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Cardiac arrest

Definition
Cardiac arrest is defined as the functional loss of mechanical cardiac activity, leading to cessation of systemic circulation.
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Pathophysiology
The most common cause of out-of-hospital cardiac arrest is ischemic heart disease, with up to 70% patients with out-of-hospital cardiac arrest having significant coronary artery disease on coronary angiography. In patients with in-hospital cardiac arrest, arrhythmias and myocardial ischemia represent the most common causes. Other causes of cardiac arrest include non-ischemic heart disease, as well as non-cardiac diseases (shock of any etiology, hypoxia, hypoglycemia, hypothermia, electrolyte and acid-base disturbances, drug overdose).
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Epidemiology
In the US, the incidence of cardiac arrest is estimated at 55 cases per 100,000 person-years. The incidence of in-hospital cardiac arrest is estimated at 1-6 cases per 1,000 hospital admissions.
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Disease course
Patients who achieve ROSC after cardiac arrest have a high mortality rate, owing to the development of post-cardiac arrest syndrome, which is characterized by multi-organ dysfunction, including post-cardiac arrest brain injury and post-cardiac arrest myocardial dysfunction.
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Prognosis and risk of recurrence
In patients with out-of-hospital cardiac arrest, 30-day survival is estimated at 5.8% in patients in whom CPR is not performed, and 13.5-13.8% in patients in whom CPR is performed. In patients with in-hospital cardiac arrest, 30-day survival is estimated at 28.3%.
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Key sources
The following summarized guidelines for the evaluation and management of cardiac arrest are prepared by our editorial team based on guidelines from the American Heart Association (AHA 2023; 2020; 2018), the European Society for Trauma and Emergency Surgery (ESTES/ESAIC 2023), the Agency for Healthcare Research and Quality (AHRQ 2023), the European Society of Intensive Care Medicine (ESICM/ERC 2022), the European Society of Cardiology (ESC 2022; 2021; 2018), the Society for Cardiovascular Angiography and Interventions (SCAI/AHA/ACC 2022), the American Heart Association (AHA/ACC 2020; 2013), the Pathway (Pathway 2020), the United Kingdom Kidney Association (UKKA 2020), the Heart Rhythm Society (HRS 2019), the International Liaison Committee on Resuscitation (ILCOR 2019), the American College of Obstetricians and Gynecologists (ACOG 2019), the American Heart Association (AHA/HRS/ACC 2019; 2018), the Wilderness Medical Society (WMS 2019; 2014), the European Society of Intensive Care Medicine (ESICM/SCCM 2018), the Canadian Association of Poison Control Centres (CAPCC/ESICM/CAEP/AAPCC/SCCM/CPS/EAPCCT/ESEM/CCCS/ACMT 2017), the Society of Critical Care Medicine (SCCM 2016), and the Asia Pacific Heart Rhythm Society (APHRS/EHRA/HRS 2013).
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Guidelines

1.Screening and diagnosis

Recognition, lay rescuer: assume that a victim is in cardiac arrest if unconscious/unresponsive with absent or abnormal breathing (only gasping).
B
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  • Recognition (healthcare provider)

2.Diagnostic investigations

Cardiac imaging: as per AHA 2021 guidelines, obtain echocardiography by trained physicians immediately following a 12-lead ECG in patients presenting with cardiac arrest or hemodynamic instability of presumed cardiovascular origin.
B

3.Respiratory support

Supplemental oxygen: consider administering supplemental oxygen during CPR, if available, at the maximal feasible inspired oxygen concentration.
C

4.Medical management

Setting of care: consider managing adult patients with nontraumatic out-of-hospital cardiac arrest in cardiac arrest centers rather than in non-cardiac arrest centers.
C

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  • Vascular access

  • Vasopressors (epinephrine, indications)

  • Vasopressors (epinephrine, nonshockable rhythm)

  • Vasopressors (epinephrine, shockable rhythm)

  • Vasopressors (epinephrine, high-dose)

  • Vasopressors (vasopressin)

  • Nonvasopressor medications (amiodarone and lidocaine)

  • Nonvasopressor medications (corticosteroids)

  • Nonvasopressor medications (other agents)

  • Management of narrow-complex tachycardia (cardioversion)

  • Management of narrow-complex tachycardia (pharmacotherapy)

  • Management of wide-complex tachycardia (pharmacotherapy)

  • Management of wide-complex tachycardia (cardioversion)

  • Management of sustained polymorphic ventricular tachycardia (defibrillation)

  • Management of sustained polymorphic ventricular tachycardia (pharmacotherapy)

  • Management of AF/atrial flutter (cardioversion)

  • Management of AF/atrial flutter (pharmacotherapy)

  • Management of bradycardia (pharmacotherapy)

  • Management of bradycardia (transvenous pacing)

5.Therapeutic procedures

Dispatch instructions: ensure that emergency medical call-takers provide CPR instructions (when deemed necessary) for adult patients in cardiac arrest.
B
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  • Initiation of resuscitation (lay rescuer)

  • Initiation of resuscitation (healthcare provider)

  • CPR technique (positioning)

  • CPR technique (opening the mouth, healthcare provider)

  • CPR technique (opening the mouth, lay rescuer)

  • CPR technique (advanced airways)

  • CPR technique (compression depth and rate)

  • CPR technique (compression fraction and pauses)

  • CPR technique (ventilation)

  • CPR technique (compression-to-ventilation ratio)

  • CPR technique (mechanical devices)

  • CPR technique (interposed abdominal compression CPR)

  • CPR technique (precordial thump)

  • CPR technique (percussion pacing)

  • CPR technique (cough CPR)

  • CPR technique (extracorporeal CPR)

  • Defibrillation

  • Electrical pacing

  • Monitoring of resuscitation

  • Discontinuation of resuscitation

  • ECMO

6.Perioperative care

Perioperative cardiac arrest, choice of approach
Perform closed chest cardiac compression in patients with cardiac arrest.
B
Consider performing open chest cardiac massage if a ROSC has not been achieved with closed chest cardiac compression and veno-arterial ECMO is not available.
C

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  • Perioperative cardiac arrest (post-cardiac surgery)

  • Perioperative cardiac arrest (hemorrhage)

  • Perioperative cardiac arrest (pulseless rhythms)

  • Perioperative cardiac arrest (tension pneumothorax)

  • Perioperative cardiac arrest (cardiac tamponade)

  • Perioperative cardiac arrest (PE)

  • Perioperative cardiac arrest (gas embolism during laparoscopy)

  • Perioperative cardiac arrest (REBOA and resuscitative thoracotomy)

  • Perioperative cardiac arrest (monitoring)

  • Perioperative cardiac arrest (health professional training)

7.Specific circumstances

Pregnant patients, planning and preparation: plan team for cardiac arrest in pregnancy in collaboration with the obstetric, neonatal, emergency, anesthesiology, intensive care, and cardiac arrest services.
B
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  • Pregnant patients (resuscitation)

  • Pregnant patients (resuscitative hysterotomy)

  • Neonatal patients (therapeutic temperature management)

  • Neonatal patients (supplemental oxygen)

  • Patients with electrolyte abnormalities

  • Patients with PE

  • Patients with asthma

  • Patients with anaphylaxis

  • Patients with beta-blocker overdose

  • Patients with CCB overdose

  • Patients with sodium channel blocker overdose

  • Patients with cardiac glycoside overdose

  • Patents with local anesthetic overdose

  • Patients with opioid overdose

  • Patients with cocaine overdose

  • Patients with benzodiazepine overdose

  • Patients with sympathomimetic overdose

  • Patients with CO poisoning

  • Patients with cyanide poisoning

  • Patients with organophosphate or carbamate poisoning

  • Patients with accidental hypothermia

  • Patients after drowning

  • Patients after lightning injury

8.Follow-up and surveillance

Post-resuscitation care, early care: implement a comprehensive, structured, multidisciplinary system of care in a consistent manner for the treatment of post-cardiac arrest patients.
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  • Post-resuscitation care (temperature control, targeted management)

  • Post-resuscitation care (temperature control, therapeutic hypothermia)

  • Post-resuscitation care (temperature control, prevention of fever)

  • Post-resuscitation care (temperature control, rewarming)

  • Post-resuscitation care (neuromuscular blockade)

  • Post-resuscitation care (management of seizures)

  • Post-resuscitation care (therapies with no evidence for benefit)

  • Post-resuscitation evaluation (rhythm monitoring)

  • Post-resuscitation evaluation (cardiac imaging)

  • Post-resuscitation evaluation (coronary angiography)

  • Post-resuscitation evaluation (revascularization)

  • Post-resuscitation evaluation (provocation tests)

  • Post-resuscitation evaluation (genetic testing)

  • Post-resuscitation evaluation (evaluation for extra-cardiac causes)

  • Neuroprognostication (general principles)

  • Neuroprognostication (clinical evaluation)

  • Neuroprognostication (laboratory evaluation)

  • Neuroprognostication (electroencephalography)

  • Neuroprognostication (neuroimaging)

  • Recovery and survivorship

  • Post-cardiac arrest ICD implantation (ischemic heart disease)

  • Post-cardiac arrest ICD implantation (coronary artery spasm)

  • Post-cardiac arrest ICD implantation (cardiomyopathies)

  • Post-cardiac arrest ICD implantation (Brugada syndrome)

  • Post-cardiac arrest ICD implantation (short QT syndrome)

  • Post-cardiac arrest ICD implantation (early repolarization pattern)

  • Post-cardiac arrest ICD implantation (adult congenital heart disease)

  • Post-cardiac arrest ICD implantation (idiopathic ventricular tachycardia/VF)

  • Organ donation

9.Quality improvement

Public access defibrillation
Ensure public access defibrillation is available at sites where cardiac arrest is more likely to occur.
B
Promote community training in basic life support to increase bystander CPR rate and automated external defibrillator use.
B