CARDIOPULMONARY RESUSCITATIONAND CARDIAC ARREST IN ADULTS:Major Challenges and Advances over the Past Fifty Years

5th Congress of Cardiologists and Angiologists of Bosnia and Herzegovina and

1st Congress of Cardiovascular Nursing in Bosnia and Herzegovina

May 28, 2010

A. Maziar Zafari, MD., PhD, FACC, FAHAAssociate Professor of Medicine

Emory University School of Medicine

Early Attempts at Resuscitation

Elisha's mouth to mouth resuscitation

(Bible, 2 Kings, IV, 34):

 "...And he went up, and lay upon the child, and put his mouth upon his mouth, and his eyes upon his eyes, and his hands upon his hands; and he stretched himself upon the child; and the flesh of the child waxed warm."

Early Ages - Inversion Method

Early Ages - Heat Method

Early Ages - Flagellation Method

1530 - Bellows Method

1711 - Fumigation Method

1770 - Inversion Method

1803 - Russian Method

1812 - Trotting Horse Method

1856 - Roll Method

Late 1892 - Tongue stretching

Hieronymus Bosch 1490, "The Ascent of the Blessed"

Scientific and Programmatic Highlights of the Modern History of CPR

1740 The Paris Academy of Sciences officially recommends mouth-to-mouth resuscitation for drowning victims.

1767 The Society for the Recovery of Drowned Persons becomes the first organized effort to deal with sudden death.

1891 Dr. Friedrich Maass performs the first documented chest compression in humans.

1903 Dr. George Crile reports the first successful use of external chest compressions in human resuscitation.

1954 James Elam is the first to prove that expired air is sufficient to maintain adequate oxygenation.

1956 Peter Safar and James Elam invent mouth-to-mouth resuscitation.

1957 The United States military adopts the mouth-to-mouth resuscitation method  to revive unresponsive victims.

1960 CPR is developed. The AHA starts a program to acquaint physicians with close-chest cardiac resuscitation.

1963 Cardiologist Leonard Scherlis starts the AHA's CPR Committee, and the same year, the AHA formally endorses CPR.

1966 Standardized training and performance standards for CPR are established.

1972 Leonard Cobb holds the world's first mass citizen training in CPR in Seattle, Washington called Medic 2.

1981 A program to provide telephone instructions in CPR begins in King County, Washington. 

1984 A program with fire fighter EMTs using AEDs begins in King County, Washington

1991 The chain of survival is introduced in 1991 as a model of efficiency and synergy in resuscitation efforts.

2000 The world’s first international conference is assembled specifically to produce international resuscitation guidelines.

2005 ILCOR publishes the 2005 International Consensus on CPR and ECC Science with Treatment Recommendations.

2010 The International Consensus on CPR and ECC Science with Treatment Recommendations is planned for publication in October.

Adult Chain of Survival

American Heart Association

The chain of survival was first introduced in 1991 as a model of efficiency and synergy in resuscitation efforts

European Resuscitation Council

I. The 3-phase model in VT/VF arrest integrating and characterizing specifically the time

relationships of the value of rapid defibrillation, CPR performance, and the need for other measures.

Phase Time Intervention

I. Electrical 0-5 min Defibrillation

II. Circulatory 5-15 min Chest Compressions

III. Metabolic >15 min Hypothermia

Weisfeldt and Becker. JAMA 2002.

II. The introduction of inexpensive, easy-to-use Automatic External Defibrillators.

Zafari, et al. J Am Coll Cardiol 2004.

In-Hospital Cardiac Arrest

Weaver et al. N Engl J Med 2002.

III. The need to translate animal data on CPR performance and effectiveness from the laboratory data into the clinical arena.

Sanders, et al. J Am Coll Cardiol 1985. Kern, et al. Resuscitation 1998.

IV. Introduction of devices that may improve perfusion during cardiopulmonary resuscitation

and thus may improve survival.

Halperin, et al. J Am Coll Cardiol 2004.

Halperin, et al. N Engl J Med 1993

V. Cardiocerebral resuscitation is useful in patients with out-of-hospital cardiac arrest.

Kern, et al. Circulation 2002. Ewy. Circulation 2005.

“Why is it that every time I press on his chest he opens his eyes,and every time I stop to breathe for him he goes back to sleep?”

A lay rescuer who had been given 9-1-1 dispatch telephone instructions in CPR

Ewy, et al. J Am Coll Cardiol 2009.

VI. Registry-based information on in-hospital and out-of-hospital CPR:

The National Registry of Cardiopulmonary Resuscitation

Chan, et al. N Engl J Med 2008. Bloom, et al. Am Heart J 2007.

VII. Change in the characteristics of the population suffering cardiac arrest:

Zheng, et al. Circulation 2001.

VIII. New paradigms that may affect resuscitation.

Lloyd, et al. Circulation 2008.

IX. The Post-Cardiac Arrest Syndrome and new technologies that may impact on resuscitation.

Neumar, et al. Circulation 2008.

Neumar, et al. Resuscitation 2004.

X. Moderate Hypothermia in patients who after out-of-hospital cardiac arrest have not awakened when they

reach the emergency department.

The Hypothermia after Cardiac Arrest Study Group. N Engl J Med 2002.

XI. The state of consciousness during cardiac arrest.

The AWAreness during Resuscitation Experiment (AWARE) is an ongoing study run by the

Human Consciousness Project.

Flatliners, 1990 with Julia Roberts and Kiefer Sutherland.

Abella et al. JAMA 2005.

XII. Quality of CPR Performance

Summary and Conclusions

• Advances in resuscitative medicine are founded on the basic science understanding of physiology and pathophysiology as well as advances in understanding of the causal mechanisms involved in successful or unsuccessful resuscitation.

• Survival is correlated with the speed and quality with which definitive therapies such as chest compressions and defibrillation are begun after cardiac arrest.

Push hard, push fast, minimize interruptions.

• Automated detection algorithms and technological advances in early defibrillation, chest compression, and post cardiac arrest care have the potential to increase survival to discharge in patients with out-of-hospital and in-hospital cardiac arrest.