Page 678 - ACCCN's Critical Care Nursing

Resuscitation 655

as standardised recording of outcome data did not exist,
TABLE 24.1 Causes of cardiac arrest resuscitation endeavours could not be compared mean-
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ingfully between countries. Consequently, the Inter-
Primary causes Secondary causes national Liaison Committee on Resuscitation (ILCOR)
was formed in 1992 to promote global discussion and
Acute myocardial infarction Cessation of breathing
Cardiomyopathy Airway obstruction consistency of guidelines between these international
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Electrical shock (low- and high-voltage) Severe bleeding resuscitation councils. The AHA, ARC, NZRC, ERC and
Congenital heart disease (e.g. prolonged Hypothermia ILCOR guidelines are subject to constant review and
Q-T) Metabolic disturbance modification based on emerging scientific data. Guide-
Drugs Electrical disturbance lines and recommendations are classified according to
Trauma
Neuromuscular disease scientific evidence. The most recent substantive guide-
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lines from ILCOR were published in October 2010, with
the ARC and NZRC guidelines published in January 2011.
arrest is asphyxia. Cardiac arrest in children is rare and While it is recognised there are differences between the
even more rarely sudden, 14,15 with the common causes various councils, this chapter primarily reports on the
being trauma, congenital heart disease, long QT syn- ARC and NZRC recommendations.
drome, drug overdose, hypoxia and hypothermia. The
most common arrhythmia in infants is bradycardia, and
the prognosis is especially poor if asystole is present. 14,16 SURVIVAL OF OUT-OF-HOSPITAL ARRESTS
Despite recent advances in resuscitation and technology,
PATHOPHYSIOLOGY the survival rate for out-of-hospital cardiac arrest (OHCA)
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remains poor. Factors associated with higher rates of
In sudden cardiac arrest with cardiac origin, it is believed mortality for adults are: age over 80 years, unwitnessed
that myocardial ischaemia leads to ventricular irritability arrest, delays before commencing CPR, defibrillation
and the progression from ventricular tachycardia to ven- response times longer than 8 minutes, and non-
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tricular fibrillation (VF) and ultimately asystole. After ventricular tachycardia/fibrillation rhythm. The outcome
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the onset of VF (in animal studies), carotid arterial blood statistics for children after OHCA are similarly poor.
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flow continues for approximately 4 minutes even in the Marked differences in the inclusion criteria and outcome
absence of cardiac compressions, as coronary perfusion definitions may, however, also explain the wide varia-
pressure (the pressure gradient between the aorta and the tions in survival rates from cardiac arrests. In recogni-
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right atrium) falls over this period. This initial phase tion of these variations, the Utstein guidelines were
is characterised by minimal ischaemic injury, and it is developed and implemented to consistently document,
during this time that defibrillation is most likely to result monitor and compare out-of-hospital cardiac arrests.
in the restoration of a perfusing rhythm, while initiation These guidelines:
of effective cardiac compressions will increase the coro-
nary perfusion pressure. 17 l establish uniform terms and definitions for out-of-
hospital resuscitation
Progression of the cardiac arrest beyond 4 minutes results l establish a reporting template for resuscitation studies
in accumulation of toxic metabolites, depletion of high- to ensure comparability
energy phosphate stores, and the initiation of ischaemic l define time points and time intervals relating to
cascades. A high probability of irreversible cellular cardiac resuscitation
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injury exists where a cardiac arrest extends for longer than l define clinical items and outcomes that emergency
10 minutes, and the return of a spontaneous circulation medical systems should gather
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during this period may initiate a reperfusion injury (see l develop methods for describing resuscitation systems.
Chapter 11 for further discussion).
RESUSCITATION SYSTEMS SURVIVAL FROM IN-HOSPITAL ARRESTS
AND PROCESSES In-hospital resuscitation, as with OHCA, have survival
Many factors such as age, pres-
22,23
rates of around 20%.
Since the rediscovery of the effectiveness of closed-chest ence or absence of morbidity before or during the hospi-
cardiopulmonary resuscitation (CPR) in 1960 and its tal admission, absence of ‘not-for-resuscitation’ orders,
subsequent widespread adoption, CPR has saved the lives asystole and non-ICU location contribute to the low
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of many, potentially ensuring years of productive life. in-hospital survival rates. 24,25
As CPR quickly became one of the most widely-used and
researched procedures, voluntary coordinating bodies MANAGEMENT
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developed throughout the world. Organisations such as
the European Resuscitation Council (ERC), the American The overall aim of managing a patient in arrest is the
Heart Association (AHA), the New Zealand Resuscitation prompt restoration of a spontaneous perfusing rhythm
Council (NZRC), the Heart and Stroke Foundation of with minimal neurological dysfunction. It is well recog-
Canada, and the Southern African and Australian Resus- nised that successful outcome from cardiac arrest is
citation Councils (ARCs) established practice guidelines dependent on several key factors: (a) early recognition of
to improve standards in resuscitation, and coordinated cardiac arrest; (b) immediate effective CPR, (c) optimis-
resuscitation activities on a national basis. 19,20 However, ing response times, and (d) early defibrillation. 26,27 The