Cardiac Arrest Management
What is Cardiac Arrest and Cardiac Resuscitation?
Cardiac arrest (or cardiopulmonary arrest) is the sudden, unexpected, and potentially reversible cessation of mechanical cardiac activity. It leads to cessation of blood circulation (no pulse) and breathing (apnea or gasping). Without immediate intervention, death occurs within less than 5 to 10 minutes due to cerebral anoxia.
Cardiac resuscitation (or cardiopulmonary resuscitation - CPR) is the set of maneuvers and techniques aimed at restoring effective blood circulation and spontaneous breathing. It is based on a chain of survival with several links:
- Early recognition of cardiac arrest (unconsciousness, absence of normal breathing, absence of pulse).
- Call for help (197 in Tunisia).
- Immediate chest compressions (thoracic compressions).
- Early defibrillation (if the rhythm is shockable: ventricular fibrillation or pulseless ventricular tachycardia).
- Advanced resuscitation (intubation, medications, post-cardiac arrest care).
In Tunisia, our intensive care and interventional cardiology departments are equipped to manage cardiac arrest at all stages of the chain of survival, according to international guidelines (ERC – European Resuscitation Council, AHA – American Heart Association).
Why is Cardiac Resuscitation an Absolute Emergency?
Cardiac arrest is the leading cause of death in Europe and the United States (approximately 350,000 cases per year). In the absence of immediate resuscitation, survival decreases by 7 to 10% per minute of waiting. Effective CPR (quality chest compressions) can maintain minimal cerebral perfusion and double or even triple the chances of survival. Early defibrillation (< 3-5 minutes) allows recovery of up to 50-70% of patients with a shockable rhythm. Every minute counts: "Time is brain" as for stroke, but also "Time is heart".
How to Recognize Cardiac Arrest? (Life-Saving Actions)
It is essential for every citizen to know how to recognize a cardiac arrest:
- Unconsciousness: the person does not respond, does not react to verbal or painful stimulation.
- Absence of normal breathing: the person is not breathing or has "gasps" (agonal breathing, slow, noisy, ineffective). Normal breathing should be checked for less than 10 seconds.
- Absence of pulse (to be checked by a professional): no carotid or femoral pulse.
- Cyanosis (bluish discoloration) and dilated pupils appear rapidly.
Action to take by the general public (ERC 2021):
- Safety: ensure the scene is safe for yourself and the victim.
- Consciousness + breathing: gently shake the victim, speak loudly, look at the chest (no normal breathing movement).
- Call for help: 197 (Tunisia) or 190 (ambulance), or the local emergency number. Activate speakerphone.
- Immediate chest compressions: place the heel of one hand on the center of the chest (sternum), the other hand on top. Arms straight, compress to a depth of 5-6 cm, at a rate of 100-120 compressions per minute. Allow the chest to fully recoil between each compression.
- Use an automated external defibrillator (AED) if available: follow the voice prompts, place the pads on the bare chest, let the device analyze the rhythm, deliver a shock if indicated, immediately resume chest compressions after the shock.
- Alternate compressions and ventilations (if trained): 30 compressions / 2 ventilations (mouth-to-mouth or with a mask). If not trained, perform only compressions (Hands-only CPR).
- Do not stop until help arrives.
How is Cardiac Arrest Managed in Tunisia?
In-hospital management of cardiac arrest follows a structured protocol (ERC/AHA 2020-2024 guidelines).
In-Hospital Advanced Resuscitation (if Admitted During Active Arrest)
If the patient arrives at the emergency department or intensive care unit in active cardiac arrest, the medical team continues CPR:
- High-quality chest compressions (100-120/min, depth 5-6 cm, rotation every 2 minutes).
- Artificial ventilation: face mask with bag (Ambu) then endotracheal intubation (endotracheal tube). Ventilation with 10-12 ventilations/min, FiO2 100%.
- Cardiac rhythm monitoring: monitor or defibrillator with pads. Three possible rhythms:
- Shockable rhythms: ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). → immediate defibrillation (200 J biphasic).
- Non-shockable rhythms: asystole (flat line) or pulseless electrical activity (PEA). → no shock, continue CPR.
- IV access and medications: epinephrine (1 mg IV every 3-5 minutes), amiodarone (300 mg IV bolus then 150 mg) for refractory VF/VT.
- Search for and treatment of reversible causes (4Hs-4Ts):
- 4Hs: Hypovolemia (hemorrhage), Hypoxia, Hypothermia (< 34°C), Hydrogen ion disorders (acidosis, hyperkalemia, hypokalemia, hypocalcemia).
- 4Ts: Tamponade (cardiac), Tension pneumothorax, Thrombosis (coronary or pulmonary), Toxins (drug overdose).
- Termination of resuscitation: after 30 minutes of effective CPR without return of spontaneous circulation (ROSC) and in the absence of a treated reversible cause, termination may be decided.
Post-Cardiac Arrest Management (Post-ROSC)
After the return of spontaneous circulation (return of a pulse), the patient is transferred to a cardiac intensive care unit or multidisciplinary intensive care unit. Post-cardiac arrest management is crucial for neurological survival:
Hemodynamic and Ventilatory Control
- Target mean arterial pressure (MAP) > 65 mmHg (vasopressors: norepinephrine).
- Target oxygen saturation (SpO2) 94-98% (avoid harmful hyperoxia).
- Target PaCO2 normocapnia (35-45 mmHg) or slight hypocapnia for brain protection.
Therapeutic Hypothermia (or Targeted Temperature Management)
Therapeutic hypothermia (32-36°C for 24 hours) is indicated in comatose patients after cardiac arrest (non-traumatic cause). It reduces mortality and severe neurological sequelae by 30-40%. In Tunisia, we cool patients using external systems (cooling blankets) or endovascular systems (cooling catheter).
Emergency Coronary Angiography (Post-Arrest Angioplasty)
The most common cause of cardiac arrest (70% of cases) is ST-segment elevation myocardial infarction (STEMI). Emergency coronary angiography with primary angioplasty (stent placement) should be performed urgently (< 2 hours), even if the patient is comatose. In Tunisia, our interventional cardiologists are trained to manage these unstable patients.
Circulatory Support (ECMO)
For refractory arrests (no ROSC despite CPR > 20-30 minutes), venoarterial ECMO (VA ECMO) may be offered in expert centers. It provides temporary extracorporeal oxygenation and circulation, allowing treatment of the underlying cause (PCI, coronary bypass). In Tunisia, several university hospitals have this advanced technique.
Neurological Care (Post-Anoxic Brain Injury)
- Prevention of seizures (continuous EEG if possible).
- Glycemic control (avoid hypoglycemia and severe hyperglycemia).
- Adapted sedation (recommended during hypothermia).
- Early neurological assessment (Glasgow Coma Scale, brainstem reflexes, respiratory pattern).
- Brain MRI at 3-7 days to assess anoxic lesions.
Etiology and Secondary Prevention
After the critical phase (3-5 days), an in-depth etiological workup is performed: coronary angiography if not done, echocardiography, cardiac MRI (myocarditis, cardiomyopathy), electrical workup (ECG, Holter), electrolyte panel, toxicology screen. Depending on the cause, specific treatments are initiated: antiplatelets, anticoagulants, beta-blockers, statins, ACEi/ARB, implantation of an implantable cardioverter-defibrillator (ICD) for recurrent ventricular arrhythmias or cardiomyopathy.
What are the Prognoses and Sequelae After Cardiac Arrest?
Prognosis depends on several factors: initial rhythm (VF/VT has better prognosis), time to CPR, quality of compressions, time to defibrillation, etiology, age, and comorbidities. Overall:
- Survival to hospital discharge after out-of-hospital cardiac arrest is 8 to 12% (Europe, United States).
- For in-hospital cardiac arrests, survival is 15 to 25%.
- Among patients admitted alive after CPR, 50-70% survive to discharge.
- Among survivors, 60-80% regain good neurological status (CPC 1 or 2: complete independence or mild disability).
- Possible sequelae are: cognitive disorders (memory, attention, executive functions), anxiety-depressive syndromes (post-traumatic), severe asthenia, myoclonus, post-anoxic epilepsy, myocardial lesions.
What to Do After Cardiac Arrest? Post-Resuscitation Rehabilitation
Hospital discharge (average duration 14 to 30 days) marks the beginning of multidisciplinary rehabilitation:
- Physical therapy: regaining muscle strength (frequent acquired weakness), walking, balance.
- Speech therapy / neuropsychology: cognitive rehabilitation (memory, attention), treatment of language disorders.
- Psychologist / Psychiatrist: post-traumatic stress disorder (30-50% of survivors), depression, anxiety.
- Cardiac rehabilitation program: supervised exercise retraining, therapeutic education (cardiovascular risk factors), smoking cessation, Mediterranean diet, stress management.
- Long-term cardiology and rehabilitative follow-up: consultation at 1, 3, 6, 12 months, echocardiography, stress test, Holter ECG.
- Living with an implantable cardioverter-defibrillator (ICD): education, precautions, follow-up in electrophysiology consultation.
In Tunisia, post-cardiac arrest cardiac and neurological rehabilitation centers offer stays of 4 to 8 weeks at very competitive rates.
Why Choose Tunisia for Cardiac Arrest Management?
Tunisia has high-level intensivists, interventional cardiologists, and electrophysiologists, trained in the best European and North American centers. Resuscitation and cardiology equipment is modern: biphasic defibrillators, multi-parameter monitors, ultrasound machines, 24/7 catheterization laboratories with primary angioplasty, therapeutic hypothermia systems, VA ECMO capability in some university hospitals.
Advantages
- Competitive intervention times: post-arrest coronary angiography performed < 2 hours in specialized centers (within European standards).
- Complete chain of survival management: integrated emergency services, intensive care, interventional cardiology, and cardiac rehabilitation.
- All-inclusive packages: our packages include ICU hospitalization, advanced CPR, defibrillation, intubation, therapeutic hypothermia (if indicated), coronary angiography with angioplasty, medications (epinephrine, amiodarone, vasopressors), continuous monitoring, and the post-arrest cardiac rehabilitation program.
- Quality post-arrest care: Tunisia applies the same ERC/AHA guidelines as Europe, with survival and favorable neurological outcome rates comparable to specialized centers.