410
Occasional
Survey
CARDIOPULMONARY RESUSCITATION
Perspectives and Problems BERNARD MESSERT
CHARLES E.
QUAGLIERI
Department of Neurology, Veterans Administration Hospital and University of Wisconsin, Madison, Wisconsin 53705, U.S.A.
SINCE the initial description of the closed-chest method of cardiopulmonary resuscitation (c.P .R.),1 house staff, nurses, and laymen trained in first-aid have become enthusiastic practitioners of the art.2 In the past fifteen years the closed-chest method of C.P.R. has evolved from what often were poorly organised sponefforts by bystanders to highly organised teamwork by trained physicians, nurses, and paramedical personnel. Electronic alarm systems and even automated resuscitators facilitating the maintenance of long-sustained efforts of reanimation are now available. The relative ease of application of closed-chest massage results frequently in excessive permissiveness. Many individuals presenting with an apparent sudden loss of consciousness due to syncope, seizures, or other neurological and medical causes may be subjected to resuscitative efforts and, when recovered, counted as a C.P.R. success. Despite recent glowing reports of the results of resuscitation, basically a small proportion of patients eventually leave the hospital. This small minority involves a limited number of diagnostic categories representing not only the better-risk cases but also cases taneous
erroneously diagnosed as cardiac arrest.
due to ventricular fibrillation. Of the 15 survivors who in fact did not experience cardiac arrest, 10 were eventual found to have sustained either a simple syncope or an epileptic seizure. 5 survivors experienced a primary pulmonary problem-in 1 case food aspiration. The length of the resuscitation procedure in the survivors ranged from very brief with almost immediate return to normal vital signs in 2 cases to a ninety-minute effort in 1. Age range of the non-survivors was 25-85 with a mean of 64 years, while that of the survivors was 51-77 with a mean of 66 years. Complete necropsy including examination of the brain was performed in 147 cases (80.3%) and gross neuropathologicalevidence of cerebral oedema was found in 38 (26%) cases. DISCUSSION
Most reports of c.P.R.s note
an
overall survival of
10-15%.3-5 Lemire and Johnson2 have lately related
a
decade of experience, with an overall survival-rate of 19.1%. Out of 1204 resuscitations attempted in the tenyear period, 230 survivors were discharged from their hospitals. That study was well controlled; but commonly the category of excellent results is inflated with patients who have experienced a vasovagal syncope, a seizure, a fall with concussion and/or contusion, or paroxysmal disorders affecting consciousness, and also with patients who revive with a single chest thump or brief resuscitative manoeuvres without the morbidity of the
long procedure.Ó
yield of the procedure is generally inversely proportional to its duration. But patients who fail to revive despite prolonged efforts include many poorrisk cases, terminal tumour cases, and elderly patients with multiple-system disease who eventually die through The eventual
failure of one system
METHODS
The study consists in a prospective evaluation of 183 patients during a period of three years (1972-75) in which one us was notified of every C.P.R. attempt in the Madison, Wisconsin, Veterans Administration Hospital. Each patient’s
of
chart as well as a standard form documenting events such as times of occurrence, drugs administered, and defibrillation, filled out by the physician in charge at the time of the arrest, were reviewed. The Madison VA is a 438-bed general medicalsurgical installation fully staffed twenty-four hours a day. A designated code blue team, consisting of an internist, cardiologist, anesthesiologist, general surgeon, and two nurses,
responds to every cardiopulmonary arrest. RE-SUL.TS
A total of 218 separate C.P.R. efforts were directed at 183 patients. 48 of the patients survived an initial C.P.R. However, 22 of the 48 eventually died, 20 in the hospital
either of recurrent arrest (occasionally multiple) or from a combination of the primary medical or surgical disease and/or results of the arrest. 2 patients died within two months of their discharge. 26 (14%) ultimately were discharged from the hospital and were considered long-term survivals. However, when those patients who were found not to have had a true cardiac arrest were discounted, only 11 patients (6%) were identified as having undergone cardiac arrest, and had been resuscitated and restored to a satisfactory functional status and discharged. In 7 of the 11 survivors (64%) the arrest was
or another. An expected finding was the relation of success to time and place of resuscitation. 8 of 11 survivors were resuscitated in the c.C.U., and 9 of 11 successes occurred between 1 and 6 P.M.-a period of full staffing. 3 cases of food aspiration were found; a 4th was suspected but died without post-mortem verification, Only 1 patient was successfully resuscitated when food was found almost inadvertently on immediate attempts at intubation. In 3 cases apparently no attempt to intubate was made, and food was found in the larynx of 2 by the pathologist. Only 2 survivors were identified as having fractured ribs after the C.P.R.; 1 other patient had a lacerated
larynx. An interesting sidelight was the strikingly high number of patients with neurological problems who underwent C.P.R. 33% of the patients carried neurological diagnoses such as recent cerebral infarction, organic brain syndrome, or neuropathy. Although this might seem to imply that the risk of sudden death increases if one has a neurological disease, more probably it reflects the high incidence of neurological disorders in an ageing population with multiple-system involvement. 2 of the 11I survivors had a neurological disorder. A profile of the ideal candidate for successful C.P.R can be seen to emerge. The patient would have an arrest in the C.C.U. in mid-afternoon, would not have a multisystem disease (e.g., a neurological disorder), and
411 an easily and quickly reversible cardiac If arrhyrhmia. food aspiration is thought to be a possible 6ause, intubation must be undertaken immediately. If a mask is used because of lack of training or from exredlency, the chance of survival will be nil. Finally, surnvat chances will be better if the patient does not suffer from complications of the procedure such as multiple rib fractures with flail chest or ruptured viscera.7 Age does not seem to be a factor. Of the 183 patients, 28 were eventually discharged from the hospital; 2 died of their primary illness within Mo months after discharge. Only 26 patients remained as actual long-term survivors with an apparent percentage survival of 15.3% if discharges from the hospital are considered and 14.2% survival if the long-term or at least a two-month survival is considered. However, if from these noncritical data one removes the non-arrest cases—e.g., syncopes, seizure, a suicidal attempt, and other miscellaneous non-cardiopulmonary causes totalling 11 patients (with 1 food aspiration)--one is left with only 14 long-term survivors, or a rather lower (7.6%) survival-rate. Finally, if one removes the non-truly cardiac arrest such as. pure pulmonary failure and pneumothorax, which in this study accounted for 5 patients, one is left with only 9 essential cardiac-arrest survivors, most of whom presented with fibrillation rather than asystole, and the survival-rate becomes a modest 4.9% (see accompanying table).
110uld have
DATA ON PROSPECTIVE STUDY OF
183
PATIENTS SUBMITTED TO
218
C.P.R.
’In these 28 cases the causes were cardiac disease 11, syncope and miscellaneous 11, primary respiratory failure 5, and food aspiration 1. jDeaths caused by cardiac arrest and/or primary disease. jDeaths at home within two months.
hyperextended position throughout resuscitation. Finally, circulatory impedance is increased on the venous side by the sludging and congestion of flow from reflux forces in the venous sinuses and large veins transmitted up from the atria via the superior vena cava and jugular veins by the forces applied to the precordium. In patients free of arteriosclerotic changes, chest massage results in two nearly equal opposing forces: satisfactory forward propulsion of blood from the cardiac cavities to the brain time that increased intrathoracic pressure flow in the venous systems. This inimpedes creased back-pressure can be expected to have some effects on the intracerebral vascular bed resulting in further stagnation of both arterial and venous blood89 and must be responsible at least in part for the production of brain oedema. Venous back-pressure has also been implicated as a cause of pulmonary oedema during resuscitation. 10 It is likely that the degree of brain oedema becomes directly proportional to the duration of the application of the pressure. The effects of the combined anoxic oedema and the oedema secondary to the resuscitation-related forces might also result in cardiacrhythym abnormalities by ischaemia and/or herniation of brain-stem and medullary centres. Vagocortical-centre (area 13) involvement might also explain the brady-i rhythmias frequently noted during resuscitation. 11 In our study gross neuropathological evidence of cerebral oedema (e.g., evidence of herniation) was found in 38 (26%) of 147 post-mortem examinations. Prevention or reduction of brain oedema can possibly be achieved by greater attention to the positioning of the patient. Excessive extension or lateral rotation of the head probably results in a double liability: first, it decreases straight arterial flow by kinking of at least the vertebral arteries; and, second, it results in venous obstruction much as from a Valsalva manoeuvre.12 Oedema-reducing compounds may well have a place early in the resuscitation procedure if the process is expected to be arduous, and they should be part of the supportive care once the initial resuscitation has been successful. at
the
same
return
CONCLUSION
study 5 survivors remained in a chronic vegetative state. Survival, however, was limited to four to six weeks for each of these patients. The rate of chronic vegetative state was 2.7% of all resuscitation but t0.4’’t of the initial survivors. The actual duration of C.P.R. is of critical importance. In
our
Brain oedema over and above that caused by anoxia can be caused by the application of closed-chest massage. This oedema is evidenced by the general appearance and the increased weight of the brain post mortem. Closed-chest massage produces almost equivalent pressures in all chambers of the heart. Measured intraluminal arterial peaks denote only pressure gradients and do not necessarily imply forward arterial flow. Arterial blood-flow depends on the difference in pressure between the ventricles and arteries. Whatever forward occurs is probably impeded by arteriosclerotic changes in the carotid and vertebral arteries and the cir:!e of Furthermore, hyperextension of the neck sth underlying arteriosclerosis of the vessels and spon:i iosis of the cervical spine can seriously impede :rtebrai flow. Intubation requires this hyperextension of h: neck, and frequently the patient is maintained in this
the degree of sophistication of the closed-chest resuscitation technique and availability of permassage sonnel in most institutions, a plateau in the yield of the procedure seems to have been reached. The limitations to the successful outcome of C.P.R. in many cases may well reside in the morbidity inherent in the procedure itself. One possible way to extend the value and success-rate of C.P.R. would be to pay special attention to the problem of brain oedema secondary to venous back-pressure. Statistical reports of success/failure rates should not include non-arrest cases. Special attention should be directed to rapidly reversible food aspiration accidents.
Despite
REFERENCES 1.
Kouwenhoven, W. B., Jude, J. R., Knickerbocker, G. G. J. Am. med. Ass. 1960, 173, 1064. 2. Lemire, J. G., Johnson, A. L. New Engl. J. Med. 1972, 286, 970. 3. Johnson, A. L., Tanser, P. H., Ulan, R. A. Am. J. Cardiol. 1967, 20, 831 4. Hollingsworth, J. H. Ann. intern. Med. 1969, 71, 459. 5. Stephenson, H. E. J. Am. med. Ass. 1972, 222, 93. 6. Pennington, J. E., Taylor, J., Lown, B. New Engl. J. Med. 1970, 283, 1192. 7. Poulsen, H., Holmdahl, M., Jorgensen, L., Nixon, P., Jude, J. Acta anœsthes. scand. 1968, suppl. 29, p. 319. 8. Thomsen, J. E., Stenlund, R. R., Rowe, G. G. J. Am. med. Ass. 1968,
205, 116.
Occasional
Survey
CARDIOPULMONARY RESUSCITATION
Perspectives and Problems BERNARD MESSERT
CHARLES E.
QUAGLIERI
Department of Neurology, Veterans Administration Hospital and University of Wisconsin, Madison, Wisconsin 53705, U.S.A.
SINCE the initial description of the closed-chest method of cardiopulmonary resuscitation (c.P .R.),1 house staff, nurses, and laymen trained in first-aid have become enthusiastic practitioners of the art.2 In the past fifteen years the closed-chest method of C.P.R. has evolved from what often were poorly organised sponefforts by bystanders to highly organised teamwork by trained physicians, nurses, and paramedical personnel. Electronic alarm systems and even automated resuscitators facilitating the maintenance of long-sustained efforts of reanimation are now available. The relative ease of application of closed-chest massage results frequently in excessive permissiveness. Many individuals presenting with an apparent sudden loss of consciousness due to syncope, seizures, or other neurological and medical causes may be subjected to resuscitative efforts and, when recovered, counted as a C.P.R. success. Despite recent glowing reports of the results of resuscitation, basically a small proportion of patients eventually leave the hospital. This small minority involves a limited number of diagnostic categories representing not only the better-risk cases but also cases taneous
erroneously diagnosed as cardiac arrest.
due to ventricular fibrillation. Of the 15 survivors who in fact did not experience cardiac arrest, 10 were eventual found to have sustained either a simple syncope or an epileptic seizure. 5 survivors experienced a primary pulmonary problem-in 1 case food aspiration. The length of the resuscitation procedure in the survivors ranged from very brief with almost immediate return to normal vital signs in 2 cases to a ninety-minute effort in 1. Age range of the non-survivors was 25-85 with a mean of 64 years, while that of the survivors was 51-77 with a mean of 66 years. Complete necropsy including examination of the brain was performed in 147 cases (80.3%) and gross neuropathologicalevidence of cerebral oedema was found in 38 (26%) cases. DISCUSSION
Most reports of c.P.R.s note
an
overall survival of
10-15%.3-5 Lemire and Johnson2 have lately related
a
decade of experience, with an overall survival-rate of 19.1%. Out of 1204 resuscitations attempted in the tenyear period, 230 survivors were discharged from their hospitals. That study was well controlled; but commonly the category of excellent results is inflated with patients who have experienced a vasovagal syncope, a seizure, a fall with concussion and/or contusion, or paroxysmal disorders affecting consciousness, and also with patients who revive with a single chest thump or brief resuscitative manoeuvres without the morbidity of the
long procedure.Ó
yield of the procedure is generally inversely proportional to its duration. But patients who fail to revive despite prolonged efforts include many poorrisk cases, terminal tumour cases, and elderly patients with multiple-system disease who eventually die through The eventual
failure of one system
METHODS
The study consists in a prospective evaluation of 183 patients during a period of three years (1972-75) in which one us was notified of every C.P.R. attempt in the Madison, Wisconsin, Veterans Administration Hospital. Each patient’s
of
chart as well as a standard form documenting events such as times of occurrence, drugs administered, and defibrillation, filled out by the physician in charge at the time of the arrest, were reviewed. The Madison VA is a 438-bed general medicalsurgical installation fully staffed twenty-four hours a day. A designated code blue team, consisting of an internist, cardiologist, anesthesiologist, general surgeon, and two nurses,
responds to every cardiopulmonary arrest. RE-SUL.TS
A total of 218 separate C.P.R. efforts were directed at 183 patients. 48 of the patients survived an initial C.P.R. However, 22 of the 48 eventually died, 20 in the hospital
either of recurrent arrest (occasionally multiple) or from a combination of the primary medical or surgical disease and/or results of the arrest. 2 patients died within two months of their discharge. 26 (14%) ultimately were discharged from the hospital and were considered long-term survivals. However, when those patients who were found not to have had a true cardiac arrest were discounted, only 11 patients (6%) were identified as having undergone cardiac arrest, and had been resuscitated and restored to a satisfactory functional status and discharged. In 7 of the 11 survivors (64%) the arrest was
or another. An expected finding was the relation of success to time and place of resuscitation. 8 of 11 survivors were resuscitated in the c.C.U., and 9 of 11 successes occurred between 1 and 6 P.M.-a period of full staffing. 3 cases of food aspiration were found; a 4th was suspected but died without post-mortem verification, Only 1 patient was successfully resuscitated when food was found almost inadvertently on immediate attempts at intubation. In 3 cases apparently no attempt to intubate was made, and food was found in the larynx of 2 by the pathologist. Only 2 survivors were identified as having fractured ribs after the C.P.R.; 1 other patient had a lacerated
larynx. An interesting sidelight was the strikingly high number of patients with neurological problems who underwent C.P.R. 33% of the patients carried neurological diagnoses such as recent cerebral infarction, organic brain syndrome, or neuropathy. Although this might seem to imply that the risk of sudden death increases if one has a neurological disease, more probably it reflects the high incidence of neurological disorders in an ageing population with multiple-system involvement. 2 of the 11I survivors had a neurological disorder. A profile of the ideal candidate for successful C.P.R can be seen to emerge. The patient would have an arrest in the C.C.U. in mid-afternoon, would not have a multisystem disease (e.g., a neurological disorder), and
411 an easily and quickly reversible cardiac If arrhyrhmia. food aspiration is thought to be a possible 6ause, intubation must be undertaken immediately. If a mask is used because of lack of training or from exredlency, the chance of survival will be nil. Finally, surnvat chances will be better if the patient does not suffer from complications of the procedure such as multiple rib fractures with flail chest or ruptured viscera.7 Age does not seem to be a factor. Of the 183 patients, 28 were eventually discharged from the hospital; 2 died of their primary illness within Mo months after discharge. Only 26 patients remained as actual long-term survivors with an apparent percentage survival of 15.3% if discharges from the hospital are considered and 14.2% survival if the long-term or at least a two-month survival is considered. However, if from these noncritical data one removes the non-arrest cases—e.g., syncopes, seizure, a suicidal attempt, and other miscellaneous non-cardiopulmonary causes totalling 11 patients (with 1 food aspiration)--one is left with only 14 long-term survivors, or a rather lower (7.6%) survival-rate. Finally, if one removes the non-truly cardiac arrest such as. pure pulmonary failure and pneumothorax, which in this study accounted for 5 patients, one is left with only 9 essential cardiac-arrest survivors, most of whom presented with fibrillation rather than asystole, and the survival-rate becomes a modest 4.9% (see accompanying table).
110uld have
DATA ON PROSPECTIVE STUDY OF
183
PATIENTS SUBMITTED TO
218
C.P.R.
’In these 28 cases the causes were cardiac disease 11, syncope and miscellaneous 11, primary respiratory failure 5, and food aspiration 1. jDeaths caused by cardiac arrest and/or primary disease. jDeaths at home within two months.
hyperextended position throughout resuscitation. Finally, circulatory impedance is increased on the venous side by the sludging and congestion of flow from reflux forces in the venous sinuses and large veins transmitted up from the atria via the superior vena cava and jugular veins by the forces applied to the precordium. In patients free of arteriosclerotic changes, chest massage results in two nearly equal opposing forces: satisfactory forward propulsion of blood from the cardiac cavities to the brain time that increased intrathoracic pressure flow in the venous systems. This inimpedes creased back-pressure can be expected to have some effects on the intracerebral vascular bed resulting in further stagnation of both arterial and venous blood89 and must be responsible at least in part for the production of brain oedema. Venous back-pressure has also been implicated as a cause of pulmonary oedema during resuscitation. 10 It is likely that the degree of brain oedema becomes directly proportional to the duration of the application of the pressure. The effects of the combined anoxic oedema and the oedema secondary to the resuscitation-related forces might also result in cardiacrhythym abnormalities by ischaemia and/or herniation of brain-stem and medullary centres. Vagocortical-centre (area 13) involvement might also explain the brady-i rhythmias frequently noted during resuscitation. 11 In our study gross neuropathological evidence of cerebral oedema (e.g., evidence of herniation) was found in 38 (26%) of 147 post-mortem examinations. Prevention or reduction of brain oedema can possibly be achieved by greater attention to the positioning of the patient. Excessive extension or lateral rotation of the head probably results in a double liability: first, it decreases straight arterial flow by kinking of at least the vertebral arteries; and, second, it results in venous obstruction much as from a Valsalva manoeuvre.12 Oedema-reducing compounds may well have a place early in the resuscitation procedure if the process is expected to be arduous, and they should be part of the supportive care once the initial resuscitation has been successful. at
the
same
return
CONCLUSION
study 5 survivors remained in a chronic vegetative state. Survival, however, was limited to four to six weeks for each of these patients. The rate of chronic vegetative state was 2.7% of all resuscitation but t0.4’’t of the initial survivors. The actual duration of C.P.R. is of critical importance. In
our
Brain oedema over and above that caused by anoxia can be caused by the application of closed-chest massage. This oedema is evidenced by the general appearance and the increased weight of the brain post mortem. Closed-chest massage produces almost equivalent pressures in all chambers of the heart. Measured intraluminal arterial peaks denote only pressure gradients and do not necessarily imply forward arterial flow. Arterial blood-flow depends on the difference in pressure between the ventricles and arteries. Whatever forward occurs is probably impeded by arteriosclerotic changes in the carotid and vertebral arteries and the cir:!e of Furthermore, hyperextension of the neck sth underlying arteriosclerosis of the vessels and spon:i iosis of the cervical spine can seriously impede :rtebrai flow. Intubation requires this hyperextension of h: neck, and frequently the patient is maintained in this
the degree of sophistication of the closed-chest resuscitation technique and availability of permassage sonnel in most institutions, a plateau in the yield of the procedure seems to have been reached. The limitations to the successful outcome of C.P.R. in many cases may well reside in the morbidity inherent in the procedure itself. One possible way to extend the value and success-rate of C.P.R. would be to pay special attention to the problem of brain oedema secondary to venous back-pressure. Statistical reports of success/failure rates should not include non-arrest cases. Special attention should be directed to rapidly reversible food aspiration accidents.
Despite
REFERENCES 1.
Kouwenhoven, W. B., Jude, J. R., Knickerbocker, G. G. J. Am. med. Ass. 1960, 173, 1064. 2. Lemire, J. G., Johnson, A. L. New Engl. J. Med. 1972, 286, 970. 3. Johnson, A. L., Tanser, P. H., Ulan, R. A. Am. J. Cardiol. 1967, 20, 831 4. Hollingsworth, J. H. Ann. intern. Med. 1969, 71, 459. 5. Stephenson, H. E. J. Am. med. Ass. 1972, 222, 93. 6. Pennington, J. E., Taylor, J., Lown, B. New Engl. J. Med. 1970, 283, 1192. 7. Poulsen, H., Holmdahl, M., Jorgensen, L., Nixon, P., Jude, J. Acta anœsthes. scand. 1968, suppl. 29, p. 319. 8. Thomsen, J. E., Stenlund, R. R., Rowe, G. G. J. Am. med. Ass. 1968,
205, 116.
