The Latest in CPR

I can remember the first time I did CPR. It was over 30 years ago and I was nervous as heck. I remember an "old-timer" telling me to just settle down and relax. After all this time, I cannot remember what that patient looked like, but I do remember the sage advice from a more experienced voice.

Little did I know at the time that the simple technique of doing chest compressions while ventilating had a long and storied history. Over the years, the method of resuscitating someone who is not breathing and does not have a heartbeat has changed with research and technology. Trying to resuscitate the dead dates back to the Egyptians, some 3,500 years ago. When someone died, the Egyptians would hang the patient by his or her feet, applying chest pressure to assist expiration and releasing the pressure to assist inspiration. About 1,000 years ago, the dead had a tube put in their trachea and bellows (the same used for fireplaces) were used to put air into them.

The Dutch Humane Society in 1767 published instructions for resuscitating drowning victims: "Keep the victim warm, give mouth-to-mouth ventilation and perform insufflation of smoke burning tobacco into the rectum." Other methods of resuscitation that have been tried over the years include flogging or beating the victims until they responded, bouncing a person on a trotting horse and rolling a person over a barrel.

The first record of external chest compression was written about by John Howard in the 18th century. About the same time, Dr. Friedrich Maass reported the first use of chest compressions on humans. In 1904, Dr. George Washington Crile reported the first successful resuscitation of a patient using external chest compressions. Later, he would do experiments on animals using chest compressions, artificial respiration and epinephrine.

In 1952, Dr. Paul Zoll and a team of other doctors in Boston applied electric charges externally to the chest to resuscitate two patients whose hearts had stopped. The first patient lived only 20 minutes. The second patient survived for 11 months after 52 hours of electrical stimulation. In 1959, Dr. James Elam wrote the instructional booklet Rescue Breathing, which was distributed throughout the United States. He later produced films demonstrating the life-saving technique and contributed with Peter Safar in the development of a mannequin called Resusci Anne, produced by Laerdal of Norway, which allowed the public to learn the technique in a safe manner.

All of this eventually evolved into what we use today. In 1960, W.B. Kouwenhoven, J.R. Jude and G.G. Knickerbocker rediscovered the use of external chest compressions while testing defibrillation on an animal that was in ventricular fibrillation. Their paper describing this discovery of using chest compressions while ventilating is generally credited as being the impetus for use of cardiopulmonary resuscitation (CPR) today. Even since the 1960s, CPR has changed. First, there were an initial five quick breaths and then a 15-to-2 ratio of compression to ventilations. At some point in the past 40-something years, a precordial thump was given, but then it was removed some years later.

Now come two new versions of performing CPR. The first is in new guidelines released by the American Heart Association on March 31, 2008, and designed for civilians who are not emergency response personnel, such as firefighters, EMTs, paramedics or hospital personnel. This new technique is called Hands-Only CPR and it calls for trained or untrained bystanders to do only chest compressions when someone collapses from a cardiac arrest. The new and simplified guidelines issued by the American Heart Association are designed to encourage more people to perform CPR. The theory is based on the fact that people say they did not perform CPR because they thought they would do something wrong or they did not want to do mouth-to-mouth.

A recent study conducted in Arizona demonstrates results that triple the survival rates for out-of-hospital cardiac arrest victims. The new approach, called minimally interrupted cardiac resuscitation (MICR), focuses on maximizing blood flow to the heart and brain through a series of coordinated interventions. It includes an initial series of 200 uninterrupted chest compressions, heart rhythm analysis with a single shock, 200 immediate post-shock chest compressions before the pulse check, early administration of epinephrine to stimulate the heart, and delayed placement of a flexible plastic tube into the trachea for the purpose of ventilating the lungs. Among 886 patients who suffered cardiac arrest in two cities, survival-to-hospital discharge increased from 4 of 218 patients (1.8%) in the before MICR training group to 36 of 668 patients (5.4%) in the after MICR training group.

The approach to saving a person in cardiac arrest has certainly evolved from what the Egyptians performed some 3,500 years ago. I have no doubt that the new methods described in this column will change in the future and newer methods will be introduced that will declare better results. We'll have to wait and watch to see what those new strategies are.