Student perceptions of sudden cardiac arrest: a qualitative inquiry

Sudden cardiac arrest (SCA) is the number one cause of death in young athletes in high school and university settings. Survival and outcomes of SCA is dependent on appropriate recognition of symptoms and immediate cardiopulmonary resuscitation (CPR), along with a shock from an automatic external defibrillator (AED). The three aims of the authors' study presented in this article were: to describe university students' perceptions and beliefs about sudden cardiac arrest, to describe university students' understanding of an AED and their level of preparedness to recognize and respond to a life threatening emergency event, and to identify university students' experiences of responding to handling life-threatening emergency events. Qualitative methodology was employed using semi-structured interviews and thematic analysis. Three major themes emerged from data analysis: confusion, uncertainty, and fear/uncomfortableness. These themes characterised participant's perceptions about SCA. The authors concluded that a lack of understanding of what SCA is and participants' inability to respond to an emergency event was evident.     

Guidelines for appropriate in-hospital emergency team time management: the Brooke Army Medical Center approach

Successful outcome following cardiac arrest have been reported in the range of 13-59%. It is well established that the time from the onset of a ventricular arrhythmia to successful defibrillation predicts outcome. Recent out of hospital arrest protocols minimizing time to defibrillation have reported significant improvement in outcomes. The Bethesda conference and American Heart Association (AHA) both set standards for defibrillation time for in hospital codes but do not set standards for other interventions. In February 2000, the Brooke Army Medical Center (BAMC) cardiopulmonary resuscitation committee published time guidelines for the initiation of CPR, emergency team arrival, first defibrillation and first medication. We sought to evaluate resuscitation outcomes before and after this intervention. Methods: Data on each response time was prospectively collected as was etiology for the event, emergency location, patient age, gender, and emergency outcome for the 7 months prior to the guideline introduction and 15 months afterwards. Results: The mean response times (in minutes) for initiation of CPR (1.3 vs. 0.4), emergency team arrival (1.6 vs. 1.2), first defibrillation (7.8 vs. 6.6) and first medication (4.1 vs. 3.8) demonstrated trends toward improvement. Compliance with the time standards also increased (67-91, 85-95, 67-71 and 93-86%, respectively). Emergency survival trended toward improvement (47 vs. 57%) while discharge survival significantly increased from 3 to 24% (P=0.017). Conclusions: Setting time guidelines for Advanced Cardiac Life Support (ACLS) improved initiation of CPR, emergency team arrival, first defibrillation, and first medication administration. These time reductions were accompanied by improved event survival and a statistically improved survival to discharge.     

Inter Association Task Force Recommendations on Emergency Preparedness andManagement of Sudden Cardiac Arrest in High School andCollege Athletic Programs: A Consensus Statement

Objective. To assist high school andcollege athletic programs prepare for andrespond to a sudden cardiac arrest (SCA). This consensus statement summarizes our current understanding of SCA in young athletes, defines the necessary elements for emergency preparedness, andestablishes uniform treatment protocols for the management of SCA. Background: Sudden cardiac arrest is the leading cause of death in young athletes. The increasing presence of andtimely access to automated external defibrillators (AEDs) at sporting events provides a means of early defibrillation andthe potential for effective secondary prevention of sudden cardiac death. An Inter-Association Task Force was sponsored by the National Athletic Trainers' Association to develop consensus recommendations on emergency preparedness andmanagement of SCA in athletes. Recommendations. Comprehensive emergency planning is needed for high school andcollege athletic programs to ensure an efficient andstructured response to SCA. Essential elements of an emergency action plan include establishing an effective communication system, training of anticipated responders in cardiopulmonary resuscitation andAED use, access to an AED for early defibrillation, acquisition of necessary emergency equipment, coordination, andintegration of on-site responder andAED programs with the local emergency medical services system, andpractice andreview of the response plan. Prompt recognition of SCA, early activation of the emergency medical services system, the presence of a trained rescuer to initiate cardiopulmonary resuscitation, andaccess to early defibrillation are critical in the management of SCA. In any collapsed andunresponsive athlete, SCA should be suspected andan AED applied as soon as possible for rhythm analysis anddefibrillation if indicated.     

Comparison of cardiopulmonary resuscitation techniques using video camera recordings.

OBJECTIVE--To use video recordings to compare the performance of resuscitation teams in relation to their previous training in cardiac resuscitation. METHODS--Over a 10 month period all cardiopulmonary resuscitations carried out in an accident and emergency (A&E) resuscitation room were videotaped. The following variables were monitored: (1) time to perform three defibrillatory shocks; (2) time to give intravenous adrenaline (centrally or peripherally); (3) the numbers and grade of medical and nursing staff involved in the resuscitation; (4) the experience and training of these personnel. RESULTS--Of 101 resuscitations recorded, 69 were carried out by the A&E team alone and 32 by the hospital cardiac arrest team. Resuscitation procedures were carried out significantly more rapidly by the former. Skills and protocols were most effectively used when the resuscitation team was led by an experienced doctor who had received specific training in cardiopulmonary resuscitation, that is, Advanced Life Support course (ALS) or Advanced Cardiac Life Support course (ACLS). Such an individual was always present at A&E team resuscitations but in only 6% of cardiac arrest team resuscitations. CONCLUSIONS--ALS course completion should be regarded as a vital part of the training of any doctor involved in cardiopulmonary resuscitation.     

Quality of cardio-pulmonary resuscitation (CPR) during paediatric resuscitation training: Time to stop the blind leading the blind

AimsRecent evidence suggested that the quality of cardio-pulmonary resuscitation (CPR) during adult advanced life support training was suboptimal. This study aimed to assess the CPR quality of a paediatric resuscitation training programme, and to determine whether it was sufficiently addressed by the trainee team leaders during training.MethodsCPR quality of 20 consecutive resuscitation scenario training sessions was audited prospectively using a pre-designed proforma. A consultant intensivist and a senior nurse who were also Advanced Paediatric Life Support (APLS) instructors assessed the CPR quality which included ventilation frequency, chest compression rate and depth, and any unnecessary interruption in chest compressions. Team leaders’ response to CPR quality and elective change of compression rescuer during training were also recorded.ResultsAirway patency was not assessed in 13 sessions while ventilation rate was too fast in 18 sessions. Target compression rate was not achieved in only 1 session. The median chest compression rate was 115 beats/min. Chest compressions were too shallow in 10 sessions and were interrupted unnecessarily in 13 sessions. More than 50% of training sessions did not have elective change of the compression rescuer. 19 team leaders failed to address CPR quality during training despite all team leaders being certified APLS providers.ConclusionsThe quality of CPR performance was suboptimal during paediatric resuscitation training and team leaders-in-training had little awareness of this inadequacy. Detailed CPR quality assessment and feedback should be integrated into paediatric resuscitation training to ensure optimal performance in real life resuscitations.     

Mouth-to-mouth ventilation of cardiac arrested humans using a barrier mask

INTRODUCTION: Concern for possible disease transmission during mouth-to-mouth resuscitation has decreased the incidence of bystander cardiopulmonary resuscitation (CPR). Barrier masks have become available that may be effective in CPR as well as protective against cross-contamination. HYPOTHESIS: A silicone rubber barrier mask incorporating a one-way-valved airway (Kiss of Life [KOL]) designed to prevent contamination of the rescuer, permits satisfactory mouth-to-mouth ventilation of victims of cardiopulmonary arrest. METHODS: Ten adult patients who did not survive non-traumatic cardiac arrest were ventilated with exhaled room air using a KOL barrier mask while external cardiac massage continued. Arterial blood gases were obtained every two minutes for a maximum of 10 minutes. The operator was blinded to the results of these blood tests. RESULTS: Eight men and two women with ages from 55 to 99 years were studied. Four patients were edentulous and two of these had marked mandibular atrophy. The two patients with mandibular atrophy were poorly ventilated with the barrier mask. One other patient was not ventilated successfully. This patient had undergone multiple attempts at endotracheal intubation and had transtracheal needle ventilation performed prior to use of the barrier mask. One patient had elevated PaCO2 despite being well-ventilated clinically. Six patients were ventilated well clinically and had satisfactory PaCO2 and PaO2 values. CONCLUSION: The barrier mask studied appears to be an effective aid to ventilation in CPR. Patients without facial support, as in edentulous patients with mandibular atrophy, are not ventilated well with this device.     

H ANDBOOK OF U RGENT C ARE M EDICINE , 2 ND E DITION

Abstract

Background. Hyperglycemia is common in the early period following resuscitation from cardiac arrest and has been shown to be a predictor of neurologic outcome in retrospective studies. Objective. To evaluate neurologic outcome and early postarrest hyperglycemia in a swine cardiac arrest model. Methods. Electrically induced ventricular fibrillation cardiac arrest was induced in 22 anesthetized and instrumented swine. After 7 minutes, cardiopulmonary resuscitation (CPR) and Advanced Cardiac Life Support were initiated. Twenty-one animals were resuscitated and plasma glucose concentration was measured at intervals for 60 minutes after resuscitation. The animals were observed for 72 hours and the neurologic score was determined at 24-hour intervals. Results. Ten animals had a peak plasma glucose value ≥226 mg/dL during the initial 60 minutes after resuscitation. The neurologic scores at 72 hours in these animals (mean score = 0, mean overall cerebral performance category = 1) were the same as those in the animals with a peak plasma glucose value <226 mg/dL. The end-tidal carbon dioxide (CO₂) values measured during CPR, times to restoration of spontaneous circulation, and epinephrine doses were not significantly different between the animals with a peak glucose concentration ≥226 mg/dL and those with lower values. The sample size afforded a power of 95% to detect a 50-point difference from the lowest score (0 points) of the porcine neurologic outcome scale. Conclusion. In this standard porcine model of witnessed out-of-hospital cardiac arrest, early postresuscitation stress hyperglycemia did not appear to affect neurologic outcome. During the prehospital phase of treatment and transport, treatment of hyperglycemia by emergency medical services providers may not be warranted.     

T ERMINATION OF R ESUSCITATION IN THE P REHOSPITAL S ETTING FOR A DULT P ATIENTS S UFFERING N ONTRAUMATIC C ARDIAC A RREST

The National Association of EMS Physicians (NAEMSP) supports out-of-hospital termination of resuscitation for adult, nontraumatic cardiac arrest patients who have not responded to full resuscitative efforts. The following factors should be considered in establishing termination of resuscitation protocols: 1) Termination of resuscitation may be considered for any adult patient who suffers sudden cardiac death that is likely to be medical. 2) Unwitnessed cardiac arrest with delayed initiation of cardiopulmonary resuscitation (CPR) beyond 6 minutes and delayed defibrillation beyond 8 minutes has a poor prognosis. 3) In the absence of “do not resuscitate” or advanced directives, a full resuscitative effort including CPR, definitive airway management, medication administration, defibrillation if necessary, and at least 20 minutes of treatment following Advanced Cardiac Life Support (ACLS) guidelines should be performed prior to declaring the patient dead. 4) A patient whose rhythm changes to, or remains in, ventricular fibrillation or ventricular tachycardia should have continued resuscitative efforts. Patients in asystole or pulseless electrical activity should be strongly considered for out-of-hospital termination of resuscitation. 5) Logistic factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. 6) Online medical direction should be established prior to termination of resuscitation. The decision to terminate efforts should be a consensus between the on-scene paramedic and the online physician. 7) The on-scene providers and family should have access to resources, such as clergy, crisis workers, and social workers. 8) Quality review is necessary to ensure appropriate application of the termination protocol, law enforcement notification, medical examiner or coroner involvement, and family counseling.     

Use of advanced life support skills

BACKGROUND: The Advanced Life Support (ALS) Provider Course trains healthcare professionals in a standardised approach to the management of a cardiac arrest. In the setting of limited resources for healthcare training, it is important that courses are fit for purpose in addressing the needs of both the individual and healthcare system. This study investigated the use of ALS skills in clinical practice after training on an ALS course amongst members of the cardiac arrest team compared to first responders. METHODS: Questionnaires measuring skill use after an ALS course were distributed to 130 doctors and nurses. RESULTS: 91 replies were returned. Basic life support, basic airway management, manual defibrillation, rhythm recognition, drug administration, team leadership, peri- and post-arrest management and resuscitation in special circumstances were used significantly more often by cardiac arrest team members than first responders. There was no difference in skill use between medically and nursing qualified first responders or arrest team members. CONCLUSION: We believe that the ALS course is more appropriately targeted to members of a cardiac arrest team. In our opinion the recently launched Immediate Life Support course, in parallel with training in the recognition and intervention in the early stages of critical illness, are more appropriate for the occasional or first responder to a cardiac arrest.     

How bystanders perceive their cardiopulmonary resuscitation intervention; a qualitative study

The importance of bystander cardiopulmonary resuscitation (CPR) prior to arrival of the emergency medical service is well documented. In Sweden, CPR is initiated prior to emergency medical services (EMS) arrival in about 30% of cardiac arrests out-of-hospital, a figure which should be improved urgently. To do so, it is of interest to know more about the bystanders' perceptions of their intervention. A qualitative method inspired by the phenomenographic approach was applied to 19 bystanders who had performed CPR. In the analysis, five main categories and 14 subcategories emerged. The main categories were: to have a sense of humanity, to have competence, to feel an obligation, to have courage and to feel exposed. Interviews described how humanity and concern for another human being were the foundation of their intervention. CPR training offers the possibility to give appropriate help in this emergency. If the aim of CPR training was extended beyond teaching the skill of CPR to include preparation of the rescuer for the intervention and his/her reactions, this might increase the number of people able to take action in the cardiac arrest situation.     

Preliminary study of the relationship between the cardiopulmonary arrest time and its consequences in trauma patients

The proposal of this research was to obtain parameters to start or maintain cardiopulmonary resuscitation (CPR) in victims of trauma. The duration of the cardiac arrest and the CPR of the survivors was described, as well as the cerebral performance and the mortality of these victims 24, 48 and 72 hours after these events had happened. With the results of this characterization the relation between duration of cardiac arrest time, CPR and mortality were described. Data for this report were collected in Hospital das Clínicas da Faculdade de Medicina da Universidade de S?o Paulo emergency department. A big amount of the victims (93.4%) presents severe trauma and main cause of death was brain injury. Survival at 72 hours after CPR was 10%. The assessment, during the 72 hour period, of the survivors from cardiac arrest of traumatic cause has shown bad cerebral performance of those victims in that period of time. The survivor after the first episode of CPR was strongly related to cardiac arrest time when compared with CPR time. The time of cardiac arrest < or = 4 minutes and CPR < or = 20 minutes was related to survival more than 72 hours.     

Termination of resuscitation in the prehospital setting for adult patients suffering nontraumatic cardiac arrest

The National Association of EMS Physicians (NAEMSP) supports out-of-hospital termination of resuscitation for adult, nontraumatic cardiac arrest patients who have not responded to full resuscitative efforts. The following factors should be considered in establishing termination of resuscitation protocols: 1) Termination of resuscitation may be considered for any adult patient who suffers sudden cardiac death that is likely to be medical. 2) Unwitnessed cardiac arrest with delayed initiation of cardiopulmonary resuscitation (CPR) beyond 6 minutes and delayed defibrillation beyond 8 minutes has a poor prognosis. 3) In the absence of “do not resuscitate” or advanced directives, a full resuscitative effort including CPR, definitive airway management, medication administration, defibrillation if necessary, and at least 20 minutes of treatment following Advanced Cardiac Life Support (ACLS) guidelines should be performed prior to declaring the patient dead. 4) A patient whose rhythm changes to, or remains in, ventricular fibrillation or ventricular tachycardia should have continued resuscitative efforts. Patients in asystole or pulseless electrical activity should be strongly considered for out-of-hospital termination of resuscitation. 5) Logistic factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. 6) Online medical direction should be established prior to termination of resuscitation. The decision to terminate efforts should be a consensus between the on-scene paramedic and the online physician. 7) The on-scene providers and family should have access to resources, such as clergy, crisis workers, and social workers. 8) Quality review is necessary to ensure appropriate application of the termination protocol, law enforcement notification, medical examiner or coroner involvement, and family counseling. PREHOSPITAL EMERGENCY CARE 2000;4:190-195     

Cardiac arrest in the community. How to improve survival rates

A coordinated community response to cardiac arrest can be successful if the response time to administration of cardiopulmonary resuscitation (CPR) is less than four minutes and to administration of advanced cardiac life support (ACLS) is less than eight minutes. Elements needed to achieve this goal include rapid access to the emergency medical system; widespread CPR training; rapid response of first responders trained in basic life support; rapid response time to ACLS, including resuscitation at the scene; and an evaluation system to determine the effectiveness of the response and then implementation of changes to prevent future mistakes. The response to cardiac arrest should be kept simple, and the community should work with the resources it possesses. Most communities already have the necessary elements and simply need to coordinate the effort into a reasonable approach. Perhaps with such an approach, 80% of deaths from sudden cardiac arrest could be prevented.     

Doctor-based basic cardiopulmonary resuscitation course: an alternative to the conventional approach

United Christian Hospital initiated a doctor-based cardiopulmonary resuscitation (CPR) Program. It is a two-hour, focused, adult CPR course, suitable for adults of different age groups and of different educational levels. The course was rated highly by the participants. Most trainees acquired CPR knowledge and skills, and had confidence to perform CPR. This type of training could improve the rate of bystander CPR for out-of-hospital cardiac arrest patients in this region. Avoiding the complexity and pass-fail psychology that is used in the traditional CPR training curriculum, it can be an alternative to the traditional four-hour instructor-based Basic Life Support (BLS) course.     

The physiological effect on rescuers of doing 2min of uninterrupted chest compressions

OBJECTIVES: To analyse how rescuers tolerate the effort derived of giving uninterrupted chest compressions during 2min. MATERIALS AND METHODS: Twenty-three healthy volunteers, nurses and doctors of the Intensive Care Unit (ICU), members of the hospital cardiac arrest team, were enrolled in the study. Using a training manikin, participants were asked to perform chest compressions during 2min at a rate of 100min(-1). The oxygen saturation and cardiac rate of the subjects were monitored using pulse oximetry before and after one and 2min performing chest compressions. The percentage of the maximal heart rate of the rescuer over the theoretical maximum allowed in a conventional stress test was calculated, taking into account age and body mass index (BMI) of the subjects. Fatigue was measured using a visual analogical scale (VAS). RESULTS: The means (+/-S.D.) of chest compressions in the first and second minutes were 103+/-12, and 104+/-11, respectively. The mean percent of the maximum heart rate observed was 61+/-8%. None of the subjects had difficulties to complete the test. All subjects recovered their basal values in less than 2min, and the mean value recorded in the VAS was 3+/-2. CONCLUSIONS: The practice of uninterrupted chest compressions during 2min by the same rescuer is well tolerated by health professionals trained in cardiopulmonary resuscitation (CPR).     

Progress of the advanced life support courses in Europe and beyond

The Advanced Life Support (ALS) course was designed initially to teach, and thereby enhance the practice and effectiveness of, resuscitation from cardiac arrest. The target candidates were doctors, nurses and paramedics, and particularly those working in areas likely to encounter such an emergency.     

Nurses' behaviour regarding CPR and the theories of reasoned action and planned behaviour.

Cardiopulmonary resuscitation (CPR) has been used in hospitals for approximately 40 years. Nurses are generally the first responders to a cardiac arrest and initiate basic life support while waiting for the advanced cardiac life support team to arrive. Speed and competence of the first responder are factors contributing to the initial survival of a person following a cardiac arrest. Attitudes of individual nurses may influence the speed and level of involvement in true emergency situations. This paper uses the theories of reasoned action and planned behaviour to examine some behavioural issues with CPR involvement.     

Education in cardiopulmonary resuscitation in Sweden and its clinical consequences

Aim

To describe the use of cardiopulmonary resuscitation (CPR) training programmes in Sweden for 25 years and relate those to changes in the percentage of patients with out of hospital cardiac arrest (OHCA) who receive bystander CPR.

Methods

Information was gathered from (a) the Swedish CPR training registry established in 1983 and includes most Swedish education programmes in CPR and (b) the Swedish Cardiac Arrest Register (SCAR) established in 1990 and currently covers about 70% of ambulance districts in Sweden.

Results

CPR education in Sweden functions according to a cascade principle (instructor-trainers who train instructors who then train rescuers in CPR). Since 1989, 5000 instructor-trainers have taught more than 50,000 instructors who have taught nearly 2 million of Sweden's 9 million inhabitants adult CPR. This is equivalent to one new rescuer per 100 inhabitants every year in Sweden. In addition, since 1989, there are 51,000 new rescuers in Advanced Life Support (ALS), since 1996, 41,000 new Basic Life Support (BLS) rescuers with Automated External Defibrillation (AED) training, and since 1998, there are 93,000 new rescuers in child CPR. As a result of this CPR training the number of bystander CPR attempts for OHCA in Sweden increased from 31% in 1992 to 55% in 2007.

Conclusion

By using a cascade principle for CPR education nearly 2 million rescuers were educated in Sweden (9 million inhabitants) between 1989 and 2007. This resulted in a marked increase in bystander CPR attempts.     

A prediction survival model for out-of-hospital cardiopulmonary resuscitations

Aims

The aims of this study were to double check old (Resuscitation Predictor Scoring [RPS], Advanced Cardiac Life Support, and Early Prediction Score [EPS]) and form new (Serbian Quality of Life immediately [SR-QOLi], Serbian Quality of Life short-term [SR-QOLs], and Serbian Quality of Life long-term [SR-QOLl]) scores for survival prediction in out-of-hospital cardiopulmonary resuscitation (OHCPR) in Serbia.

Methods

A prospective, 2-year, multicentric study was designed. By the means of the Utstein style, OHCPR performed and its outcome were followed. In every patient, immediate (i) (Return of Spontaneus Circulation [ROSC] >20 min), short-term (s) (to hospital discharge), and long-term [1] (1 year upon) survival after the OHCPR, under the application of RPS, ASCLS, and EPS models, was evaluated. We assessed the association between survival rate and individual predictors of OHCPR using RPS, ASCLS, and EPS: cardiopulmonary resuscitation (CPR) started (>4 or <4 minutes after out-of-hospital cardiac arrest), swallowing activity (present or not), the primary arrest mode (cardiac or respiratory), and initial pupillar photoreaction (present or absent). By the successive-logistic and linear-regression analysis method, the additional model of the type SR-QOL (SR-QOLi, SR-QOLs, and SR-QOLl) was created.

Results

We found that bystander CPR, witnessed arrest, shockable rhythms, CPR within 4 minutes, pupillar photoreaction, and primary cardiac arrest mode were associated with improved survival. Cumulative survival upon OHCPR was 12.7% for immediate, 11.3% before patient's discharge, and 10% after 12 months. Applied on our sample, standard scores displayed satisfactory (RPS) and good (Advanced Cardiac Life Support and EPS) degree of survival prediction in OHCPR. In receiver operator characteristic (ROC) analysis, SR-QOLi (ROC = 0.833) and SR-QOLs (ROC = 0.882) were defined as a good models and SR-QOLl (ROC = 0.913) was defined as an excellent model for prediction of outpatient CPR outcomes.

Conclusion

In the course of the research, SR-QOL models were created for prediction of the immediate (SR-QOLi), short-term (SR-QOLs), and long-term (SR-QOLl) survival after the OHCPR, better predictions in our environment.     

Effects of naloxone on the adrenomedullary response during and after cardiopulmonary resuscitation in dogs

To determine the effects of naloxone, an opiate antagonist, on the adrenomedullary response to cardiac arrest, plasma epinephrine and norepinephrine levels were measured before, during, and after cardiac arrest in dogs. Ventricular fibrillation was induced in 12 dogs anesthetized with pentobarital sodium (30 mg/kg) and standard American Heart Association cardiopulmonary resuscitation (CPR) was begun using a mechanical device. At 6.5 minutes of CPR, naloxone (10 mg/kg) or 0.9% saline (10 ml) was given intravenously. At 12 minutes of CPR, the cardiac ventricles were electrically defibrillated. Plasma epinephrine and norepinephrine levels were measured before ventricular fibrillation; at 2.5, 4.5, 9.5, and 11.5, minutes of CPR; and at 5, 10, 15, and 20 minutes after resuscitation. Epinephrine and norepinephrine increased from prearrest levels of 3.66 +/- 0.67 (+/- SE) and 24.02 +/- 3.67 ng/ml to 66.67 +/- 9.65 and 74.00 +/- 9.91 ng/ml, respectively, at 4.5 minutes of CPR. After resuscitation, norepinephrine levels remained slightly elevated, while epinephrine fell to prearrest levels. Naloxone did not cause a significant change in either epinephrine or norepinephrine from 6.5 minutes of CPR (time of treatment) through 20 minutes postresuscitation. In addition, naloxone had no effect on either the end-diastolic pressure difference during CPR or resuscitation outcome. We conclude that cardiac arrest causes significant increases in plasma epinephrine and norepinephrine levels, which remain elevated for the duration of the arrest, and that naloxone has no effect on these levels.