Elsevier

Resuscitation

Volume 51, Issue 1, October 2001, Pages 27-32
Resuscitation

Spontaneous subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest

https://doi.org/10.1016/S0300-9572(01)00381-1Get rights and content

Abstract

Objective: Spontaneous subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest is poorly evaluated. We analyse disease-specific and emergency care data in order to improve the recognition of subarachnoid haemorrhage as a cause of cardiac arrest. Design: We searched a registry of cardiac arrest patients admitted after primarily successful resuscitation to an emergency department retrospectively and analysed the records of subarachnoid haemorrhage patients for predictive features. Results: Over 8.5 years, spontaneous subarachnoidal haemorrhage was identified as the immediate cause in 27 (4%) of 765 out-of-hospital cardiac arrests. Of these 27 patients, 24 (89%) presented with at least three or more of the following common features: female gender (63%), age under 40 years (44%), lack of co-morbidity (70%), headache prior to cardiac arrest (39%), asystole or pulseless electric activity as the initial cardiac rhythm (93%), and no recovery of brain stem reflexes (89%). In six patients (22%), an intraventricular drain was placed, one of them (4%) survived to hospital discharge with a favourable outcome. Conclusions: Subarachnoid haemorrhage complicated by cardiac arrest is almost always fatal even when a spontaneous circulation can be restored initially. This is due to the severity of brain damage. Subarachnoid haemorrhage may present in young patients without any previous medical history with cardiac arrest masking the diagnosis initially.

Sumàrio

Objectivo: A hemorragia subaracnoideia espontânea como causa de paragem cardı́aca pré-hospitalar está mal avaliada. Desenho: Analisámos dados especı́ficos da doença e dos cuidados de emergência como forma de melhorar o reconhecimento da hemorragia subaracnoideia espontânea como causa de paragem cardı́aca. Método: Procurámos retrospectivamente os registos de doentes vı́timas de paragem cardı́aca (PCR) admitidos num departamento de emergência após ressuscitação primária com sucesso e analisámos os registos dos doentes com hemorragia subaracnoideia espontânea para caracterı́sticas predictivas. Resultados: Num perı́odo de 8.5 anos a hemorragia subaracnoideia espontânea foi identificada como causa imediata em 27 (4%) de 764 paragens cardı́acas pré-hospitalares. Destes 27 doentes, 24 (89%) apresentaram-se com pelo menos três das seguintes caracterı́sticas comuns: sexo feminino (63%), idade inferior a 40 anos (44%), ausência de co-morbilidade (70%), cefaleia a preceder a paragem cardı́aca (39%), assistolia ou actividade eléctrica sem pulso como ritmo cardı́aco inicial (93%) e ausência de recuperação dos reflexos do tronco cerebral (89%). Em seis doentes (22%) foi colocado dreno intraventricular, um dos quais (4%) sobreviveu e teve alta hospitalar. Conclusões: A hemorragia subaracnoideia complicada de paragem cardı́aca é quase sempre fatal, mesmo quando é possı́vel restabelecer inicialmente a circulação espontânea. Isto é devido à gravidade da lesão cerebral. A hemorragia subaracnoideia pode-se apresentar como paragem cardı́aca em doentes jovens sem qualquer história médica prévia, mascarando o diagnóstico inicial.

Introduction

Spontaneous subarachnoid haemorrhage is the most frequent neurological disorder leading to out-of-hospital cardiac arrest [1], [2], [3]. In subarachnoid haemorrhage, the spontaneous rupture of a cerebral aneurysm causes a sudden increase in intracranial pressure, leading to sympathetic hyperstimulation with release of catecholamines, which may produce cardiac arrhythmias [4], [5], [6], [7]. Direct mechanical compression of the brainstem centres seems to be another probable cause of cardiac and respiratory arrest [2], [8], [9].

There are no reliable data about the number of deaths due to subarachnoid haemorrhage in the out-of-hospital setting, and how many patients with cardiac arrest due to subarachnoid haemorrhage are admitted to hospital after restoration of a spontaneous circulation. It is estimated that 30% of patients overall with subarachnoid haemorrhage not complicated by cardiac arrest die in the first 24 h, many of them before arriving at the hospital [10]. As the clinical presentation of subarachnoid haemorrhage complicated by cardiac arrest is obscure, a precise diagnosis is often difficult, although it may be important for further medical management of the patient.

To enable better recognition of subarachnoid haemorrhage as a cause of cardiac arrest, we analysed the clinical presentation, diagnosis, therapy and outcome of patients with cardiac arrest caused by subarachnoid haemorrhage retrospectively.

Section snippets

Materials and methods

Data from patients admitted after out-of-hospital cardiac arrest to the emergency department of an urban tertiary care university hospital were recorded according to the Utstein protocol [11]. Cardiac arrest was defined according to the criteria of the American Heart Association as sudden collapse followed by loss of consciousness and the absence of both spontaneous respiration and pulse requiring cardiopulmonary resuscitation (CPR) [12], [13]. The following data were documented on arrival: sex

Results

During the 8.5-year period, 765 patients were admitted to the emergency department after successful resuscitation from out-of-hospital cardiac arrest. Spontaneous subarachnoid haemorrhage was identified as the immediate cause of cardiac arrest in 27 (4%) patients. The median time to return of spontaneous circulation was 22 min (IQR: 15–26). In 23 of the 27 patients, subarachnoid haemorrhage was suspected clinically and confirmed by cranial computerized tomography. In four patients where

Discussion

We found that out-of-hospital cardiac arrest caused by spontaneous subarachnoid haemorrhage has an extremely poor prognosis. Only one of 27 patients survived to hospital discharge with a favourable neurology. We were able to identify several factors suggesting subarachnoid haemorrhage as cause of out-of-hospital cardiac arrest.

Subarachnoid haemorrhage leading to cardiac arrest affected women more often than men, which confirms prior studies [1], [3], [17]. Our population of patients with

Acknowledgements

We thank Dr Marcus Müllner for critically reading the manuscript and for constructive advice.

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