5 points to remember about out of hospital cardiac arrest

1.  The most common cause of primary OHCA (PEA), is severe primary cardiac failure (advanced heart failure, global primary myocardial ischemia etc.). The second most common cause is hypoxemia/a respiratory event.  Other considerations include reversible etiologies (metabolic, massive bleed, PE, tamponade, think the 5 H and T's).

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2. Less than 10% of OHCA patients survive to hospital discharge with good neurologic recovery.  In making decisions, consider factors associated with poor prognosis: lack of bystander CPR, time to ROSC > 30 minutes, non shockable rhythm, lactate > 7, pH < 7.2, age greater than 85 and pre-existing severe organ dysfunction including end-stage renal disease 

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3.  Post arrest, the ECG should be scrutinized for ST elevation. The ST elevation should persist at least 10 minutes after ROSC.  If there is persistent ST elevation, most of these patients have an acute coronary occlusion and these patients should be considered for urgent coronary angiography.  Consider the differential diagnosis including ST elevation secondary to the arrest itself, hyperkalemia, pulmonary embolism, intracranial hemorrhage.

4.  If there is no ST elevation on the EKG after arrest, recent trials have confirmed no benefit to immediate coronary angiography. The main causes of death in these patients are neurological or multi organ failure. Most of these patients will have coronary artery disease but this is chronic coronary artery disease and intervention does not improve mortality. 

5.  Modern trials show that prevention of post arrest hyperthermia with low normal temperature is as effective as cooling. Current guidelines suggest temperature control <36 degrees (previously <32 degrees).