Cardiorespiratory resuscitation

The American VOLUME

95

Journal of Surgery MAY

1958

NUMBER

FIVE

EDITORIAL

Cardiorespiratorv G

Resuscitation tion, has, for simplicity’s as “ FIagging.”

speaking, up to the end of WorId War I, respiratory resuscitation in this country impIied artificia1 respiration. In 1913 ChevaIier Jackson urged endotracheal insufllation to suppIement manual artificia1 respiration. In 1928 Jackson’s suggestion was revived in the announcement of new equipment for the treatment of asphyxia neonatorum.’ In May, 1933, as the resuIt of the First Conference of the Society for the Prevention of Asphyxia1 Death, Inc., now known as the National Resuscitation Society, Inc., wide pubIicity was accorded the over-a11 probIem of asphyxia, with emphasis on endotracheal insufllation. The Journal of the American Medical Association devoted sixteen coIumns of abstracts to this event, and reIeased an editoria1 (Current Comment) on JuIy 29, 1933, which concIuded as foIIows: “The JournaI has deprecated repeatedIy the formation of specia1 societies for every tiny phase of medica investigation and practice; nevertheIess this new organization (S. P. A. D., Inc.) may serve an especiaIIy usefu1 purpose in meeting a trend in medica practice that cannot be met in any other way.” In 1938 the Committee on Asphyxia of the A. M. A., in a questionnaire sent to the department of obstetrics in each medical schoo1 in the United States, stressed a classification of the stages of asphyxia, citing specific conditions in which Iaryngoscopy and intubation shouId be used. During the past fifteen years the technic of Iaryngoscopy, endotracheal suction, intubation and endotrachea1 ins&laENERALLY

CARDIAC

sake, become known

RESUSCITATION

Shortly after WorId War II, increased attention was directed to the failure of the heart, ventricuIar fibrillation and cardiac standstill. FoIIowing the pacemaker and countershocks to overcome the effects of fibrillation came the dramatic suggestion that the thorax be opened at once and that manua1 massage of the heart be instituted without deIay. The impact of this suggestion was promptly reflected in the medica1 and Iay press. By this time the postoperahazards of infection were minimized by the newIy discovered antibiotics. It is presentIy considered quite proper to open the chest of a dying patient without regard to the sterilization of the surgeon’s hands or of the patient’s chest. Lay press reIeases have brought about acceptance of the procedure by the layman, thereby eIiminating an important deterrent. For exampIe, a woman undergoing a routine physical examination presented an unusua1 scar on the Ieft waI1 of the chest. Asked to expIain, she replied quite casually, “Oh, I was having an intravenous anesthetic for a D and C. My heart stopped and it had to be massaged.” The number of cardiac arrests and fibriIIations treated by open chest surgery appear to be on the increase. Whether these cases have occurred in the past and have been negIected or whether they are actualIy occurring more frequentIy is diffIcuIt to determine. In any event the potential hazard has now come to be accepted as rea1 by many surgeons whose immediate and direct reaction has been to Iearn how

1FLAGG, P. J. Treatment of asphyxia in new-born; preIiminary report of practica1 application of modern scientific methods. J. A. M. A., gr: 78%791, 1928. 729

American Journal of Surgery.

Volume go. May, 1998

FIagg to meet it by surgery, assisted by drugs and defibriIIation equipment. If it is true that nine of ten cardiac arrests occur because of hypoxia induced by anoxic, anemic, stagnant and histotoxic anoxia, why shouId hypoxia be permitted or toIerated? In response to a statement that go per cent of all cardiac deaths were due to hypoxia, Claude S. Beck of CIeveIand states, “There are two ways that the heart stops beating: (I) fibriIIation and (2) standstiI1. FibriIIation is due to fauIty distribution of oxygen within the heart. It is not due to inadequate oxygenation, but it is due to checkerboard distribution. Hypoxia is, therefore, not reIated to this type of death, but for a11 other conditions, hypoxia produces death. Once you get away from heart disease, most deaths are due to hypoxia.” CARDIORESPIRATORY

RESUSCITATION

Present emphasis on the surgica1 treatment of cardiac arrest has obscured the fact that cardiac resuscitation is, in reaIity, a fina desperate suppIement to respiratory resuscitation. It is not an isoIated entity, a procedure which one shouId be caIIed to face in a normal, we11 oxygenated heart. Emphasis shouId be shifted from cardiac massage to the prevention of hypoxia, thereby eIiminating much of the need for surgical intervention. Hypoxia kilts at Ieast 50,000 persons a year; cardiac arrest an estimated 5,000.” If the greater part of this 5,000 is due to hypoxia, the indications for an intensive effort toward pre2H~~~~~, R. M., Six years'experience with the cardiac resuscitation course. Arch. Surg., 73: 813-819,1956. CIeveland

730

vention are cIear. For those hearts which fail after preventative efforts, skiIIed cardiac massage through the open chest is mandatory. There wouId appear to be no age Iimit to open chest or transdiaphragmatic cardiac massage. Since the cardiac arrest of the newborn may, in the great majority of instances, be assumed to be of hypoxic origin, massage is indicated when respiratory resuscitation has faiIed. Ready access to a bIoodIess fieId, aIready “ FIagged ” and supported by endotrachea1 oxygen insuflation, offers breathtaking possibiIities from a reoxygenated respiratory center. Since the aIternative is obviousIy earIy buria1, what at first glance may seem a shocking procedure wiI1, on reflection, be justified. The virgin fieId of open chest cardiac resuscitation of the newborn awaits university research which wiI1 offer refresher materia1 on the pathologic physioIogy of the newborn cardiorespiratory system, an accurate means of diagnosing arrest of the heart and precise recordings of the effect of massage-the whole guided by a conviction that respiratory resuscitation has faiIed. Cardiorespiratory resuscitation is presentIy an “orphan” in the medica schoo1 curriculum. The speciaIties regard it as an uninteresting routine, yet it must carry the burden of a major cause of death on one hand and accept cIose affrIiation with first aid groups on the other. Cardiorespiratory resuscitation must find “a IocaI habitation and a name” in the medica schoo1 curricuIum if the present “rash” of cardiac deaths is to be reduced. PALUEL J. FLAGG, M.D., New York, New York