Sudden death prognosis
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editors-In-Chief:
Prognosis Following Cardiac Arrest
The out-of-hospital cardiac arrest (OHCA) has a worse survival rate (2-8% at discharge and 8-22% on admission), than an in-hospital cardiac arrest (15% at discharge). The principal determining factor is the initially documented rhythm. Patients with VF/VT have 10-15 times more chance of surviving than those suffering from Pulseless electrical activity or Asystole (as they are sensitive to defibrillation, whereas asystole and PEA are not).
Since mortality in case of OHCA is high, programs were developed to improve survival rate. A study by Bunch et al showed that, although mortality in case of ventricular fibrillation is high, rapid intervention with a defibrillator increases survival rate to that of patients that did not have a cardiac arrest.Eisenberg MS, Mengert TJ (2001). "Cardiac resuscitation". N. Engl. J. Med. 344 (17): 1304–13. PMID 11320390. Unknown parameter |month= ignored (help)</ref>[1]
Survival is mostly related to the cause of the arrest (see above). In particular, patients who have suffered hypothermia have an increased survival rate, possibly because the cold protects the vital organs from the effects of tissue hypoxia. Survival rates following an arrest induced by toxins is very much dependent on identifying the toxin and administering an appropriate antidote. A patient who has suffered a myocardial infarction due to a blood clot in the Left coronary artery has a lower chance of survival as it cuts of the blood supply to most of the left ventricle (the chamber which must pump blood to the whole of the systemic circulation).
Cobbe et al (1996) conducted a study into survival rates from out of hospital cardiac arrest. 14.6% of those who had received resuscitation by ambulance staff survived as far as admission to an acute hospital ward. Of these, 59.3% died during that admission, half of these within the first 24 hours. 46.1% survived to hospital discharge (this is 6.75% of those who had been resuscitated by ambulance staff), however 97.5% suffered a mild to moderate neurological disability, and 2% suffered a major neurological disability. Of those who were successfully discharged from hospital, 70% were still alive 4 years after their discharge.[2][3]
Cardiac arrest is the third leading cause of coma. Approximately 80% of patients who suffered a cardiac arrest and admitted to the hospital, will be in coma for varying lengths of time with approximately 40% entering into a persistent vegetative state and 80% die within 1 year. On the other hand, if a patient survives till discharge without significant neurological impairment, he/she can expect a fair to good quality of life. However, they may have some changes in their energy levels, emotions and memory function secondary to neuronal insult. Clinically, neurological manifestation of cardiac arrest manifest as seizures, sensory and motor deficits, spinal cord compromise, myoclonus, amnesia, persistent vegetative state. The duration of hypoxia/ischemia determines the extent of neuronal injury i.e. in patients who suffer hypoxia for less than 5minutes, are less likely to have permanent neurologic defects, while with prolonged, global hypoxia, patients may develop myoclonus or persistent vegetative state.[4]
Thomassen A and Wernberg M conducted a study into prevalence and prognostic significance of coma after cardiac arrest outside intensive care and coronary units where 181 patients resuscitated from cardiac arrest were reviewed. In patients who suffered cardiac arrest outside hospital, 84% were comatose for more than 1hour and 56% for more than 24 hours. There was no significant neuronal damage if coma lasted less than 24hours. However, in patients who were comatose for more than 24 hours, had a bad prognosis. Of the patients reviewed, 85 remained comatose for more than 24hours and only 7 of them were discharged alive, but with severe neurological impairment with severity increasing with duration of coma. Of the patients who were in coma for more than 7days, none regained consciousness and 80 patients died in coma.[5]
Ballew (1997) performed a review of 68 earlier studies into prognosis following in-hospital cardiac arrest. They found a survival to discharge rate of 14% (this roughly double the rate for out of hospital arrest found by Cobbe et al (see above)), although there was a wide range (0-28%).[6]
Several high profile organisations (such as St John Ambulance and the British Heart Foundation) have promoted the "Chain of Survival", which is made up of 4 links, as a way to maximise prognosis following arrest:
- Early Access - Identifying patients at risk of cardiac arrest early is the best way of improving prognosis, as it is often possible to prevent the arrest. Similarly, if the arrest is witnessed there is a much greater chance of survival, as treatment can begin straight away before tissue hypoxia sets in.
- Early CPR - CPR is unlikely to revive the patient, but it does buy some time by keeping a (limited) circulation going until it is possible to reverse the arrest, thereby increasing the chances of this reversal being successful, and minimising the risk of cerebral hypoxia (which can lead to neurological impairment following return of circulation).
- Early defibrillation - Patients who present with VF/VT can be defibrillated, and the earlier this happens the better, as VF/VT often degenerate into asystole (which is unshockable).
- Early hospital care - Many patients suffer further arrests within the first 24 hours of admission, so it is better that they are in hospital where their chances of survival are a little higher.
References
- ↑ Bunch TJ, White RD, Gersh BJ; et al. (2003). "Long-term outcomes of out-of-hospital cardiac arrest after successful early defibrillation". N. Engl. J. Med. 348 (26): 2626–33. doi:10.1056/NEJMoa023053. PMID 12826637. Unknown parameter
|month=ignored (help) - ↑ Lyon RM, Cobbe SM, Bradley JM, Grubb NR (2004). "Surviving out of hospital cardiac arrest at home: a postcode lottery?". Emerg Med J. 21 (5): 619–24. doi:10.1136/emj.2003.010363. PMC 1726412. PMID 15333549. Unknown parameter
|month=ignored (help) - ↑ Cobbe SM, Dalziel K, Ford I, Marsden AK (1996). "Survival of 1476 patients initially resuscitated from out of hospital cardiac arrest". BMJ. 312 (7047): 1633–7. PMC 2351362. PMID 8664715. Unknown parameter
|month=ignored (help) - ↑ Mellion ML (2005). "Neurologic consequences of cardiac arrest and preventive strategies". Medicine and Health, Rhode Island. 88 (11): 382–5. PMID 16363390. Unknown parameter
|month=ignored (help) - ↑ Thomassen A, Wernberg M (1979). "Prevalence and prognostic significance of coma after cardiac arrest outside intensive care and coronary units". Acta Anaesthesiologica Scandinavica. 23 (2): 143–8. PMID 442945. Unknown parameter
|month=ignored (help) - ↑ Ballew KA (1997). "Cardiopulmonary resuscitation". BMJ. 314 (7092): 1462–5. PMC 2126720. PMID 9167565. Unknown parameter
|month=ignored (help)