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Managing out-of-hospital cardiac arrest survivors: 1. Neurological perspective
  1. University of Edinburgh Cardiovascular Unit
  2. Cardiology Department
  3. Royal Infirmary
  4. 1 Lauriston Place
  5. Edinburgh EH3 9YW, UK

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Survival from out-of-hospital cardiac arrest is becoming an increasingly common occurrence, because of defibrillation initiatives and increased public awareness of basic life support skills.1-4 Two main factors determine survival from an out-of-hospital cardiac arrest: prompt administration of effective cardiopulmonary resuscitation (CPR); and early defibrillation. In addition to increasing the number of victims who survive to discharge, these interventions also allow some individuals to survive who would have otherwise succumbed immediately, only for them to die later because of the sequelae of cerebral hypoxia. Thus, there is an increasing population of cardiac arrest victims who survive with neurological injury. For those who avoid lethal brain injury, the initial priority is the assessment of the risk of further arrhythmic events. This is important because treatments such as revascularisation, antiarrhythmic drugs, and implantable cardioverter defibrillators (ICDs) reduce the risk of subsequent death in some subgroups. Resuscitated cardiac arrest victims present a challenge on two fronts: assessment and treatment of neurological injury, and assessment and intervention to minimise risk of further arrhythmic events. This first article focuses on early management and neurological sequelae of cardiac arrest. The second article in this series focuses on investigating the substrate for cardiac arrest, and interventions that reduce the risk of further arrhythmic events.

Immediate management

After admission, resuscitated cardiac arrest victims may be unstable for several reasons. Nearly half require mechanical ventilation, and aspiration of gastric contents may exacerbate respiratory compromise. Peri-arrest arrhythmias are common, and management guidelines are published by the Resuscitation Council (UK).5 Hypotension can result from the process that leads to the cardiac arrest (for example, myocardial infarction) and from post-resuscitation myocardial stunning, necessitating the use of inotropes or mechanical circulatory support, or both. Many resuscitated cardiac arrest victims are elderly and have serious underlying comorbidity. Essential to their management is involvement of their …

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