In-Hospital Cardiac Arrest: How to Improve Survival?

Abstract

A cardiac problem is often the substrate for cardiac arrest (CA) (Table 1), but other diseases may be the underlying cause of sudden death, which in 75% of cases is due to ventricular fibrillation (VF) or ventricular tachycardia (VT), in 20% to bradyarrythmia, and in 5% to atrioventricular dissociation [1–5]. In Italy, CA strikes more than 60 000 people/year, with a 10% overall mortality, 20% of which occurs in people with no signs of disease at all [1]. The chance of survival in case of CA strictly depends on the rapidity of intervention and on the correct execution of four basic, but fundamental steps – the ‘chain of survival’ [2]. The very first step is activation of the emergency system, in case the patient is unconsciousness (of course, this step involves activating local emergency services). This is immediately followed by step 2, basic cardiopulmonary resuscitation, also known as basic life support (BLS) [3], which consists of a sequence of chest compressions and artificial ventilation. Defibrillation, the third step, is the only therapy able to stop VF/VT, the main cause of death in CA, while advanced cardiopulmonary resuscitation or advanced cardiac life support (ACLS) is the last step. Since its discovery, external defibrillation has been the cornerstone of emergency cardiac care (ECC) and the principal intervention in most successful resuscitations from full cardiac arrest. A large body of out-of-hospital research [4, 6–9] shows that the rapidity of defibrillation is the most important determinant of survival in CA due to shockable arrhythmia. Even though most CAs occur outside hospitals, the problem is still a major concern inside the hospital. In Italian hospitals, 85% of patients hospi-