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ASPECTS OF CARDIAC RESUSCITATION
49 These abnormalities were not found in tissues from patients with myocardial infarction and hypertensive heart-disease. We suggest that in endomyocardial fibrosis cardiac necrosis induces the formation of circulating heart-antibodies, and that the cryoprecipitates are instrumental in the deposition of fibrin. Although the mechanism remains to be elucidated fully, there is evidence suggesting that coagulation may be directly initiated by antigen-antibody complexes, rather than being secondary to tissue damage. Robbins and Stetson2 showed that antigen-antibody complexes accelerated clotting in vitro. More recently it has been demonstrated that the presence of large amounts of immune complexes in the circulation accelerated coagulation, resulting in widespread fibrin deposits in capillaries, especially in the glomeruli.3 These observations suggest that in E.M.F. patients the widespread fibrin deposits and circulating IgG/IgM complexes may be causally related. Secondary organisation of the fibrin could conceivably lead to extensive fibrosis, especially in view of the propensity of darkly pigmented races to keloid formation. It is of interest that IgM-IgG cryoglobulinsemia was recently postulated to be an autoimmune phenomenon.45 Laboratory of Immunopathology, University of Amsterdam, P.O.B. 200, Amsterdam, H. VAN DER GELD. The Netherlands. Makerere University College Medical School, Mulago Hospital, P.O.B. 2072, Kampala, K. SOMERS. Uganda, East Africa. Laboratory of Immunopathology, University of Amsterdam, P.O.B. 200, Amsterdam, F. PEETOOM. The Netherlands.
ASPECTS OF CARDIAC RESUSCITATION SIR,-Dr. Gilston’s article (Nov. 20) prompts me to report here the results of cardiac resuscitation at this hospital since we began to record details seven months ago. During this time, the emergency team (registrars in anxsthesics, medicine, and surgery) has been called to 52 patients with unexpected circulatory arrest: in the wards or corridors (37), the surgical intensive-treatment unit (12), the operating-theatre suite (2), and the X-ray department (1). 14 of these 52 patients were successfully resuscitated, and have been discharged from hospital; 1 of these 14 had survived a first episode of cardiac arrest thirteen months before. Of the 38 failures, 7 had massive pulmonary embolism, 3 dissecting aortic aneurysm, and 1 a ruptured heart; in the remaining 28, the initial or subsequent resuscitation attempts were ultimately abandoned when it was clear that the brain was irretrievably damaged or that the heart was mechanically defunct, even though QRS complexes might still be visible in the electrocardiogram. The survival-rate for the surgical intensive-treatment unit (4 survivors out of 12, or 33%) is little different from that for the rest of the hospital (25%), but the figures for the unit are weighted by some patients with severe heart-disease under observation after cardiac surgery. The survival-rate for patients with circulatory arrest in the early days after frank myocardial infarction was 5 out of 14 (36%), and might have been improved by routine cardiac monitoring, since few badly shocked patients are admitted here. Circulatory arrest was due to ventricular fibrillation in 27 patients, and 11 of these survived after defibrillation by directcurrent (D.C.) shock through the closed chest. Ventricular asystole was found in 12 patients: 3 of these survived-2 were maintained by endocardial pacing until resolution of their post-infarction auriculoventricular block, and 1 resumed sinus rhythm spontaneously after external massage only. In 13
episodes
the basic
arrhythmia
was
not
determined, usually
because evident cerebral death at the time of the team’s arrival made electrocardiosraohv suoerfluous. 2. Robbins, J., Stetson, C. A. J. exp. Med. 1959, 109, 1. 3. Vassali, P., McCluskey, R. T. Ann. N.Y. Acad. Sci. 1964, 116, 1065. 4. van Loghem-Langereis, E., Peetoom, F., van der Hart, M., van Loghem, J. J., Bosch, E., Goudsmit, R. Int. Congr. Blood Transf. (in the
press). 5. Peetoom,
F.,
van
Loghem-Langereis,
E. Vox
Sang. 1965, 10,
281.
Intravenous or intracardiac adrenaline has occasionally proved useful in rendering fine ventricular fibrillation coarser and so more susceptible to reversion by D.C. shock. Intravenous calcium chloride has appeared to enhance ventricular ejection after defibrillation. Propranolol, intravenously and later orally, has seemed to suppress ectopic ventricular rhythms, and may thus have prevented recurrences of ventricular fibrillation. Expert attention to the respiratory problems of the immediate post-arrest situation has been invaluable. These results contrast favourably with the available data for the preceding sixteen months during which there were only about 6 long-term survivals from over 100 resuscitation attempts by a similar team. The principal reasons for this improvement are, probably: (1) the more prompt and skilled immediate treatment by the nursing, medical, and auxiliary staff on the spot; and (2) the much greater use now made of intravenous bicarbonate to combat metabolic acidosis. It is now standard practice to give 50-100 mEq. sodium bicarbonate to every patient with circulatory arrest of more than thirty seconds’ duration, and to give three or four 50 mEq. increments during the ensuing ten to thirty minutes if spontaneous heart-action is not quickly restored. In the patients reported here, external massage only was used, and this was rarely continued beyond thirty minutes. But a young patient with cardiac arrest, which occurred during anxsthesia at a sister-hospital, had external massage for fifteen minutes followed by internal massage for a hundred and fifteen minutes before ventricular defibrillation was accomplished by the first D.c. shock adminiftered, alternating-current shocks having failed. He received a total of 750 mEq. sodium bicarbonate during the period of cardiac arrest, and his arterial pH and standard bicarbonate were respectively 7-42 and 26 mEq. per litre three hours after resumption of spontaneous heart-action. He made a complete recovery. Viable patients with asystole, whether " primary " or induced by a defibrillating shock, may pose particularly difficult problems in management, since external cardiac pacing is rarely effective, and the establishment of intracardiac-electrode pacing takes time. Perhaps in such cases, when precordial blows, external massage, ventilation, shocks, and drugs (including atropine) have failed to restart the heart, the chest should be opened and skilled internal cardiac massage commenced without undue delay. In this way, the brain may be kept alive long enough to make installation of a temporary pacemaking system a practical possibility in a higher proportion of cases. Queen Elizabeth Hospital, D. W. EVANS. Birmingham, 15.
RENAL AUTOTRANSPLANTATION
SiR,—The report1 of Dr. Serrallach-Mila and his colleagues a new method of revascularisation of the kidney by autotransplantation is hardly new. This surgical procedure must have been advocated by those German surgeons who were pioneering kidney transplantation at the beginning of this century. But I strongly advocated this procedure in Modern Trends in Urology (1953) as follows: " The clinical need for autotransplantation of the kidney is no doubt extremely small. ’If, however, a ureter is extensively involved in a tumour about
of the colon and rectum, it may be desirable in an occasional case to conserve the kidney if the other is not present or is not in good condition. With further improvements in operative and restorative techniques, it may not be so formidable a procedure to carry on and autotransplant the kidney on to the iliac vessels and re-implant the sectioned ureter into the bladder ". My own experiments had shown by this time that normal function could be expected from a kidney properly autotransplanted to the pelvis. I spent a lot of time autotransplanting kidneys, and the clinical application was constantly in mind. Again, in 1962 in Operative Surery Service (part 15, p. 15),
growth
1.
Serrallach-Mila, N., Paravisini, J., Mayol-Valls, P., Alberti, J., Casellas, A., Nolla-Panadés, J. Lancet, 1965, ii, 1130.
ASPECTS OF CARDIAC RESUSCITATION SIR,-Dr. Gilston’s article (Nov. 20) prompts me to report here the results of cardiac resuscitation at this hospital since we began to record details seven months ago. During this time, the emergency team (registrars in anxsthesics, medicine, and surgery) has been called to 52 patients with unexpected circulatory arrest: in the wards or corridors (37), the surgical intensive-treatment unit (12), the operating-theatre suite (2), and the X-ray department (1). 14 of these 52 patients were successfully resuscitated, and have been discharged from hospital; 1 of these 14 had survived a first episode of cardiac arrest thirteen months before. Of the 38 failures, 7 had massive pulmonary embolism, 3 dissecting aortic aneurysm, and 1 a ruptured heart; in the remaining 28, the initial or subsequent resuscitation attempts were ultimately abandoned when it was clear that the brain was irretrievably damaged or that the heart was mechanically defunct, even though QRS complexes might still be visible in the electrocardiogram. The survival-rate for the surgical intensive-treatment unit (4 survivors out of 12, or 33%) is little different from that for the rest of the hospital (25%), but the figures for the unit are weighted by some patients with severe heart-disease under observation after cardiac surgery. The survival-rate for patients with circulatory arrest in the early days after frank myocardial infarction was 5 out of 14 (36%), and might have been improved by routine cardiac monitoring, since few badly shocked patients are admitted here. Circulatory arrest was due to ventricular fibrillation in 27 patients, and 11 of these survived after defibrillation by directcurrent (D.C.) shock through the closed chest. Ventricular asystole was found in 12 patients: 3 of these survived-2 were maintained by endocardial pacing until resolution of their post-infarction auriculoventricular block, and 1 resumed sinus rhythm spontaneously after external massage only. In 13
episodes
the basic
arrhythmia
was
not
determined, usually
because evident cerebral death at the time of the team’s arrival made electrocardiosraohv suoerfluous. 2. Robbins, J., Stetson, C. A. J. exp. Med. 1959, 109, 1. 3. Vassali, P., McCluskey, R. T. Ann. N.Y. Acad. Sci. 1964, 116, 1065. 4. van Loghem-Langereis, E., Peetoom, F., van der Hart, M., van Loghem, J. J., Bosch, E., Goudsmit, R. Int. Congr. Blood Transf. (in the
press). 5. Peetoom,
F.,
van
Loghem-Langereis,
E. Vox
Sang. 1965, 10,
281.
Intravenous or intracardiac adrenaline has occasionally proved useful in rendering fine ventricular fibrillation coarser and so more susceptible to reversion by D.C. shock. Intravenous calcium chloride has appeared to enhance ventricular ejection after defibrillation. Propranolol, intravenously and later orally, has seemed to suppress ectopic ventricular rhythms, and may thus have prevented recurrences of ventricular fibrillation. Expert attention to the respiratory problems of the immediate post-arrest situation has been invaluable. These results contrast favourably with the available data for the preceding sixteen months during which there were only about 6 long-term survivals from over 100 resuscitation attempts by a similar team. The principal reasons for this improvement are, probably: (1) the more prompt and skilled immediate treatment by the nursing, medical, and auxiliary staff on the spot; and (2) the much greater use now made of intravenous bicarbonate to combat metabolic acidosis. It is now standard practice to give 50-100 mEq. sodium bicarbonate to every patient with circulatory arrest of more than thirty seconds’ duration, and to give three or four 50 mEq. increments during the ensuing ten to thirty minutes if spontaneous heart-action is not quickly restored. In the patients reported here, external massage only was used, and this was rarely continued beyond thirty minutes. But a young patient with cardiac arrest, which occurred during anxsthesia at a sister-hospital, had external massage for fifteen minutes followed by internal massage for a hundred and fifteen minutes before ventricular defibrillation was accomplished by the first D.c. shock adminiftered, alternating-current shocks having failed. He received a total of 750 mEq. sodium bicarbonate during the period of cardiac arrest, and his arterial pH and standard bicarbonate were respectively 7-42 and 26 mEq. per litre three hours after resumption of spontaneous heart-action. He made a complete recovery. Viable patients with asystole, whether " primary " or induced by a defibrillating shock, may pose particularly difficult problems in management, since external cardiac pacing is rarely effective, and the establishment of intracardiac-electrode pacing takes time. Perhaps in such cases, when precordial blows, external massage, ventilation, shocks, and drugs (including atropine) have failed to restart the heart, the chest should be opened and skilled internal cardiac massage commenced without undue delay. In this way, the brain may be kept alive long enough to make installation of a temporary pacemaking system a practical possibility in a higher proportion of cases. Queen Elizabeth Hospital, D. W. EVANS. Birmingham, 15.
RENAL AUTOTRANSPLANTATION
SiR,—The report1 of Dr. Serrallach-Mila and his colleagues a new method of revascularisation of the kidney by autotransplantation is hardly new. This surgical procedure must have been advocated by those German surgeons who were pioneering kidney transplantation at the beginning of this century. But I strongly advocated this procedure in Modern Trends in Urology (1953) as follows: " The clinical need for autotransplantation of the kidney is no doubt extremely small. ’If, however, a ureter is extensively involved in a tumour about
of the colon and rectum, it may be desirable in an occasional case to conserve the kidney if the other is not present or is not in good condition. With further improvements in operative and restorative techniques, it may not be so formidable a procedure to carry on and autotransplant the kidney on to the iliac vessels and re-implant the sectioned ureter into the bladder ". My own experiments had shown by this time that normal function could be expected from a kidney properly autotransplanted to the pelvis. I spent a lot of time autotransplanting kidneys, and the clinical application was constantly in mind. Again, in 1962 in Operative Surery Service (part 15, p. 15),
growth
1.
Serrallach-Mila, N., Paravisini, J., Mayol-Valls, P., Alberti, J., Casellas, A., Nolla-Panadés, J. Lancet, 1965, ii, 1130.