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 diagnosedheart

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 ifCPR
(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 6070% of
SCD
Among adults, ischemic heart
disease is the predominant cause of
arrest with 30% of people atautopsy
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,
drowningandpulmonary 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 ofoxygen
Hydrogenions (Acidosis) - An abnormal pH

in the body
HyperkalemiaorHypokalemia- Both
excess and inadequate potassium can be
life-threatening.
Hypothermia- A lowcore body temperature
HypoglycemiaorHyperglycemia- Low or
high blood glucose

Ts
TabletsorToxins
CardiacTamponade- 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 attackor 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 druguse is a
cause of sudden cardiac arrest.

D iag n osis

 Cardiac arrest is synonymous withclinical death.

Usually diagnosed clinically by the absence of a

pulse.
In many cases lack ofcarotid pulseis the
gold standardfor 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
professionalsor 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 asagonal 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
ahealthy diet,exercise, and
smoking cessationare important.
For people at risk of heart disease,
measures such asblood pressurecontrol,
cholesterollowering, 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 deteriorationand
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 theirvital signsand 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
(includingdefibrillator) 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 unitsand
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
thechest compressions

D efi
brillation
there is increasing use of public

access defibrillation. This involves

placing
automated external defibrillatorsin
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 ofepinephrine,atropine,
andamiodarone. Vasopression
overall does not improve or worse
outcomes but may be of benefit in
those with asystoleespecially 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
calledtherapeutic hypothermia. People
are cooled over a 24 hour period, with a
target temperature of 3234C (90
93F). 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 directivemakes it clear
that in the event of cardiac arrest the person
does not wishcardiopulmonary resuscitation
.Other directive may be made to stipulate
the desire forintubationin the event of
respiratory failureor 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 fibrillationand pulseless
ventricular tachycardia[7]If
defibrillation is delayed the rhythm is
likely to degenerate intoasystolefor
which outcomes are worse.

 Early advanced care - Early

Advanced Cardiac Life Supportis the

final link in the chain of survival.

PrecordialThum p
Themay 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 leastfive 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