[Cardiac arrest; cardiac massage for 40 minutes; further neurological evolution; absence of sequels].
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Biological Evolution↗
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Randomized comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from cardiac arrest : the Cardiac Arrest Study Hamburg (CASH).
BACKGROUND: We conducted a prospective, multicenter, randomized comparison of implantable cardioverter-defibrillator (ICD) versus antiarrhythmic drug therapy in survivors of cardiac arrest secondary to documented ventricular arrhythmias. METHODS AND RESULTS: From 1987, eligible patients were randomized to an ICD, amiodarone, propafenone, or metoprolol (ICD versus antiarrhythmic agents randomization ratio 1:3). Assignment to propafenone was discontinued in March 1992, after an interim analysis conducted in 58 patients showed a 61% higher all-cause mortality rate than in 61 ICD patients during a follow-up of 11.3 months. The study continued to recruit 288 patients in the remaining 3 study groups; of these, 99 were assigned to ICDs, 92 to amiodarone, and 97 to metoprolol. The primary end point was all-cause mortality. The study was terminated in March 1998, when all patients had concluded a minimum 2-year follow-up. Over a mean follow-up of 57+/-34 months, the crude death rates were 36.4% (95% CI 26.9% to 46.6%) in the ICD and 44.4% (95% CI 37.2% to 51.8%) in the amiodarone/metoprolol arm. Overall survival was higher, though not significantly, in patients assigned to ICD than in those assigned to drug therapy (1-sided P=0.081, hazard ratio 0.766, [97.5% CI upper bound 1.112]). In ICD patients, the percent reductions in all-cause mortality were 41.9%, 39.3%, 28. 4%, 27.7%, 22.8%, 11.4%, 9.1%, 10.6%, and 24.7% at years 1 to 9 of follow-up. CONCLUSIONS: During long-term follow-up of cardiac arrest survivors, therapy with an ICD is associated with a 23% (nonsignificant) reduction of all-cause mortality rates when compared with treatment with amiodarone/metoprolol. The benefit of ICD therapy is more evident during the first 5 years after the index event.
Aged↗
Survey of cardiac arrests and cardiac arrest trolleys in a district general hospital.
In a 12-month period there were 137 cardiac arrests in a district general hospital. Cardiopulmonary resuscitation was instituted within 3 minutes in 82%. Delay in 18% was due to equipment failure. Survival at 6 months was 12%. Of the 18% of inappropriate arrests, 42% had 'do-not-resuscitate' orders in the casenotes. Survival did not depend on age, sex, location, presence of an anaesthetist, experience of house officer, time of day or admission diagnosis. Survival was more likely in the presence of ventricular fibrillation and absence of intubation. Of the 32 arrest trolleys, 66% were geographically acceptable to the area they served and 9% had significant deficiencies (these were situated in patient waiting areas and were infrequently checked).
Adult↗
A cardiac arrest is a cardiac arrest is a cardiac arrest.
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Consensus Statements as Topic↗
Fibrinolysis in cardiac arrest.
Cardiac arrest is a classic contraindication for fibrinolysis, due to possible hemorrhagic complications. Most cardiac arrests, particularly those occurring out-of-hospital, are caused by vascular thrombosis, including myocardial infarction and pulmonary embolism, in which fibrinolysis has proved to be an effective treatment. Indeed, there are several reports and clinical trials suggesting that fibrinolysis may be a safe and effective therapeutic option in patients with cardiac arrest of presumed cardiovascular cause. Based on a case of successful fibrinolytic treatment of a pulmonary embolism patient with cardiac arrest, these questions are reviewed.
Fibrinolytic Agents↗
SOD1 overexpression and female sex exhibit region-specific neuroprotection after global cerebral ischemia due to cardiac arrest.
Cardiac arrest is often associated with poor neurologic outcome since therapeutic options are limited. We tested the hypothesis that overexpression of CuZn superoxide dismutase (SOD+/-) is neuroprotective in a new murine model of cardiac arrest and cardiopulmonary resuscitation (CPR). Second, we investigated if female and male mice sustain similar injury and if sex-specific outcomes are altered by SOD overexpression. Neuronal injury was quantified 3 days after 8 mins of KCl-induced cardiac arrest by calculating the percentage of ischemic neurons for caudoputamen and hippocampal CA1 region. In rostral caudoputamen, less neuronal cell loss was found for SOD+/- mice (31%+/-22%) when compared with wild-type (WT) mice (47%+/-31%, P<0.05). Superoxide dismutase overexpression did not reduce injury in the caudal caudoputamen. No sex-linked protection was evident in either genotype in the caudoputamen. Female WT mice had less CA1 injury than male WT mice (26%+/-31% versus 54%+/-30%, P<0.05), whereas no sex difference was found in SOD+/- mice (female: 42%+/-29%; male: 37%+/-37%). Comparison of hippocampal injury between genotypes revealed no differences for either males or females. In conclusion, SOD1 overexpression and female sex were associated with significant neuroprotection in this murine cardiac arrest model. However, no additive neuroprotection was observed, and these beneficial effects were restricted to specific brain regions.
Animals↗
Seasonal variation of deaths from fatal myocardial infarction, primary cardiac arrest, sudden cardiac death, and refractory congestive heart failure in older persons living in New York City.
OBJECTIVE: To investigate if there is seasonal variation in cardiac deaths in older persons living in a nursing home in New York City. DESIGN: In a prospective study, the major clinical cause of death of all persons aged 60 years and older residing in a nursing home in New York City during a 15-year period was investigated. The author carefully reviewed the major cause of death with the physicians taking care of all persons who died in the nursing home or after transfer to a general hospital. We investigated whether there was seasonal variation in deaths from either fatal myocardial infarction, primary cardiac arrest, sudden cardiac death, or refractory congestive heart failure. SETTING: A large nursing home in which 1265 older persons died of fatal myocardial infarction, primary cardiac arrest, sudden cardiac death, or refractory congestive heart failure during a 15-year period. PATIENTS: The 1265 persons who died from cardiac causes included 410 men and 855 women, mean age 83 +/- 8 years at the time of death. MEASUREMENTS AND MAIN RESULTS: During a 15-year period, 1265 older persons died of fatal myocardial infarction, primary cardiac arrest, sudden cardiac death, or refractory congestive heart failure. Cardiac deaths occurred from December through March in 497 of 1265 persons (39%), from April through July in 378 of 1265 persons (30%), and from August through November in 390 of 1265 persons (31%). The frequency of cardiac deaths was significantly greater between December and March (P < 0.001). The incidence of cardiac deaths between December and March was 1.29 times greater than the average of the incidence of cardiac deaths during the two other 4-month periods. CONCLUSION: The frequency of cardiac deaths in older persons living in a nursing home in New York City significantly increased 1.29 times during the period December through March compared with the average of the two other 4-month periods (P < 0.001).
Journal Article↗
Unexpected cardiac arrest after cardiac surgery: incidence, predisposing causes, and outcome of open chest cardiopulmonary resuscitation.
STUDY OBJECTIVES: To assess the incidence of acute mechanical causes precipitating sudden cardiac arrest in cardiac surgery patients during the immediate postoperative period. In addition, we report the success rate of cardiopulmonary resuscitation (CPR) in which open-chest CPR was employed at an early stage of the resuscitation effort. METHODS: Data on all cardiac surgical patients who suffered a sudden cardiac arrest during the first 24 h after surgery were collected prospectively. CPR consisted of conventional closed-chest CPR initially and was followed within 3 to 5 min, if needed, by open-chest CPR. RESULTS: Of 3,982 patients undergoing cardiac surgery over a 30-month period, 29 patients (0.7%) had a sudden cardiac arrest. Of these, 13 patients (45%) were successfully resuscitated with closed-chest CPR, 14 (48%) with open-chest CPR, and 2 (7%) died despite closed- and open-chest CPR. Four CPR survivors died subsequently in the ICU, yielding an overall hospital discharge rate of 79%. Perioperative myocardial infarction was the underlying cause of sudden cardiac arrest in 14 patients (48%), and mechanical impediments to cardiac function (tamponade or graft malfunction) in another 8 (28%) patients; in the remaining 7 patients (24%), no underlying cause was found. The length of ICU stay was 6+/-1 (mean+/-SE) days. None of the patients developed wound infection and all were neurologically intact at hospital discharge. CONCLUSION: Mechanical factors account for a substantial portion (28%) of causes of sudden cardiac arrest occurring in hemodynamically stable patients during the immediate postoperative period. This high incidence, in conjunction with the high survival rate achieved by open CPR, supports an early approach to open-chest CPR in this group of patients.
Cardiac Surgical Procedures↗
Standby...cardiac arrest...standby...cardiac arrest.
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Cardiopulmonary Resuscitation↗
Successful defibrillation of a dental patient in cardiac arrest.
Cardiac arrest is a very rare event in a dental patient. However, practitioners have a duty of care to their patients if ever such an event occurs. The cardiac arrest discussed in this case report occurred in an elderly person with an implanted pacemaker whilst undergoing restorative dental treatment. Cardiac arrest was diagnosed and cardiopulmonary resuscitation instituted immediately, followed within three minutes by successful defibrillation using the School's semi-automatic defibrillator.
Aged↗
High dose epinephrine in refractory pediatric cardiac arrest.
Cardiac arrest has a poor prognosis, regardless of age group. Children who fail to respond to two standard doses of epinephrine (0.01 mg/kg) rarely survive to hospital discharge, and most die without the return of spontaneous circulation (ROSC). We treated seven consecutive children in cardiac arrest with high dose epinephrine (0.2 mg/kg) after failure to respond to two standard doses. Six had prompt and sustained ROSC. By comparison, in the previous 20 consecutive pediatric patients with cardiac arrest in which there was no response to two standard doses of epinephrine, none had ROSC. Previous animal data as well as anecdotal human experience suggest that the standard epinephrine dose (0.01 mg/kg) may be much too low.
Adolescent↗
Factors associated with survival and eventual cerebral status following cardiac arrest.
Cardiac arrests at two acute hospitals were investigated over a 5-month period. The outcome expressed as short-term and long-term survival was correlated with diagnosis, age, sex and technical details of the resuscitation. Survivors were followed up for 3 months to detect any remaining cerebral deficit. Of 108 patients who suffered cardiac arrest, 23 (21.3%) survived to be discharged from hospital, 58 (53.7%) died immediately and 27 (25%) survived for periods ranging from 1 hour to 30 days following cardiac arrest, before eventual death. Evidence of cerebral impairment was present initially in three patients (2.7%) at discharge from hospital. After 3 months however cerebral impairment was present in only one patient (0.9%). Survival was highest in patients suffering ventricular fibrillation following myocardial infarction where 16 out of 35 (47%) survived. Certain groups of patients were identified where the ultimate survival was predictably nil. Although some survived for short periods it was concluded that the attempted resuscitation in these patients was inappropriate and unjustified.
Adolescent↗
Functional status and quality of life in long-term survivors of cardiac arrest after cardiac surgery.
OBJECTIVE: To assess long-term survival, functional status, and quality of life in patients who experienced cardiac arrest after cardiac surgery. DESIGN: Prospective, observational study. SETTING: An 18-bed, adult cardiac surgery intensive care unit in a tertiary teaching center. PATIENTS: Twenty-nine cardiac surgery patients who suffered an unexpected cardiac arrest in the immediate postoperative period. INTERVENTIONS: The New York Heart Association classification and a questionnaire based on the Nottingham Health Profile were used to evaluate functional status and quality of life 4 yrs after hospital discharge. MEASUREMENTS AND MAIN RESULTS: Of the 29 patients who experienced cardiac arrest during the first 24 hrs after cardiac surgery, 27 patients (93%) were successfully resuscitated and 23 patients (79%) survived to hospital discharge. Evaluation 4 yrs postdischarge showed that, of the 29 patients, 16 patients (55%) were still alive (long-term survivors). Functional status assessment of long-term survivors revealed that 12 patients (75%) were grouped in New York Heart Association class I, 3 patients (19%) in class II, and 1 patient (6%) in class III. None of them had a neurologic deficit. They all were living independently at home, without need of any nursing care. No patient reported any abnormal emotional reactions, and six patients (38%) had mild sleep disturbances, such as early awaking. Regarding activities of daily living, 20% returned to work, 94% were able to look after their home, 96% had a social life, 63% were sexually active, 81% were involved in their hobbies, and 75% had gone on holidays. CONCLUSIONS: Cardiac surgery patients who experience an unexpected cardiac arrest in the immediate postoperative period have a 55% chance of being alive 4 yrs postdischarge. The majority of these long-term survivors has a good outcome with respect to functional status and quality of life.
Activities of Daily Living↗
Extracorporeal membrane oxygenator rescue in children during cardiac arrest after cardiac surgery.
BACKGROUND: Conventional cardiopulmonary resuscitation (CPR) for cardiac arrest after open-heart surgery in children is often unsuccessful despite the ability to perform open-chest massage. The purpose of this study was to review our results with mechanical support as rescue therapy in children with sudden circulatory arrest after cardiac surgery. METHODS AND RESULTS: From 1981 through 1991, we have used mechanical support with an extracorporeal membrane oxygenator (ECMO) circuit for cardiac support in 33 children. Eleven of the 33 patients (age, 15 +/- 7 months) suffered cardiac arrest intractable to conventional open-chest massage 39 +/- 15 hours after an open-heart procedure. The mean duration of CPR was 65 +/- 9 minutes until ECMO flow was started. ECMO support was continued for 112 +/- 8 hours. One patient had ECMO discontinued due to bleeding (survived); three were discontinued from ECMO and died from neurological complications; and one died of cardiac dysfunction. Sepsis on ECMO was seen in one patient (survived). Overall early survival was seven of 11 (64%) with one patient requiring heart transplantation due to irreversible cardiac dysfunction. One child died late (1 month) after ECMO support. There were no long-term sequelae in the survivors. CONCLUSIONS: We conclude that ECMO rescue in children with postcardiotomy cardiac arrest is a feasible option in selected patients even after prolonged CPR (as long as 60 minutes).
Cardiac Surgical Procedures↗
Cardiac arrest.
Cardiac arrest is easily recognized clinically and requires immediated cardiopulmonary resuscitation (CPR) by well trained personnel. The importance of prophylaxis is emphasized in high risk patients. The ABC regime of CPR and the technique of blind defibrillation are recommended in the management of cardiac arrest. Good results may be expected with ventricular fibrillation associated with some correctable factor or myocardial infarction. With a satisfactory CPR technique and prompt resuscitation, the incidence of complications is low.
Adult↗
Postresuscitative intensive care: neuroprotective strategies after cardiac arrest.
Cardiac arrest is a common disease in the United States, and many patients will die as a result of the neurological damage suffered during the anoxic period, or will live in a neurologically debilitated state. When cardiopulmonary-cerebral resuscitation results in the return of spontaneous circulation, intensive care is required to optimize neurological recovery. Such "brain-oriented" therapies include routine care, such as positioning and maintenance of volume status; optimization of cerebral perfusion, with the use of vasopressors if needed; management of increased intracranial pressure with agents such as hypertonic saline; assuring adequate oxygenation and avoiding hypercapnia; aggressive fever control; intensive glucose control, with the use of an insulin drip if needed; and management of seizures if they occur. To date, no neuroprotectant medications have been shown to improve neurological outcome. Induced moderate therapeutic hypothermia is utilized as a neuroprotective maneuver. Future treatment options and advanced monitoring techniques are also discussed. Further study to optimize neuroprotective strategies when treating patients who survive cardiac arrest is needed.
Brain Infarction↗
Possibilities of brain protection with tirilazad after cardiac arrest.
Cardiac arrest and resuscitation often create a cerebral insult caused by the initial cessation of blood flow, followed by the incomplete ischemia of cardiopulmonary resuscitation (low flow), and, following the return of spontaneous circulation, by the post-resuscitation syndrome. A cascade of physiologic, vascular, and biochemical events is set in motion, including changes in neuropeptides, electrolytes such as calcium and magnesium, excitatory neurotransmitters such as glutamate and acetylcholine, lymphokines such as interleukin-1, and arachidonic acid metabolites such as prostaglandins and leukotrienes; and formation of oxygen free radicals and lactic acid. Oxygen free radical-induced lipid peroxidation appears to increase tissue injury during and after brain ischemia. The 21-aminosteroid U74006F (tirilazad mesylate) is a novel inhibitor of lipid membrane peroxidation induced by oxygen free radicals, which has been shown, in animal models of subarachnoid hemorrhage, central nervous system trauma, and cerebral ischemia, to limit the extent of secondary tissue damage, thus improving functional recovery. Since tirilazad appears to have little or no behavioral or physiologic side effects, it appears to be an ideal agent for widespread brain ischemia prophylaxis. Tirilazad mesylate studies in out-of-hospital cardiac arrest are currently being planned.
Antioxidants↗
Implantable cardioverter defibrillator compared with antiarrhythmic drug treatment in cardiac arrest survivors (the Cardiac Arrest Study Hamburg).
In 1987, the Cardiac Arrest Study Hamburg (CASH), a prospective, multicenter, randomized controlled study, was started in survivors of sudden cardiac death resulting from documented ventricular tachyarrhythmias. Through December 1991, 230 survivors (46 women, 184 men; mean age 57 +/- 11 years) of cardiac arrest caused by ventricular tachyarrhythmias were randomly assigned to receive either oral propafenone (56 patients), amiodarone (56 patients), or metoprolol (59 patients) or to have an implantable defibrillator (59 patients) without concomitant antiarrhythmic drugs. The primary endpoint of the study was total mortality. In March 1992, the propafenone arm of CASH was stopped because of excess mortality compared with the implantable defibrillator group. This article presents preliminary results of the comparison of implantable defibrillator therapy with propafenone therapy. A significantly higher incidence of total mortality, sudden death (12%), and cardiac arrest recurrence or sudden death (23%) was found in the propafenone group compared with the implantable defibrillator-treated patients (0%, p < 0.05). It was concluded that, in survivors of cardiac arrest, propafenone treatment is less effective than implantable defibrillator treatment.
Amiodarone↗