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A review of cardiopulmonary resuscitation and its history
Disease-a-Month 59 (2013) 165–167
Contents lists available at SciVerse ScienceDirect
Disease-a-Month journal homepage: www.elsevier.com/locate/disamonth
A review of cardiopulmonary resuscitation and its history Robert Aitchison, BA, Pamela Aitchison, BSN, RN, Ernest Wang, MD, FACEP, Morris Kharasch, MD, FACEP
The first guidelines for the performance of closed-chest cardiopulmonary resuscitation (CPR) were published in 1966. However, earlier attempts at resuscitation extend back hundreds of years.
1. Airway In 1768, the Dutch Humane Society was founded by physicians and laypeople to work together to assist victims of drowning. The society created and disseminated rules and methods of resuscitation. At that time, it was thought that victims of drowning died due to inhaled water. Initial resuscitation attempts focused on hanging the victim upside down or rolling them inverted on barrels. In 1889, Sir Henry Head developed the cuffed endotracheal tube. In 1895, Alfred Kirstein invented the laryngoscope in order to better visualize the trachea. Dr. Peter Safar, an anesthesiologist, in the mid-twentieth century investigated various techniques for airway management. He found that 50% of patients’ airways would be opened by a head tilt; the remaining 50% could be opened with either thrusting the mandible forward or the insertion of an oropharyngeal airway.1
2. Breathing One of the earliest recorded references of artificial breathing is found in the old testament. In 2 Kings 4:32–35, the prophet Elisha brings a boy to life after placing his mouth on the mouth of a child. In the 1500s, Paracelsus mentions the use of fireside bellows to mechanically ventilate drowning victims. Mouth-to-mouth resuscitation techniques were first described by Dominque Jean Larrey, Napoleon’s chief battlefield surgeon. In 1732, William Tossach used mouth-to-mouth to successfully resuscitate a coal miner. However, in the 1770s the usage of expelled air fell out of favor when Scheele discovered oxygen. In 1861, the chest-pressure arm lift method was modified by Dr. Henry Silvester from an earlier chest-pressure method by Marshall Hall. In 1958, papers published by Archer Gordon, James Elam, and Peter Safar showed 0011-5029/$ - see front matter & 2013 Published by Mosby, Inc. http://dx.doi.org/10.1016/j.disamonth.2013.03.002
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R. Aitchison et al. / Disease-a-Month 59 (2013) 165–167
that the prone position does not leave the airway patent and that expelled air contains sufficient oxygen levels for resuscitation. Initially, the tools of respiratory resuscitation were solely found in emergency medicine. Dr. Claude Beck, a surgeon, in 1921 recounts that he had to call the fire department for a ‘‘pulmotor’’ to attempt resuscitation on a surgery patient. In the 1960s, endotracheal intubation and positive pressure ventilation became the standard of care.
3. Circulation The first cardiac compressions were performed in the open thorax. In 1874, a German physiologist, Moritz Schiff noted carotid pulsation after manually squeezing a canine heart, which gave rise to the term cardiac massage. Rudolph Boehm and Louis Mickwitz demonstrated the effectiveness of closed cardiac massage on cats by pressing on the sternum. In 1892, Freidrich Maass was credited with the first successful closed-chest cardiac massage on a human. In 1901, the first successful open-chest cardiac massage was performed by Dr. Kristian Igelsrud, a Norwegian physician,2 after an anesthesia-induced arrest due to chloroform. Until 1958, cardiac arrests were treated with open cardiac massage. However, in 1958, William Kouwenhoven, an electrophysioloigist, rediscovered closed-chest cardiac massage, after performing research on canines.3 Because of the simplicity of this method, it quickly became the standard of care in cardiac arrests.
4. Defibrillation In 1791, Galvani showed that electricity would cause contractions in muscle tissue. Dr. John McWilliam studied mammalian hearts and showed that death was often preceded by ‘‘fibrillar’’ motions in the heart. In 1891, he published the hypothesis that fibrillation of the ventricles probably took place in humans prior to death. In 1901, Willem Einthoven invented the string galvanometer, which allowed for noninvasive recording, diagnosis, and treatment of irregular electrical cardiac activity. In 1947, Claud Beck performed the first successful open human defibrillation after 70 min of open cardiac massage. In 1955, Paul Zoll performed the first successful closed-chest human defibrillation. In 1962, Dr. Bernard Lown demonstrated that direct current was superior to alternating current for defibrillation.4 In 1979, the first portable automatic external defibrillator (AED) was developed.5
5. Education and dissemination Drs. Beck and Leighninger trained the first in-hospital resuscitation team in the 1930s at Case Western Reserve University in Cleveland. In addition, in the 1960s, mobile intensive care unit ambulances were created and staffed by physicians. Asmund Laerdal created a mannequin to facilitate cardiopulmonary resuscitation (CPR) education in 1960. In 1961, Dr. Beck and Lois Horwitz educated lay rescuers in Cleveland. In 1966, the first CPR guidelines were published, but they were not recommended for use by the general public. Dissemination of CPR into the community was done on a mass scale in 1970 by Drs. Cobb, Kopass, and Eisenberg in Seattle. They demonstrated that delivery of CPR by bystanders increased the likelihood of survival to hospital discharge for victims. In 1974, the training of laypersons was recommended. This was followed by the offering of the first Advance Cardiac Life Support (ACLS) training courses in 1976.5 This allowed highly trained prehospital providers to administer medications in the field. In 1983, the American Heart Association (AHA) established guidelines specific to the resuscitation of neonatal and pediatric victims.5 In the 1990s, the Early Access Public Defibrillation programs were developed to provide easy access to AEDs.5 In 2004, the AHA and International Liaison Committee on Resuscitation released a statement that pediatric victims
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between the ages of 1 and 8 years may be defibrillated by an AED when there are no signs of circulation.5 In 2005, the AHA revised guidelines for CPR that recommended a new compression to ventilation ratio of 30:2 for all victims when CPR is performed by a single rescuer; when there are 2 providers, adult and pediatric patients should receive a ratio of 30:2 and infants 15:2.6 In 2008, hands-only compression was recommended for lay rescuers.5 In 2010, new guidelines were published updating the techniques and algorithms of basic CPR and advanced life support techniques in special populations and situations.7 This edition of Disease-a-Month will provide both an overview of the processes and recent changes involved in both basic and advanced life support for neonatal, pediatric, and adult patients. Additional special topics of ischemic stroke, acute coronary syndromes, and ethical considerations will also be covered. References 1. Safar P, Escarraga LA, Chang F. Upper airway obstruction in the unconscious patient. J Appl Physiol. 1959;14: 760–764. ˚ 2. Strømskag KE. Kristian Igelsrud og den første apne hjertekompresjon [Kristian Igelsrud and the first successful direct heart compression]. Tidsskr Nor Laegeforen. 2002;122(30):2863–2865. [in Norwegian]. 3. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. J Am Med Assoc. 1960;173:1064–1067. 4. Lown B. Biography of Dr. Lown. /http://www.bernardlown.org/bio.htmlS; Accessed 12.02.13. 5. American Heart Association. History of CPR. /http://www.heart.org/HEARTORG/CPRAndECC/WhatisCPR/CPRFact sandStats/History-of-CPR_UCM_307549_Article.jspS; Accessed 18.12.12. 6. Hazinski MF, Nadkarni VM, Hickey RW, O’Connor R, Becker LB, Zaritsky A. Major changes in the 2005 AHA Guidelines for CPR and ECC: reaching the tipping point for change. Circulation. 2005;112:IV206–IV211. [pmid:16314349]. 7. Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S640–S656.
Suggested reading Cooper JA, Cooper JD, Cooper JM. Cardiopulmonary resuscitation: history, current practice, and future direction. Circulation. 2006;114:2839–2849.
Contents lists available at SciVerse ScienceDirect
Disease-a-Month journal homepage: www.elsevier.com/locate/disamonth
A review of cardiopulmonary resuscitation and its history Robert Aitchison, BA, Pamela Aitchison, BSN, RN, Ernest Wang, MD, FACEP, Morris Kharasch, MD, FACEP
The first guidelines for the performance of closed-chest cardiopulmonary resuscitation (CPR) were published in 1966. However, earlier attempts at resuscitation extend back hundreds of years.
1. Airway In 1768, the Dutch Humane Society was founded by physicians and laypeople to work together to assist victims of drowning. The society created and disseminated rules and methods of resuscitation. At that time, it was thought that victims of drowning died due to inhaled water. Initial resuscitation attempts focused on hanging the victim upside down or rolling them inverted on barrels. In 1889, Sir Henry Head developed the cuffed endotracheal tube. In 1895, Alfred Kirstein invented the laryngoscope in order to better visualize the trachea. Dr. Peter Safar, an anesthesiologist, in the mid-twentieth century investigated various techniques for airway management. He found that 50% of patients’ airways would be opened by a head tilt; the remaining 50% could be opened with either thrusting the mandible forward or the insertion of an oropharyngeal airway.1
2. Breathing One of the earliest recorded references of artificial breathing is found in the old testament. In 2 Kings 4:32–35, the prophet Elisha brings a boy to life after placing his mouth on the mouth of a child. In the 1500s, Paracelsus mentions the use of fireside bellows to mechanically ventilate drowning victims. Mouth-to-mouth resuscitation techniques were first described by Dominque Jean Larrey, Napoleon’s chief battlefield surgeon. In 1732, William Tossach used mouth-to-mouth to successfully resuscitate a coal miner. However, in the 1770s the usage of expelled air fell out of favor when Scheele discovered oxygen. In 1861, the chest-pressure arm lift method was modified by Dr. Henry Silvester from an earlier chest-pressure method by Marshall Hall. In 1958, papers published by Archer Gordon, James Elam, and Peter Safar showed 0011-5029/$ - see front matter & 2013 Published by Mosby, Inc. http://dx.doi.org/10.1016/j.disamonth.2013.03.002
166
R. Aitchison et al. / Disease-a-Month 59 (2013) 165–167
that the prone position does not leave the airway patent and that expelled air contains sufficient oxygen levels for resuscitation. Initially, the tools of respiratory resuscitation were solely found in emergency medicine. Dr. Claude Beck, a surgeon, in 1921 recounts that he had to call the fire department for a ‘‘pulmotor’’ to attempt resuscitation on a surgery patient. In the 1960s, endotracheal intubation and positive pressure ventilation became the standard of care.
3. Circulation The first cardiac compressions were performed in the open thorax. In 1874, a German physiologist, Moritz Schiff noted carotid pulsation after manually squeezing a canine heart, which gave rise to the term cardiac massage. Rudolph Boehm and Louis Mickwitz demonstrated the effectiveness of closed cardiac massage on cats by pressing on the sternum. In 1892, Freidrich Maass was credited with the first successful closed-chest cardiac massage on a human. In 1901, the first successful open-chest cardiac massage was performed by Dr. Kristian Igelsrud, a Norwegian physician,2 after an anesthesia-induced arrest due to chloroform. Until 1958, cardiac arrests were treated with open cardiac massage. However, in 1958, William Kouwenhoven, an electrophysioloigist, rediscovered closed-chest cardiac massage, after performing research on canines.3 Because of the simplicity of this method, it quickly became the standard of care in cardiac arrests.
4. Defibrillation In 1791, Galvani showed that electricity would cause contractions in muscle tissue. Dr. John McWilliam studied mammalian hearts and showed that death was often preceded by ‘‘fibrillar’’ motions in the heart. In 1891, he published the hypothesis that fibrillation of the ventricles probably took place in humans prior to death. In 1901, Willem Einthoven invented the string galvanometer, which allowed for noninvasive recording, diagnosis, and treatment of irregular electrical cardiac activity. In 1947, Claud Beck performed the first successful open human defibrillation after 70 min of open cardiac massage. In 1955, Paul Zoll performed the first successful closed-chest human defibrillation. In 1962, Dr. Bernard Lown demonstrated that direct current was superior to alternating current for defibrillation.4 In 1979, the first portable automatic external defibrillator (AED) was developed.5
5. Education and dissemination Drs. Beck and Leighninger trained the first in-hospital resuscitation team in the 1930s at Case Western Reserve University in Cleveland. In addition, in the 1960s, mobile intensive care unit ambulances were created and staffed by physicians. Asmund Laerdal created a mannequin to facilitate cardiopulmonary resuscitation (CPR) education in 1960. In 1961, Dr. Beck and Lois Horwitz educated lay rescuers in Cleveland. In 1966, the first CPR guidelines were published, but they were not recommended for use by the general public. Dissemination of CPR into the community was done on a mass scale in 1970 by Drs. Cobb, Kopass, and Eisenberg in Seattle. They demonstrated that delivery of CPR by bystanders increased the likelihood of survival to hospital discharge for victims. In 1974, the training of laypersons was recommended. This was followed by the offering of the first Advance Cardiac Life Support (ACLS) training courses in 1976.5 This allowed highly trained prehospital providers to administer medications in the field. In 1983, the American Heart Association (AHA) established guidelines specific to the resuscitation of neonatal and pediatric victims.5 In the 1990s, the Early Access Public Defibrillation programs were developed to provide easy access to AEDs.5 In 2004, the AHA and International Liaison Committee on Resuscitation released a statement that pediatric victims
R. Aitchison et al. / Disease-a-Month 59 (2013) 165–167
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between the ages of 1 and 8 years may be defibrillated by an AED when there are no signs of circulation.5 In 2005, the AHA revised guidelines for CPR that recommended a new compression to ventilation ratio of 30:2 for all victims when CPR is performed by a single rescuer; when there are 2 providers, adult and pediatric patients should receive a ratio of 30:2 and infants 15:2.6 In 2008, hands-only compression was recommended for lay rescuers.5 In 2010, new guidelines were published updating the techniques and algorithms of basic CPR and advanced life support techniques in special populations and situations.7 This edition of Disease-a-Month will provide both an overview of the processes and recent changes involved in both basic and advanced life support for neonatal, pediatric, and adult patients. Additional special topics of ischemic stroke, acute coronary syndromes, and ethical considerations will also be covered. References 1. Safar P, Escarraga LA, Chang F. Upper airway obstruction in the unconscious patient. J Appl Physiol. 1959;14: 760–764. ˚ 2. Strømskag KE. Kristian Igelsrud og den første apne hjertekompresjon [Kristian Igelsrud and the first successful direct heart compression]. Tidsskr Nor Laegeforen. 2002;122(30):2863–2865. [in Norwegian]. 3. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. J Am Med Assoc. 1960;173:1064–1067. 4. Lown B. Biography of Dr. Lown. /http://www.bernardlown.org/bio.htmlS; Accessed 12.02.13. 5. American Heart Association. History of CPR. /http://www.heart.org/HEARTORG/CPRAndECC/WhatisCPR/CPRFact sandStats/History-of-CPR_UCM_307549_Article.jspS; Accessed 18.12.12. 6. Hazinski MF, Nadkarni VM, Hickey RW, O’Connor R, Becker LB, Zaritsky A. Major changes in the 2005 AHA Guidelines for CPR and ECC: reaching the tipping point for change. Circulation. 2005;112:IV206–IV211. [pmid:16314349]. 7. Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S640–S656.
Suggested reading Cooper JA, Cooper JD, Cooper JM. Cardiopulmonary resuscitation: history, current practice, and future direction. Circulation. 2006;114:2839–2849.