Shortly after starting your night shift, you get STAT paged to bed 34. You rush to the room and find the nurses giving chest compressions. You wrack your brain to remember sign-out – wasn’t this the man who came in with chest pain, no ECG changes, but a concerning history? He was stable, just waiting on an inpatient bed! Not anymore, you sigh. You hold compressions to take a look at the monitor, and see V-fib. “Charge to 200 joules,” you say. “Clear!” calls the tech. The patient jumps with the force of the electricity. The nurse resumes compressions, but a few moments later, the patient moans, moving his hand to his chest. As you hold on compressions and continue to stabilize the patient, you wonder if he would be a good candidate to go to the cath lab . . .
Shortly afterward, you get a call from paramedics about a young man who collapsed suddenly while dancing at a nightclub. “He’s in full cardiac arrest,” they say, and you rush back to the critical care bay. You arrive in the resuscitation bay just as EMS arrives. “It’s V-fib,” the paramedic tells you. “He got 1 shock on the way over, and we’re due for a rhythm check now. EMS had them doing CPR at the scene, and they were doing a pretty good job. It’s only been about 10 minutes since the 911 call– the club is right around the corner from here.” You pause CPR and glance at the monitor. It’s still V-fib, so you deliver a shock at 200 joules and one of the nurses takes over CPR. “Great compressions,” you tell him, and you mean it - just the right depth and rate, and no pauses for nonsense. “I’ve got access, Doc,” says the technician. “Perfect,” you respond, “let’s give a milligram of epi.” You sound like you’re in control, but your mind is racing Why V-fib in a seemingly healthy young man?
Cardiac arrest refers to the abrupt cessation of effective mechanical function of the heart. It may be caused by a variety of cardiac and noncardiac diseases.1 There are more than half a million adult cardiac arrests in the United States each year, with approximately 325,000 outside the hospital and 200,000 in the hospital. There is a slight male predominance, with 57% of cases occurring in men.2 Cardiac arrest occurs in all age groups, though incidence increases with age.2
Survival to hospital discharge occurs in approximately 10% of out-of-hospital arrest cases overall, though survival rates are more than 30% for bystander-witnessed cases.3 In-hospital arrest survival is approximately 20%,4,5 though this estimate varies substantially by hospital6 and time of arrest.7 The presenting cardiac rhythm is an important predictor of outcome in cardiac arrest. The first documented rhythm is ventricular fibrillation (VF) in 17% of cases, ventricular tachycardia (VT) in 7%, pulseless electrical activity (PEA) in 37%, and asystole in 39%.8
Survival to hospital discharge is better overall for shockable rhythms, with more than 33% of patients surviving VF/VT arrests compared to approximately 10% for PEA and asystole.8,9
The body of literature on cardiac arrest is vast, with more than 40,000 articles in PubMed. Fortunately, the International Liaison Committee on Resuscitation (ILCOR) regularly reviews the literature and synthesizes it into practice guidelines for its member organizations, including the American Heart Association (AHA). The AHA publishes guideline updates every 5 years, and these are the “gold standard” in cardiac arrest science. The guidelines summarize clinical resuscitation protocols and their evidentiary basis, as well as noting areas where scientific evidence is lacking. The 2015 updates, published on October 15, 2015 in the journal Circulation, served as the starting point for this review, with additional targeted literature searches performed to address specific clinical questions.
The 2015 AHA guidelines emphasize the importance of immediate, continuous, high-quality cardiopulmonary resuscitation (CPR) and early defibrillation, while recognizing the relative paucity of evidence supporting more “advanced” interventions. Key points from the 2015 guidelines include the following:10
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
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Julianna Jung, MD
October 1, 2016
November 1, 2019
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 0.5 Pharmacology CME credits
Upon completion of this article, you should be able to:
Date of Original Release: October 1, 2016. Date of most recent review: October 10, 2016. Termination date: October 1, 2019.
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