Current concepts in the management of cardiac arrest
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Editor, – I read Dr John Holmes' 'Current concepts in the management of cardiac arrest' and saved the wall chart (Aust Prescr 1997;20:41-5 and reprinted as insert to Aust Prescr 1997, Vol. 20 No. 4). Thank you for this excellent article and publication.
I would share an experience that relates to the decision to stop treatment. Many years ago, on a footpath in the city, I came across a man who, while jogging, had a cardiac arrest. With an assistant, we applied CPR for 40 minutes before the arrival of an intensive care ambulance crew who were prepared to abandon this man. After having oxygen and sodium bicarbonate, he sat up, was loaded into the ambulance and taken to hospital. I heard no more until some 3 months later.
On a Sunday morning, he came to my house to thank me for my perseverance and said that he had some further cardiac arrests in the hospital and was now about to return to his work as a civil engineer. I understand that 'one swallow does not a summer make'. My concern is that, with the technologicalisation of our world, statistics will come to totally dominate everything that we do.
Throughout the CPR, this man, although his perfusion status clearly had deteriorated, maintained reactive pupils. Yet, in spite of my pointing this out to the otherwise very well-trained ambulance officers, they decided that more than 20 minutes without technological assistance was enough to declare some one dead.
On this rather slim level of experience, I would nonetheless till take exception to the statement 'Cardiac arrest with no return of spontaneous circulation for greater than 30 minutes is usually hopeless'. I would certainly emphasise that withdrawal of treatment could be considered, but not in the absence of a clear clinical assessment. For example, if the neurological reactivity is still present, then maybe not abandoning hope at this stage is still indicated.
Dr John L. Holmes, the author of the article, comments:
The issue of cessation of resuscitative efforts in cardiac arrest is always difficult. Basic cardiac life support (i.e. cardiopulmonary resuscitation alone) provides a circulatory output of only 500-750 mL/minute of relatively hypoxaemic blood. This can maintain cerebral and myocardial viability for no more than a few minutes. Whilst there have been several anecdotal reports of prolonged cardiopulmonary resuscitation resulting in successful outcomes, in such cases there may well have been cardiac activity and low grade spontaneous circulation which is not easily detectable in the absence of physiological monitoring.
Dr Handsjuk rightly points out that resuscitation should be continued if there is any evidence of ongoing neurological activity and reactive pupils are certainly indicative of brain stem perfusion. However, resuscitation should be ceased if, despite advanced cardiac life support interventions for 20-25 minutes, the pupils have remained fixed and dilated and throughout the resuscitation there has been a definite absence of spontaneous circulation.
This should be a positive clinical decision and is predicated on the knowledge that, given the above criteria, outcomes are universally dismal.