This document discusses sudden cardiac arrest (SCA) and sudden cardiac death (SCD). SCA refers to sudden cessation of cardiac activity that may be reversible by interventions like defibrillation, while SCD is uncorrected SCA that leads to death. SCD is defined as natural death from cardiac causes within one hour of symptoms in someone who may have unrecognized heart disease. About 500,000 cases occur annually in the US, accounting for 10-15% of natural deaths. Risk factors include prior arrhythmias, low ejection fraction, heart disease, and family history. Treatment involves cardiopulmonary resuscitation, defibrillation if needed, and treating underlying causes. Advanced cardiac life support may include int

1. Dr. Shreyash Trived
Dr. (Prof.) V. Priyadarshi Unit

2. INTRODUCTION
Sudden cardiac arrest (SCA) and sudden
cardiac death (SCD) refer to the sudden
cessation of cardiac activity with
hemodynamic collapse.
If an intervention (e.g., defibrillation) restores
circulation, the event is referred to as SCA. If
uncorrected, an SCA event leads to death and is
then referred to as SCD.

3. DEFINITION OF SUDDEN CARDIAC
DEATH
Sudden cardiac death is defined as “natural death due
to cardiac causes in a person who may or may not have
previously recognized heart disease but in whom the
time and mode of death are unexpected.

4. In the context of time, sudden is defined for most
clinical and epidemiologic purposes as 1 hour or less
between a change in clinical status heralding the
onset of the terminal clinical event and the cardiac
arrest itself.
To satisfy clinical, scientific, legal, and social
considerations, four temporal elements must be
considered: (1) prodromes, (2) onset of terminal
event, (3) cardiac arrest, and (4) biologic death

5. SCD viewed from four temporal
perspectives

6. EPIDEMIOLOGY OF SCD
Approx. 5,00,000 CASES IN U.S.A PER ANNUM
Accounts for 10-15% of natural deaths and 50 % deaths
from cardiac causes.
BIMODAL AGE DISTRIBUTION with peaks between
birth and 6 months of age & after 65 yrs of age
Male preponderance
May be the first presentation of cardiovascular disease
in 25% of patients

7. AGE RELATED RISK FOR SCD

8.  Prior Episode of V.TACH
 Low LVEF.
 Previous Myocardial Infarction.
 Coronary Artery Disease
 Family History of SCD.
 Cardiomyopathy
 Congestive Heart Failure
 Long QT Syndrome.
 Right Ventricular Dysplasia.
Risk Factors of Sudden Cardiac Death (SCD)

10. SUDDEN CARDIAC ARREST
Abrupt cessation of cardiac mechanical function,
which may be reversible by a prompt intervention
(e.g., defibrillation) but will lead to death in its
absence.

11. Three Basic ECG Patterns with
Cardiac Arrest
Ventricular tachyarrhythmia-- ventricular fibrillation
(VF)/sustained type of pulseless ventricular
tachycardia
Ventricular asystole or a brady-asystolic rhythm with
an extremely slow rate
Pulseless electrical activity (PEA), previously referred
to as electromechanical dissociation.

14. Ventricular Tachycardia

15. SUDDEN CARDIAC ARREST
The probability of achieving successful resuscitation
from cardiac arrest is related to-
Interval from onset of loss of consciousness to
institution of resuscitative efforts
The setting in which the arrest occurs
The mechanism ( VT, VF, PEA, ASYSTOLE) of CA
Clinical status of the patient before the cardiac arrest.

16. SUDDEN CARDIAC ARREST
Return of circulation and survival rates as a result of
defibrillation decreases almost linearly from first to
10th min.

17. SUDDEN CARDIAC ARREST
After 5 min, survival rates are no better than 25-30% in
out of hospital setting
Outcome in ICU and other in-hospital environments is
heavily influenced by patients preceding clinical status

18. SUDDEN CARDIAC ARREST
When the mechanism is pulseless VT, the outcome is
best
VF is the next most successful
Asystole and PEA generate dismal outcome statistics

19. Successful resuscitation following cardiac arrest requires an
integrated set of coordinated actions represented by the links in the
Chain of Survival

20. The links include the following:
Immediate recognition of cardiac arrest and
activation of the emergency response system
Early CPR with an emphasis on chest
compressions
Rapid defibrillation
Effective advanced life support
Integrated post– cardiac arrest care

21. Signs and symptoms
The most reliable sign is absence of pulse
Unconsciousness/Unresponsiveness
No respiratory movements
No blood pressure
Pupils begin dilating within 45 secs.
Seizures- may or may not occur
Death like appearance
Lips and nail beds turn blue and skin turns pale

22. INITIAL RESPONSE
As soon as a cardiac arrest is suspected , confirmed, or
even considered to be impending, calling an
emergency rescue system is the immediate priority

23. BLS (Basic Life Support)

24. The goal of this activity is to maintain viability of the
CNS, heart and other vital organs until definitive
intervention can be achieved.
Fundamental aspects of BLS include-
Immediate recognition of SCA and activation of
emergency response system
Early CPR
Rapid defibrillation with an automated external
defibrillator (when appropriate)

25. Immediate recognition and
activation of emergency response
system
If a lone rescuer finds an unresponsive adult or
witnesses an adult who suddenly collapses, after
ensuring that the scene is safe, the rescuer should
check for a response by tapping the victim at the
shoulder and by shouting at him
The trained or untrained bystander should activate the
community emergency response system, or if in an
institution with an emergency response system call
that facility’s emergency response number

26. Unresponsiveness
If the victim also has absent or abnormal breathing(ie,
only gasping) the rescuer should assume that the
victim is in cardiac arrest

27. PULSE CHECK:
▪ Studies have shown that both lay rescuers and health
care providers (HCP) have difficulty detecting a pulse.
▪The lay rescuer should not check for a pulse
▪If the HCP doesn’t definitely feel a pulse within 10 secs
he should start chest compressions.

28. EARLY CPR
A change in the 2010 AHA guidelines for CPR is to
recommend the initiation of compressions before
rescue breaths
Change from ABC to CAB

29. RESCUER SPECIFIC CPR STRATEGIES
Untrained lay rescuer:- Hands-only (chest
compression only) CPR, with an emphasis on push
hard and push fast until an AED arrives or HCP take
over
Trained lay rescuer:- should start chest compressions
first. add rescue breaths in the ratio of 30
compressions to two breaths if able to do so
HCP:- Cycle of 30:2 until an advanced air way is
placed; then continuous chest compressions with 1
breath every 6 to 8 secs.

30. Technique : chest compressions
Place victim on a firm surface in supine position
Rescuer kneeling besides victim’s chest (out of
hospital) or standing besides bed (in hospital)
Place heel of one hand over the lower half of sternum.
Heel of the other hand should be on top of the first so
that they overlap and are parallel.
Arms should be straight and perpendicular to chest of
victim

32. Technique: Rescue breaths
Open airway- Head tilt and chin lift/ Jaw thrust
Mouth to mouth
Mouth to barrier device
Mouth to nose and mouth and stoma
Ventilation with bag and mask
Ventilation with supraglottic airway- LMA, esophageal
combitube, king airway device

33. Technique: Rescue breaths
To provide mouth-to-mouth rescue breaths, open the
victim’s airway- pinch the victim’s nose- and create an
airtight mouth-to-mouth seal. Give 1 breath over 1
second, take a “regular” (not a deep) breath, and give a
second rescue breath over 1 second
Advanced airway- 1 breath every 6-8 secs
ASYNCHRONOUS with compressions

34. Opening the airway

35. Providing basic ventilation
Mouthtomouthventilation
Mouthtonoseventilation
Mouthtobarrierdevice
Bag mask ventilation

36. Advanced airways
ETtube
combitube
LMA

37. Summary of Key BLS Components
for Adults, Children and Infants

42. ADVANCED CARDIAC LIFE SUPPORT

43. This next step in resuscitative sequence is designed to
achieve a stable Return of Spontaneous Circulation (
ROSC), and hemodynamic stabilization
There should not be an abrupt cessation of BLS, rather
a merging and transition from one level of activity to
the next.

44. Goals of ACLS
Revert the cardiac rhythm to one that is
hemodynamically effective-by
defibrillation/cardioversion
To optimize ventilation-through placement of an
advanced airway (i.e., intubation)
To maintain and support the restored circulation-
monitoring and use of drugs

45. Basics of ACLS
Immediately after activating emergency response,
start CPR
Attach monitor/defibrillator minimizing interruptions
in CPR
Shockable rhythm- defibrillate with recommended
shock energy and immediately resume CPR for 2 mins
(5 cycles)

48. Rhythm-Based Management of
Cardiac Arrest

49. Paddles and electrode pads: anterior-lateral position
Any doubt about the presence of a pulse chest
compressions
Rhythm can be diagnosed before CPR is initiated

50. Defibrillation: Electrode Placement

51. VF/Pulseless VT

52. Resume CPR while charging the defibrillator
Chest compressions should switch at every 2-minute
cycle to minimize fatigue

53. Defibrillation Strategies
Waveform and Energy
Biphasic defibrillator: manufacturer’s recommended
energy dose (120-200 J)
Unaware of the effective dose range: maximal dose

54. Defibrillation Strategies
Waveform and Energy
Second and subsequent energy levels should be at
least equivalent, and higher energy levels may be
considered if available.
Monophasic defibrillator: 360 J
Subsequent shocks at the previously successful energy
level

55. Drug Therapy in VF/Pulseless VT
Amiodarone: first-line antiarrhythmic agent
Magnesium sulfate
Torsades de pointes associated with a long QT interval

56. Treating Potentially Reversible
Causes of VF/Pulseless VT
Refractory VF/pulseless VT: AMI

59. PEA/Asystole

60. Drug Therapy for PEA/Asystole
Vasopressor can be given as soon as feasible
Available evidence suggests that the routine use of
atropine during PEA or asystole is unlikely to have a
therapeutic benefit .
For this reason atropine has been removed from the
cardiac arrest algorithm.

61. Treating Potentially Reversible
Causes of PEA/Asystole
PEA
reversible conditions
treated successfully if those conditions are identified and
corrected
Hypoxemia: advanced airway
severe volume loss or sepsis: administration of empirical
IV/IO crystalloid.
severe blood loss: blood transfusion
pulmonary embolism: empirical fibrinolytic therapy (Class
IIa, LOE B)
tension pneumothorax: needle decompression

62. Treating Potentially Reversible
Causes of PEA/Asystole
Asystole
end-stage rhythm that follows prolonged VF or PEA, and
for this reason the
prognosis is generally much worse

65. MONITORING DURING CPR
Mechanical parameteres
Rate of compression: ≥ 100/min
Depth of compression: ≥2 inches (5 cm)
Rate of ventilation: 1 breath every 6-8 s (8-10
breath/min)

66. Physiologic Parameters
Pulse
End-Tidal CO2
Coronary Perfusion Pressure and Arterial Relaxation
Pressure
Central Venous Oxygen Saturation
Pulse Oximetry
Arterial Blood Gases
Echocardiography

67. End-Tidal CO2
If PETCO2 is <10 mm Hg, it is reasonable to consider
trying to improve CPR quality by optimizing chest
compression parameters .
If PETCO2 abruptly increases to a normal value (35-40
mm Hg), it is reasonable to consider that this is an
indicator of ROSC.

68. Coronary Perfusion Pressure and Arterial
Relaxation Pressure
Increased CPP correlates with improved 24-hour
survival rates and is associated with improved
myocardial blood flow and ROSC
If the arterial relaxation “diastolic” pressure is <20 mm
Hg, it is reasonable to consider trying to improve
quality of CPR by optimizing chest compression
parameters or giving a vasopressor or both.

69. Pulse oximetry-typically does not provide a reliable
signal because pulsatile blood flow is inadequate in
peripheral tissue beds
Routine measurement of arterial blood gases during
CPR has uncertain value
Absence of cardiac motion on echocardiogaphy during
resuscitation of patients in cardiac arrest was highly
predictive of inability to achieve ROSC

70. Medications for Arrest Rhythms

71. Epinephrine
It is reasonable to consider administering a 1 mg dose
of IV/IO epinephrine every 3-5 minutes during adult
cardiac arrest .
If IV/IO access is delayed or cannot be established,
epinephrine may be given endotracheally at a dose of
2-2.5 mg.

72. Vasopressin
Nonadrenergic peripheral vasoconstrictor
1 dose of vasopressin 40 units IV/IO may replace either
the first or second dose of epinephrine in the
treatment of cardiac arrest .

73. Amiodarone
An initial dose of 300 mg IV/IO can be followed by 1
dose of 150 mg IV/IO.
For recurrent or refractory VF/VT.

74. Lidocaine
Considered if amiodarone is not available
The initial dose is 1-1.5 mg/kg IV.
If VF/pulseless VT persists, additional doses of 0.5-
0.75 mg/kg IV push may be administered at 5- to 10-
minute intervals to a maximum dose of 3 mg/kg.

75. Magnesium Sulfate
Torsades de pointes
IV/IO bolus of magnesium sulfate at a dose of 1-2 g
diluted in 10 mL D5W.

76. SUMMARY OF UPDATES; ACLS 2010
ABC  CAB
Untrained/Lay people  Hand-only CPR
CPR Depth from 1 ½ to 2 inches  minimum 2 inches
Minimum pauses in CPR even if needed

77. Cont……
Professional rescuers  quantitative waveform
capnography confirm intubation and CPR quality
Atropine deleted from PEA & Asystole management
To reduce time to defib.  AED training should not be
limited

78. Cont……
Look, Listen and Feel removed from BLS Algorithm
Continued de-emphasis on pulse check for health care
providers and no pulse check for lay persons

79. Understanding the importance of diagnosing and
treating the underlying cause is fundamental to
management of all cardiac arrest rhythms.

81. POST CARDIAC ARREST CARE

82. ●Initial management is focused on establishing and
maintaining hemodynamic stability and supportive
care.
●Amiodarone or lidocaine is often used to prevent
recurrent ventricular tachyarrythmia
●Therapeutic hypothermia-confers a modest
improvement in neurological outcome
● Immediate coronary angiography with
revascularization if indicated may improve survival in
pt with ischemic etiology

83. Survivors of SCA should have a detailed CVS
evaluation including:-
ECG/ECG Monitoring/24 hr ambulatory ECG
Lab:- cardiac markers, electrolytes, drug levels for
toxicity, tox screen,
Echocardiography
Electrophysiological testing
Cardiac MRI
Genetic testing for channelopathies

84. SUDDEN CARDIAC ARREST
Causes of death during hospitalization after
successfully resuscitated CA-
Anoxic encephalopathy and infections subsequent to
prolonged respirator dependence account for 60% of
deaths
30% occur as a consequence of refractory low cardiac
output states
Recurrent arrhythmias account for only 10% of in-
hospital deaths

85. PREVENTION OF SCD

86. PRIMARY PREVENTION
① Identifying individuals at high risk of SCD:-
▪Combination of factors more useful
▪Most imp parameter-LVEF
▪EP testing, ambulatory ECG, SAECG, HRV, T WAVE
Alternans have been used
②Pharmacological agents-
▪Beta blockers, ACEI, Amiodarone
▪Revascularisation
▪ ICD/CRT

87. SECONDARY PREVENTION
Antiarrythmics- amiodarone, sotalol
ICD

88. THANK YOU FOR YOUR
ATTENTION!!