Download Evolution of resuscitation from the past to the present

Evolution of resuscitation from the
past to the present - evidence matters
A history of CPR
Dr. TSOI Ludwig
Director, Resuscitation Council of Hong Kong
President, Hong Kong Society for Emergency Medicine & Surgery
Content
An overview
History of CPR
Airway
Ventilation
Chest compression
Defibrillation
Modern CPR – why evidence matters
What is Cardiac Arrest?
Sudden loss of consciousness and
breathing
Cardiac output ceases
Coronary and cerebral blood flows stop
Expected Effect of CPR
CPR has potential of re-establishing
spontaneous circulation, often in
conjunction with electrical
defibrillation
But CPR is likely to be successful
only if it is instituted early
Chain of Survival
AHA (1991) introduced concept ‘‘chain of survival’’
Addressing
This chain includes four links:
Utstein template
Template for documenting the sequence of
interventions
Begin with call for emergency assistance,
documents arrival time of rescuers
(including by-standers), interventions
performed by emergency medical
responders at site, and sequences of
interventions that follow
Figure 1. Overview of EMS-treated cardiac arrests with an abridged Utstein template (May 1,
1998, to December 31, 2006).
Taku Iwami et al. Circulation. 2009;119:728-734
Copyright © American Heart Association, Inc. All rights reserved.
Automated External
Defibrillator (AED)
In ventricular fibrillation (VF),
automated external defibrillators (AEDs)
have empowered nonprofessionals to
reverse VF
Current evidence supports value of
bystander-initiated CPR program and
Public Access Defibrillation (PAD)
History of CPR
Until the nineteenth
century, routine
resuscitation from death
was not viewed as feasible
Modern cardiopulmonary
resuscitation emerged only
during latter half of
twentieth century
1934
Causes of cardiac arrest
1. In the 1900s, asphyxia was a major cause of
cardiac arrest
Airway devices and mechanical interventions
2. Electrical causes became significant causes of
cardiac arrest
Prompted the development and use of
defibrillation
External mechanical
methods for restoring
blood circulation were a
development of 1960s
Sequence of
interventions was
established under the
acronym ABCD
History of airway intervention
Ancient
Babylonian (200BC –
400AD) lamb
Reed
This anticipated the modern
method of securing the airway
followed by mechanical
ventilation
Air Pipe
First endotracheal tube
Endotracheal
tube airway
Tongue be withdrawn and
displaced to extreme right corner
of the mouth
1870 Friedrich Trendelenburg
(1844 - 1924) popularized “tube”
Howard B. The direct method of artificial respiration. Lancet 1877;2:193–6
Laryngoscope
Kirstein A. Autoskopie des larynx
und der trachea. Archiv
Laryngologie Rhinologie
1895;3:156–64 [German]
Alfred Kirstein
(1863 – 1922)
OPA
Peter Safar (1924 – 2003)
Head tilt-chin lift
Ancient
Egyptian Mythology Isis
Hebrew Bible Elisha
Mouth-to-nose method
200 BC – 500 AD: Hebrews used mouth-to-nose
ventilation for resuscitation of newborn infants
Primitive fireplace bellows - Galen (175 AD) first
described bellows-to-nostril ventilation in human
Mouth-tomouth
“I applied my Mouth close to
his…, I blew again my Breath as
strong as I could…his Thorax
continued to play…”
Dr. William Tossach (1732)
Exhaled air
“devitalized” air vs. Oxygen
Drowning
Drowning
1857 Marshall Hall – “chest-pressure”
1861 Silvester – “chest-compression arm-lift” –
various modifications
Tank respirator
Drinker respirator or “iron lung”
Intermittent positive pressure
ventilation (IPPV)
1952 Bjørn Ibsen (Denmark)
Mouth-to-mask ventilation
1954 Dr. Elam J. O.
1950s Endotracheal tube
Bennet
Compact
ventilator
1958 Ruben “self-refilling bag”
Engstrom
Ancient
Hebrews Bible I King Chapter 17 Elijah
“Then he stretched himself upon the child three times…”
Barrel and Horse methods
Direct cardiac compressions
Moritz Schiff described in 1874
Precordium compression
1878 Rudolph Boehm and Louis Mickwitz – cats
1883 Koening – chloroform patient
1891 Friedrich Maass – successful
Open-chest cardiac massage
1901 Kristian Igelsrud (1867 - 1940)
Rediscover chest compression
1958 William Kouwenhoven: all survived to discharge
External chest compression + assisted ventilation
Ventricular fibrillation (VF)
1889 John McWilliam – VF cause of cardiac arrest
Defibrillation
1899 Prevost and
Battelli – 1st
defibrillation
Energy level
1933 Hooker et al - dogs
Milestones of defibrillation
1940 Carl Wiggers – dog
1947 Claude Beck – boy (openchest defib)
1955 Paul Zoll – man (closedchest defib)
1962 Bernard Lown – direct current
monophasic waveform defibrillation
1979 1st portable external defibrillator
Modern era of CPR
Since 1960*
Mini-thoracotomy discard in favor of closed-chest
compressions
Electrical defibrillation
Layperson CPR
Manikin for CPR training
Utstein Template
*Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. J Am
Med Assoc 1960;173:1064–7.
Evidence matters
1966 AHA – 1st National Conference on
Standards for CPR and Emergency Cardiac
Care
Rapid response systems evolved
HK: ~5000 OHCA (internal
communication)
Survival rate: still low
Lack of by-stander CPR – the weakest link
What is evidence?
Evidence = Evidence-based medicine is the
conscientious explicit and judicious use of current best
evidence in making decisions about the care of
individual patients
≠ randomized controlled studies (RCT) or systemic
review of RCT
When RCT or systemic review lacking
EBM Pyramid
AHA and International Liaison Committee on
Resuscitation (ILCOR) – review and publish
guidelines with emerging evidence every 5 years
2005 Uninterrupted precordial compression
2010 Change from ABC to CAB
2015 Check pulse and breathing at the
same time
Grading of evidence into practice
Local consideration
Airway
Prehospital LMA (? ET tube)
Breathing
Compression only CPR
Circulation
Mechanical chest compression (Lucas 2)
EMCO-CPR
Reference
Ristagno G, Tang W, Weil MH. Cardiopulmonary
Resuscitation: From the Beginning to the Present Day.
Crit Care Clin 25 (2009) 133–151
Nakagawa Y, Weil MH, Tang W. The history of CPR.
In: Weil MH, Tang W, editors. CPR. Resuscitation of
the Arrested Heart. Philadelphia: WB Saunders; 1999.
p. 1–12.
Harrison-Paul R. A history of mechanical devices for
providing external chest compressions. Resuscitation
2007;73(3):330–6.
Thank you