Within eight years, Priestly would discover the element oxygen and Squires of London would record the first-ever use of electricity in resuscitation:
…he tried the effects of electricity. Twenty minutes elapsed before he could apply the shock [to the 3 year old child who had fallen out of a 1st story window], which he gave to various parts of the body in vain; but upon transmitting a few shocks through the thorax, he perceived a small pulsation; in a few minutes the child began to breathe….her health was restored (4).
Resuscitation became a legitimate science during the 19th century with literature replete of experimental successes in laboratory animal resuscitations. Techniques included using closed and open heart massage, manual ventilation using specialized medical bellows, and then finally, in 1899, documented cessation of ventricular fibrillation by electricity. Jean Louis Prevost and Frederic Batelli reported that they had defibrillated a dog successfully with the use of two electrodes―one on the head and one in the rectum―with high voltage AC current (13).
As the 20th century dawned, George Washington Crile―the cofounder of the Cleveland Clinic and considered by many as the most innovative researcher in the field of resuscitation―described successful closed chest cardiac massage in man and the first use of saline and epinephrine infusion in cardiac arrest in 1903. after the Russians Gurvich and Yuniev had demonstrated the superiority of DC current to AC current in defibrillation in 1939, Beck (1947) and Zoll (1956) published their successes in humans of open and closed chest defibrillation respectively.13 Even though the advent of the modern defibrillator loomed imminently, the practicality of widespread dissemination of the cumbersome equipment needed to provide these shocks was not yet manifest. Thus, Kouwenhoven and colleagues created a technique of closed chest cardiac massage that could keep patients alive long enough to receive definitive treatment, and modern CPR was born (14).
Epidemiology of Cardiopulmonary Arrest
In the United States an estimated 375,000 to 750,000 hospitalized patients suffer a cardiopulmonary arrest (CA) requiring advanced cardiac life support (ACLS) annually (15). The incidence of CA is estimated to be as high as 1–2% of all patients admitted to academic hospitals with a prevalence of 58 to 71 people per 100,000 nationally (16,17). The demographics of over 14,000 patients resuscitated for a CA are summarized in Table 1; patient comorbidities are listed in Figure 1.18 The typical CA patient is a white male in his seventh decade of life with a history of cardiac, pulmonary, or renal disease suffering from a pre-arrest arrhythmia or respiratory problem. Over 86% of patients are either on continuous cardiac monitoring (telemetry) or have a witnessed CA.
When primary respiratory arrests are excluded (such as from opiate overdose or post-anesthesia), only approximately 1 in 7 patients will survive an in-hospital resuscitation to discharge (1,19). Survivors’ initial rhythms are typically either pulseless ventricular tachycardia (VT) (35%) or ventricular fibrillation (VF) (34%), but fully 20% of survivors have initial “rhythms” of asystole or pulseless electrical activity (PEA)―which comprise virtually two–thirds of all arrests―suggesting a meager benefit to resuscitation of this subgroup of patients. Almost one third of survivors who lived independently pre-arrest are unable to be discharged home and between 14-23% of survivors―whose pre-arrest neurological function was normal―develop moderate to severe cognitive deficits after resuscitation (18,20). Fewer than 2% of survivors suffer coma or a persistent vegetative state. Neither gender nor advanced age appears to be a negative predictor of survival (1,21).
Time is Life Lost
The goals of resuscitation are two-fold: preservation of neurological function and prevention of early death. Expedient resuscitation maximizes the likelihood of positive outcomes, but too often, precious time is life lost spent performing unnecessary diagnostic maneuvers or unimportant interventions that have little impact on prognosis. The overarching target in in-hospital adult resuscitation is minimizing the time it takes for patients to receive defibrillation. All other activities are only a mean to this end. The remainder of this review will focus on seven highly effective strategies for successful resuscitations.