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CHAPTER 23: Cardiopulmonary Resuscitation

Benjamin S. Abella

KEY POINTS

  • Most cardiac arrests in the community setting occur as a result of coronary artery disease and cardiac ischemia.

  • Given the high mortality of cardiac arrest, prevention is crucial.

  • High-quality cardiopulmonary resuscitation (CPR) and prompt defibrillation when appropriate are crucial therapies to increase survival from cardiac arrest.

  • Advanced cardiopulmonary life support (ACLS) guidelines provide treatment algorithms for different cardiac rhythms of arrest.

  • Automatic external defibrillators provide a means for rapid defibrillation by the public.

  • Rapid response teams have been developed to help decrease the incidence of in-hospital cardiac arrest.

INTRODUCTION

Cardiac arrest, defined as the sudden complete loss of cardiac output and therefore blood pressure, is the leading cause of death in the United States and much of the developed world, claiming at least 300,000 lives each year in the United States alone.1 In the majority of cases, myocardial ischemia in the setting of coronary artery disease represents the underlying etiology of arrest. Conversely, cardiac arrest is the initial presentation of myocardial ischemia in approximately 20% of patients.2 A wide variety of other processes can lead to cardiac arrest, including septic shock, electrolyte abnormalities, hypothermia, pulmonary embolism, and massive trauma (Table 23-1).

TABLE 23-1Etiologies of Cardiac Arrest
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TABLE 23-1 Etiologies of Cardiac Arrest

  • Myocardial ischemia/infarction

  • Primary cardiac arrhythmia

  • Hypothermia

  • Septic shock

  • Trauma

  • Systemic inflammatory response syndrome

  • Tension pneumothorax

  • Myocardial pump failure

    • Pulmonary embolism

    • Cardiac tamponade

    • Ventricular wall rupture

    • Severe valvular disease

    • Infiltrative cardiomyopathy

    • Inflammatory cardiomyopathy

  • Massive hemorrhage

    • Postoperative

    • Trauma

    • Gastrointestinal bleeding

  • Hypoxemia/respiratory failure

    • Pneumonia

    • Pulmonary embolism

    • Status asthmaticus

    • Suffocation, eg, foreign-body aspiration

  • Electrolyte derangement

    • Hyperkalemia

    • Hypocalcemia

  • Drug toxicity/overdose

    • Digoxin

    • β-Blockers

    • Calcium channel blockers

    • Tricyclic antidepressants

Note: This list is by no means exhaustive; a number of etiologies are grouped by mechanism, although some likely involve multiple mechanisms (eg, pulmonary embolism causing hypoxemia and right ventricular pump failure). Myocardial ischemia and primary cardiac arrhythmia are the most common underlying pathophysiologic mechanisms in cardiac arrest, especially in out-of-hospital arrest.

Survival from cardiac arrest remains low, even after the introduction of electrical defibrillation and cardiopulmonary resuscitation (CPR) over 50 years ago. In scenarios with the best chance of survival (witnessed ventricular fibrillation arrest with rapid defibrillation), survival to hospital discharge ranges from 30% to 46%,3,4 although overall out-of-hospital arrest survival even in communities with well-developed systems of bystander response has been reported from 14% to 18%.5,6 Recent epidemiologic studies in the United States and Europe have demonstrated survival to discharge rates from out-of-hospital arrest of 9.8% and 10.3%, respectively.7,8 Even after successful resuscitation from cardiac arrest, many patients die within 24 to 48 hours despite aggressive intensive care. Reperfusion injury, a subject of much basic science investigation, is thought to be involved in this postarrest deterioration.9,10

Demographic data from multiple studies demonstrate that the peak incidence of out-of-hospital cardiac ...

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