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JAMA Mar 2019In-hospital cardiac arrest is common and associated with a high mortality rate. Despite this, in-hospital cardiac arrest has received little attention compared with... (Review)
Review
IMPORTANCE
In-hospital cardiac arrest is common and associated with a high mortality rate. Despite this, in-hospital cardiac arrest has received little attention compared with other high-risk cardiovascular conditions, such as stroke, myocardial infarction, and out-of-hospital cardiac arrest.
OBSERVATIONS
In-hospital cardiac arrest occurs in over 290 000 adults each year in the United States. Cohort data from the United States indicate that the mean age of patients with in-hospital cardiac arrest is 66 years, 58% are men, and the presenting rhythm is most often (81%) nonshockable (ie, asystole or pulseless electrical activity). The cause of the cardiac arrest is most often cardiac (50%-60%), followed by respiratory insufficiency (15%-40%). Efforts to prevent in-hospital cardiac arrest require both a system for identifying deteriorating patients and an appropriate interventional response (eg, rapid response teams). The key elements of treatment during cardiac arrest include chest compressions, ventilation, early defibrillation, when applicable, and immediate attention to potentially reversible causes, such as hyperkalemia or hypoxia. There is limited evidence to support more advanced treatments. Post-cardiac arrest care is focused on identification and treatment of the underlying cause, hemodynamic and respiratory support, and potentially employing neuroprotective strategies (eg, targeted temperature management). Although multiple individual factors are associated with outcomes (eg, age, initial rhythm, duration of the cardiac arrest), a multifaceted approach considering both potential for neurological recovery and ongoing multiorgan failure is warranted for prognostication and clinical decision-making in the post-cardiac arrest period. Withdrawal of care in the absence of definite prognostic signs both during and after cardiac arrest should be avoided. Hospitals are encouraged to participate in national quality-improvement initiatives.
CONCLUSIONS AND RELEVANCE
An estimated 290 000 in-hospital cardiac arrests occur each year in the United States. However, there is limited evidence to support clinical decision making. An increased awareness with regard to optimizing clinical care and new research might improve outcomes.
Topics: Adult; Aged; Clinical Decision-Making; Electric Countershock; Female; Heart Arrest; Hospitalization; Humans; Male; Practice Guidelines as Topic; Prognosis; Quality Improvement; Resuscitation; Survival Rate; United States
PubMed: 30912843
DOI: 10.1001/jama.2019.1696 -
Circulation Oct 2023In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory... (Review)
Review
2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
Topics: Humans; Adrenergic beta-Antagonists; American Heart Association; Benzodiazepines; Cardiopulmonary Resuscitation; Digoxin; Heart Arrest; United States
PubMed: 37721023
DOI: 10.1161/CIR.0000000000001161 -
Journal of the Royal Society of Medicine Jan 2015Traumatic cardiac arrest is known to have a poor outcome, and some authors have stated that attempted resuscitation from traumatic cardiac arrest is futile. However,... (Review)
Review
Traumatic cardiac arrest is known to have a poor outcome, and some authors have stated that attempted resuscitation from traumatic cardiac arrest is futile. However, advances in damage control resuscitation and understanding of the differences in pathophysiology of traumatic cardiac arrest compared to medical cardiac arrest have led to unexpected survivors. Recently published data have suggested that outcome from traumatic cardiac arrest is no worse than that for medical causes of cardiac arrest, and in some groups may be better. This review highlights key areas of difference between traumatic cardiac arrest and medical cardiac arrest, and outlines a strategy for the management of patients in traumatic cardiac arrest. Standard Advanced Life Support algorithms should not be used for patients in traumatic cardiac arrest.
Topics: Advanced Cardiac Life Support; Heart Arrest; Heart Massage; Humans; Hypovolemia; Life Support Care; Thoracotomy; Wounds and Injuries
PubMed: 25572990
DOI: 10.1177/0141076814560837 -
Critical Care (London, England) Dec 2022In-hospital cardiac arrest (IHCA) is associated with a high risk of death, but mortality rates are decreasing. The latest epidemiological and outcome data from several... (Review)
Review
In-hospital cardiac arrest (IHCA) is associated with a high risk of death, but mortality rates are decreasing. The latest epidemiological and outcome data from several cardiac arrest registries are helping to shape our understanding of IHCA. The introduction of rapid response teams has been associated with a downward trend in hospital mortality. Technology and access to defibrillators continues to progress. The optimal method of airway management during IHCA remains uncertain, but there is a trend for decreasing use of tracheal intubation and increased use of supraglottic airway devices. The first randomised clinical trial of airway management during IHCA is ongoing in the UK. Retrospective and observational studies have shown that several pre-arrest factors are strongly associated with outcome after IHCA, but the risk of bias in such studies makes prognostication of individual cases potentially unreliable. Shared decision making and advanced care planning will increase application of appropriate DNACPR decisions and decrease rates of resuscitation attempts following IHCA.
Topics: Humans; Retrospective Studies; Heart Arrest; Hospitals
PubMed: 36474215
DOI: 10.1186/s13054-022-04247-y -
JAMA Pediatrics Mar 2021Pediatric in-hospital cardiac arrest (IHCA) occurs frequently and is associated with high morbidity and mortality. The objective of this narrative review is to summarize... (Review)
Review
IMPORTANCE
Pediatric in-hospital cardiac arrest (IHCA) occurs frequently and is associated with high morbidity and mortality. The objective of this narrative review is to summarize the current knowledge and recommendations regarding pediatric IHCA and cardiopulmonary resuscitation (CPR).
OBSERVATIONS
Each year, more than 15 000 children receive CPR for cardiac arrest during hospitalization in the United States. As many as 80% to 90% survive the event, but most patients do not survive to hospital discharge. Most IHCAs occur in intensive care units and other monitored settings and are associated with respiratory failure or shock. Bradycardia with poor perfusion is the initial rhythm in half of CPR events, and only about 10% of events have an initial shockable rhythm. Pre-cardiac arrest systems focus on identifying at-risk patients and ensuring that they are in monitored settings. Important components of CPR include high-quality chest compressions, timely defibrillation when indicated, appropriate ventilation and airway management, administration of epinephrine to increase coronary perfusion pressure, and treatment of the underlying cause of cardiac arrest. Extracorporeal CPR and measurement of physiological parameters are evolving areas in improving outcomes. Structured post-cardiac arrest care focused on targeted temperature management, optimization of hemodynamics, and careful intensive care unit management is associated with improved survival and neurological outcomes.
CONCLUSIONS AND RELEVANCE
Pediatric IHCA occurs frequently and has a high mortality rate. Early identification of risk, prevention, delivery of high-quality CPR, and post-cardiac arrest care can maximize the chances of achieving favorable outcomes. More research in this field is warranted.
Topics: Cardiopulmonary Resuscitation; Heart Arrest; Hospitalization; Humans; Pediatrics; United States
PubMed: 33226408
DOI: 10.1001/jamapediatrics.2020.5039 -
Minerva Anestesiologica May 2010Following successful resuscitation from cardiac arrest, neurological impairment as well as other types of organ dysfunction still cause significant morbidity and... (Review)
Review
Following successful resuscitation from cardiac arrest, neurological impairment as well as other types of organ dysfunction still cause significant morbidity and mortality. The whole-body ischemia-reperfusion response that occurs during cardiac arrest and subsequent restoration of systemic circulation results in a series of pathophysiological processes that have been termed the post-cardiac arrest syndrome. The components of the post-cardiac arrest syndrome comprise post-cardiac arrest brain injury, post-cardiac arrest myocardial dysfunction, the systemic ischemia-reperfusion response and persistent precipitating pathology. Management of the post-cardiac arrest syndrome involves intensive care support with input from various other medical specialties in a coordinated fashion. Management of ventilation aims for normal carbon dioxide values and normoxia rather than hyperoxia. Management of the circulation commonly requires vasoactive support to overcome (often transient) myocardial dysfunction. Particular attention should be given to evidence of cardiac ischemia and referral for urgent angiography and percutaneous coronary intervention, if appropriate, should be available to all. Optimizing neurological recovery will involve seizure control, management of hyperglycemia and therapeutic hypothermia. Prognostication following cardiac arrest remains difficult, but there are diagnostic tests that may be used with some degree of accuracy.
Topics: Heart Arrest; Humans; Nervous System Diseases; Recovery of Function; Reperfusion Injury; Resuscitation; Syndrome
PubMed: 20395899
DOI: No ID Found -
Circulation Jan 2024Cardiac arrest is common and deadly, affecting up to 700 000 people in the United States annually. Advanced cardiac life support measures are commonly used to improve... (Review)
Review
2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Cardiac arrest is common and deadly, affecting up to 700 000 people in the United States annually. Advanced cardiac life support measures are commonly used to improve outcomes. This "2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support" summarizes the most recent published evidence for and recommendations on the use of medications, temperature management, percutaneous coronary angiography, extracorporeal cardiopulmonary resuscitation, and seizure management in this population. We discuss the lack of data in recent cardiac arrest literature that limits our ability to evaluate diversity, equity, and inclusion in this population. Last, we consider how the cardiac arrest population may make up an important pool of organ donors for those awaiting organ transplantation.
Topics: Humans; United States; American Heart Association; Cardiopulmonary Resuscitation; Emergency Medical Services; Heart Arrest; Emergency Treatment
PubMed: 38108133
DOI: 10.1161/CIR.0000000000001194 -
Heart (British Cardiac Society) Dec 2015Cardiac arrest is a leading cause of death in developed countries. Although a majority of cardiac arrest patients die during the acute event, a substantial proportion of... (Review)
Review
Cardiac arrest is a leading cause of death in developed countries. Although a majority of cardiac arrest patients die during the acute event, a substantial proportion of cardiac arrest deaths occur in patients following successful resuscitation and can be attributed to the development of post-cardiac arrest syndrome. There is growing recognition that integrated post-resuscitation care, which encompasses targeted temperature management (TTM), early coronary angiography and comprehensive critical care, can improve patient outcomes. TTM has been shown to improve survival and neurological outcome in patients who remain comatose especially following out-of-hospital cardiac arrest due to ventricular arrhythmias. Early coronary angiography and revascularisation if needed may also be beneficial during the post-resuscitation phase, based on data from observational studies. In addition, resuscitated patients usually require intensive care, which includes mechanical ventilator, haemodynamic support and close monitoring of blood gases, glucose, electrolytes, seizures and other disease-specific intervention. Efforts should be taken to avoid premature withdrawal of life-supporting treatment, especially in patients treated with TTM. Given that resources and personnel needed to provide high-quality post-resuscitation care may not exist at all hospitals, professional societies have recommended regionalisation of post-resuscitation care in specialised 'cardiac arrest centres' as a strategy to improve cardiac arrest outcomes. Finally, evidence for post-resuscitation care following in-hospital cardiac arrest is largely extrapolated from studies in patients with out-of-hospital cardiac arrest. Future studies need to examine the effectiveness of different post-resuscitation strategies, such as TTM, in patients with in-hospital cardiac arrest.
Topics: Cardiopulmonary Resuscitation; Centralized Hospital Services; Combined Modality Therapy; Coronary Angiography; Delivery of Health Care, Integrated; Early Diagnosis; Heart Arrest; Hospitalization; Humans; Hypothermia, Induced; Models, Organizational; Out-of-Hospital Cardiac Arrest; Percutaneous Coronary Intervention; Predictive Value of Tests; Quality of Health Care; Risk Factors; Treatment Outcome
PubMed: 26385451
DOI: 10.1136/heartjnl-2015-307450 -
Circulation Jan 2024The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence.... (Review)
Review
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
Topics: Humans; Cardiopulmonary Resuscitation; American Heart Association; Heart Arrest; Emergency Medical Services; Critical Care
PubMed: 38014539
DOI: 10.1161/CIR.0000000000001163 -
Journal of the American College of... Aug 2020Focused transthoracic echocardiography (TTE) during cardiac arrest resuscitation can enable the characterization of myocardial activity, identify potentially treatable... (Review)
Review
Focused transthoracic echocardiography (TTE) during cardiac arrest resuscitation can enable the characterization of myocardial activity, identify potentially treatable pathologies, assist with rhythm interpretation, and provide prognostic information. However, an important limitation of TTE is the difficulty obtaining interpretable images due to external and patient-related limiting factors. Over the last decade, focused transesophageal echocardiography (TEE) has been proposed as a tool that is ideally suited to image patients in extremis-those in cardiac arrest and periarrest states. In addition to the same diagnostic and prognostic role provided by TTE images, TEE provides unique advantages including the potential to optimize the quality of chest compressions, shorten cardiopulmonary resuscitation interruptions, guide resuscitative procedures, and provides a continuous image of myocardial activity. This review discusses the rationale, supporting evidence, opportunities, and challenges, and proposes a research agenda for the use of focused TEE in cardiac arrest with the goal to improve resuscitation outcomes.
Topics: Cardiopulmonary Resuscitation; Clinical Competence; Echocardiography, Transesophageal; Heart Arrest; Humans; Quality Improvement
PubMed: 32762909
DOI: 10.1016/j.jacc.2020.05.074