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=== Intervention ===
 
[[Catheter ablation]] can only be performed for patients with sustained monomorphic [[ventricular tachycardia]] based on these characteristics:
 
*Incessant [[VT]] or electrical storm due to [[myocardial]] scar tissue
 
* Sustained [[VT]] and recurrent [[ICD]] shock in [[ischemic heart disease]]
 
 
 
 
 
 
 
 
 
 
Most out-of-hospital cardiac arrests occur following a [[Myocardial infarction]] (heart attack), and present initially with a heart rhythm of [[Ventricular fibrillation]]. The patient is therefore likely to be responsive to [[defibrillation]], and this has become the focus of pre-hospital interventions. Several organisations promote the idea of a "[[chain of survival]]", of which defibrillation is a key step. The links are:
* '''Early recognition''' - If possible, recognition of illness before the patient develops a cardiac arrest will allow the rescuer to prevent its occurrence. Early recognition that a cardiac arrest has occurred is key to survival - for every minute a patient is in cardiac arrest, their chances of survival drop by roughly 10% <ref name="RCUK2005">Resuscitation Council UK (2005). ''Resuscitation Guidelines 2005'' London: Resuscitation Council UK.</ref>
* '''Early [[Cardiopulmonary resuscitation|CPR]]''' - This buys time by keeping vital organs perfused with oxygen whilst waiting for equipment and trained personnel to reverse the arrest. In particular, by keeping the brain supplied with oxygenated blood, chances of neurological damage are decreased.
* '''Early defibrillation''' - This is the only effective for [[Ventricular fibrillation]], and also has benefit in [[Ventricular tachycardia]]<ref name = "RCUK2005"/>. If defibrillation is delayed, then the rhythm is likely to degenerate into [[Asystole]], for which outcomes are markedly worse.
* '''Early post-resuscitation care''' - Treatment and rehabillitation in a hospital by specialist staff helps to prevent further complications, attempts to fully reverse the underlying cause, and promotes quality of life.
 
If one or more links in the chain are missing or delayed, then the chances of survival drop significantly. In particular, bystander CPR is an important indicator of survival: if it has not been carried out, then resuscitation is associated with very poor results. Paramedics in some jurisdictions are authorised to abandon resuscitation altogether if the early stages of the chain have not been carried out in a timely fashion prior to their arrival.
 
Because of this, considerable effort has been put into educating the public on the need for CPR. In addition, there is increasing use of public access defibrillation. This involves placing [[Automated external defibrillator]]s in public places, and training key staff in these areas how to use them. This allows defibrillation to take place prior to the arrival of emergency services, and has been shown to lead to increased chances of survival. In addition, it has been shown that those who suffer arrests in remote locations have worse outcomes following cardiac arrest <ref name="pmid15333549">{{cite journal |author=Lyon RM, Cobbe SM, Bradley JM, Grubb NR |title=Surviving out of hospital cardiac arrest at home: a postcode lottery? |journal=Emerg Med J |volume=21 |issue=5 |pages=619–24 |year=2004 |month=September |pmid=15333549 |pmc=1726412 |doi=10.1136/emj.2003.010363 |url=}}</ref>: these areas often have [[First responder]] schemes, whereby members of the community receive training in resuscitation and are given a defibrillator, and called by the emergency medical services in the case of a collapse in their local area.
 
===Treatment of in Hospital Cardiac Arrest===
Treatment within a hospital usually follows [[advanced life support]] protocols. Depending on the [[diagnosis]], various treatments are offered, ranging from [[defibrillation]] (for [[ventricular fibrillation]] or [[ventricular tachycardia]]) to [[surgery]] (for cardiac arrest which can be reversed by surgery - see causes of arrest, above) to [[medication]] (for [[asystole]] and [[pulseless electrical activity|PEA]]). All will include[[CPR]].  Consult the AHA guidelines for the most up to date algorithms.
 
===Management During the Peri-arrest Period===
The period (either before or after) surrounding a cardiac arrest is known as the '''peri-arrest period'''. During this period the patient is in a highly unstable condition and must be constantly monitored in order to halt the progression or repeat of a full cardiac arrest. The [[preventative treatment]] used during the peri-arrest period depends on the causes of the impending arrest and the likelihood such an event occurring.


==2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care and 2006 ACC/AHA/ESC Guidelines for Management of Patients With Cardiac Arrest (DO NOT EDIT) <ref name="pmid20956224">{{cite journal| author=Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW et al.| title=Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal=Circulation | year= 2010 | volume= 122 | issue= 18 Suppl 3 | pages= S729-67 | pmid=20956224 | doi=10.1161/CIRCULATIONAHA.110.970988 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20956224  }} </ref><ref name="pmid16935995">{{cite journal| author=Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M et al.| title=ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. | journal=Circulation | year= 2006 | volume= 114 | issue= 10 | pages= e385-484 | pmid=16935995 | doi=10.1161/CIRCULATIONAHA.106.178233 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16935995}}</ref>==
==2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care and 2006 ACC/AHA/ESC Guidelines for Management of Patients With Cardiac Arrest (DO NOT EDIT) <ref name="pmid20956224">{{cite journal| author=Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW et al.| title=Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal=Circulation | year= 2010 | volume= 122 | issue= 18 Suppl 3 | pages= S729-67 | pmid=20956224 | doi=10.1161/CIRCULATIONAHA.110.970988 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20956224  }} </ref><ref name="pmid16935995">{{cite journal| author=Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M et al.| title=ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. | journal=Circulation | year= 2006 | volume= 114 | issue= 10 | pages= e385-484 | pmid=16935995 | doi=10.1161/CIRCULATIONAHA.106.178233 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16935995}}</ref>==

Revision as of 20:56, 30 January 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Sara Zand, M.D.[2]

Urgent Treatment

Medical Therapy

2017AHA/ACC/HRS Guideline for management of sudden cardiac arrest and ventricular arrhythmia

Recommendations for management of cardiac arrest
CPR (Class I, Level of Evidence A):

❑ CPR should be done according to basic and advanced cardiovascular life support algorithms

Amiodarone (Class I, Level of Evidence A) :

❑ In the recurrence of ventricular arrhythmia after maximum energy shock delivery and unstable hemodynamic, amiodarone should de infused

Direct current cardioversion : (Class I, Level of Evidence A)

❑ In ventricular arrhythmia and unstable hemodynamic, direct current cardioversion should be delivered

Revascularization:(Class I, Level of Evidence B)

❑ In patients with polymorphic VT and VF and evidence of acute STEMI in ECG, coronary angiography and emergency revascularization is advised

Wide QRS tachycardia: (Class I, Level of Evidence C)

❑ Wide QRS tachycardia should be considered as VT if the diagnosis is unclear

Intravenous procainamide (Class 2a, Level of Evidence A):

❑ In hemodynamically stable VT, intravenous procainamide is recommended

Intravenous lidocaine : (Class 2a, Level of Evidence B)

❑ Lidocaine is recommended in witness cardiac arrest due to polymorphic VT, VF unresponsed to CPR, defibrillation or vasopressor therapy

Intravenous betablocker : (Class 2a, Level of Evidence B)

❑ In polymorphic VT due to myocardial ischemia, intravenous betablocker maybe helpful

Intravenous Epinephrine : (Class 2b, Level of Evidence A)

❑ In cardiac arrest administration of 1 mg epinephrine every 3-5 minutes during CPR is recommended

Intravenous amiodarone : (Class 2b, Level of Evidence B)

❑ In hemodynamic stable VT, infusion amiodarone or sotalole maybe considered

High dose of intravenous epinephrine : (Class III , Level of Evidence A)

❑ In cardiac arrest, administration of high dose epinephrine>1 mg bolouses is not beneficial
❑ In refractory VF not related to torsades de pointes, administration of intravenous magnesium is not beneficial

Intravenous amiodarone : (Class III , Level of Evidence B)

❑In acute myocardial infarction, prophylactic administration of lidocaine or amiodarone for prevention of VT is harmful

Intravenous verapamil, diltiazem : (Class III , Level of Evidence C)

❑ In a wide QRS tachycardia with unknown origin, administration of verapamil and diltiazem is harmful


 
 
 
 
 
 
 
 
 
 
Sustained monomorphic VT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hemodynamic stability
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stable
 
 
 
 
 
 
 
 
 
 
 
Unstable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
12-Lead ECG, history, physical exam
 
 
 
 
 
 
 
 
 
 
 
Dirrect current cardioversion,ACLS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Notifying disease causing VT
 
 
 
Cardioversion(class1)
 
 
 
 
 
 
 
VT termination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Structural heart disease
 
 
 
Intravenous procainamide (class2a)
 
 
 
 
 
Yes, therapy of underlying heart disease
 
NO, cardioversion (class1)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NO, Ideopathic VT
 
 
 
Intravenous amiodarone or sotalole (class2b)
 
 
 
 
 
 
 
 
VT termination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Verapamil sensitive VT: Verapamil outflow tract VT: betablocker (class2a)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Effective
 
Non effective: cardioversion
 
 
 
 
 
 
 
 
Yes,therapy of underlying heart disease
 
NO, Sedation ,anesthesia, reassess antiarrhythmic therapy, repeating cardioversion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Therapy to prevent recurrence of VT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No VT termination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Catheter ablation (class1)
 
 
Catheter ablation (class1)
 
Verapamil , betablocker (class2a)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Intervention

Catheter ablation can only be performed for patients with sustained monomorphic ventricular tachycardia based on these characteristics:

2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care and 2006 ACC/AHA/ESC Guidelines for Management of Patients With Cardiac Arrest (DO NOT EDIT) [3][4]

Class III
"1. Adenosine should not be given for unstable or for irregular or polymorphic ventricular tachycardias, as it may cause degeneration of the arrhythmia to VF. (Level of Evidence: C)"
"1. Verapamil is contraindicated for wide complex tachycardias unless known to be of supraventricular origin. (Level of Evidence: B)"
"1. If one of these antiarrhythmic agents is given, a second agent should not be given without expert consultation. (Level of Evidence: B)"
Class IIa
" 1. Cardioversion with monophasic waveforms should begin at 200 J and increase in stepwise fashion if not successful. (Level of Evidence: B) "
" 2. If the etiology of the rhythm cannot be determined, the rate is regular, and the QRS is monomorphic, recent evidence suggests that IV adenosine is relatively safe for both treatment and diagnosis.[5] (Level of Evidence: B) "
" 3. If IV antiarrhythmics are administered, procainamide can be considered. (Level of Evidence: B) "
" 4. If antiarrhythmic therapy is unsuccessful, cardioversion or expert consultation should be considered. (Level of Evidence: C) "
Class IIb
" 1. Monomorphic VT with a pulse responds well to monophasic or biphasic waveform cardioversion (synchronized) shocks at initial energies of 100 J. If there is no response to the first shock, it may be reasonable to increase the dose in a stepwise fashion. (Level of Evidence: C) "
" 2. Precordial thump may be considered for patients with witnessed, monitored, unstable ventricular tachycardia if a defibrillator is not immediately ready for use. (Level of Evidence: C) "
" 3. If IV antiarrhythmics are administered, amiodarone or sotalol can be considered. (Level of Evidence: B) "

Management of Cardiac Arrest (DO NOT EDIT) [4]

Class I
"1 After establishing the presence of definite, suspected, or impending cardiac arrest, the first priority should be activation of a response team capable of identifying the specific mechanism and carrying out prompt intervention. (Level of Evidence: B) "
"2 Cardiopulmonary resuscitation (CPR) should be implemented immediately after contacting a response team. (Level of Evidence: A) "
"3 In an out-of-hospital setting, if an AED is available, it should be applied immediately and shock therapy administered according to the algorithms contained in the documents on CPR (334,335) developed by the AHA in association with the International Liaison Committee on Resuscitation (ILCOR) and/or the European Resuscitation Council (ERC).[6][7] (Level of Evidence: C) "
"4 For victims with ventricular tachyarrhythmic mechanisms of cardiac arrest, when recurrences occur after a maximally defibrillating shock (generally 360 J for monophasic defibrillators), intravenous amiodarone should be the preferred antiarrhythmic drug for attempting a stable rhythm after further defibrillations. (Level of Evidence: B) "
"5 For recurrent ventricular tachyarrhythmias or nontachyarrhythmic mechanisms of cardiac arrest, it is recommended to follow the algorithms contained in the documents on CPR (334,335) developed by the AHA in association with ILCOR and/or the ERC.[6][7] (Level of Evidence: C) "
"6 Reversible causes and factors contributing to cardiac arrest should be managed during advanced life support, including management of hypoxia, electrolyte disturbances, mechanical factors, and volume depletion. (Level of Evidence: C) "
Class IIa
"1 For response times greater than or equal to 5 min, a brief (less than 90 to 180 s) period of CPR is reasonable prior to attempting defibrillation. (Level of Evidence: B)"
Class IIb
"1 A single precordial thump may be considered by health care professional providers when responding to a witnessed cardiac arrest. (Level of Evidence: C)"

Management of Cardiac Arrest in Athletes (DO NOT EDIT) [4]

Class I
"1 Preparticipation history and physical examination, including family history of premature or SCD and specific evidence of cardiovascular diseases such as cardiomyopathies and ion channel abnormalities, is recommended in athletes. (Level of Evidence: C)"
"2. Athletes presenting with rhythm disorders, structural heart disease, or other signs or symptoms suspicious for cardiovascular disorders should be evaluated as any other patient but with recognition of the potential uniqueness of their activity. (Level of Evidence: C)"
"3. Athletes presenting with syncope should be carefully evaluated to uncover underlying cardiovascular disease or rhythm disorder. (Level of Evidence: B)"
"4. Athletes with serious symptoms should cease competition while cardiovascular abnormalities are being fully evaluated. (Level of Evidence: C)"
Class IIb
"1. Twelve-lead ECG and possibly echocardiography may be considered as preparticipation screening for heart disorders in athletes. (Level of Evidence: B)"

References

  1. ↑ Priori, Silvia G.; Blomström-Lundqvist, Carina; Mazzanti, Andrea; Blom, Nico; Borggrefe, Martin; Camm, John; Elliott, Perry Mark; Fitzsimons, Donna; Hatala, Robert; Hindricks, Gerhard; Kirchhof, Paulus; Kjeldsen, Keld; Kuck, Karl-Heinz; Hernandez-Madrid, Antonio; Nikolaou, Nikolaos; Norekvål, Tone M.; Spaulding, Christian; Van Veldhuisen, Dirk J. (2015). "2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death". European Heart Journal. 36 (41): 2793–2867. doi:10.1093/eurheartj/ehv316. ISSN 0195-668X.
  2. ↑ Al-Khatib, Sana M.; Stevenson, William G.; Ackerman, Michael J.; Bryant, William J.; Callans, David J.; Curtis, Anne B.; Deal, Barbara J.; Dickfeld, Timm; Field, Michael E.; Fonarow, Gregg C.; Gillis, Anne M.; Granger, Christopher B.; Hammill, Stephen C.; Hlatky, Mark A.; Joglar, José A.; Kay, G. Neal; Matlock, Daniel D.; Myerburg, Robert J.; Page, Richard L. (2018). "2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death". Circulation. 138 (13). doi:10.1161/CIR.0000000000000549. ISSN 0009-7322.
  3. ↑ Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW; et al. (2010). "Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 122 (18 Suppl 3): S729–67. doi:10.1161/CIRCULATIONAHA.110.970988. PMID 20956224.
  4. ↑ 4.0 4.1 4.2 Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M; et al. (2006). "ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". Circulation. 114 (10): e385–484. doi:10.1161/CIRCULATIONAHA.106.178233. PMID 16935995.
  5. ↑ Staudinger T, Brugger S, Röggla M, Rintelen C, Atherton GL, Johnson JC; et al. (1994). "[Comparison of the Combitube with the endotracheal tube in cardiopulmonary resuscitation in the prehospital phase]". Wien Klin Wochenschr. 106 (13): 412–5. PMID 8091765.
  6. ↑ 6.0 6.1 "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 112 (24 Suppl): IV1–203. 2005. doi:10.1161/CIRCULATIONAHA.105.166550. PMID 16314375. Retrieved 2012-11-05. Unknown parameter |month= ignored (help)
  7. ↑ 7.0 7.1 Nolan JP, Deakin CD, Soar J, Böttiger BW, Smith G (2005). "European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support". Resuscitation. 67 Suppl 1: S39–86. doi:10.1016/j.resuscitation.2005.10.009. PMID 16321716. Retrieved 2012-11-05. Unknown parameter |month= ignored (help)


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