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PubMed2005

Inconsistencies in cardiac arrest reporting.

Data relating to survival from in-hospital cardiac arrest are used to audit staff performance and to help to determine whether new resuscitation techniques are effective. Individual studies into outcome from cardiac arrest have defined inclusion and exclusion criteria, but no such national criteria have been published to enable constant auditing of cardiac arrests. The aim of this survey was to investigate the consistency with which in-hospital cardiac arrests are recorded throughout the United Kingdom. Such data are, almost universally, collected by Resuscitation Officers (RO). A questionnaire was sent to ROs across the UK asking them to state how they would interpret and categorise hypothetical, but nonetheless typical, clinical situations involving a cardiac arrest team being called. These included an event where the patient had regained consciousness prior to the arrival of the cardiac team and also an event where rigor mortis was already present and the resuscitation promptly abandoned upon the arrival of the cardiac arrest team. The percentage survival to discharge of adult cardiac arrests for each hospital was also requested. This identified whether inclusion or exclusion of certain clinical events may have influenced cardiac arrest survival figures for that hospital. It is clear from this study that in-hospital clinical events when a cardiac arrest team is called are audited with a great deal of inconsistency. Some events, such as a patient who has rigor mortis, are excluded as a false or inappropriate call in some hospitals and included as an unsuccessful resuscitation in others. There is a need for guidance on the inclusion and exclusion criteria for auditing of cardiac arrests so that meaningful data can be obtained from across the UK and useful conclusions drawn. The situation at present will result in data being audited that are of limited use. In the era of evidence-based medicine, it seems vital to obtain accurate cardiac arrest survival figures in order to have any hope of improving them.

Cardiopulmonary Resuscitation↗

PubMed1990

Management of survivors of out-of-hospital cardiac arrest.

Sudden cardiac death is a major cause of death in the western world. Since a 1-year recurrence rate of 30% is expected in survivors of sudden death, treatment is mandatory. If an apparent cause (e.g. proarrhythmia or acute ischemia) exists, treatment is generally directed at its alleviation. However, in most patients no obvious cause is found. Both noninvasive and invasive diagnostic procedures are employed to uncover treatable etiologies. If a treatable cause is not found, an electrophysiological study may be employed to tailor antiarrhythmic therapy. At this point, many patients still cannot be offered an adequate antiarrhythmic treatment. For these patients, amiodarone, antiarrhythmic surgery or an implantable defibrillator may be appropriate options. Algorithms for diagnostic and therapeutic interventions in survivors of sudden cardiac death are delineated.

Death, Sudden↗

PubMed2004

Is female sex associated with increased survival after out-of-hospital cardiac arrest?

AIM: To evaluate survival after out-of-hospital cardiac arrest in relation to sex. METHODS: All patients with out-of-hospital cardiac arrest included in the Swedish Cardiac Arrest Registry between 1990 and 2000 in whom cardiopulmonary resuscitation (CPR) was attempted and who did not have a crew witnessed arrest were included. The registry covers 85% of the inhabitants of Sweden (approximately 8 million inhabitants). P-values were adjusted to differences in age. Survival was defined as patients being hospitalised alive and being alive one month after cardiac arrest. In all, 23,797 patients participated in the survey of which 27.9% were women. RESULTS: Among women 16.4% were hospitalised alive versus 13.2% among men ( P<0.001). After one month 3.0% among women were alive versus 3.4% among men (NS). In a multivariate analysis considering differences in age and various factors at resuscitation female sex was an independent predictor for patients being hospitalised alive (odds ratio 1.66; 95% confidence limits 1.49-1.84) and for being alive after one month (odds ratio 1.27; 95% confidence limits 1.03-1.56). Women differed from men as they were older ( P<0.001 ), had a lower prevalence of witnessed cardiac arrest ( P=0.01), a lower occurrence of bystander CPR (P<0.001), a lower occurrence of ventricular fibrillation as initial arrhythmia (P<0.001) and a lower occurrence of cardiac disease judged to be the cause of cardiac arrest ( P<0.0001 ). On the other hand they had a cardiac arrest at home more frequently ( P<0.001 ). CONCLUSION: Among patients suffering out-of-hospital cardiac arrest in Sweden which was not crew witnessed and in whom resuscitation efforts were attempted, female sex was associated with an increased survival.

Adolescent↗

PubMed1991

Current treatment of patients surviving out-of-hospital cardiac arrest.

Most out-of-hospital cardiac arrests result from the sudden onset of a sustained ventricular arrhythmia in the absence of a new myocardial infarction. Individuals who survive cardiac arrest are at high risk for recurrent arrhythmias and sudden unexpected death. To prevent recurrent cardiac arrest, effective treatment must be provided during hospitalization after the initial episode. Caring for the survivor of cardiac arrest requires a detailed clinical investigation to define the underlying cardiac anatomy and left ventricular function and to elucidate the mechanism and characteristics of the patient's arrhythmia. Appropriate antiarrhythmic therapy, such as drugs or a nonpharmacological intervention (eg, implantable cardioverter-defibrillator), is then selected based on these considerations. In addition, ischemia is treated aggressively with beta-adrenergic blocking agents and, when appropriate, with surgical coronary artery revascularization.

Arrhythmias, Cardiac↗

PubMed1986

Trendelenburg pulmonary embolectomy for cardiac arrest secondary to massive pulmonary embolism.

Cardiac arrest secondary to massive pulmonary embolism is rarely reversible by nonsurgical measures. A patient sustained refractory cardiac arrest and was resuscitated by Trendelenburg pulmonary embolectomy without cardiopulmonary bypass. This report describes the diagnosis and treatment of this 37-year-old man and provides a review of the literature on pulmonary embolectomy for patients in whom cardiac arrest has occurred. Awareness of the feasibility of salvaging patients with cardiac arrest secondary to massive pulmonary embolism may lead to wider application of pulmonary embolectomy when conventional resuscitation is unsuccessful.

Adult↗

PubMed1996

Ventricular fibrillation in a swine model of acute pediatric asphyxial cardiac arrest.

STUDY OBJECTIVE: To determine cardiac rhythms in a swine model of acute pediatric asphyxial cardiac arrest. DESIGN: Prospective electrocardiographic evaluation of 36 piglets. SETTING: University hospital laboratory. INTERVENTION: Piglets were acutely asphyxiated by endotracheal tube clamping until 10 min after loss of aortic pulsations. Resuscitative efforts were then provided. RESULTS: None of the animals had ventricular fibrillation (VF) when loss of aortic pulsations occurred (11 +/- 2 min after clamping). Fourteen of the 36 piglets exhibited VF during the asphyxial insult. VF converted to asystole in four piglets prior to resuscitation. Immediately prior to resuscitation, VF occurred in 10 piglets, asystole in 19 piglets, and bradyarrhythmias in seven piglets. CONCLUSION: VF occurs frequently in this piglet model of prolonged asphyxial cardiac arrest, consistent with recent observations in pediatric prehospital cardiac arrests. VF occurred late in the asphyxial process.

Animals↗

PubMed1984

The potential use of automatic defibrillators in the home for management of cardiac arrest.

Ventricular fibrillation, an abnormal cardiac rhythm, occurs in at least two-thirds of the 400,000 people who die out of the hospital from sudden cardiac arrest. This rhythm can be treated successfully by electric countershock, a procedure known as defibrillation. The survival rate following such cardiac arrest is directly related to the rapidity of response; the shorter the time from collapse to defibrillation, the more patients will survive. There are two basic options to shorten the time from collapse to defibrillatory shock. The first is to upgrade the emergency medical system. The second is to provide spouses and family members of potential cardiac arrest patients with automatic home defibrillators. This article considers the effectiveness of the second option, home defibrillation, compared with that of an equally costly upgrade in existing emergency medical service systems. The comparisons depend on the existing level of emergency medical service system, the cost of the home defibrillator, and the rate at which a home defibrillator would be used appropriately. The comparisons suggest that in many circumstances home defibrillation is an appropriate option to be considered.

Costs and Cost Analysis↗

PubMedDate not supplied

Using geographic information systems to evaluate cardiac arrest survival.

OBJECTIVE: To evaluate cardiac arrest survival using geographical information systems (GIS) methodology. METHODS: Patient data were obtained from a fire district Utstein-style adult cardiac arrest registry that also included address data. All incident locations were geocoded and fire station first-due areas were mapped by using the new computer-aided dispatch geographic data. Retrospective assignment of first-due versus second-due fire response unit was done by using a GIS "point-in-polygon" algorithm Survival to hospital admission was the primary outcome measure for incidents responded to by first-due versus second-due apparatus controlling for other potential predictors of survival using logistic regression. Cluster analysis was also performed to evaluate potential areas of high or low rates of survival. RESULTS: There were 461 eligible patients with an average age of 67+/-17 years, 63% were male, 53% had a witnessed arrest, bystander cardiopulmonary resuscitation was performed in 38%, bystander automatic external defibrillator (AED) Page: 1 was used in 0.01%, ventricular fibrillation or ventricular tachycardia were the presenting rhythms in 44%, the average response time was 5.5+/-2.1 minutes, and survival to hospital admission was 17%. There was no significant difference in response time between survivors (4.97 minutes) and non-survivors (5.52 minutes), (difference 0.55 minutes, 95%CI -0.08 to 1.18 min). The number of cardiac arrest calls varied from 1 to 49 for each station and the rate of second-due response varied from 0 to 19%. There was a nonsignificant association of survival to hospital admission for the first-due area cohort: odds ratio 0.70, 95% CI 0.38-1.29. CONCLUSION: GIS is a new methodology for analyzing EMS incident data. It adds a spatial component of analysis to traditional statistical techniques. No spatial difference was found on patient survival in this analysis.

Aged↗

PubMed1995

Astrocyte-derived growth factor (S100 beta) and motor function in rats following cardiac arrest.

Following 10-min cardiac arrest and resuscitation, the central serotonergic system and motor function of rats were found to be affected and later on restored. Astrocyte-derived growth factor (S100 beta) is known to promote survival and neurite outgrowth of serotonergic neurons. In the present study, brain levels of S100 beta were investigated with quantitative immunoblot analysis at various time points following cardiac arrest. Significant reductions of S100 beta were found in the cerebral cortex (30%), midbrain (35%), and cerebellum (46%) of rats 3 days postcardiac arrest. In contrast, at 14 and > 45 days, significant increases of S100 beta were detected in the cerebral cortex (57%; 81%), midbrain (70%; 97%), and cerebellum (84%; 157%). The results indicate that reactive astrocytosis and elevated levels of S100 beta may participate in the recovery processes following hypoxic-ischemic insults to the brain.

Analysis of Variance↗

PubMed2006

Role of thrombolytic agents in cardiac arrest.

The prognosis of patients having a cardiac arrest is generally poor, with a few exceptions. Interventions that aim to improve outcome in cardiac arrest have proved to be disappointing. In particular, no drug has been reliably proved to increase survival to discharge after cardiac arrest. Given that coronary thrombosis in situ and pulmonary thromboembolism are implicated in a large proportion of patients with cardiac arrest, the use of thrombolytic agents has been suggested. Case reports and animal studies have shown favourable results, and have proposed plausible mechanisms to explain them. This is a review of the current literature focusing on the use of thrombolysis during cardiac arrest. A comprehensive literature search was carried out on Medline from 1966 to January 2006, Embase from 1988 to January 2006 and the Cochrane Library, using the Ovid interface. Six articles were selected for review. Although some results are encouraging, all the studies currently available are limited by size and flaws in design.

Animals↗

PubMed1985

Ambulatory electrocardiographic recordings at the time of fatal cardiac arrest.

The relation between arrhythmias at cardiac arrest and the outcome of arrest is poorly understood. The Holter monitor tracings of 13 patients were reviewed after they sustained an in-hospital cardiac arrest during ambulatory electrocardiographic monitoring. All had a prior cardiac arrest or cardiac syncope. Twelve patients had ventricular tachycardia (VT) as their initial arrest arrhythmia and 1 patient had bradycardia followed by ventricular fibrillation (VF). VT degenerated to VF in 10 of 12 patients after a mean interval of 96 +/- 31 seconds (+/- standard error of the mean). The number of VT runs increased significantly during the hour immediately preceding arrest (p = 0.004). Despite prompt resuscitation efforts in 12 patients, only 6 survived. The 6 survivors and 6 nonsurvivors were not different with regard to age, ejection fraction, extent of coronary artery narrowing and time to first defibrillation. However, degeneration to VF within 30 seconds of arrest (5 of 6 nonsurvivors and 1 of 6 survivors, p = 0.04) and a slower rate of VT at the onset of arrest (166 beats/min in nonsurvivors and 227 beats/min in survivors, p = 0.02) were associated with unsuccessful resuscitation.

Adult↗

PubMed1996

The effect of experience of on-site physicians on survival from prehospital cardiac arrest.

Outcome from prehospital cardiac arrest was studied 1 year before (Period I) and after (Period II) a reorganisation of the work and the simultaneous change of all physicians participating in the care of prehospital patients in the emergency medical service system in Helsinki. There were 444 patients during Period I and 395 patients during Period II. Resuscitation was initiated in 279 patients during Period I and in 323 patients (P < 0.001) during Period II. The number of patients with ventricular fibrillation who suffered a witnessed cardiac arrest due to presumed heart disease was 120 and 130, respectively. During Period I, 70 of these patients were successfully resuscitated and admitted to hospital, 41 (34%) survived to discharge home from hospital. Corresponding figures during Period II were 79 and 33 (25%, NS). Compared with Period I, a larger proportion of the successfully resuscitated patients either died in hospital or were discharged to an institution during Period II (P < 0.05).

Cardiopulmonary Resuscitation↗

PubMed1989

Neurologic management following cardiac arrest.

Optimal neurologic outcome after cardiac arrest requires careful attention to the details of both intracranial and extracranial homeostasis. A high index of suspicion regarding the potential causes and complications of cardiac arrest facilitates discovery and treatment of problems before they adversely affect neurologic outcome. The future is bright for resuscitation research: Our fundamental understanding of cerebral ischemia and its consequences has dramatically improved, and this knowledge can hopefully be transferred to clinical useful modes of therapy. However, the transition from a promising, therapeutically effective intervention in animals to the demonstration that treatment is effective following cardiac arrest in humans is an important and difficult step. The patient population is heterogeneous before the insult, the duration and severity of the insult are variable, and the effectiveness of cardiopulmonary resuscitation varies among institutions. Therefore, the only means of demonstrating clinical efficacy is the performance of a large clinical trial. The Resuscitation Research Center at the University of Pittsburgh has developed and coordinated a multicenter, multinational team of investigators who have completed one definitive trial of postarrest barbiturate therapy and are currently completing a similar trial using a calcium entry blocker. Despite the formidable obstacles posed by such comprehensive efforts, they provide the mechanism for determining whether the cost of a new treatment modality is justified by the likelihood of improved mortality or morbidity.

Brain Ischemia↗

PubMed1994

Plasma endothelin following cardiac arrest: differences between survivors and non-survivors.

Cardiac arrest is associated with major metabolic disturbances, including severe hypoxia and large increases in circulating catecholamines, both of which are known to stimulate generation of the potent endothelium-derived vasoconstrictor peptide endothelin-1. We have, therefore, examined plasma immunoreactive endothelin concentrations following cardiac arrest. Blood was sampled at 10-min intervals from a central venous catheter inserted at onset of resuscitation in 38 patients (13 female; mean age, 67 years) presenting with cardiac arrest to the Accident and Emergency Department at the Royal Infirmary of Edinburgh. Plasma immunoreactive endothelin concentrations (mean +/- S.D.) in patients following cardiac arrest (5.4 +/- 2.3 pg/ml) were no different from those in healthy subjects (5.1 +/- 1.2 pg/ml). There was no significant difference between endothelin concentrations at presentation in survivors and non-survivors of cardiac arrest. However, non-survivors had a significant fall in endothelin concentrations with time from onset of resuscitation from 5.4 +/- 2.2 pg/ml to 3.5 +/- 1.8 pg/ml (P = 0.002), while survivors had a non-significant increase in concentrations. On multiple regression analysis there was a significant association between higher plasma endothelin concentration and survival (r = 0.37; P = 0.009). The failure of plasma endothelin to increase after cardiac arrest is unexpected. Although the fall in plasma endothelin with time in non-survivors may reflect the adverse physiological milieu that occurs during cardiac arrest, it is also possible that low endothelin concentrations contribute to the poor prognosis in this condition.

Aged↗

PubMed1991

Limitations of open-chest cardiac massage after prolonged, untreated cardiac arrest in dogs.

STUDY OBJECTIVES: Open-chest cardiac massage is an effective method of resuscitation if instituted within 15 minutes of normothermic cardiac arrest that has failed to respond to ongoing closed-chest CPR efforts. The usefulness of invasive forms of CPR after various periods of untreated cardiac arrest is less certain. This study was performed to determine the effectiveness of open-chest resuscitation after prolonged periods of untreated cardiac arrest. SETTING AND DESIGN: Prospective, controlled laboratory investigation using an animal model of cardiac arrest. Open-chest cardiac massage initially was compared to standard closed-chest compression CPR. The efficacy of open-chest CPR then was evaluated after ten and 40 minutes of untreated ventricular fibrillation. TYPE OF PARTICIPANTS: Twenty mongrel dogs (24 +/- 1 kg). MEASUREMENTS AND MAIN RESULTS: After 20 minutes of untreated ventricular fibrillation, open-chest resuscitation was significantly better than closed-chest efforts for the production of coronary perfusion pressure (58 +/- 14 vs 2 +/- 1 mm Hg; P less than .05) and initial resuscitation success (five of five vs one of five; P less than .03). Open-chest cardiac massage was equally effective for initial resuscitation if begun after ten or 20 minutes of untreated ventricular fibrillation (five of five vs five of five), but if untreated ventricular fibrillation continued for 40 minutes prior to instituting open-chest massage, no resuscitation benefit was found (none of five; P less than .005). There were marked differences in 24-hour survival depending on the length of time untreated cardiac arrest continued prior to instituting open-chest resuscitation efforts. After 20 minutes of ventricular fibrillation, initial resuscitation was successful with open-chest massage, but long-term survival was poor. CONCLUSION: Open-chest cardiac massage did not produce long-term survival if untreated cardiac arrest persisted for 20 or more minutes prior to invasive resuscitation efforts.

Animals↗

PubMed2006

Prehospital interventions to improve neurological outcome following cardiac arrest.

As many cases of cardiac arrest occur outside of the health care setting, prehospital treatment may dramatically affect patient outcomes. The three major interventions that have been studied are chest compressions and ventilation, electrical defibrillation, and medications. Recent studies show that increasing the rate of cardiopulmonary resuscitation (CPR), decreasing the rate of ventilation, and initiation of CPR prior to defibrillation may result in improved survival. Biphasic defibrillators can restore perfusing rhythms while minimizing myocardial injury. Public access to automatic defibrillators has been shown to increase the survival of cardiac arrest patients. Medications such as amiodarone, vasopressin, and thrombolytics also may have a role in the prehospital treatment of cardiac arrest. Recent advances in these areas will be reviewed with a discussion of the effect of each intervention on the restoration of circulation and neurological outcomes.

Anti-Arrhythmia Agents↗

PubMed2006

Systematic review of percutaneous cardiopulmonary bypass for cardiac arrest or cardiogenic shock states.

BACKGROUND: Cardiogenic shock and cardiac arrest are common, lethal, debilitating and costly. Percutaneous cardiopulmonary bypass is an innovative strategy for treating these disorders that consists of rapid initiation of cardiopulmonary bypass and extracorporeal maintenance of circulation until restoration of an effective cardiac output. Multiple case reports suggest that percutaneous bypass is efficacious in patients with these disorders but these experiences have not been collated. Therefore, we have reviewed systematically the published experience with percutaneous bypass in patients with cardiogenic shock or cardiac arrest. OBJECTIVES: The objectives were to describe the proportion of patients with cardiogenic shock or cardiac arrest who achieved restoration of spontaneous circulation or survival to discharge with percutaneous bypass. A secondary objective was to describe adverse effects associated with percutaneous bypass, if feasible. DESIGN: Articles were identified by using a comprehensive search of English-language MEDLINE from 1966 to September 2005. PATIENTS: Individuals in cardiogenic shock or cardiac arrest. INTERVENTIONS: Percutaneous cardiopulmonary bypass. ANALYSIS: Effects were summarized as inverse-variance weighted means, standard errors, median and interquartile range. RESULTS: Included were 85 studies of 1494 patients with cardiogenic shock, cardiac arrest or both. Studies were case reports, case-series or case-control studies of heterogeneous interventions in heterogeneous patients. The proportion of patients weaned was mean, 76.8+/-4.2%, and median, 66.0% (IQR 50%, 100%). The proportion of patients who survived to discharge was mean, 47.4+/-4.5%, and median 40.0% (IQR 20%, 75%). Fifty-two studies included 533 patients in cardiogenic shock. The proportion of patients who survived to discharge was mean, 51.6+/-6.5%, and median 38.5% (IQR 23.4%, 76.3%). Fifty-four studies included 675 patients in cardiac arrest. The proportion of patients who survived to discharge was mean, 44.9+/-6.7%, and median, 42.3% (IQR 15.4%, 75%). Five studies with 286 subjects had both patients with cardiogenic shock or cardiac arrest. CONCLUSIONS: Percutaneous bypass is an efficacious intervention in patients with cardiac arrest or cardiogenic shock. Adequately-powered experimental studies of current percutaneous bypass technologies are required to demonstrate whether it is safe, effective and cost-effective.

Cardiopulmonary Bypass↗

PubMed1993

Neuropsychological, academic, and adaptive functioning in children who survive in-hospital cardiac arrest and resuscitation.

Children suffering cardiac arrest (CA) are not uncommon in certain pediatric populations. Due to the increasing survival rates of child CA patients, there is a growing interest in, and concern for, their long-term intellectual, academic, emotional, and adaptive functioning. This article describes the possible neurologic sequelae of CA in children and presents standardized assessment results on 25 children, 2 to 15 years of age, who survived a CA while in the hospital. A majority of these children exhibited low-average to deficient levels of performance on neuropsychologic, achievement, and adaptive behavior measures. Duration of cardiac arrest and a medical risk score were significantly correlated with decreased functioning in child CA patients. Children who suffer a cardiac arrest are at high risk for academic struggles, and many may need special education services.

Adolescent↗