A 59-year-old man comes to visit a friend in the hospital and collapses in the parking lot. He had been feeling unwell all day due to vague chest discomfort. A bystander witnesses his collapse, finds no pulse, and immediately calls for help. Which of the following is the most important factor for survival in this patient?

Question

A 59-year-old man comes to visit a friend in the hospital and collapses in the parking lot.  He had been feeling unwell all day due to vague chest discomfort.  A bystander witnesses his collapse, finds no pulse, and immediately calls for help.  Which of the following is the most important factor for survival in this patient?

Quizplus · Accepted Answer

11ec25c8_d195_1d25_bc81_0b60526d8d2b_MD0003_00 This patient had a witnessed out-of-hospital sudden cardiac arrest (SCA). The most common cause of out-of-hospital SCA in adults is sustained ventricular tachycardia/fibrillation due to acute myocardial ischemia or infarction. Both these rhythms can cause pulseless cardiac arrest with a shockable rhythm (as opposed to asystole and pulseless electrical activity, which cause pulseless cardiac arrest with a nonshockable rhythm). Despite best efforts, resuscitation for out-of-hospital SCA is successful in only one-third of patients, and only about 10% of all patients are eventually discharged from the hospital. Multiple factors affect overall survival in patients with witnessed SCA (see table). The most critical factor determining overall patient survival is elapsed time to effective resuscitation. This includes effective bystander cardiopulmonary resuscitation (CPR) (eg, chest compressions), prompt rhythm analysis, and early defibrillation for patients found to be in a shockable rhythm. Ventricular fibrillation almost never terminates spontaneously, and early rhythm analysis and defibrillation are the only effective means to reestablish perfusing cardiac rhythm and improve patient survival. (Choice A) Early administration of effective bystander CPR is an important factor that determines patient survival after out-of-hospital SCA. Studies in SCA patients have shown better outcomes and improved survival to discharge with compression-only CPR as compared to standard CPR that includes rescue breathing. Therefore, American Heart Association guidelines recommend that untrained lay rescuers should perform compression-only CPR prior to arrival of emergency personnel. The importance of chest compressions is further highlighted by the recommendation for single rescuers to initiate chest compressions before rescue breaths. (Choice C) Endotracheal intubation should be performed to secure the airway as a part of overall management only after the patient has been resuscitated successfully with restoration of circulation. Placement of an endotracheal tube should not delay the initial efforts of rhythm analysis and early defibrillation. (Choice D) The initial approach in patients with out-of-hospital SCA should be prompt and effective CPR, prompt rhythm analysis, and early defibrillation if indicated. Advanced cardiac life support guidelines recommend epinephrine only in patients with asystole, pulseless electrical activity, or refractory ventricular arrhythmias unresponsive to defibrillation. (Choice E) Acute myocardial ischemia or infarction is the leading cause of SCA due to ventricular tachycardia/fibrillation. Patients who survive the initial resuscitation efforts should undergo coronary angiography to evaluate for coronary artery disease. Educational objective: Despite advances in therapy, the overall survival rate for patients with sudden cardiac arrest remains quite poor. The most important factors in improving patient survival are prompt effective resuscitation with adequate bystander cardiopulmonary resuscitation, prompt rhythm analysis, and defibrillation in patients found to be in a shockable rhythm (eg, ventricular fibrillation).

A 59-Year-Old Man Comes to Visit a Friend in the Hospital