FEATURE EMERGENCY MEDICINE
electrical current was first reported in 1956 and lead to the process of making defibrillators rapidly available wherever emergency cardiac care was provided. Basic cardiopulmonary resuscitation
(CPR) resulted from a series of observations. Safer and Elam independently confirmed the value of mouth-to-mouth ventilation in adults after reading and observing this technique being performed by midwives to revive newborn babies. In 1960 Kouwenhoven observed that compression of the chest created palpable pulses during cardiac arrest in the operating room. Over the next several years, Safer and Kouwenhoven combined the two techniques and called the process cardiopulmonary resuscitation. Kouwenhoven documented 14 patients who survived cardiac arrest as a result of closed chest cardiac message, reported at the 1960 Maryland Medical Society Meeting in Ocean City, Maryland. The first consensus guidelines occurred in 1966, sponsored by the National Academic of Science. They recommended that all medical personnel involved in emergency cardiac care (ECC) should receive training in CPR.
HISTORICAL PERSPECTIVE The 2010 AHA Guidelines for Emergency Cardiovascular Care are released coincident with the 50th
anniversary of
modern CPR. Modern cardiopulmonary resuscitation has been in use for emergency cardiac care for over 40 years. Until 1960 successful resuscitation was limited to respiratory arrest. Emergency thoracotomy with open chest heart massage evolved from military medicine and battlefield surgery, but success was severely limited by the need for trained physicians and equipment to be immediately available. Termination of ventricular fibrillation by externally applied
INTERNATIONAL GUIDELINES FOR CPR AND ECC Rapidly after the recognition of the life-saving potential of CPR, world- wide attention occurred. Initially, this was focused in the United States and sponsored politically and financially by the American Heart Association. Recognition of need for an international consensus leads to the creation of the International Liaison Committee on Resuscitation (ILCOR) and the 2000 International Guidelines for CPR and ECC, updated in 2005. The United States and medical societies from more than 20 different countries were active participants. These guidelines provide ECC providers with techniques, standards of practice and the impetus to acquire equipment and resources to perform CPR/ACLS. One further important addition was the introduction of evidence-based medicine to create evidence-based resuscitation guidelines. This resulted in an international consensus that includes: Effective emergency cardiac care
«The traditional three- shock sequence (200, 300, 360) has been replaced by one single shock per cycle because of evidence that the success rate is higher on the first attempt»
The chain of survival The efficacy of defibrillation Advanced cardiac life support Public access CPR Public access defibrillation
CURRENT ISSUES IN RESUSCITATION Despite world-wide availability of CPR/ ACLS training, increasingly sophisticated equipment/pharmacology, EMT training and in-hospital cardiac arrest teams, the outcome of resuscitation has not improved as much as the resources would seem to justify. Excellent evidence establishes that early defibrillation improves outcome and conversely, delays increases morbidity in direct proportion to time. Further evidence supports the efficacy of biphasic defibrillation to provide improved performance at lower currents. Other evidence, however, is critical of
current practice. There is a wide range of survival from cardiac arrest between systems, with some systems substantially better than others (up to a five-fold difference). One important variable is CPR in out-of-hospital cardiac arrest. When bystander CPR is provided, outcomes improve. High quality chest compressions at adequate rate and with full relaxation after each compression, to facilitate full chest recoil improve survival. When combined with dispatcher systems capable of ad hoc training, the result is improved outcome. To improve bystander response, chest compressions without rescue breathing (“hands-only CPR”) appear to achieve improved bystander response with equivalent outcomes to conventional CPR. The 2010 ILCOR International Consensus on CPR and ECC updated the 2005 Guidelines using 356 experts from 29 countries, reviewing more than 400 pieces of evidence. Although good quality chest compressions are known to be essential
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