Claire Dawson
Cardiac arrest is a medical emergency that occurs when the heart suddenly stops beating due to an electrical issue. It usually happens without warning, and immediate treatment is crucial to prevent fatal consequences. In a hospital setting, a cardiac arrest is referred to as a crash or a code, and designated crash teams or code teams are summoned to respond to these emergencies. These teams consist of staff with specialized expertise and equipment, including defibrillators and drugs, to resuscitate patients and stabilize their condition. The goal of treatment is to restore blood circulation and prevent long-term health complications or death. This involves interventions such as CPR, defibrillation, cardiac pacing, and targeted temperature management to improve neurological outcomes.
| Characteristics | Values |
|---|---|
| Treatment Goal | Rapidly achieve a return of spontaneous circulation |
| Treatment Methods | CPR, defibrillation, cardiac pacing, targeted temperature management (TTM) |
| Treatment Plan | Tests to decide on a treatment plan to reduce the risk of long-term health problems and death |
| Tests | Electrocardiogram (ECG or EKG), Heart MRI, Blood tests, Ultrasound |
| Treatment Options | Medication, Pacemaker, Implantable cardioverter defibrillator (ICD), Cardiac rehabilitation |
| Survival Rate (In-Hospital) | 26% |
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What You'll Learn
Administer CPR and use a defibrillator
Administering CPR and using a defibrillator are crucial steps in treating cardiac arrest. When a person experiences cardiac arrest, their heart stops beating due to an electrical issue, and immediate treatment is necessary for survival. Brain damage is likely if cardiac arrest lasts for more than 5 minutes without intervention, and death is likely after 8 minutes. Thus, CPR and defibrillation must be administered as quickly as possible.
CPR Administration
Cardiopulmonary resuscitation (CPR) is a critical step in treating cardiac arrest. It involves performing chest compressions to pump oxygen-containing blood from the heart and lungs to the brain and other organs. Here are the steps to administer CPR:
- Check Responsiveness: Shake the person and loudly ask, "Are you okay?" to determine if they are unresponsive.
- Check Breathing: Turn the person's body face up and check if they are not breathing or are breathing abnormally, such as gasping or irregular breaths (agonal breathing).
- Call for Help: If the person is unresponsive and not breathing normally, call for emergency medical services (EMS) immediately.
- Start Chest Compressions: Begin CPR by pushing down at least 2 inches in the center of the chest at a rate of 100 to 120 pushes per minute. Allow the chest to return to its normal position after each push.
- Open the Airway: The second priority is to open the person's airway by tilting their head back and lifting their chin.
- Provide Rescue Breaths (if trained): Lay rescuers can provide compression-only CPR or, if trained, may give rescue breaths delivered mouth-to-mouth for adults, adolescents, and children.
- Continue CPR Until Help Arrives: Continue administering CPR until the person starts to breathe or move, or until EMS or skilled help arrives.
Using a Defibrillator
A defibrillator is a machine that delivers electric shocks to restore normal heart function. The common type used outside hospitals is the automated external defibrillator (AED), which is easy to use and provides voice instructions. Here's how to use a defibrillator:
- Retrieve the Defibrillator: While one rescuer administers CPR, another should retrieve the AED if one is available nearby.
- Turn on the AED: As soon as you have the AED, turn it on and follow the voice prompts or written instructions.
- Follow AED Instructions: The AED will determine if the person has an abnormal heart rhythm that can be treated with defibrillation. If so, it will deliver an electric shock to correct the rhythm.
- Resume CPR After Shock: If a shock is delivered, immediately resume chest compressions after the shock is administered.
Both CPR and defibrillation are vital components of treating cardiac arrest. CPR provides oxygenated blood to the brain and body, while defibrillation can restore normal heart function. The prompt initiation of these treatments significantly improves the chances of survival for individuals experiencing cardiac arrest.
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Use targeted temperature management (TTM)
Targeted temperature management (TTM) is a cornerstone of post-cardiac arrest care for patients who remain unresponsive after the return of spontaneous circulation. TTM involves maintaining a constant temperature of between 32°C and 36°C for at least 24 hours, followed by fever prevention and treatment.
TTM is recommended for adults with out-of-hospital cardiac arrest (OHCA) with an initial shockable rhythm who remain unresponsive post-return of spontaneous circulation (ROSC). It is also suggested for adults with OHCA with non-shockable rhythms and adults with in-hospital cardiac arrest (IHCA) with any rhythm who remain unresponsive post-ROSC.
The use of TTM in the treatment of cardiac arrest has evolved over the years. Initial trials in 2002 found that mild therapeutic hypothermia improved neurological outcomes. The suggested temperature range was expanded in 2015 when a large trial found that outcomes were not better at 33°C compared to 36°C.
In 2021, the TTM2 trial was published, which was a large, multicenter, randomized clinical trial of temperature management for neuroprotection after cardiac arrest. This trial included 1900 unresponsive adult patients successfully resuscitated from OHCA. Patients were randomized to hypothermia (target temperature of 33°C) or normothermia (target temperature <37.8°C) for 28 hours, followed by gradual rewarming. The results of the TTM2 trial demonstrated that hypothermia did not lead to improved mortality or morbidity.
Despite the findings of the TTM2 trial, the use of TTM in the treatment of cardiac arrest continues to be recommended by organizations such as the European Resuscitation Council (ERC) and the Australian and New Zealand Committee on Resuscitation (ANZCOR). These guidelines recommend therapeutic hypothermia of between 33-36°C for 24 hours, followed by normothermia for at least 72 hours after ROSC for both IHCA and OHCA.
It is important to note that TTM is associated with multiple physiological changes, some of which may lead to complications during treatment. Healthcare professionals must be aware of and prepared for these potential complications, as early recognition and treatment can improve overall survival.
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Prescribe medication and treatment
Following a cardiac arrest, the patient will likely be unconscious and unresponsive, with no pulse. The first step is to call for emergency medical services and begin cardiopulmonary resuscitation (CPR) and defibrillation, if possible, to restore blood flow and circulation. CPR involves chest compressions at a rate of 100-120 compressions per minute, allowing the chest to return to its normal position between compressions. Defibrillation can be administered via an automated external defibrillator (AED) by following the prompts provided. These initial steps are critical in improving the patient's chances of survival and reducing the risk of long-term health problems, including brain damage due to oxygen deprivation.
Once the patient is stabilised and their vital signs have returned, it is important to identify the underlying cause of the cardiac arrest to guide further treatment and prevent future episodes. Tests such as electrocardiograms (ECG or EKG), heart magnetic resonance imaging (heart MRI), and blood tests can help diagnose heart conditions and identify specific arrhythmias. Genetic testing may also be recommended for the patient and their family members to assess the presence of inherited conditions that increase the risk of cardiac arrest.
To reduce the risk of recurrent cardiac arrest, doctors may prescribe medication to address specific underlying conditions. Additionally, cardiac rehabilitation may be recommended to improve the patient's confidence, fitness, and strength. This may include psychological support, health education, and exercise sessions. The patient's overall recovery time will depend on the cause of the cardiac arrest and the duration of time their heart was not beating.
In-hospital treatment for cardiac arrest involves designated crash or code teams, consisting of staff with expertise in resuscitation. They are equipped with specialised crash carts containing a defibrillator and drugs to respond to cardiac emergencies. Medical emergency teams also play a crucial role in preventing cardiac arrest by treating patients in the acute phase of their illness. Additionally, critical care outreach teams provide education to non-specialist staff and facilitate transfers between intensive care units and general hospital wards.
Targeted temperature management (TTM) is an international guideline-recommended treatment following cardiac arrest. It involves cooling the patient's body temperature to 32–36 °C (90–97 °F) for 24 hours, followed by gradual rewarming over the next 12 to 24 hours. This technique aims to improve neurological outcomes, although its effectiveness is still under ongoing study.
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Refer to cardiac rehabilitation
Cardiac arrest is a life-threatening medical emergency that occurs when the heart suddenly stops beating due to an electrical issue. It requires immediate treatment, and even with prompt medical intervention, patients may experience long-term health complications and are at risk of subsequent cardiac events. Therefore, it is crucial to provide ongoing care and support to help patients recover and prevent future episodes.
Cardiac rehabilitation is a comprehensive and holistic program designed to help patients recover and improve their cardiovascular health after experiencing a cardiac event, such as a heart attack or heart failure. It involves a team of healthcare professionals, including doctors, nurses, and pharmacists, as well as the patient's family and friends, working together to address the physical and mental aspects of cardiac health.
The program consists of three integral components: exercise counselling and training, education for heart-healthy living, and counselling to reduce stress. In the initial phase, patients may start with simple activities like walking down the hallway in the hospital, gradually progressing to more strenuous activities like riding a stationary bike several times a week. Exercise is carefully supervised, and in rare cases, if it leads to adverse events, patients are promptly treated, and their care team is notified.
Education plays a vital role in empowering patients to manage their risk factors and make heart-healthy choices. This includes guidance on nutrition, smoking cessation, and other lifestyle modifications. Additionally, stress management is a critical component of cardiac rehab, as stress can negatively impact heart health. Counselling helps patients identify and address everyday stressors, promoting overall well-being.
To access cardiac rehabilitation services, patients typically require a referral from their healthcare provider. Unfortunately, low referral rates, particularly for women, older adults, and ethnic minorities, contribute to the underutilisation of these valuable services. Hospital-based interventions promoting automatic referrals have been shown to increase referral rates significantly. Patients should also ensure that the chosen rehab centre is conveniently located, has certified staff, and accepts their insurance to facilitate their participation in the program.
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Conduct tests to determine treatment
Conducting tests to determine the best course of treatment is a crucial step in treating cardiac arrest. The tests can help identify the underlying cause of the cardiac arrest, which is essential for developing an effective treatment plan to reduce the risk of long-term health problems and death.
One of the tests used to diagnose cardiac arrest and identify the specific type of arrhythmia is an electrocardiogram (ECG or EKG). This test helps to monitor the electrical activity of the heart and can be used to guide treatment decisions, particularly regarding the use of defibrillation. Clinicians classify cardiac arrest into “shockable” versus “non-shockable” rhythms, with ventricular fibrillation and pulseless ventricular tachycardia being “shockable” and responsive to defibrillation, while asystole and pulseless electrical activity are “non-shockable” and require alternative treatments.
Another test that can be performed is a Heart MRI (magnetic resonance imaging). This imaging technique provides detailed visuals of the heart's structure and can help identify any structural abnormalities or damage that may have contributed to the cardiac arrest. Blood tests are also useful in determining the cause of cardiac arrest, as they can reveal electrolyte imbalances that affect the heart's electrical conduction.
In addition to these tests, genetic testing may be recommended for individuals who have experienced cardiac arrest. This is particularly relevant if there is a family history of abnormal heart rhythms or cardiac issues, as certain conditions that increase the risk of cardiac arrest can be inherited. Genetic testing can help identify these predispositions and guide preventative measures for the patient and their blood relatives.
Point-of-care ultrasound (POCUS) is another valuable tool for examining the movement of the heart and its force of contraction at the patient's bedside. POCUS provides real-time visuals of cardiac wall motion contractions, aiding in the diagnosis and treatment of cardiac arrest in hospital settings.
These tests, along with others, provide vital information that guides treatment decisions. They help healthcare providers tailor their approach to the specific needs of each patient, reducing the risk of future cardiac events and improving long-term outcomes.
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Frequently asked questions
Call 999 immediately and start CPR. If there is a defibrillator nearby, use it. Follow any instructions from the 999 operator until emergency services take over.
In hospitals, cardiac arrest is referred to as a "crash" or a "code". Designated staff members with expertise in resuscitation, known as crash teams or code teams, are called to the scene. They bring a specialised cart of equipment, including a defibrillator and drugs, called a "crash cart" or "crash trolley".
After successful defibrillation, most people need hospital care to recover from the effects of their cardiac arrest and prevent future heart problems. Doctors will recommend medication and treatment, such as a pacemaker or implantable cardioverter defibrillator (ICD), to reduce the risk of another cardiac arrest. They may also refer the patient to cardiac rehabilitation to help rebuild their confidence, fitness and strength levels.
