Advances and controversies in cardiopulmonary resuscitation in the young.

Pediatric resuscitation is most frequently required for respiratory arrest. Cardiac arrest is a rare and ominous event and usually develops as a complication of shock or respiratory failure. Once asystolic cardiac arrest occurs, the outcome of any resuscitation is dismal; if cardiopulmonary arrest persists longer than 15 minutes in the normothermic child, further efforts are unlikely to result in patient recovery. For this reason, attention must focus on prevention of arrest and prompt restoration of oxygenation and ventilation, heart rate, and systemic perfusion.     

Haemodynamics of cardiac arrest and resuscitation

PURPOSE OF REVIEW: This review will summarize the available data regarding the haemodynamic changes occurring following cardiac arrest in humans and animal models. RECENT FINDINGS: Following cardiac arrest due to ventricular fibrillation without cardiopulmonary resuscitation, blood flow exponentially falls but continues for approximately 5 min until the pressure gradient between the aorta and the right heart is completely dissipated. During cardiopulmonary resuscitation forward flow occurs into the aorta during the compression phase. Coronary blood flow is retrograde during the compression phase and antegrade during the decompression phase. Carotid blood flow takes over a minute to reach plateau levels following the initiation of chest compressions, and even brief interruptions of compressions result in a dramatic reduction in carotid blood flow which takes a minute or so to recover to plateau levels when compressions are reinstituted. Coronary perfusion pressure during the release phase of cardiopulmonary resuscitation has been shown to be a powerful predictor of the likelihood of recovery of spontaneous circulation following restoration of electrical activity. SUMMARY: Recent studies have provided important insights into the haemodynamics of cardiac arrest and of cardiopulmonary resuscitation which may inform more effective strategies for the management of cardiac arrest in the future.     

Cardiopulmonary resuscitation traumatic cardiac arrest - there are survivors. An analysis of two national emergency registries

Introduction  

Cardiac arrest following trauma occurs infrequently compared with cardiac aetiology. Within the German Resuscitation Registry a traumatic cause is documented in about 3% of cardiac arrest patients. Regarding the national Trauma Registry, only a few of these trauma patients with cardiac arrest survive. The aim of the present study was to analyze the outcome of cardiopulmonary resuscitation (CPR) after traumatic cardiac arrest by combining data from two different large national registries in Germany.     

Cardiology: improving nurses' resuscitation skills.

Nurses have a crucial role to play in determining whether victims of cardiac arrest survive, but skills vary and, perhaps because of the onerous responsibility placed upon them, some nurses feel less than confident in using their abilities to the full. The author describes a resuscitation training course for staff in one hospital, designed to bolster confidence and to ensure all nurses are equally competent in giving assistance when cardiac arrest occurs.     

Rapid change in pulmonary vascular hemodynamics with pulmonary edema during cardiopulmonary resuscitation

Previous studies have shown that pulmonary edema occurs in half of all pre-hospital cardiac arrest victims who cannot be successfully resuscitated and is a major cause of hypoxemia and poor lung compliance during resuscitation. Pulmonary vascular hypertension and elevation of pulmonary capillary wedge pressure have been observed during cardiac resuscitation in humans. To further define the time course of the pulmonary hemodynamic changes, pulmonary artery diastolic pressure (PAd) was measured on a computerized trend recorder prior to, during, and immediately after arrest in three adult patients. Prior to arrest, PADP was 20.9 +/- 3.1 mm Hg. The PADP rose in all three patients by an average of 30.6% after 5-10 minutes and 71.3% after 10-15 minutes of CPR. Peak PADP reached 35.8 +/- 5.1 mm Hg (difference from pre-arrest level significant, P less than 0.001). In both patients who were resuscitated successfully, the PADP returned to baseline within 5 minutes of effective spontaneous circulation. The finding that such hemodynamic changes occur rapidly during resuscitation and can reverse quickly with resumption of effective spontaneous circulation is consistent with the time course for the early development of pulmonary edema. Development of pulmonary edema many hours following successful resuscitation likely involves other mechanisms.     

In-hospital cardiac arrest: Is outcome related to the time of arrest?

BACKGROUND: Whether outcome from in-hospital cardiopulmonary resuscitation (CPR) is poorer when it occurs during the night remains controversial. This study examined the relationship between CPR during the various hospital shifts and survival to discharge. METHODS: CPR attempts occurring in a tertiary hospital with a dedicated, certified resuscitation team were recorded prospectively (Utstein template guidelines) over 24 months. Medical records and patient characteristics were retrieved from patient admission files. RESULTS: Included were 174 in-hospital cardiac arrests; 43%, 32% and 25% in morning evening and night shifts, respectively. Shift populations were comparable in demographic and treatment related variables. Asystole (p < 0.01) and unwitnessed arrests (p = 0.05) were more common during the night. Survival to discharge was poorer following night shift CPR than following morning and evening shift CPR (p = 0.04). When asystole (being synonymous with death) was excluded from the analysis, the odds of survival to discharge was not higher for witnessed compared to unwitnessed arrest but was 4.9 times higher if the cardiac arrest did not occur during the night shift (p = 0.05, logistic regression). The relative risk of eventual in-hospital death for patients with return of spontaneous circulation (ROSC) following night shift resuscitation was 1.9 that of those with ROSC following morning or evening resuscitation (Cox regression). CONCLUSIONS: Although unwitnessed arrest is more prevalent during night shift, resuscitation during this shift is associated with poorer outcomes independently of witnessed status. Further research is required into the causes for the increased mortality observed after night shift resuscitation.     

Cardiopulmonary resuscitation standards for clinical practice and training in the UK

The Royal College of Anaesthetists, the Royal College of Physicians, the Intensive Care Society and the Resuscitation Council (UK) have published new resuscitation standards. The document provides advice to UK healthcare organisations, resuscitation committees and resuscitation officers on all aspects of the resuscitation service. It includes sections on resuscitation training, resuscitation equipment, the cardiac arrest team, cardiac arrest prevention, patient transfer, post resuscitation care, audit and research. The document makes several recommendations. Healthcare institutions should have, or be represented on, a resuscitation committee that is responsible for all resuscitation issues. Every institution should have at least one resuscitation officer responsible for teaching and conducting training in resuscitation techniques. Staff with patient contact should be given regular resuscitation training appropriate to their expected abilities and roles. Clinical staff should receive regular training in the recognition of patients at risk of cardiopulmonary arrest and the measures required for the prevention of cardiopulmonary arrest. Healthcare institutions admitting acutely ill patients should have a resuscitation team, or its equivalent, available at all times. Clear guidelines should be available indicating how and when to call for the resuscitation team. Cardiopulmonary arrest should be managed according to current national guidelines. Resuscitation equipment should be available throughout the institution for clinical use and for training. The practice of resuscitation should be audited to maintain and improve standards of care. A do not attempt resuscitation (DNAR) policy should be compiled, communicated to relevant members of staff, used and audited regularly. Funding must be provided to support an effective resuscitation service.     

241例心跳骤停与心肺脑复苏的回顾性分析

目的 探讨心跳骤停患者的临床特点及救治经验，以提高心肺脑复苏成功率。方法 回顾性分析我科1990年10月至2002年10月十二年间院内及院外急救的241例心跳骤停患者的临床资料，初步分析治疗与预后的关系。结果 241例心跳骤停患者中，初步复苏成功10例，最终复苏成功(心肺脑均复苏)仅4例，复苏率分别为4．62％、1．82％。1990至1998年间复苏成功率较低，初步复苏成功率1．38％，最终复苏成功率0。1999至2002年间复苏成功率明显提高，初步复苏成功率8．24％，最终复苏成功率4．12％。自1998年我科开展院外急救以来，尚无一例院外心跳骤停者复苏成功。结论 心跳骤停患者抢救成功与否与抢救人员专业水平、抢救开始时间、抢救措施正确与否、对室颤患者能否早期除颤及患者原发病是否可逆等因素密切相关。     

Two-stage resuscitation of the cat brain after prolonged cardiac arrest

Following prolonged cardiac arrest, reperfusion of the brain is endangered by the low blood perfusion pressure during the early resuscitation phase. In order to avoid low perfusion brain injury, a two-stage resuscitation protocol was applied to cats submitted to 30 min potassium chloride induced cardiac arrest: first, the heart was resuscitated, followed — after stabilisation of blood pressure — by recirculation of the brain. During cardiac resuscitation the brain was disconnected from the general circulation by inflating a pneumatic cuff around the neck. The results were compared with the outcome of conventional one-stage resuscitation following 15 min cardiac arrest. Cardiac resuscitation was successful in 5 out of 8 animals with 15 min and in 6 out of 13 animals with 30 min cardiac arrest. In successfully resuscitated animals of both groups, brain energy metabolism recovered to normal within 3 h although two-stage resuscitation increased brain ischemia time to 37–61 min. Twostage resuscitation, in consequence, is a promising approach for revival of the brain after prolonged cardiac arrest.     

Cardiopulmonary resuscitation standards for clinical practice and training in the UK

The Royal College of Anaesthetists, the Royal College of Physicians, the Intensive Care Society and the Resuscitation Council (UK) have published new resuscitation standards. The document provides advice to UK healthcare organisations, resuscitation committees and resuscitation officers on all aspects of the resuscitation service. It includes sections on resuscitation training, resuscitation equipment, the cardiac arrest team, cardiac arrest prevention, patient transfer, post-resuscitation care, audit and research. The document makes several recommendations. Healthcare institutions should have, or be represented on, a resuscitation committee that is responsible for all resuscitation issues. Every institution should have at least one resuscitation officer responsible for teaching and conducting training in resuscitation techniques. Staff with patient contact should be given regular resuscitation training appropriate to their expected abilities and roles. Clinical staff should receive regular training in the recognition of patients at risk of cardiopulmonary arrest and the measures required for the prevention of cardiopulmonary arrest. Healthcare institutions admitting acutely ill patients should have a resuscitation team, or its equivalent, available at all times. Clear guidelines should be available indicating how and when to call for the resuscitation team. Cardiopulmonary arrest should be managed according to current national guidelines. Resuscitation equipment should be available throughout the institution for clinical use and for training. The practice of resuscitation should be audited to maintain and improve standards of care. A do not attempt resuscitation (DNAR) policy should be compiled, communicated to relevant members of staff, used and audited regularly. Funding must be provided to support an effective resuscitation service.     

Historical perspectives on anesthetic-related cardiac arrest and resuscitation

Contemporary interest in resuscitation was historically related to anesthetic death. Primitive techniques of anesthetic administration, loss of airway control, and psychologically influenced sudden death contributed to unanticipated respiratory and cardiac arrest. Airway obstruction has remained the principal factor in asphyxial death, necessitating crucial preservation of respiratory function during induction of anesthesia. Early, disorganized overdose and arrest interventions included: application of cold water, manual artificial respiration, heat, friction and galvanic battery application. Cardiopulmonary resuscitation, after years of research and experimentation became an integrated plan of attack: mouth-to-mouth ventilation and maneuvers eliminating pharyngeal obstruction were proven effective; internal and external cardiac massage was incorporated and definitive drug therapy began with epinephrine, strychnine, caffeine, carbon dioxide, amyl nitrate, coramine, metrazol and procaine. Defibrillation proved electricity converted ventricular fibrillation to normal sinus rhythm. Significant lethality still occurs from anesthetic-induced cardiac arrest, despite technological advances. Causes of operating room cardiac arrests are numerous and include sudden death syndrome. Constant vigilance distinguishes variable patient response. Immediate recognition and coordinated intervention assures success.     

Reservations and recommendations regarding sodium bicarbonate administration in cardiac arrest

The American Heart Association's (AHA) revised "Standards and Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC)" recommend that bicarbonate be used ". . . only at the discretion of the physician directing the resuscitation." Reliance upon arterial blood gases is suggested for bicarbonate administration to the patient in cardiac arrest. However, recent literature suggests that arterial blood gases may not reflect the severe cellular acidosis that occurs at the tissue level during cardiac arrest. This article reviews the literature support for this recommendation and for the primary reliance upon hyperventilation to treat the acidosis of cardiac arrest patients. This is a very significant change in the management of the acidosis of cardiac arrest. As with most changes in traditional clinical practice, it will be difficult to overturn years of physician behavior.     

Rescue percutaneous coronary intervention during cardiopulmonary resuscitation

If sudden cardiac arrest occurs during cardiac catheterization, the underlying coronary condition may be defined immediately by coronary angiography. This may, in turn, allow a lifesaving attempt of percutaneous coronary intervention (PCI). We report on two patients with critical proximal disease of the left coronary artery in whom successful PCI during cardiopulmonary resuscitation (CPR) led to the restoration of a spontaneous circulation and long-term survival.     

"Putting it all together" to improve resuscitation quality

Solutions to improve care provided during cardiac arrest resuscitation attempts must be multifaceted and targeted to the diverse number of care providers to be successful. In this article, new approaches to improving cardiac arrest resuscitation performance are reviewed. The focus is on a continuous quality improvement paradigm highlighting improving training methods before actual cardiac arrest events, monitoring quality during resuscitation attempts, and using quantitative debriefing programs after events to educate frontline care providers.     

In-hospital resuscitation among the elderly: Substantial survival to hospital discharge

The appropriateness of aggressive resuscitation in many clinical settings has been questioned. Survival rates from cardiac arrest in the elderly are generally reported as poor, and satisfactory results from resuscitation attempts prolonged beyond 15 minutes are said to be rare. It was the purpose of this study to examine success rates for resuscitation in a cohort of elderly inpatients suffering cardiac arrest. We retrospectively reviewed 213 consecutive cardiac arrests occurring during a 12-month period in a single large tertiary private hospital. Patient age, presenting rhythm, and survival to hospital discharge were recorded. Elderly was defined as age 70 years or older. Cardiac arrests in the elderly totaled 89. Average age in this cohort was 76.2 ± 4.5 years. Eighteen patients (20.2%) had return of spontaneous circulation and 8 patients survived to hospital discharge (44.4% of those with return of spontaneous circulation). No significant difference in age or presenting rhythm of survivors versus nonsurvivors could be demonstrated, although a trend to more frequent ventricular fibrillation or ventricular tachycardia was seen (P = .059, Fisher's exact). Time for resuscitation averaged 25.75 ± 9.2 minutes for survivors and 32.6 ± 22.1 minutes for nonsurvivors. Survival to hospital discharge occurs in 9% of in-hospital cardiac arrests in the elderly following average CPR times substantially in excess of 15 minutes.     

心肺复苏流程记录单的设计及应用

为进一步规范心肺复苏抢救的护理记录内容,提高护理病历质量,以心肺骤停患者抢救流程为基础,设计了心肺复苏流程记录单.经过2年的临床应用,效果明显.心肺复苏流程记录单可规范心肺复苏抢救的护理记录内容,提高护士心肺复苏抢救的能力和病历书写质量,改进心肺复苏抢救流程,并在提高心肺复苏成功率上具有一定的作用.     

心肺复苏家兔血浆ET、CGRP含量变化的研究

目的 研究血浆内皮素（ＥＴ）与降钙素基因相关肽（ＣＧＲＰ）在心脏骤停缺血／再灌注损伤前后含量变化规律及意义。方法 制作家兔心脏骤停缺血／再灌注模型。观察心肺复苏后各时相血浆ＥＴ、ＣＧＲＰ、血压及心电变化。结果 动物在心脏骤停及复苏即刻血浆ＥＴ含量明显变化（Ｐ〈０．０５），而血浆ＣＧＲＰ水平降低（Ｐ〈０．０５），复苏后０．５小时血浆ＥＴ明显升高（Ｐ〈０．０１），复苏后２小时血浆ＥＴ、ＣＧＲＰ均较复苏前有明显上升（Ｐ〈０．０５）。结论 在心脏骤停缺血／再灌注损伤过程中ＥＴ、ＣＧＲＰ水平变化及相关关系可能是一种调节机制并在病理生理过程中起重要作用。     

Persistent Ventricular Fibrillation During Therapeutic Hypothermia and Prolonged High-Dose Vasopressor Therapy: Case Report

Background: Recent emphasis on high quality prehospital cardiopulmonary resuscitation has resulted in more out-of-hospital cardiac arrest victims surviving to the emergency department. As such, standardized in-hospital post-cardiac arrest care is necessary to assure optimal neurological recovery. Although therapeutic hypothermia has arisen as a key component in the post-cardiac arrest care paradigm, its interaction with other therapies remains poorly defined. Objective: The purpose of this communication is to demonstrate a potential interaction between therapeutic hypothermia and routinely administered resuscitation medications. Case Report: We present a case of idiopathic ventricular fibrillation in a previously healthy 36-year-old man who developed persistent ventricular fibrillation in the setting of mild therapeutic hypothermia and high doses of routine resuscitation medications. Conclusion: This case illustrates the importance of understanding the potential interaction between therapeutic hypothermia and resuscitation medications along with the need for a systematic and standardized, multi-disciplinary approach to post-cardiac arrest care.     

ICU内心肺复苏的执行与结果分析

目的:探讨ICU内心肺复苏的执行与结果。方法:以队列研究的方式,前瞻性观察我院经培训的ICU医生实施心肺复苏的具体情况。结果:(1)心跳呼吸骤停有三种形式,以心跳骤停为主,且以室性逸搏最多。(2)均能给予人工通气,首次除颤成功率88.5%。(3)呼吸骤停组及室速 室颤组复苏成功率高(23.8%比2.9%,P<0.01;42.9%比14.5%,P<0.05),室性逸搏 等电位线组复苏成功率低(15.5比70.5%,P<0.01)。结论:ICU内心跳呼吸骤停的最多形式是室性逸搏。呼吸骤停及室速、室颤的复苏成功率高,而室性逸搏的复苏成功率低。     

Initiation of resuscitation in patients with prehospital bradyasystolic cardiac arrest in Helsinki

The factors influencing the decision to initiate resuscitation in prehospital cardiac arrest patients encountered in bradyasystole due to presumed heart disease were studied. For this purpose, the characteristics and circumstances of arrest of the patients encountered in asystole and electromechanical dissociation, seen by a physician-staffed prehospital emergency care unit in a tiered emergency medical system, were reviewed. During the study period, resuscitation was initiated in 83 bradyasytolic patients. The characteristics of these patients were compared with those of 72 patients in asystole or electromechanical dissociation declared dead on the scene without resuscitation. The presence of EMD was the most important factor influencing the decision to resuscitate (P less than 0.001), even if the arrest was unwitnessed, while the patient's age was of less importance. For the patients with a witnessed arrest, the delay before treatment was initiated also affected the decision. Successful resuscitation and survival of the patients was similar to earlier reports. The results provide guidelines in the decision making of initiation of resuscitation when developing our emergency care system into one with non-physicians as advanced life support providers.