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Every year, approximately 6.8 to 8.5 million persons throughout the world1 sustain cardiac arrest. About 70% of cardiac arrests occur out of hospital. The proportion of cardiac arrest patients who are treated varies from about 54.6% (United States) to about 28.3% (Asia). The proportions with ventricular fibrillation (VF) and survival vary from 11% and 2%, respectively, in Asia, to 28% and 6% in North America, 35% and 9% in Europe, and 40% and 11% in Australia.2 About half of cardiac arrest victims are <65 years old.

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Ventricular tachyarrhythmias are the initiating event in about 80% of patients with out-of-hospital primary cardiac arrest. During ambulatory electrocardiogram (ECG) monitoring of 157 witnessed cardiac arrests, Bayés de Luna et al3 documented 70% with ventricular tachycardia (VT) and VF, 13% with torsades de pointes, and 17% with bradyarrhythmias. Untreated VF deteriorates to asystole in about 15 minutes.4 For patients with sudden cardiac arrest, the rate of survival declines rapidly by about 7% to 10% for each minute without defibrillation.5 If delay to defibrillation exceeds 12 minutes,6 survival is of the order of 0% to 5%.

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The Chain of Survival

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The structured emergency care system concept for treatment of cardiac arrest is called the Chain of Survival and includes four components: Early Access, Early CPR, Early Defibrillation, and Early Advanced Care. If a community's prehospital EMS can be activated promptly, reach the patient within 5 minutes of collapse, and deliver the first shock shortly thereafter, survival in excess of 15% to 20% can be expected, with recent reports of >30% survival.7,8 With delayed initiation of CPR, defibrillation, and access to the patient by the emergency services, the impact of advanced life support measures is small (Figure 13B-1). Improved survival can only occur if structured emergency care systems allow trained providers to access the patient rapidly and deliver the appropriate treatment in a timely fashion. Delays in initiating the various links weaken the chain and adversely affect the next link, resulting in a decreased chance of a good outcome for the patient.

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Figure 13B-1.
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Incremental survival benefits by the links in the Chain of Survival. ACLS, advanced cardiac life support. [Reproduced, with permission, from the National Resuscitation Council, Singapore.]

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The basic life support assessments and interventions are often called the Primary ABCD Survey, and the advanced life support assessments and interventions are often called the Secondary ABCD Survey.

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An organized approach to resuscitation begins with the Primary ABCD and blends smoothly with the Secondary ABCD. These are summarized in the Universal ACLS Algorithm (Figure 13B-2). This method helps any ACLS provider remember the sequence of resuscitation actions and, therefore, be less likely to miss any of the vital steps in the care of the patient.

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Figure 13B-2.
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