I'm interested in studying medicine in the future and this question is really bothering me. So most sources would say that Cardiac Arrest occurs when the heart 'stops functioning normally' and hence cannot pump blood effectively to our organs, including the brain which causes us to lose consciousness and breathing. We also know that a defibrillator cannot be used to restart a heart that has no rhythm, only to reset a chaotic one. So why then, is an AED useful if cardiac arrest causes the heart to stop? (assuming that that's what happens during cardiac arrest...) Does the rapid CPR cause it to start having some sort of rhythm again? Or is it that cardiac arrest actually doesn't STOP the heart completely, but the slightest ventricular fibrillation could cause oxygen deficiency in the brain and cause us to lose consciousness?

1) What happens to the heart in cardiac arrest?

During a cardiac arrest, the electrical and mechanical activity is compromised (either one or both) such that the heart does not pump blood sufficiently to sustain life.

This can be either due to an abnormal electrical rhythm, such as ventricular fibrillation, or a condition such as hypovolemic shock where the preload of the heart (the volume of blood in the chambers prior to the start of a contraction) is insufficient to have a useful amount of normal blood flow.

2) Why is an AED useful?

An automated external defibrillator is useful for two abnormal heart rhythms: pulseless ventricular tachycardia and ventricular fibrillation. The shock from an AED essentially resets the electrical system of the heart in hope that it will resume normal activity afterwards. In many cases, this may work.

The reason that an AED is not the cure-all for cardiac arrest is that there are many reasons for someone to go into an abnormal rhythm and only rarely are abnormal rhythms an isolated problem by themselves. Typically, someone goes into ventricular fibrillation because they are having a heart attack. Only by opening up the artery that has been blocked in a cardiac catheterization suite can the inciting event be treated. Shocking the patient may get them back to a normal rhythm for some time but until the blockage is fixed or the tissue beyond the blockage is completely dead and therefore electrically inert they will go back into the abnormal rhythm.

I remember one patient whom I had flown to the cath lab who was shocked 13 times, the last time being in the hallway prior to the doors of the cath lab. Once the blocked artery was opened he stopped going into abnormal rhythms.

3) Does CPR do something else?

In some cases, the heart can mechanically be defibrillated. The old "precordial thump", which was taught to those of us with grey hair back when advanced cardiovascular life support was a 3 full day class, can (every once in a while) shock the heart enough for return of spontaneous circulation. There is a reason it is no longer taught, along with "cough CPR" not being mentioned.

CPR, at best, produces maybe one third of normal cardiac output. It can support oxygenation of vital organs and prevent clinical death (pulselessness and apnea) from becoming biologic death (dead beyond any hope of resuscitation). A hypoxic heart is not likely to have enough oxygen for normal electrical function. It doesn't make sense to try to zap someone into oblivion without at least giving them a fighting chance with CPR. This is the reason for the old "shock first" with witnessed arrest and "shock fast" with unwitnessed arrest strategies that I believe were put into the ACLS protocols maybe around the year 2000.

4) Pacemakers

Defibrillation and cardioversion are distinctly different from internal or external pacemakers. Think of defibrillation and cardioversion as a sledgehammer and a temporary transvenous pacemaker as a jeweler's hammer. Ventricular fibrillation and pulseless ventricular tachycardia require a big whack. Really big. Sometimes two distinct defibrillator units at the same time big ("dual simultaneous defibrillation" - google scholar it, it's neat stuff). However, getting the heart to beat in an organized manner requires a much more gentle touch. We are talking 200 Joules of a big whack versus 0.2 mA of pacing current the last time I had floated a wire in someone's heart. Pacing is a firm but gentle zap. It gets the electrical system to beat but orders of magnitude less than what is required to reset the system from V-fib.

Finally, there is no "slight" ventricular fibrillation. That's an all or nothing rhythm. The reason that "cough CPR" is still useful to those of us board-certified in emergency medicine is that we have toys the majority of the population does not know how to use. Consciousness can be maintained many seconds beyond cardiac arrest. If I have you on a cardiac monitor and you go into asystole in front of me, I can likely keep you conscious for a minute or longer if you actually obey my instructions for cough CPR.

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    Do you have any references to any articles which back up your claims and maybe provide more depth? – Chris Rogers Jan 28 at 23:34
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    This is a really good answer, but as @Chris mentioned, supporting references are expected here. They don't have to be extensive, just sufficient to support your main points. – Carey Gregory Jan 29 at 5:20
  • Welcome @RudyB, awesome answer! We have a references standard even for docs - and I know it's kind of a pain to add a reference or two when you've spent like 12 grueling years post-high school training (let alone X years working) to obtain that knowledge base, it really helps maintain the quality of the site and gives non-medical-professionals additional reading material to further explore and understand better. And partially because we can't certify who has what level of training/education here. – DoctorWhom Jan 29 at 21:30
  • I would love to add references, but aside from a general EKG interpretation text (Dubin's has always been my favorite), the ACLS Student Manual and, for more depth, the consensus publications in Circulation the rest of my statements have been an overview of how we got here from where we were 30 years ago in resuscitation, information from manufacturer's manuals for defib/ pacer units that are not available online, and an unpublished case series that I cannot publicly release. Please provide some more specifics for which references as my one answer could probably have 30. – RudyB Feb 5 at 2:23

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