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Cardiac Arrest and ECMO
Questions and Answers
1
You arrive on the scene at a local restaurant to find a 65-year-old gentleman who reportedly had a witnessed cardiac arrest. Cardiopulmonary resuscitation (CPR) was started by bystanders. How common is out-of-hospital cardiac arrest?
350,000 patients suffer an out-of-hospital cardiac arrest annually in the United States, and the overall fatality rate is over 90%.
2
After you stabilize your patient, what is important information to gather at the scene?
It is useful prognostically to determine whether the cardiac arrest was witnessed or unwitnessed, as well as the duration of time before CPR and duration of bystander CPR. Of course, obtaining any preceding symptoms, relevant medical history, medications, allergies, and trauma sustained during the arrest is also important.
3
How often do people survive out-of-hospital cardiac arrest?
Overall, about 25%–30% of patients survive to hospital admission, and just under 10% survive to hospital discharge. The highest survival rate, with 30% discharged from the hospital alive, is in witnessed arrests with shockable initial rhythm and immediate bystander CPR. Asystole as the initial rhythm carries the worst prognosis, likely because it often signifies extended downtime. Unwitnessed arrest has a survival to hospital discharge of about 4%. Cardiac arrest witnessed by a 911 responder leads to about 18%–20% survival to hospital discharge on average.
4
What are the priorities in prehospital care for cardiac arrest?
The interventions that have been shown to have the greatest impact on survival remain high-quality CPR—including adequate depth, rate, and recoil with minimal interruptions—and defibrillation in patients with a shockable rhythm. Effective oxygenation and ventilation increases in importance as the duration of the arrest becomes longer, and may be the most important factor in selected patients with a respiratory cause for their arrest. It remains controversial whether mask ventilation, supraglottic airway, or endotracheal intubation has any relative survival benefit; whichever is chosen, the effectiveness should be monitored by waveform capnography. Treatment of reversible causes of arrest is important, although many of these are difficult to identify in the prehospital setting. Chest compressions and airway management generally should take priority over vascular access and medication administration.
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