Journal of Emergencies, Trauma, and Shock
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Cardiac arrest survival in emergency departments


 Department of Medicine, IGMC, Shimla, Himachal Pradesh, India

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Date of Submission15-Oct-2018
Date of Acceptance16-Oct-2018
 


How to cite this URL:
Chauhan V. Cardiac arrest survival in emergency departments. J Emerg Trauma Shock [Epub ahead of print] [cited 2021 Nov 27]. Available from: https://www.onlinejets.org/preprintarticle.asp?id=314953




Cardiac arrest (CA) has been traditionally divided into out of hospital CA (OHCA) and in-hospital CA (IHCA). Survival in OHCA is lower (3%–16%) than IHCA, and these two areas need separate research and practice approach to impact survival after CA. IHCA can be divided into CA occurring in emergency department (EDCA) and CA occurring elsewhere in the hospitals. The sparse literature available on EDCA shows that it has higher survival rates compared to the rest of the IHCA and OHCA.[1] Resuscitation in patients of CA has three main aspects that need further research and guidance, i.e., prevention of CA in ED, do not attempt resuscitation (DNAR) orders, and post-CA care of the patients.

The DNAR decision is a crucial one needing further research and guidance. In many countries, the DNAR has no legal support and doctors have to provide cardiopulmonary resuscitation (CPR) to all patients irrespective of their perceived outcomes. Attempting CPR on patients who are unlikely to survive involves higher costs, false hopes, discomfort, frustration, sadness for families, and resource consumption for the society. Studies have shown that two-third of patients with extremely poor chances of survival were managed without DNAR and incurred very high costs of care.[2] CA survival postarrest resuscitation in-hospital prognostic tool was developed to estimate the likelihood of being discharged alive with good neurological outcome after an IHCA.[2] This study showed that in the best prognostic decile (n = 2396), DNAR orders were placed in the first 12 h for 169 (7.1%) patients, and 1550 (64.7%) were discharged with favorable neurologic outcome. In contrast, of the 2667 patients in the worst prognostic decile, 108 (4%) patients had a favorable outcome, yet only 959 (36%) patients had DNAR orders placed.[2] Therefore, research into various aspects of DNAR especially in the EDCA can benefit the society by the allocation of scarce hospital resources toward the patients with better prognosis.

In addition, efforts should be made to prevent CA when the patient is either in the hospital or ED. The resuscitation council of the United Kingdom has recommended the following steps to prevent IHCA and improve survival in them:[3]

  1. Place critically ill patients, or those at risk of clinical deterioration, in areas where the level of care is matched to the level of patient sickness
  2. Regularly monitor such patients using simple vital sign observations (e.g., pulse, blood pressure, and respiratory rate). Match the frequency and type of observations to the severity of illness of the patient
  3. Use an early warning system to identify patients who are critically ill, at risk of clinical deterioration or cardiopulmonary arrest or both
  4. Use a patient vital signs chart that encourages and permits the regular measurement and recording of early warning scores
  5. Ensure that the hospital has a clear policy that requires a clinical response to deterioration in the patient's clinical condition. Provide advice on the further clinical management of the patient and the specific responsibilities of medical and nursing staff
  6. Introduce into each hospital a clearly identified response to critical illness. This will vary between sites but may include an outreach service or clinical team capable of responding to acute clinical crises. This team should be alerted, using an early warning system, and the service must be available 24 h a day
  7. Ensure that all clinical staff are trained in the recognition, monitoring, and management of the critically ill patient
  8. Agree a hospital DNAR policy, based on national guidelines, and ensure that it is understood by all clinical staff. Identify patients who do not wish to receive CPR and those for whom CA is an anticipated terminal event for whom CPR would be inappropriate
  9. Audit all cardiac arrests, “false arrests,” unexpected deaths, and unanticipated intensive care unit admissions, using a common dataset. Audit the antecedents and clinical responses to these events.


A CA review of 430 hospitals over 6 years has shown that ventricular tachycardia or ventricular fibrillation (VT/VF) was responsible for 29% of EDCA compared to 11% in general nonmonitored nursing units (floor). VT/VF is known to have the best survival rates and this explains the highest discharge survival rate for EDCA, i.e., 23% compared with 16% in intensive care unit, and 11% on the floor.[1] Other factors that differentiate ED patients from other in-hospital patients include younger age, less comorbidities, higher chances of being in shock, and hypotension. EDCA patients received defibrillation earlier than floor patients while the CPR was started at the same time.[1]

ED teams are good at providing CPR to the CA patients, but just like any disaster, successful return of spontaneous circulation is not the end but beginning of the hard work. In addition to the standardized resuscitation guidelines, we also need high-quality family support systems to cover all aspects of pre- and post-CA care. All efforts should be made to prevent a CA. Wherever possible an evidence-based decision of DNAR should be placed on record in consultation with the family of the patient. EDCA has a better outcome compared to both OHCA and IHCA, and there is a potential for further improvement through research in this area.



 
   References Top

1.
Cardiac Arrest in the Emergency Department. Available from: https://www.professional.heart.org/professional/ScienceNews/UCM_433033_Cardiac-Arrest-in-the-Emergency-Department.jsp. [Last accessed on 2018 Oct 15].  Back to cited text no. 1
    
2.
Angus DC. Successful resuscitation from in-hospital cardiac arrest – What happens next? JAMA 2015;314:1238-9.  Back to cited text no. 2
    
3.
Prevention of Cardiac Arrest and Decisions about CPR. Available from: https://www.resus.org.uk/resuscitation-guidelines/prevention-of- cardiac-arrest-and-decisions-about-cpr/. [Last accessed on 2018 Oct 15].  Back to cited text no. 3
    

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Correspondence Address:
Vivek Chauhan,
Department of Medicine, IGMC, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JETS.JETS_114_18





 

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