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Out of hospital cardiac arrest

Clinical Discipline(s)/Organ System(s)
Cardiovascular System, Emergency Medicine, Intensive Care Medicine, Ethics
Progress Test Topic(s)
Seriously ill patient
Description
A 60 year old Indian man is brought to hospital by ambulance. He had collapsed whilst out shopping and a bystander started cardiopulmonary resuscitation (CPR) straight away as he had no pulse. He was picked up by the paramedics after 12 minutes of CPR and took 8 minutes to arrive at the Emergency Department resuscitation room, where you are a medical student shadowing the Emergency Department registrar.
Applied Science for Medicine 
   - Anatomy of the heart and thorax
   - Physiology of the heart: electrical conduction, synchronous and asynchronous cardioversion
   - Science of electrical conduction and defibrillation; direct and alternating current
   - Electrophysiology of ventricular tachycardia and fibrillation
   - How chest compressions generate blood pressure
   - Aetiology of cardiac arrest
   - Mechanisms of hypoxic cellular injury including late apoptosis
   - Pharmacology of amiodarone, adrenaline
Clinical and Communication Skills 
   - History from a witness of the cardiac arrest
   - Examine for signs of life and confirm cardiac arrest;check for reversible causes of cardiac arrest
   - Cardiac arrest algorithm: shockable and unshockable rhythm, Compressions-Airway-Breathing (CAB), assess quality of resuscitation provided
   - Recognise risk factors for cardiac arrest, advance care directive
   - Classify cardiac arrest according to the underlying cardiac rhythm
   - Differential diagnosis of cardiac arrest
   - Identify shockable ECG rhythms – ventricular tachycardia and ventricular fibrillation
   - Perform chest compressions, airway maneouvres and the use airway adjuncts
   - Use of a defibrillator and mini-jets
   - Management of reversible causes of cardiac arrest; treatment of hyperkalaemia
   - Indications for therapeutic hypothermia, thrombolysis for massive pulmonary embolus, pericardiocentesis for cardiac tamponade, needle thoracotomy for tension pneumothorax
   - Cessation of attempted resuscitation
   - Prognosis of witnessed and unwitnessed cardiac arrest, post-cardiac arrest
   - Role of the cardiac arrest team, emergency medical services and pre-hospital care
Personal and Professional Skills 
   - Breaking bad news; discussion relating to poor prognosis and dying
   - Ethics: life and death decision-making
   - Ethics: treatment and futility
   - Professional obligations and legal aspects of 'Do Not Attempt Resuscitation' (DNAR) order
   - Continued professional development
Hauora Māori 
   - Ethnic disparities in time to treatment for cardiac arrest
   - Unequal treatment for the management of cardiovascular disease
   - Communication with whānau about poor prognosis and dying
   - Access to cultural resources when poor prognosis and death
Population Health 
   - Cardiac arrest in the community: high risk groups, prognosis, opportunities for prevention
   - Awareness of the general features of the coronary heart disease epidemic in New Zealand
   - Debate the pros and cons of wider distribution of defibrillators in community settings
   - Development of guidelines and protocols
Conditions to be considered relating to this scenario
Common
ventricular fibrillation, ventricular tachycardia, pulseless electrical activity, asystole, pulmonary embolism, myocardial infarction, hypotension (any cause), trauma, electrolyte imbalance
Less common but 'important not to miss'
tension pneumothorax, cardiac tamponade, hypothermia, overdose, aortic dissection, massive/submassive pulmonary embolism
Uncommon
pericarditis, myocarditis
Related Scenarios
[Arrhythmias], [Acute chest pain]