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In a patient with sudden death, a thorough evaluation of potential causes is essential to exclude preventable causes of recurrence.
In a patient with sudden death, a thorough evaluation of potential causes is essential to exclude preventable causes of recurrence.
===Reversible Causes===
[[Cardiopulmonary resuscitation]] (CPR), including adjunctive measures such as defibrillation, intubation and drug administration, is the standard of care for initial treatment of cardiac arrest. However, most cardiac arrests occur for a reason, and unless that reason can be found and overcome, CPR is often ineffective, or if it does result in a return of spontaneous circulation, this is short lived. <ref name="RCUK2005">Resuscitation Council UK (2005). ''Resuscitation Guidelines 2005'' London: Resuscitation Council UK.</ref>. As highlighted above, a variety of disease processes can lead to a cardiac arrest, however they usually boil down to one or more of the "Hs and Ts" (see below).
====H's====
* [[Hypovolemia|'''H'''ypovolemia]] - A lack of circulating [[body fluids]], principally [[blood]] volume. This is usually (though not exclusively) caused by some form of [[bleeding]], [[anaphylaxis]], or [[pregnancy]] with gravid uterus. [[Cardiac arrest#Peri-arrest period|Peri-arrest treatment]] includes giving [[Intravenous therapy|IV fluids]] and [[blood transfusions]], and controlling the source of any [[bleeding]] - by direct pressure for external bleeding, or emergency surgical techniques such as [[esophagogastroduodenoscopy]] (i.e. [[esophageal varices]]) and [[thoracotomy]] for internal bleeding.
* [[Hypoxia|'''H'''ypoxia]] - A lack of [[oxygen]] to the [[heart]], [[brain]] and other [[vital organ]]s. This can be identified through a careful assessment of breath sounds and tuble placement. Treatment may include providing oxygen, proper ventilation, and good [[cardiopulmonary resuscitation|CPR]] technique.
* [[Hydrogen|'''H'''ydrogen]] ions ([[Acidosis]]) - An abnormal pH in the body as a result of shock, [[Diabetic ketoacidosis]], [[renal failure]], or [[tricyclic antidepressant]] overdose. This can be treated with proper ventilation, good [[cardiopulmonary resuscitation|CPR]] technique, and buffers like [[sodium bicarbonate]].
* [[Hyperkalemia|'''H'''yperkalemia]] or [[Hypokalemia|'''H'''ypokalemia]] - The most life threatening [[electrolyte]] derangement is [[hyperkalemia]] (too much potassium). The classic presentation is the [[chronic renal failure]] patient who has missed a [[dialysis]] appointment and presents with [[weakness]], [[nausea]], and broad [[QRS complex]]es on the [[electrocardiogram]]. The most important initial therapy is the administration of [[calcium]], either with [[calcium gluconate]] or [[calcium chloride]]. Other therapies may include nebulized [[albuterol]], [[sodium bicarbonate]], [[glucose]], and [[insulin]]. The diagnosis of [[hypokalemia]] (not enough [[potassium]]) can be suspected when there is a history of [[diarrhoea]] or [[malnutrition]]. Loop [[diuretic]]s may also contribute. The [[electrocardiogram]] may show depressed T waves and prominent U waves. [[Hypokalemia]] is an important cause of acquired [[long QT syndrome]], and may predispose the patient to [[torsades de pointes]]. [[Digitalis]] use may increase the risk that [[hypokalemia]] will produce life threatening [[arrhythmia]]s.
* [[Hypothermia|'''H'''ypothermia]] - A low [[body temperature|core body temperature]], defined clinically as a [[temperature]] of less than 35 degrees Celsius. The patient is re-warmed either by using a [[heart-lung machine|cardiac bypass]] or by irrigation of the body cavities (such as thorax, peritoneum, bladder) with warm fluids; or warmed [[IV]] fluids. [[CPR]] only is given until the core body temperature reached 30 degrees Celsius, as [[defibrillation]] is ineffective at lower temperatures. Patients have been known to be successfully resuscitated after periods of hours in hypothermia and cardiac arrest, and this has given rise to the often-quoted medical truism, "You're not dead until you're warm and dead."
* [[Hypoglycemia|'''H'''ypoglycemia]] or [[Hyperglycemia|'''H'''yperglycemia]] - Low blood glucose from insulin reactions, [[diabetic ketoacidosis|DKA]], [[nonketotic hyperosmolar coma]]. This condition can be suspected when the patient is known to be a [[diabetic]]. The treatment may include fluids, [[potassium]], [[glucose]] (for hypoglycemia), and [[insulin]] (for hyperglycemia).
====T's====
* [[Tablets|'''T'''ablets]] or [[Toxins|'''T'''oxins]] - [[Tricyclic antidepressant]]s, [[phenothiazines]], [[beta blocker]]s, [[calcium channel blocker]]s, [[cocaine]], [[digoxin]], [[aspirin]], [[acetominophen]]. This may be evidenced by items found on or around the patient, the patient's medical history (i.e. drug abuse, medication) taken from family and friends, checking the [[medical records]] to make sure no interacting drugs were prescribed, or sending [[blood]] and [[urine]] samples to the [[toxicology]] lab for report. Treatment may include specific [[antidote]]s, fluids for volume expansion, vasopressors, [[sodium bicarbonate]] (for [[tricyclic antidepressant]]s), [[glucagon]] or [[calcium]] (for [[calcium channel blocker]]s), [[benzodiazepine]]s (for [[cocaine]]), or [[cardiopulmonary bypass]].
* [[Cardiac tamponade|Cardiac '''T'''amponade]] - Blood or other fluids building up in the [[pericardium]] can put pressure on the heart so that it is not able to beat. This condition can be recognized by the presence of a narrowing [[pulse pressure]], muffled [[heart sounds]], distended neck veins, [[electrical alternans]] on the [[electrocardiogram]], or [[echocardiogram]]. This is treated in an emergency by inserting a needle into the [[pericardium]] to drain the fluid ([[pericardiocentesis]]), or if the fluid is too thick then an emergency [[thoracotomy]] is performed to cut the pericardium and release the fluid.
* [[Tension pneumothorax|'''T'''ension pneumothorax]] - The build up of air into one of the [[pleural cavity|pleural cavities]], which causes a [[mediastinum|mediastinal]] shift. When this happens, the [[great vessels]] (particularly the [[superior vena cava]]) become kinked, which limits [[blood]] return to the [[heart]]. The condition can be recognized by severe air hunger, [[hypoxia]], jugular venous distension, hyperressonance to percussion on the effected side, and a tracheal shift away from the effected side. The tracheal shift often requires a chest [[x-ray]] to appreciate. This is relieved in an emergency by a needle [[thoracotomy]] (inserting a needle catheter) into the 2nd [[intercostal space]] at the mid-[[clavicle|clavicular]] line, which relieves the pressure in the [[pleural cavity]].
* [[Thrombosis|'''T'''hrombosis]] ([[Myocardial infarction]]) - If the patient can be successfully resuscitated, there is a chance that the [[myocardial infarction]] can be treated, either with [[thrombolysis|thrombolytic therapy]] or [[percutaneous coronary intervention]].
* [[Thrombosis|'''T'''hromboembolism]] ([[Pulmonary embolism]]) - Usually diagnosed at autopsy. Patients in [[asystole]] or [[pulseless electrical activity]] have a poor prognosis. If this can be detected early, the patient may receive [[dopamine]], [[heparin]], and [[thrombolytic]]s.
* [[Physical trauma|'''T'''rauma]] ([[Hypovolemia]]) - Reduced blood volume from acute injury or primary damage to the [[heart]] or [[great vessels]]. Cardiac arrest secondary to [[Physical trauma|trauma]], particularly [[blunt trauma]], has a very poor [[prognosis]].


== Complete Differential Diagnosis for Sudden Cardiac Death ==  
== Complete Differential Diagnosis for Sudden Cardiac Death ==  

Revision as of 08:55, 2 February 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sara Zand, M.D.[2]

Overview

Cardiac arrest is synonymous with Clinical death. All disease processes leading to death have a period of (potentially) reversible cardiac arrest. The causes of arrest are, therefore, numerous. However, many of these conditions, rather than causing an arrest themselves, promote one of the reversible causes, which then triggers the arrest (e.g. Choking leads to Hypoxia which in turn leads to an arrest). In some cases, the underlying mechanism cannot be overcome, leading to an unsuccessful resuscitation. Among adults, ischemic heart disease is the predominant cause of arrest. At autopsy 30% of victims show signs of recent myocardial infarction. Other cardiac conditions potentially leading to arrest include structural abnormalities, arrhythmias, and cardiomyopathies. Non-cardiac causes include infections, overdoses, trauma and cancer, in addition to many others.

Causes

Sudden cardiac arrest may be caused by :

Causes of Sudden Death Including Sudden Cardiac Death by Organ System

Cardiovascular

Amyloid cardiopathy, Congestive heart failure, Ventricular rupture,

Hypoxia, Coronary thrombosis, Coronary vasospasm, Coronary artery aneurysm, Prinzmetal's variant angina ,

  • Pericardial

Cardiac tamponade,

Asymmetric septal hypertrophy , ST Elevation Myocardial Infarction, Dilated cardiomyopathy, Giant cell myocarditis , Hypertrophic cardiomyopathy, Kugel-Stoloff syndrome , Myocardial infarction, Myocarditis, Rupture of the papillary muscles,

  • Endocardial/Valvular

Mitral valve prolapse, Valvular aortic stenosis/insufficiency, Mitral valve disruption, Endocarditis, Prosthetic valve dysfunction,

Arrhythmogenic right ventricular cardiomyopathy, Arrhythmogenic right ventricular dysplasia, Brugada syndrome, Jervell and Lange-Nielsen Syndrome, Prolonged Q-T Interval Syndrome, Multifocal ventricular premature beats , Naxos disease , Romano-Ward syndrome , Sick sinus syndrome, Short QT syndrome , Sinus node disease, Stokes-Adams Syndrome, Sudden Arrhythmia Death Syndrome, Wolf-Parkinson-White syndrome,

Acute aortic insufficiency, Acute coronary syndrome, Aortic dissection, Aortic stenosis, Aorto-ventricular tunnel, Arteritis, Coronary artery disease, Coronary arteries - congenital malformation , Ruptured abdominal aortic aneurysm,

  • Congenital/Developmental

Congenital aortic or pulmonary valve stenosis, Congenital septal defect with eisenmenger physiology, Congenital heart block , Congenital Long QT syndrome, Noncompaction Cardiomyopathy, Sudden Infant Death Syndrome, Uhl anomaly

Snake bite

No underlying causes
  • Drug Side Effect
 Agalsidase beta, Articaine, caspofungin acetate, Clozapine, cytomegalovirus immune globulin, Drug allergy, drug overdose, Dornase Alfa, ferumoxytol, Flucytosine, galsulfase, Iodixanol, laronidase, Lincomycin Hydrochloride, Polidocanol, Potassium bicarbonate, pramipexole, prednisolone, Ramucirumab, Calcium gluconate, Dextran, Tiagabine
No underlying causes

Diabetic ketoacidosis - typically from undiagnosed diabetes, Thyrotoxicosis,

  • Environmental
 Hypothermia,
  • Gastroenterologic

Appendicitis, Gastrointestinal bleeding, Retroperitoneal bleed,

Brugada syndrome, 3-methylglutaconic aciduria, type 1, Familial dilated cardiomyopathy , Familial hypertrophic cardiomyopathy 1, Hyperbilirubinemia transient, familial neonatal, Marfan syndrome , Timothy syndrome

No underlying causes
  • Iatrogenic
 Transfusion reaction

Flu mainly in the elderly, infants, infirm or chronically ill, Neurocysticercosis , Lyme disease

No underlying causes

Apoplexy, Encephalitis, Intracranial hemmorhage, Meningitis, Stroke, Subarachnoid hemorrhage,

3-methylglutaconic aciduria, type 1, Alpha-ketoglutarate dehydrogenase deficiency , Food allergy

Amniotic fluid syndrome , Childbirth hemorrhage,

Atrial myxoma, familial

No underlying causes
  • Overdose / Toxicity

Opioid overdose , Oxycontin overdose, Pain killer overdose , Sleeping pill overdose

No underlying causes

Hypercapnia, Pickwickian Syndrome, Pulmonary embolism, Tension pneumothorax, Status asthmaticus

Hypercalcemia, Hypokalemia, Hyperkalemia,

Amyloidosis, Anaphylaxis, Myasthenia gravis, Sarcoidosis,

No underlying causes

Commotio cordis, Homicide, Motor Vehicle accident

No underlying causes
  • Miscellaneous

Shock, Asphyxia, Insect bite Sepsis syndrome, Shock

Differentiating sudden cardiac death from non-cardiac causes

Cardiac causes of sudden death

Non cardiac causes of sudden death:










In a patient with sudden death, a thorough evaluation of potential causes is essential to exclude preventable causes of recurrence.

Complete Differential Diagnosis for Sudden Cardiac Death

Cardiac causes of sudden cardiac death

Non cardiac causes of sudden cardiac death:

3-methylglutaconic aciduria, type 1







Complete Differential Diagnosis for Sudden Non-Cardiac Death

Causes of Sudden Death Including Sudden Cardiac Death by Organ System

Cardiovascular

Amyloid cardiopathy, Congestive heart failure, Ventricular rupture,

* Ischemic

Hypoxia, Coronary thrombosis, Coronary vasospasm, Coronary artery aneurysm, Prinzmetal's variant angina ,

* Pericardial

Cardiac tamponade,

* Myocardial

Asymmetric septal hypertrophy , ST Elevation Myocardial Infarction, Dilated cardiomyopathy, Giant cell myocarditis , Hypertrophic cardiomyopathy, Kugel-Stoloff syndrome , Myocardial infarction, Myocarditis, Rupture of the papillary muscles,

* Endocardial/Valvular

Mitral valve prolapse, [[Valvular aortic stenosis/insufficiency], Mitral valve disruption, Endocarditis, Prosthetic valve dysfunction,

* Conduction/Arrhythmia

Arrhythmogenic right ventricular cardiomyopathy, Arrhythmogenic right ventricular dysplasia, Brugada syndrome, Jervell and Lange-Nielsen Syndrome, Prolonged Q-T Interval Syndrome, Multifocal ventricular premature beats , Naxos disease , Romano-Ward syndrome , Sick sinus syndrome, Short QT syndrome , Sinus node disease, Stokes-Adams Syndrome, Sudden Arrhythmia Death Syndrome, Wolf-Parkinson-White syndrome,

* Vascular

Acute aortic insufficiency, Acute coronary syndrome, Aortic dissection, Aortic stenosis, Aorto-ventricular tunnel, Arteritis, Coronary artery disease, Coronary arteries - congenital malformation , Ruptured abdominal aortic aneurysm,

Congenital/Developmental

Congenital aortic or pulmonary valve stenosis, Congenital septal defect with eisenmenger physiology, Congenital heart block , Congenital Long QT syndrome, Noncompaction Cardiomyopathy, Sudden Infant Death Syndrome, Uhl anomaly

Chemical / poisoning

Snake bite

Dermatologic No underlying causes
Drug Side Effect Agalsidase beta, Articaine, caspofungin acetate, Clozapine, cytomegalovirus immune globulin, Drug allergy, drug overdose, Dornase Alfa, ferumoxytol, Flucytosine, galsulfase, Iodixanol, laronidase, Lincomycin Hydrochloride, Polidocanol, Potassium bicarbonate, pramipexole, prednisolone, Ramucirumab, Calcium gluconate, Dextran, Tiagabine
Ear Nose Throat No underlying causes
Endocrine

Catecholaminergic polymorphic ventricular tachycardia, Diabetic ketoacidosis - typically from undiagnosed diabetes, Thyrotoxicosis,

Environmental Hypothermia,
Gastroenterologic

Appendicitis, Gastrointestinal bleeding, Retroperitoneal bleed,

Genetic

Brugada syndrome, 3-methylglutaconic aciduria, type 1, Familial dilated cardiomyopathy , Familial hypertrophic cardiomyopathy 1, Hyperbilirubinemia transient, familial neonatal, Marfan syndrome , Timothy syndrome

Hematologic No underlying causes
Iatrogenic Transfusion reaction
Infectious Disease

Flu mainly in the elderly, infants, infirm or chronically ill, Neurocysticercosis , Lyme disease

Musculoskeletal / Ortho No underlying causes
Neurologic

Apoplexy, Encephalitis, Intracranial hemmorhage, Meningitis, Stroke, Subarachnoid hemorrhage,

Nutritional / Metabolic

3-methylglutaconic aciduria, type 1, Alpha-ketoglutarate dehydrogenase deficiency , Food allergy

Obstetric/Gynecologic

Amniotic fluid syndrome , Childbirth hemorrhage,

Oncologic

Atrial myxoma, familial

Opthalmologic No underlying causes
Overdose / Toxicity

Opioid overdose , Oxycontin overdose, Pain killer overdose , Sleeping pill overdose

Psychiatric No underlying causes
Pulmonary

Hypercapnia, Pickwickian Syndrome, Pulmonary embolism, Tension pneumothorax, Status asthmaticus

Renal / Electrolyte

Hypercalcemia, Hypokalemia, Hyperkalemia,

Rheum / Immune / Allergy

Amyloidosis, Anaphylaxis, Myasthenia gravis, Sarcoidosis,

Sexual No underlying causes
Trauma

Commotio cordis, Homicide, Motor Vehicle accident

Urologic No underlying causes
Miscellaneous

Shock, Asphyxia, Insect bite Sepsis syndrome, Shock

Causes of Sudden Death Including Sudden Cardiac Death in Alphabetical Order


References

  1. ↑ Mehta, Davendra; Curwin, Jay; Gomes, J. Anthony; Fuster, Valentin (1997). "Sudden Death in Coronary Artery Disease". Circulation. 96 (9): 3215–3223. doi:10.1161/01.CIR.96.9.3215. ISSN 0009-7322.
  2. ↑ Eisenberg MS, Mengert TJ (2001). "Cardiac resuscitation". N. Engl. J. Med. 344 (17): 1304–13. PMID 11320390. Unknown parameter |month= ignored (help)
  3. ↑ . doi:10.1080/2F20961790.2019.1595352. Missing or empty |title= (help)
  4. ↑ 4.0 4.1 Basso, Cristina; Perazzolo Marra, Martina; Rizzo, Stefania; De Lazzari, Manuel; Giorgi, Benedetta; Cipriani, Alberto; Frigo, Anna Chiara; Rigato, Ilaria; Migliore, Federico; Pilichou, Kalliopi; Bertaglia, Emanuele; Cacciavillani, Luisa; Bauce, Barbara; Corrado, Domenico; Thiene, Gaetano; Iliceto, Sabino (2015). "Arrhythmic Mitral Valve Prolapse and Sudden Cardiac Death". Circulation. 132 (7): 556–566. doi:10.1161/CIRCULATIONAHA.115.016291. ISSN 0009-7322.
  5. ↑ Yap, Sing-Chien; Harris, Louise (2014). "Sudden cardiac death in adults with congenital heart disease". Expert Review of Cardiovascular Therapy. 7 (12): 1605–1620. doi:10.1586/erc.09.153. ISSN 1477-9072.

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