doi: 10.1161/01.CIR.0000057524.47305.B3
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(Circulation. 2003;107:794.)
© 2003 American Heart Association, Inc.
Cardiopulmonary Resuscitation
One Size Does Not Fit All
From the Institute of Critical Care Medicine, Palm Springs, Calif.
Correspondence to Max Harry Weil, MD, PhD, The Institute of Critical Care Medicine, 1695 North Sunrise Way, Building #3, Palm Springs, CA 92262. E-mail weilm{at}911research.org
Key Words: Editorials • cardiopulmonary resuscitation • heart arrest • defibrillation • death, sudden
The epidemic of "sudden death," primarily due to a dysrhythmic event that is triggered by ischemia of the myocardium, is the predominant mechanism of cardiac arrest in industrialized countries. The emphasis on early defibrillation and therefore on public access defibrillation is a response to this epidemic.1–4 However, the emphasis on sudden death should not dominate discussion to the extent that other mechanisms of cardiac arrest are minimized. Stated simply, one size does not fit all. In an attempt to simplify interventions by bystanders, we have had to de-emphasize "diagnosis."
Especially in younger victims of cardiac arrest, including crib death and drowning, and in individuals of all ages who have airway obstruction after aspiration of particulates, after traumatic injuries, and as a neurological complication of strokes or drug overdoses, the primary cause is asphyxia. It is in this setting that the "golden seconds" would best be preserved for restoring gas exchange. However, literally minutes are currently wasted after application of automated defibrillators (AEDs) because they are used for repetitive rhythm analysis and capacitor charging.5
These adverse effects of AEDs prompted at least 2 modifications. The first idea, which is a concept for guiding the further development of the technology, is to define 2 discrete types of cardiac arrest. The non-professional rescuer would best be prompted to priorities of intervention contingent on this differentiation. We have suggested the terms dysrhythmic or primary cardiac arrest to contrast with asphyxial, respiratory, or secondary cardiac arrest for this purpose.6
The second modification is further development of the capability of AEDs. The intelligence of the devices should be expanded to help make the distinction between dysrhythmic and asphyxial cardiac arrest and to prompt the rescuer accordingly. Such AEDs would increasingly become "resuscitation boxes," in which prompting is expanded beyond semi-automated electrical defibrillation based only on rhythm detection. The capability to detect airway obstruction and/or failure of ventilation is achievable. For instance, the addition of presently available noninvasive sensors would potentially detect the mechanical heartbeat and the pattern of breathing. In one instance, this may be accomplished with the same electrodes currently used by AEDs and in conjunction with electrical impedance methods.7 Alternatively, noninvasive sensors, such as carbon dioxide detectors near the airway, are likely to be useful.8 Because outcomes are dependent on prompt bystander intervention,9 the opportunities for improvements are great. In view of the immensity of the problem, which is estimated to affect more than 400 000 victims of out-of-hospital cardiac arrest annually, of whom less than 5% survive,10 we are very pleased that the Post-resuscitative and initial Utility in Life Saving Efforts (PULSE) initiative11 has prompted increasing awareness of the benefits of the very research that would bring such improvements in methods and devices for CPR.
Footnotes
The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.
References
1. AHA Guidelines for Cardiopulmonary Resuscitation and emergency cardiovascular care. Circulation. 2000; 102 (suppl I): I1–I384.[Medline] [Order article via Infotrieve]
2. Caffrey SL, Willoughby PJ, Pepe PE, et al. Public use of automated external defibrillators. N Engl J Med. 2002; 347: 1242–1247
3. Page RL, Joglar JA, Kowal RC, et al. Use of automated external defibrillators by a U.S. airline. N Engl J Med. 200; 343: 1210–1216
4. Valenzuela TD, Roe DJ, Nichol G, et al. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med. 2000; 343: 1206–1209.
5. Yu T, Weil MH, Tang W, et al. Adverse outcomes of interrupted precordial compression during automated defibrillation. Circulation. 2002; 106: 368–372.
6. Kamohara T, Weil MH, Tang W, et al. A comparison of myocardial function after primary cardiac and primary asphyxial cardiac arrest. Am J Respir Crit Care Med. 2001; 164: 1221–1224.
7. Pellis T, Bisera J, Tang W, et al. Expanding automatic external defibrillators to include automated detection of cardiac, respiratory, and cardiorespiratory arrest. Crit Care Med. 2002; 30 (suppl): S176–S178.[CrossRef][Medline] [Order article via Infotrieve]
8. Falk JL, Rackow EC, Weil MH. End-tidal carbon dioxide during cardiopulmonary resuscitation. N Engl J Med. 1988; 318: 607–611.[Abstract]
9. Bur A, Kittler H, Sterz F, et al. Effects of bystander first aid, defibrillation and advanced life support on neurologic outcome and hospital costs in patients after ventricular fibrillation cardiac arrest. Intens Care Med. 2001; 27: 1474–1480.[CrossRef][Medline] [Order article via Infotrieve]
10. Brown CG, Martin DR, Pepe PE. A comparison of standard-dose and high-dose epinephrine in cardiac arrest outside the hospital. N Engl J Med. 1992; 327: 1051–1055.[Abstract]
11. Weil MH, Becker L, Budinger T, et al. Workshop executive summary report: post-resuscitative and initial utility in life saving efforts (PULSE). Circulation. 2001; 103: 1182–1184.
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