronary artery disease.
• Smoking.
• High blood pressure.
• High blood cholesterol.
• Obesity.
• Diabetes.
• An inactive lifestyle.
NYN/DMA/BPL

SYMPTOMS
• Collapse suddenly and lose consciousness (pass out)
• Are not breathing or their breathing is ineffective or they are gasping for air
• Do not respond to shouting or shaking
• Do not have a pulse
NYN/DMA/BPL

WHAT ARE THE WARNING SIGNS?
• Shortness of breath (more common in women than men)
• Extreme tiredness (unusual fatigue)
• Back pain
• Flu-like symptoms
• Belly pain, nausea, and vomiting
• Chest pain, mainly angina (more common in men than women)
• Repeated dizziness or fainting, especially while exercising hard, sitting, or lying on back
• Heart palpitations, or feeling as if the heart is racing, fluttering, or skipping a beat
NYN/DMA/BPL

COMPLICATIONS
• NEUROLOGICAL IMPAIRMENT
• STROKE
• RENAL FAILURE
• CARDIOGENIC SHOCK
• DEATH
NYN/DMA/BPL

THE CHAIN OF SURVIVAL IN CARDIAC ARREST
NYN/DMA/BPL
• The ‘Chain of Survival’ refers to the sequence of events that is necessary to maximise the
chances of a cardiac arrest victim surviving.
• Survival is most likely if all links in the chain are strong: that is, if the arrest is
witnessed, help is called immediately, basic life support is administered by a trained
individual, the emergency medical services respond promptly, and defibrillation is
achieved within a few minutes.
• CPR from bystanders, often assisted by ambulance service telephone dispatchers, is
crucial.

NYN/DMA/BPL
• Good training in both basic and advanced life support is essential and
should be maintained by regular refresher courses.
• Automated external defibrillators (AEDs) are increasingly available in
public places, particularly where traffic congestion may impede the
response of emergency service, and should be used as soon as possible.
• Designated individuals can respond to a cardiac arrest using basic life
support and an automated external defibrillator.

NYN/DMA/BPL

ACE INHIBITOR
DILATE THE BLOOD VESSELS &
IMPROVE YOUR BLOOD FLOW
(CAPTOPRIL,ENELAPRIL)
B BLOCKER
REDUCE THE RISK OF REINFARCTION
& OCCURANCE OF HEART FAILURE
(ATENELOL,ESMOLOL)
ANTIARRHYMIC DRUG
TREAT ARRHYTHMIAS
(PROCAINAMIDE)
CALCIUM CHANNEL BLOCKER
RELAX SMOOTH MUSCLE
(AMLODIPINE)
MEDICAL MANAGEMENT
Papastylianou A, Mentzelopoulos S. Current pharmacological advances in the treatment of cardiac arrest. Emerg Med Int.
2012;2012:815857. doi: 10.1155/2012/815857. Epub 2011 Nov 20. PMID: 22145080; PMCID: PMC3226361.
NYN/DMA/BPL

CORONARY ANGIOPLASTY
Coronary angioplasty is a medical procedure in which a balloon is used to
open a blockage in a coronary artery narrowed by atherosclerosis.
CORONARY BYPASS SURGERY
Coronary bypass surgery is a procedure that restores blood flow to your
heart muscle by diverting the flow of blood around a section of a blocked
artery in your heart.
HEART TRANSPLANTATION
A heart transplant, or a cardiac transplant, is a surgical transplant procedure
performed on patients with end-stage heart failure or severe coronary artery
disease when other medical or surgical treatments have failed.
SURGICAL TREATMENT
SANJIB
https://www.mayoclinic.org/diseases-conditions/sudden-cardiac-arrest/diagnosis-treatment/drc-20350640#:~:text=Coronary%20bypass%20surgery.,the%20frequency%20of%20racing%20heartbeats.
NYN/DMA/BPL

POST CARDIAC ARREST
The majority of cardiac arrest survivors will need a period of time in
intensive care to achieve physiological stability, identify and
manage the underlying cause of the arrest, and optimise
neurological recovery.
NYN/DMA/BPL

ACUTE MANAGEMENT
• A MAP of > 70 mmHg should be maintained to optimise cerebral perfusion.
• Shock is common following return of spontaneous circulation (ROSC) and is
caused by a combination of the underlying condition leading to the arrest,
myocardial stunning and a post-arrest vasodilated state.
• Support with inotropes, vasopressors and occasionally mechanical support
from an intra-aortic balloon pump or venous–arterial ECMO may be required.
NYN/DMA/BPL

DAVIDSON 24TH EDITION
NYN/DMA/BPL

PROGNOSIS
• Predicting which patients will not recover from the brain injury sustained at the
time of cardiac arrest is very difficult.
• Certain features suggest that the outcome will be poor: for example, the
absence of pupillary and corneal reflexes, absence of a motor response and
persistent myoclonic jerking.
NYN/DMA/BPL

• The clinician should, where feasible, delay prognostication until a period of 72
hours of targeted temperature management has been completed.
• The bilateral absence of the ‘N20’ spike on the somatosensory evoked
potential is the most specific test to predict irrecoverable brain injury.
• This test is performed by administering an electrical impulse over a peripheral
nerve and recording the electrical impulses measured by the scalp electrodes
overlying the part of the brain expected to receive the impulse.
NYN/DMA/BPL

• Where this is not available, prognostication based on all other available
information, along with the perceived wishes relating to the level of disability
the individual would be prepared to accept, should allow a decision
regarding ongoing treatment to be made.
• Where there is doubt, more time should be given to allow assessment of
neurological recovery.
NYN/DMA/BPL

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