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Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Cardiac Arrest


Text Only Home | Graphic-Rich Site | Definition | Diagnosis | Treatment | Prognosis | Differential Diagnosis | Specialists | Rehabilitation | Comorbid Conditions | Complications | Factors Influencing Duration | Length of Disability | Return to Work | Failure to Recover | Medical Codes | References

Medical Codes

ICD-9-CM:
427.41 - Ventricular Fibrillation
427.5 - Cardiac Arrest; Cardiorespiratory Arrest

Related Terms

  • Arrest
  • Asystole
  • Cardiopulmonary Arrest
  • SCD
  • Sudden Cardiac Arrest,
  • Sudden Cardiac Death
  • Sudden Death

Overview

Cardiac arrest is an abrupt halt in the pumping action of the heart. When the heart stops pumping, blood flow and spontaneous breathing (respiration) also stop, resulting in cardiopulmonary arrest and a complete lack of oxygen delivery to vital organs. Individuals lose consciousness immediately.

Cardiac arrest is a medical emergency. Restoration of circulation to vital organs through cardiopulmonary resuscitation (CPR) is necessary to prevent permanent brain, heart, liver, lung, and kidney damage. CPR results temporarily in minimal blood flow to vital organs. For those who have cardiac arrest due to ventricular fibrillation or tachycardia, the definitive treatment is cardiac defibrillation, either by trained medical personnel, or by lay bystanders who use an Automate External Defibrillator (AED). AEDs are becoming commonly available in public areas, including airports, hotels, convention centers, and larger businesses. Cardiac arrest results in death within minutes if not immediately corrected. Cardiac arrest as a result of asystole (no electrical heart activity) or pulseless electrical activity is usually fatal, even with prompt and appropriate action by witnesses.

Cardiac arrest is different from a heart attack (myocardial infarction, MI). In an MI, blood flow to a portion of the heart is blocked, depriving that portion of the heart muscle of oxygen. The heart's ability to pump is deceased, but the individual has enough heart function to remain conscious. In contrast, sudden cardiac arrest most often occurs when the heart's electrical system malfunctions.

Cardiac arrest can occur as a result of a number of different cardiovascular, metabolic, neurologic and inflammatory diseases. In many cases of cardiac arrest, an abnormally fast heart rate (ventricular tachycardia) may lead to rapid, irregular, and uncoordinated muscle contraction in the ventricle (ventricular fibrillation), decreasing or completely stopping blood flow to the organs (cardiac output). Other disruptions in heart rhythm that may lead to cardiac arrest include a persistent, abnormally slow heartbeat (bradycardia); a sudden cessation in the rhythmic contractions of the heart muscle (asystole); and pulseless electrical activity (PEA), in which electrical activity within the heart exists, but does not result in detectable heartbeats. Cardiac arrest may also result from undiagnosed electrical instability, such as long QT syndrome associated with sudden cardiac death among young athletes (Zipes; Deo).

Other conditions that may lead to cardiac arrest include rupture of a major vessel (e.g., aortic aneurysm), obstruction of one or more coronary arteries (coronary atherosclerosis), a heart attack (acute myocardial infarction), chronic heart failure, or compression of the heart by a massive accumulation of fluid or blood in the chest cavity (acute tamponade). Cardiac arrest may also result from abnormally low blood volume caused by massive bleeding (hemorrhage), massive fluid loss in the aftermath of second- and third-degree burns over a large percentage of the body, and untreated systemic hypothermia. Difficulty breathing for any reason may increase levels of carbon dioxide in the blood, leading to respiratory acidosis and cardiopulmonary arrest. Migration of a dislodged blood clot to the lung (pulmonary embolism), electrocution or lightning strike, drug overdose, a severe allergic reaction, or the sudden cessation of breathing (respiratory arrest) may also lead to cardiac arrest.

Individuals who sustain a blow to the chest wall (e.g., from sports or a motor vehicle accident) may also experience sudden cardiac arrest that can trigger episodes of ventricular fibrillation.

Incidence and Prevalence: Each year in the US, about 670,000 people die suddenly; about 500,000 of these deaths can be attributed to cardiac causes (Neumar 64). Published estimates of the incidence of Sudden Cardiac Death (SCD) vary between 180,000 to 450,000 deaths in the US per year. By all accounts the magnitude of the problem is enormous accounting for more deaths per year than any other single cause (Kong, "Addressing"; Kong, "Systematic").

Source: Medical Disability Advisor



Diagnosis

History: The individual’s medical history is obtained as soon as possible during the treatment and resuscitation process. Family members and witnesses to the cardiac arrest may be able to provide important information. Particular attention may be paid to drug use or abuse, including use of common heart medications (e.g., digitalis) and recreational drugs such as cocaine. Any previous heart problems should be discussed. To some extent, the history and associated symptoms will depend on the nature of the underlying condition. An individual who had been experiencing a myocardial infarction (MI) may complain of pressure, tightness, or heaviness in the chest, arms (particularly the left arm), or jaw. Prior complaints of shortness of breath (dyspnea) are common, particularly in elderly individuals. Individuals may have complained of sweating, dizziness, nausea, or vomiting as well. Some individuals had reported loss of consciousness (syncope).

Physical exam: Individuals in cardiac arrest do not respond to stimuli and have stopped breathing. No pulse is detectable. Unless circulation is restored rapidly, the skin assumes a bluish-gray color (cyanosis) from lack of oxygenated blood. Since the heart is not beating, no heart sounds are audible with a stethoscope, and there is no blood pressure. Extremities may become cool to the touch. If the brain becomes oxygen deprived (hypoxic) the individual’s pupils become fixed and dilated.

Tests: In those who are successfully resuscitated (survive), determining the cause of cardiac arrest is crucial since this will direct treatment efforts. An electrocardiogram (ECG) is done to assess the electrical activity of the heart. In cases of heart attack (myocardial infarction), changes in electrical activity patterns on ECG can help identify the part of the heart involved in the infarction. Damaged heart muscle cells release enzymes into the bloodstream that can be measured by blood tests for cardiac enzyme creatine kinase (CK), isoenzyme creatine kinase-myocardial band (CK-MB), and troponin. A complete blood count, serum electrolyte concentrations, and arterial blood gas measurements are obtained to give additional information about the individual’s health status. In cases of abnormally slow heartbeat and asystole, reversible causes (low levels of important electrolytes such as (low magnesium or low potassium) must be identified or excluded. Quantitative levels of medications the individual may be taking (digoxin, quinidine, procainamide, tricyclic antidepressants) can help rule out too much or too little medication as a cause of arrhythmia. Cocaine can lead to vasospasm-induced arrhythmia, so a toxicology screen may be requested. Opioids (narcotics) depress respiratory effort, and overdoses can result in underventilation, hypoxia, and ultimately asystole (cardiac arrest). Urine drug screen testing can be performed to determine if drug use contributed.

After the individual's condition is stabilized, other tests may be done to assess heart and blood vessel structure and function. In cardiac catheterization, a tiny, flexible tube (catheter) is inserted into the femoral artery in the groin. The catheter is advanced through the artery to the heart, where it can be used to check blood flow in the coronary arteries, study blood flow and pressure in the chambers of the heart, examine heart wall motion, and check heart valve function. Blockages in the blood vessels of the heart can be visualized by injecting dye into the blood vessels and taking special x-rays (angiography). Cardiac ultrasound, echocardiography, or nuclear isotopes (thallium) may help to further evaluate heart function.

Source: Medical Disability Advisor



Treatment

Cardiac arrest requires emergency treatment. Cardiopulmonary resuscitation (CPR) must begin within 4 to 6 minutes after cardiac arrest to maintain circulation of the blood and prevent permanent brain damage. The four basic steps of life support are (1) maintain circulation through external chest (cardiac) compression; (2) establish an airway; (3) breathe for the individual, either through mouth-to-mouth or mouth-to-mask resuscitation or by compressing a bag-valve device to force air into the patient’s nose or mouth, and; (4) if indicated, apply electrical shock (defibrillation) to restore normal heart rhythm (Berg). The individual in cardiac arrest must be transported to a hospital emergency department as quickly as possible.

The complete absence of heart electrical activity (asystole or "flat-line") is more difficult to reverse than cardiac arrest caused by ventricular fibrillation. Asystole may respond to ventilation, or to IV administration of epinephrine, vasopressin, or atropine. In extreme cases, medication may be injected directly into the heart. Once the individual is stabilized, a pacemaker, which monitors the cardiac rhythm and stimulates the heart if it fails to beat, may need to be implanted.

Patients who have blockage of a heart valve or vessel caused by a blood clot (thrombus) may receive medication to break down the clot (thrombolytics) and help restore normal blood flow.

Once an individual’s condition has stabilized, he or she is transferred to a cardiac care unit (CCU) for continuous cardiac monitoring and further treatment.

Other treatments that may be used, depending on the underlying cause of cardiac arrest, include coronary angioplasty to open blocked coronary arteries, coronary bypass surgery, electrophysiology studies to map conduction pathways, radiofrequency catheter ablation to eliminate an abnormal electrical pathway, or heart surgery to correct abnormalities (valves, congenital deformities).

For individuals who have been successfully resuscitated from cardiac arrest, either anti-arrhythmic medications, or an implanted cardiac defibrillator, or both are commonly prescribed.

Source: Medical Disability Advisor



Prognosis

The outcome of cardiac arrest depends on how quickly CPR was initiated. With CPR, defibrillation, and paramedic intervention within 8 minutes, the survival rate for cardiac arrest is about 43% and can be as high as 90% if treatment is initiated within the first few minutes. The survival rate decreases by about 10% for each minute that passes before treatment is initiated (Murphy). Use of therapeutic hypothermia in comatose patients whose cardiac arrest originated with ventricular fibrillation improves survival rates and neurologic outcomes (Ornato), but this technique is not widely used. Individuals who survive cardiac arrest and hospital treatment may have a good outcome, but are still at high risk of heart dysfunction because of the underlying cardiovascular disease that precipitated cardiac arrest. Ongoing treatment of the underlying disease is usually required. Some individuals are left with long-term cognitive deficits (brain damage) due to decreased oxygen delivery to the brain (anoxia).

Source: Medical Disability Advisor



Differential Diagnosis

  • Aortic aneurysm
  • Drug overdose
  • Myocardial infarction (MI)
  • Pulmonary embolism
  • Stroke or subarachnoid hemorrhage

Source: Medical Disability Advisor



Specialists

  • Cardiovascular Internist
  • Critical Care Internist
  • Emergency Medicine Physician
  • Thoracic Surgeon
  • Vascular Surgeon

Source: Medical Disability Advisor



Rehabilitation

In cases of successful resuscitation from cardiac arrest due to myocardial infarction, coronary artery disease, or related underlying conditions, a physician may recommend participation in a hospital-based cardiac rehabilitation program. These programs seek to assist individuals in acquiring and maintaining a healthy lifestyle and ensuring a return to normal activities as soon as possible. Many include individually designed exercise programs to be followed 3 to 4 times per week for several weeks. The rehabilitation program also assists with dietary changes, weight control, and the maintenance of exercise regimens and lifestyle changes after the hospital-based program ends. Psychosocial stressors, such as depression, anxiety, anger, or social isolation, are identified, and efforts to manage them are initiated. Cognitive rehabilitation may be necessary for individuals left with cognitive deficits following cardiac arrest.

FREQUENCY OF REHABILITATION VISITS
ClassificationSpecialistTopicVisit
NonsurgicalCardiac RehabilitationCardiac ArrestUp to 2-5 visits per week within 12 weeks.

Source: Medical Disability Advisor



Comorbid Conditions

  • Abnormal lipids (Dyslipidemia)
  • Diabetes mellitus
  • Heart disease
  • High blood pressure (hypertension)
  • Obesity
  • Smoking
  • Vascular disease

Source: Medical Disability Advisor



Complications

Potential complications of cardiac arrest in those who survive include recurrence of several types of arrhythmia, including ventricular fibrillation, ventricular tachycardia, and atrial fibrillation, leading to subsequent or repeat episodes of cardiac arrest. Another potential complication includes stroke.

Source: Medical Disability Advisor



Factors Influencing Duration

Underlying causes of initial cardiac arrest, duration of arrest, severity of damage to the heart and brain, individual's age, and individual’s response to treatment and cardiac rehabilitation may influence disability.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals who have suffered a cardiac arrest should be evaluated by their physicians prior to returning to work. Information gathered from physical examination, ECG, blood tests, and exercise stress tests will be used to determine an appropriate level of activity and date of return. METs achieved on stress testing and Left Ventricular Ejection Fraction are important determinants of return to work. Physical exertion on the job should be tailored to the individual's capabilities. For some survivors of cardiac arrest, cognitive deficits may significantly affect the ability to return to work.

Risk: Due to the life threatening nature of this condition, all risk factors as well as any potential job factors must be addressed before planned return to work.

Capacity: Cardiovascular testing remains the mainstay of determining capacity for this condition. Stress testing and wearing a Holter monitor the first day(s) back at work can demonstrate what appears to be the best estimate of safe work ability. This will at minimum require stress testing. For more information, refer to "Work Ability and Return to Work," pages 274, 277.

Tolerance: Patients who have experienced any arrest are often quite worried about their condition and reassurance from objective testing is probably the best way to guide them if they are reluctant to work.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was diagnosis of cardiac arrest confirmed?
  • Was underlying cause of cardiac arrest determined?
  • If so, what was the arrhythmia that resulted in the initial arrest? Ventricular fibrillation? Tachycardia? Bradycardia? Asystole? Myocardial infarction?
  • What disease or condition was determined to be the underlying reason for the arrest?

Regarding treatment:

  • If individual is at a high risk for a recurrence, is an implantable cardioverter-defibrillator recommended, or already inserted? Has there been a recurrent episode of syncope and/or cardiac arrest?
  • Has individual been educated about lifestyle changes necessary to prevent future heart problems that could lead to heart attack, arrhythmias, and cardiac arrest?

Regarding prognosis:

  • How severely was the heart damaged? How much cardiac pumping ability (exercise capacity) is left?
  • How severely was the brain damaged? What are the residual brain injury deficits?
  • Is this individual's first cardiac arrest?
  • How old is individual?

Source: Medical Disability Advisor



References

Cited

Berg, R. A. , et al. "Part 5: Adult Basic Life Support." Circulation 122 (18 Suppl 3) (2010): S685-S705.

Cleveland Clinic Foundation. "Sudden Cardiac Death and Sudden Cardiac Arrest." Cleveland Clinic Foundation. 25 Apr. 2006. 17 Feb. 2009 <http://my.clevelandclinic.org/disorders/arrhythmias/hic_heart_disease_sudden_cardiac_death_and_sudden_cardiac_arrest.aspx>.

Deo, R. , and C. M. Albert. "Epidemiology and genetics of sudden cardiac death." Circulation 125 (4) (2012): 620-637.

Kong, M. H. , et al. "Addressing disparities in sudden cardiac arrest care and the underutilization of effective therapies." American Heart Journal 160 (4) (2010): 605-618.

Kong, M. H. , et al. "Systematic review of the incidence of sudden cardiac death in the United States." Journal of the American College of Cardiology 57 (7) (2011): 794-801.

Larsen, M. , et al. "Predicting survival from out-of-hospital cardiac arrest: A graphic model." Annals of Emergency Medicine 22 (11) (1993): 1652-1658.

Lloyd-Jones, D. R. , et al. "Heart Disease and Stroke Statistics—2010 Update." Circulation 121 (7) (2010): e46-e215.

Murphy, M. , and D. Fitzsimons. "Does attendance at an immediate life support course influence nurses’ skill deployment during cardiac arrest?" Resuscitation 62 (1) (2004): 49-54.

Neumar, Robert W., and Kevin R. Ward. "Adult Resuscitation." Rosen’s Emergency Medicine: Concepts and Clinical Practice. Eds. J. A. Marx, et al. 5th ed. St. Louis: Mosby, Inc., 2002. 64-82.

Ornato, J. P. , et al. "Future directions for resuscitation research. III. External cardiopulmonary resuscitation advanced life support." Resuscitation 32 (2) (1996): 139-158.

Poonyagariyagorn, Hataya, et al. "Cardiovascular Emergencies." Cleveland Clinic Foundation. 17 Feb. 2009 <http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/cardiovascular-emergencies/>.

Roger, V. L. , et al. "Heart disease and stroke statistics--2012 update: a report from the American Heart Association." Circulation 125 (1) (2012): e2-e220.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

Zipes, D. P. , and H. J. Wellens. "Sudden cardiac death." Circulation 98 (21) (1998): 2334-2351.

Source: Medical Disability Advisor