Chapter 121. Inpatient Cardiac Arrest and Cardiopulmonary Resuscitation

1. What are the fundamental goals of cardiopulmonary resuscitation?

2. Which components of resuscitation are considered vital to success?

3. How can the common pitfalls of resuscitation be surmounted?

4. What treatments should be instituted immediately upon successful resuscitation?

5. How should outcomes in resuscitation shape the discussion of advanced directives?

This chapter focuses on cardiopulmonary arrest and the events immediately antecedent to this life-threatening event. Cardiopulmonary resuscitation is a time-dependent, team-based effort to reverse physiologic events that may culminate in a patient's imminent death. Biblical and ancient Egyptian hieroglyphic texts allude to mouth-to-mouth ventilation in divine contexts, but other texts indicate Jewish midwives used mouth-to-mouth resuscitation as early as 3300 years ago to revive stillborn children.

Since standardization of closed chest cardiac massage was first described systematically in the medical literature in 1960, chest compressions have remained the only reliable means of reviving a patient in cardiopulmonary collapse.

In the United States an estimated 375,000 to 750,000 hospitalized patients suffer in-hospital cardiac arrest (IHCA) requiring advanced cardiac life support (ACLS) annually. The incidence of IHCA is estimated to be as high as 1–2% of all patients admitted to academic hospitals with a prevalence of approximately 65 people per 100,000 nationally.

IHCA encompasses a spectrum of disorders, from insufficient cardiac output to generate appreciable cerebral perfusion, including arrhythmia or shock, to complete cessation of cardiac activity. Vital sign anomalies can often herald impending inpatient cardiac arrest by minutes to hours, but many cardiac arrests occur suddenly and without warning. Acute pulmonary arrest may precede IHCA and can occur iatrogenically related to sedative or opiate analgesics overdose.

Since standardization of closed chest cardiac massage (CCCM) was first described systematically in the medical literature in 1960, CCCM has remained the only reliable means of reviving a patient in cardiopulmonary collapse. It is an effective and powerful intervention that, when unnecessarily delayed, can lead to poor patient outcomes. In one study, survival dropped from 34% to 14% if CCCM was delayed even as little as 60–120 seconds from the time the patient collapsed. Therefore, clinicians must recognize and respond to cardiac arrest immediately for resuscitation measures to be effective.

Advanced cardiac life support (ACLS) combines basic life support (BLS) measures with specific interventions such as medication, defibrillation, transthoracic pacing, and advanced airway management. This chapter focuses on (1) the techniques that are essential to successful cardiopulmonary resuscitation, neurologic recovery (as defined by the cerebral performance category 0–1), and (2) decision making based on patient resuscitation status.

While often considered adequate for credentialing purposes, completion of American Heart Association courses fails to result in long-term meaningful skill performance. Health care providers’ capabilities to demonstrate appropriate technique for CCCM and capabilities to successfully navigate the steps of cardiopulmonary resuscitation begin to degrade just weeks following course completion. Therefore, for the whole medical team to respond concisely and in a coordinated fashion, clinicians must have extensive medical ...