Cardiopulmonary resuscitation: Historical perspective to recent investigations

doi:10.1016/S0002-8703(99)70458-8

American Heart Journal

Volume 137, Issue 1, January 1999, Pages 39-48

https://doi.org/10.1016/S0002-8703(99)70458-8 Get rights and content

Abstract

There are at least 300,000 cardiac arrests annually in the United States. Cardiopulmonary resuscitation (CPR) effectively restores hemodynamic stability, return of spontaneous circulation (ROSC), in 40% to 60% of arrests. Prolonged survival is significantly lower because of underlying illness and the postresuscitation syndrome, specifically central nervous system injury and left ventricular stunning after resuscitation. Prognostic variables have been shown to predict survival in multivariate analyses, but no models are sufficiently accurate to predict futility. End-tidal carbon dioxide has prognostic value and can measure the efficacy of CPR. Cardiac arrest outcomes will be most improved with public education and earlier initiation of resuscitative efforts, both Basic Life Support and Advanced Cardiac Life Support, notably defibrillation. Active compression-decompression and interposed abdominal compressions improved ROSC in prospective randomized trials; abdominal compressions have also been shown to increase survival to hospital discharge. Despite 30 years of research, CPR is now performed much as it was initially. Further research into the mechanisms of cardiac arrest, development of predictive models, and improved means to improve cardiac output and survival are needed. (Am Heart J 1999;137:39-48.)

Section snippets

Outcomes

There are at least 300,000 victims of sudden cardiac death in the United States each year.² Sixty to seventy percent of cardiac arrests occur outside the hospital.³ Return of spontaneous circulation (ROSC), the restoration of hemodynamic “stability” or a perfusing rhythm, and survival to hospital admission and discharge are the end points most often used to characterize these patients’ outcomes. As Eisenberg et al⁴ have noted, the “denominator” (eg, all cardiac arrests for which emergency

Cost

Because CPR is performed in up to 40% of hospitalized patients who die, we analyzed the hospital costs of caring for these patients. In 151 consecutive arrests, 85% of the patients had ROSC and were transferred to an ICU, accumulating 357 ICU days. Seven patients (5%) were discharged from the hospital at a total cost of $1.1 million, or $161,000 per patient discharged alive.³² As in many studies, more than half the patients were successfully resuscitated, but few survived to hospital discharge.

Response time

Many studies suggest that strategies to minimize the delay between cardiac arrest and the initiation of CPR have the greatest potential to improve outcome. The diagnosis and treatment of ventricular fibrillation with defibrillation by emergency medical technicians has had the largest impact on survival. Early studies revealed “basic-level” emergency medical technicians can be trained to deliver defibrillation and can have a profound influence on survival.33, 34 Many of the trials investigating

Etiology

Coronary artery disease is the cause of sudden cardiac death in 80% of victims.³⁷ At necropsy, 40% to 70% of sudden cardiac death victims have evidence of previous myocardial infarction.³⁸ Seventy-two percent of victims of sudden cardiac death who have no prior symptoms of coronary artery disease have evidence of healed infarcts at autopsy.³⁸ Although most victims of sudden cardiac death have evidence of multivessel disease, only 30% have evidence of an acute thrombotic event.39, 40, 41 Hinkle

Circulation

Detailed guidelines for BLS and ACLS can be found in the latest American Heart Association update on CPR.⁴⁷ After unresponsiveness, lack of pulse, and apnea are confirmed in unmonitored cardiac arrests, the initial management consists of BLS, closed-chest compressions, and artificial ventilation. The mechanism by which closed-chest compressions increase forward cardiac output remains controversial. The traditional cardiac pump theory states the heart is massaged and blood forced out by direct

Pharmacotherapy

Detailed guidelines for ACLS and suggested medication algorithms for CPR are included in the 1992 edition of the American Heart Association guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care.⁴⁷ The primary drug used in ACLS is epinephrine, the adrenergic agonist of choice to increase myocardial and cerebral blood flow and decrease the defibrillation threshold. The recommended dose (1 mg) is identical to the amount used in the original dog studies and the dose is not

Conclusion

There are at least 300,000 cardiac arrests each year in the United States. Cardiopulmonary resuscitation effectively restores hemodynamic stability (ROSC) in 40% to 60% of arrests. Prolonged survival is significantly less because of underlying illness(es), not to failed CPR. Prognostic variables have been shown to predict survival in multivariate analyses, but no models are sufficiently accurate to predict futility. ETco₂ has prognostic value and can be used to measure the efficacy of CPR and

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The outcome of anaesthesia related cardiac arrest in a Sub-Saharan tertiary hospital
2016, Egyptian Journal of Anaesthesia
Anaesthesia related cardiac arrest is undesirable, and different attempts have been made to reduce the mortality associated with it through continuous specialist training, and provision of state of art equipment, combined with rigorous research.
We determined the outcome of all cardiac arrests that occurred within 24 h of a surgical procedure and anaesthesia from January 2013 to May 2014.
There were nine anaesthesia related cardiac arrest in 4229 cases, (incidence of 21.28 per 10,000), with a mortality of 7/4229; (16.55 per 10,000). There were 60 perioperative cardiac arrests (incidence of 141.88 per 10,000), with a mortality of 55/4229 (130.05 per 10,000). There was return of spontaneous circulation in 34 (56.67%) cases, among them only 7 (20.59%) survived to hospital discharge. The independent determinant of perioperative mortality was the duration of cardiac arrest ⩾ 5 min (RR 10.50, 95% CI 2.721–40.519, p < 0.001), cardiac arrest in the absence of a witness (RR 9.56, 95% CI 2.486–36.752, p < 0.001), nonstandard time of cardiac arrest (RR 3.2, 95% CI 1.792–5.714, p < 0.001), ASA physical status ⩾ III (RR 2.017, 95% CI 1.190–3.417, p = 0.017), and emergency surger (RR 2.17, 95% CI 1.151–4.049, p = 0.011).
Anaesthesia related cardiac arrest and mortality were linked to cardiovascular depression from halothane overdose in our institution. The burden can be reduced by improving on establishing standard monitoring in the perioperative period, and a team approach to patients care.
Simulation exercise to improve retention of cardiopulmonary resuscitation priorities for in-hospital cardiac arrests: A randomized controlled trial
2015, Resuscitation
Citation Excerpt :
Cardiopulmonary resuscitation (CPR) can restore circulation 40-60% of the time.1
Traditional American Heart Association (AHA) cardiopulmonary resuscitation (CPR) curriculum focuses on teams of two performing quality chest compressions with rescuers on their knees but does not include training specific to In-Hospital Cardiac Arrests (IHCA), i.e. patient in hospital bed with large resuscitation teams and sophisticated technology available.
A randomized controlled trial was conducted with the primary goal of evaluating the effectiveness and ideal frequency of in-situ training on time elapsed from call for help to; (1) initiation of chest compressions and (2) successful defibrillation in IHCA.
Non-intensive care unit nurses were randomized into four groups: standard AHA training (C) and three groups that participated in 15 min in-situ IHCA training sessions every two (2M), three (3M) or six months (6M). Curriculum included specific choreography for teams to achieve immediate chest compressions, high chest compression fractions and rapid defibrillation while incorporating use of a backboard, stepstool.
More frequent training was associated with decreased median (IQR) seconds to: starting compressions: [C: 33(25–40) vs. 6M: 21(15–26) vs. 3M: 14(10–20) vs. 2M: 13(9–20); p < 0.001]; and defibrillation: [C: 157(140–254) vs. 6M: 138(107–158) vs. 3M: 115(101–119) vs. 2M: 109(98–129); p < 0.001]. A composite outcome of key priorities, compressions within 20 s, defibrillation within 180 s and use of a backboard, revealed improvement with more frequent training sessions: [C:5%(1/18) vs. 6M: 23%(4/17) vs. 3M: 56%(9/16) vs. 2M: 73%(11/15); p < 0.001].
Results revealed short in-situ training sessions conducted every 3 months are effective in improving timely initiation of chest compressions and defibrillation in IHCA.
Effect of Transport Interval on Out-of-Hospital Cardiac Arrest Survival in the OPALS Study: Implications for Triaging Patients to Specialized Cardiac Arrest Centers
2009, Annals of Emergency Medicine
Citation Excerpt :
In fact, survival from out-of-hospital cardiac arrest is so extremely time-sensitive that, if patients do not achieve return of spontaneous circulation before arrival at the hospital, survival is exceptionally rare.11 Survival from out-of-hospital cardiac arrest is so dependent on timeliness and sequencing of specific interventions that, for decades, events occurring in the field were believed to be the only significant determinants of outcome.11-17 Perhaps this explains why a widespread sense of futility has been identified in the inhospital approach to patients who have return of spontaneous circulation but do not immediately appear to be neurologically and hemodynamically intact.
To identify any association between out-of-hospital transport interval and survival to hospital discharge in victims of out-of-hospital cardiac arrest.
Data from the Ontario Prehospital Advanced Life Support Study (January 1, 1991, to December 31, 2002), an Utstein-compliant registry of out-of-hospital cardiac arrest patients from 21 communities, were analyzed. Logistic regression identified factors that were independently associated with survival in consecutive adult, nontraumatic, out-of-hospital cardiac arrest patients and in the subgroup with return of spontaneous circulation.
A total of 18,987 patients met criteria and 15,559 (81.9%) had complete data for analysis (study group). Return of spontaneous circulation was achieved in 2,299 patients (14.8%), and 689 (4.4%) survived to hospital discharge. Median transport interval was 4.0 minutes (25th quartile 3.0 minutes; 75th quartile 6.2 minutes) for survivors and 4.2 minutes (25th quartile 3.0, 75th quartile 6.2) for nonsurvivors. Logistic regression revealed multiple factors that were independently associated with survival: witnessed arrest (odds ratio 2.61; 95% confidence interval [CI] 2.05 to 3.34), bystander cardiopulmonary resuscitation (odds ratio 2.22; 95% CI 1.82 to 2.70), initial rhythm of ventricular fibrillation/tachycardia (odds ratio 2.22; 95% CI 1.97 to 2.50), and shorter emergency medical services (EMS) response interval (odds ratio 1.26; 95% CI 1.20 to 1.33). There was no association between transport interval and survival in either the study group (odds ratio 1.01; 95% CI 0.99 to 1.05) or the return of spontaneous circulation subgroup (odds ratio 1.04; 95% CI 0.99, 1.08).
In a large out-of-hospital cardiac arrest study from demographically diverse EMS systems, longer transport interval was not associated with decreased survival. Given the growing evidence showing major influence from specialized postarrest care, these findings support conducting clinical trials that assess the effectiveness and safety of bypassing local hospitals to take patients to regional cardiac arrest centers.
Prostacyclin receptor deletion aggravates hippocampal neuronal loss after bilateral common carotid artery occlusion in mouse
2008, Neuroscience
Transient global cerebral ischemia causes delayed neuronal death in the hippocampal CA1 region. It also induces an increase in cyclooxygenase 2 (COX-2), which generates several metabolites of arachidonic acid, known as prostanoids, including prostacyclin (PGI₂). To determine the role of the PGI₂ receptor (IP) in post-ischemic delayed cell death, wild-type and IP knockout (IP^−/−) C57Bl/6 mice were subjected to 12-min bilateral common carotid artery occlusion or sham surgery, followed by 7 days of reperfusion. In the sham-operated mice, no statistical difference in CA1 hippocampal neuronal density was observed between the wild-type (2836±18/mm²) and IP^−/− (2793±43/mm²) mice. Interestingly, in animals subjected to ischemia, surviving neuronal density in wild-type mice decreased to 50.5±7.9% and that of IP^−/− mice decreased to 23.0±4.5% of their respective sham-operated controls (P<0.05). The results establish a role for the IP receptor in protecting pyramidal hippocampal neurons after this global ischemic model and suggest that IP receptor agonists could be developed to prevent delayed pyramidal neuronal cell death.
Hyperbaric oxygen improves rate of return of spontaneous circulation after prolonged normothermic porcine cardiopulmonary arrest
2008, Resuscitation
This controlled, prospective, randomized porcine study tests the hypothesis that high-dose hyperbaric oxygen (HDHBO₂) compared with normobaric oxygen (NBO₂) or standard-dose hyperbaric oxygen (SDHBO₂), improves return of sustained spontaneous circulation (ROSC) after a normothermic, normobaric, 25-min, non-intervened-upon cardiopulmonary arrest. The study incorporated a direct mechanical ventricular assist device (DMVAD) for open chest continuous cardiac compressions (OCCC) to assist advanced cardiac life support (ACLS). The experiment demonstrates a dose response to oxygen concentration in the breathing mix used in resuscitative ventilation.
Male pigs (average 30 kg weight) underwent a 25-min, normothermic, non-intervened-upon cardiopulmonary arrest. Following arrest all animals were ventilated with 100% oxygen and were subjected to OCCC, incorporating DMVAD-aided ACLS. The animals so treated were randomized to be in one of three groups, with six animals in each group. The NBO₂ group remained at 1.0 atmosphere absolute (ATA), while the SDHBO₂ and HDHBO₂ groups were initially placed at 1.9 and 4.0 ATA, respectively. Uniform, but not American Heart Association (AHA) protocol, ACLS was maintained as needed over the ensuing 2 h for all animals in all groups. At the end of 2 h, the animals were euthanized.
Continuously sustained ROSC (mean arterial pressure ≥50 mmHg at all times), without the need of the pump assist over the 2-h resuscitation attempt that followed the 25-min arrest, occurred in four out of six animals in the HDHBO₂ group, and in none of the animals in the NBO₂ or SBHBO₂ groups (p ≤ 0.001).
Our results show significantly sustained ROSC using HDHBO₂ to resuscitate swine after a 25-min, non-intervened-upon, normothermic cardiopulmonary arrest. These results could not be achieved using NBO₂ or SDHBO₂.
Evaluation of staff's retention of ACLS and BLS skills
2008, Resuscitation
To test registered nurses’ abilities to retain basic or advanced life support psychomotor skills and theoretical knowledge.
A repeated-measures, quasi-experimental design was used.
Written and performance tests (initial, post-training, and final testing) used scenarios requiring performance of advanced cardiac life support (ACLS) or basic life support (BLS) skills. Final testing was by random assignment to 3, 6, 9, or 12 months.
A convenience sample (n = 133) was used.
American Heart Association 2000 ACLS and BLS evaluation tools were used in a simulated testing environment.
Findings show nurses retain theoretical knowledge but performance skills degrade quickly. ACLS skills degrade faster than BLS skills with 63% passing BLS at 3 months and 58% at 12 months. Only 30% of participants passed ACLS skills at 3 months and 14% at 12 months. These findings are similar to the results of other investigators in over a decade of research.
Study results showed a decline in skills retention with nurses unable to perform ACLS and BLS skills to standard for the entire certification period. The need for more frequent refresher training is needed. No formal research at this institution indicates skill degradation adversely affected patient outcomes. Further research on ACLS and BLS course content, design, management, and execution is needed.

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^☆: Reprint requests: Christopher M. O’Connor, MD, Box 3356, Duke University Medical Center, Durham, NC 27710.

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Cardiopulmonary resuscitation: Historical perspective to recent investigations☆,☆☆

Abstract

Section snippets

Outcomes

Cost

Response time

Etiology

Circulation

Pharmacotherapy

Conclusion

Am J Emerg Med

Am J Emerg Med

Am J Med

Ann Emerg Med

Lancet

Chest

Lancet

Ann Emerg Med

Am J Emerg Med

Ann Emerg Med

Am J Emerg Med

Am Heart J

Am J Cardiol

J Am Coll Cardiol

Chest

Mayo Clin Proc

Ann Emerg Med

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Am J Cardiol

Lancet

Am Heart J

Ann Emerg Med

Am J Cardiol

Lancet

Ann Emerg Med

Ann Emerg Med

Lancet

J Am Coll Cardiol

Ann Emerg Med

Closed-chest cardiac massage

JAMA

Report of the Working Group on Arteriosclerosis of the National Heart, Lung, and Blood Institute (Volume 2)

Sudden coronary death in the United States: 1980-1985

Circulation

Outcome of out-ofhospital cardiac arrest in New York City. The Pre-Hospital Arrest Survival Evaluation (PHASE) Study

JAMA

Survival after cardiopulmonary resuscitation in the hospital

N Engl J Med

In-hospital cardiopulmonary resuscitation: a 30-year review

J Am Board Fam Pract

In-hospital cardiopulmonary resuscitation. Survival in 1 hospital and literature review

Medicine (Baltimore)

A comparison of active compression-decompression cardiopulmonary resuscitation with standard cardiopulmonary resuscitation for cardiac arrests occurring in the hospital

N Engl J Med

A comparison of standard-dose and high-dose epinephrine in cardiac arrest outside the hospital. The Multicenter High-Dose Epinephrine Study Group

N Engl J Med

A randomized clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest

JAMA