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Cardiac Arrest During Anesthesia W 130 Vol. 76, No. 3 Cardiac Arrest During Anesthesia W. H. CASSELS, M.D., San Mateo, and NYLA R. ELNES, M.D., Montreal, Canada circumstances, respiratory arrest may persist from SUMMARY perhaps two to twelve minutes before irreversible In cases of acute cardiac arrest from tran- damage results, because the oxygen in the lungs and sient or reversible causes resuscitation is a blood acts as a reservoir. On the other hand, cardiac distinct possibility. Prompt action is of the arrest will probably result in some irreversible dam- utmost importance. age in from two to four minutes. To counteract res- The sequelae of cardiac arrest will depend piratory arrest by artificial respiration requires only on the degree of anoxia that has developed moments because the respiratory mechanism is ac- and the amount of irreversible damage to cessible. To counteract circulatory arrest by man- brain tissue. Efficient manual artificial circu- ual circulation is likely to require minutes. The lation, begun immediately, can prevent such margin of safety in this condition is much narrower. damage. It is fairly obvious that if the heart fails because Four cases of cardiac arrest are described. of irreversible contributing circumstances such as Sudden circulatory collapse, which may or severe hemorrhage, shock, or embolus, efforts at may not imply cardiac arrest, is not uncom- cardiac resuscitation are well-nigh hopeless. On the mon during surgical procedures. Usually the other hand, in cases of acute cardiac arrest from patient recovers quickly when treatment is transient or reversible causes, resuscitation is a dis- prompt. tinct possibility and any restorative measure, no matter how drastic, is justifiable. As stated by Thompson and co-workers,8 "acute W HEN does death occur? There is no immediate cardiac cessation is conveniently classified into two criterion indicative of the transition from life groups: (1) arrest of stimulus formation or the so- to death. Years ago, cessation of respiration was called pace-maker failure, the result of which is considered synonymous with death. It was a com- cardiac standstill and (2) electrodynamic dissolu. mon practice to hold a mirror in front of a patient's tion of the cardiac cycle, of which ventricular fibril- face and if there was no condensation of moisture lation is an example." The chances of successful re- from exhaled air, he was pronounced dead. When suscitation are greater in the case of cardiac stand- it was realized that the artificial maintenance of res- still than in the case of ventricular fibrillation. For- piration could prevent death, the fallacy of this view tunately most cases fall into the former group. It is became apparent. Cessation of cardiac activity super- impossible to differentiate the two clinically unless seded cessation of respiration as the criterion of the heart is already exposed or an electrocardio- death. But again a fallacy became apparent. Some gram is in process. patients were revived after cardiac arrest. Jut as a community is not dead when its transportation sys- ETIOLOGY tem fails, so the body is not dead when respiration There are various circumstances which may lead or as a will circulation fail. But just community to acute cardiac arrest: disintegrate and cease to be a community when the resulting starvation ravages its population and dis- 1. Reflex arrest due to vagovagal stimulation. rupts all coordinated effort, so it is with the body Such stimuli may arise from surgical trauma in the when the effects of respiratory or circulatory failure region of the aorta, the hilus of the lung, the carotid result in irreparable damage. Death does not occur sinus or the vagus nerves. Weeks and co-workers'0 until after there has been so much irreversible dam- reported a case of cardiac arrest immediately fol- age to nervous tissue that restoration of coordinated lowing section of the vagus. It may also result from vital functions is impossible. traction reflexes. Similarly, it has been postulated Respiratory arrest and cardiac arrest are very that anesthetic procedures irritating the tracheo- similar functional disorders and the principles ap- bronchial tree, such as intubation, may on occasion plicable to one are equally applicable to the other. excite such reflexes. In certain cases, patients may The apparent differences are chiefly those of relative be put into peculiar positions which result in reflex urgency and relative accessibility. Depending on cardiac arrest. 2. Direct trauma to the heart, such as may occur Formerly from the Division of Anesthesia, University of Illinois Medical School, Chicago. during operations on the pericardium or heart or Presented before the Section on Anesthesia at the 80th may be caused by inadvertent pressure of retractors Annual Session of the California Medical Association, Los Angeles, May 13 to 16, 1951. on the heart or aorta, may cause cardiac arrest. March, 1952 CARDIAC ARREST DURING ANESTHESIA 131 3. Overdosage of anesthetic agents may depress 8. Dilation of the pupils may develop as anoxia the circulation, either by direct effect on the heart progresses. or by vasodilation. Chloroform, ethyl chloride and 9. The capillary refill tirne as determined by pres- cyclopropane may have direct effects on the heart, sure on the skin, and the duration of the resulting particularly by altering the conduction mechanism pallor, may be of some significance. or, in the case of chloroform and ethyl chloride, by direct depression of the myocardium. PROPHYLAXIS 4. Ventricular fibrillation. The heart, sensitized Since in many cases cardiac arrest results from by certain anesthetic agents, may react by ventricu- vagal stimulation, it is advocated that adequate lar fibrillation if subjected to an overdose of epi- atropinization be used when there is serious likeli- nephrine. This epinephrine may be introduced by hood of stimulation in one of the more sensitive injection or may be endogenous, coming from the areas. Similarly, blocking of the afferent stimuli by adrenal glands if there is stimulation or excitement infiltration with a local anesthetic agent in areas during light anesthesia. such as the hilus of the lung may prevent the con- dition. In cases in which trauma near the hilus of SIGNS OF CARDIAC ARREST the'lung, the heart or the pericardium causes ar- It is sometimes difficult to be certain whether the rhythmia, the injection of 5 cc. to 10 cc. of 1 per heart has actually stopped during a surgical proce- cent procaine solution intravenously may relieve the dure or whether its beats are so feeble that there is condition and prevent cardiac arrest. Direct appli- little evidence of circulation. Therefore all possible cation of procaine to the heart during cardiac opera- means should be utilized to make a rapid evaluation tions is sometimes utilized, although the value of of the situation. The following points should be this is more questionable. observed: 1. Absence of pulsation. If the anesthetist is feel- TREATMENT OF ACUTE CARDIAC ARREST ing the pulse at the time cardiac arrest occurs, he As has been emphasized by Bailey,2 time is of will notice the sudden absence of pulsation. More the utmost importance and a preconceived plan of often, however, other indications precede this and action should be followed in order to avoid any un- call the anesthetist's attention to the emergency. He necessary delay. Bailey stressed the value of keeping then attempts to feel the pulse but finds that he can- an accurate check on the time which has elapsed not detect it. There will also be no visible pulsation from the onset of the emergency, and he advocated in the neck. The surgeon may have access to a large that one person in the operating room be delegated artery which he may palpate to determine if there at once to be the time-keeper and to call off the pass- is any pulsation. ing minutes. Whether this is done or not, it is vitally 2. Absence of blood pressure. If attempts are important that the duration of the emergency be made to determine the blood pressure, it will be carefully observed and that the routine of action be found that no audible or visual pulsations occur. gauged according to the time which has elapsed. 3. Respiratory arrest. The most common initial All anesthetists should have some such routine in indication of cardiac arrest is the almost immediate mind, and it will probably be found that surgeons cessation of respiration due to cerebral anoxia. will respond and cooperate if the anesthetist demon- There may be a few gasps preceding this. In all cases strates his knowledge of the situation and his com- of respiratory arrest, one of the anesthetist's first petence to direct procedures. The following is an obligations is to feel for the pulse and determine if outline of a routine which may be followed. the, circulation is satisfactory. 1. Immediate. As soon as cardiac arrest is sus- 4. Pallor or cyanosis quickly follows cardiac ar- pected, several things should be done almost simul- rest. The actual color will depend somewhat on the taneously. Since only a matter of seconds need elapse peripheral distribution of blood, and the position until all are instituted, the exact order is unimpor- of the patient is a factor. The blood will gravitate tant: to the dependent parts of the body. If the head is (a) Notify the surgeon of the suspected emer- elevated, pallor of the upper part of the body may gency. be expected. If the head is lowered, congestion and (b) Lower the head of the table to a Trendelen- deep cyanosis may develop. burg position of 10 to 15 degrees. (c) Discontinue the administration of the anes- 5. Cardiac sounds cannot be heard over the pre- thetic agent and substitute pure oxygen or air.
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