Cardiopulmonary arrest

Cardiopulmonary Arrest Evaluation

of an Active Resuscitation

Program QUENTIN R. STILES, MD, Los Angeles, California BERNARD L. TUCKER, MD, Los Angeles, California BERT W. MEYER, MD, Los Angeles, California GEORGE G. LINDESMITH, MD, Los Angeles, California JOHN C. JONES, MD, Los Angeles, California

In the past ten years four developments have markedly improved the success of attempted cardiac resuscitation : the clinical application of closed chest cardiopulmonary resuscitation; the use of external cardiac defibrillation ; the design of hospital emergency programs for the immediate mobilization of necessary personnel and equipment; and the development of intensive care units and, more recently, of coronary care units. The Hospital of the Good Samaritan has had a cardiopulmonary resuscitation program for fifteen years, by which aid may be summoned by contacting the switchboard operator to state the location of the cardiopulmonary emergency. The operator then announces a code call over the page system and contacts key personnel by radio page or telephone. Staff and equipment usually appear within seconds, but are accompanied by considerable commotion and disturbance to surrounding patients. We have analyzed the over-all vaIue of these procedures and the follow-up study of the patients and the results will be presented. Material There were 305 “Dr Heart” calls from 1964 through 1970. Only those code calls received through the hospital operator were included. Three were obvious false alarms and were excluded from the study. Cardiac arrest occurring in the operating room and the cardiac catheterization laboratory, and most of those in the intensive care and cardiac care units were not included because adequate personnel and equipment were already present, making a hospitalwide emergency call unnecessary. From the Department of Surgery, Hospital of the Good Samaritan Medical Center, Los Angeles, California. Reprint requests should be addressed to Dr Stiles. 1136 West Sixth Street, Los Angeles, California 90017. Presented at the Forty-Second Annual Meeting of the Pacific Coast Surgical Association, Mexico City, Mexico, February 14-18, 1971.

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The standard method of cardiopulmonary resuscitation recommended by the American Heart Association was used. The first person arriving gave simultaneous closed chest cardiac compression and mouth to mouth or mouth to nose resuscitation until proper equipment arrived, after which respiration was maintained by mask or endotracheal tube. A plastic cannula was inserted in a vein for administration of sodium bicarbonate, adrenalin, and other drugs as needed. If ventricular fibrillation was suspected, a single external direct current electric shock was often applied, even before obtaining an electrocardiographic pattern. This management of cardiopulmonary arrest has not changed significantly during the seven year study. Results

The number of emergency calls remained relatively stable, averaging forty-three per year. The single most important question is how many patients were resuscitated and survived to be discharged from the hospital in a satisfactory condition. Forty-four (15 per cent) of the group studied were discharged from the hospital and the resuscitative efforts were, therefore, judged successful. In 41 per cent of the cases of circulatory arrest, the heart was resuscitated, but the time elapsed in 50 per cent of the heart-resuscitated cases was long enough to cause varying degrees of neurologic damage. The over-all results, however, deserve closer and more detailed analysis. There are three major goals in treating cardiopulmonary arrest: first, the rapid restoration of circulation and respiration; second, the avoidance of brain damage ; and third, the eventual discharge of the patient from the hospital in satisfactory condition. Figure 1 shows the degree of attainment of these goals on a yearly basis and demonstrates a definite trend of improvement in all three. In 1964, only 17 per cent of the hearts could

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be resuscitated to sustain adequate, unassisted circulation even for a short time ; all patients had brain damage and none survived. In 1970, more than 50 per cent of the hearts were restarted ; 38 per cent of the patients had no brain damage and 27 per cent were discharged alive to their homes. The critical factor responsible for this improvement is time. The period from circulatory failure to institution of resuscitation ,efforts has been decreased by a combination of monitoring devices and adequately trained personnel astute enough to recognize a prearrest condition and call for help before the actual arrest has occurred. There were far fewer emergent calls on the nursing shift from 11 PM to 7 AM than there were on either of the other shifts. (Table I.) The reasons are purely speculative: a desire on the part of the nurses not to disturb many people or a lack of close surveillance of the patient, so that when discovered, it was obviously too late for any resuscitative measures to be effective. During the night the survival rate was slightly higher, tending to confirm the impression of greater selectivity. Most of the calls were from the general floor area, which consists mainly of private and semiprivate rooms with a few three-bed wards. The more critical patients were placed in the twentytwo bed intensive care and coronary care units to benefit from close monitoring. Even though the condition of the patients in these areas was more serious, the survival rate after a cardiopulmonary arrest was nearly as great as that from the general floors. (Table II.) This probably reflects the advantages of close patient monitoring and a higher nurse to patient ratio. A major concern of any emergency resuscitating team is whether a resuscitative effort will restart the cardiopulmonary system but leave a brain-damaged patient, a long-term burden for the family and society. Most of those resuscitated in this study who had brain damage died within a day or two. Three patients with brain damage survived three days. The remainder lived twentytwo, twenty-one, twenty, nine, five, four, and four days. None lived long enough for transfer to a chronic care institution. In a few respirator-dependent patients, the respirator was turned off when repeated electroencephalograms over an appropriate period of time showed no electrical activity. The cardiac rhythm just prior to the resuscitative effort was known in 48 per cent of the patients. The prognosis for resuscitating the heart and brain, as well as the outlook for ultimate survival,

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Figure basis.

1.

c-x

CARD/OPLLM~ARY

_

BRAIN

*---O

PATtENT

Effectiveness

(49

t 90

RESVSCl72 TED

RESUSCI JAJED D/SCHARGED

HOME ALIVE

of resuscitation

program

on a yearly

VENTRIC FIBRILLATION

ASYSTOLE 100

Arrest

PTS.)

BRADYCARDIA

KII PTS )

(14 PTS )

-

80 70 %

60

PATIENTS

-

50 40

L

30 20

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10 _

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Figure 2. is known. TABLE

Data Number Survival TABLE

CARD/OPULhfO&%W

m

BRAIN

-

DLSCHARGED

Effectiveness

I

II Data Number Survival

I

U

RESUXfTjlTED

RESUSCITUED FROM

MZSPIML

of resuscitation

A‘LNE

when cardiac rhythm

Time of Arrest 7 AM-3 PM

3 PM-11 PM

118

11 PM-7 AM

128

15 (13%)

:: (18%)

19 (15%)

Location of Arrest General Beds

Special Units

211

84

33 (16%)

11(13%)

was poorest when asystole or a straight line on the oscilloscope monitor was present. The prognosis was much better when ventricular fibrillation was present, and this is in agreement with similar studies elsewhere [1,2]. (Figure 2.) This is not surprising since the two rhythms are time-related in that ventricular fibrillation progresses to a

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DIAGNOSIS ACUTE

Ml

HEART

FAILURE

CHRONIC LUNG DISEASE POST-OP

CARCIAC SURG

POST-OP

GENERAL

PERIPHERAL

SURG

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HEMORRHAGE ACUTE REspIRATCftY

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20

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40

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m

80

90

Figure 3. periencing

Diagnosis of patients cardiac arrest.

ex-

NUMBER OF PATIENTS

straight line pattern after several minutes of circulatory arrest. In this study bradycardia without a detectable pulse or blood pressure gave the best chance for resuscitation and recovery. This also is probably a reflection of the time factor. Bradycardia is one of the early signs of an anoxic heart and may progress to ventricular fibrillation or directly to asystole. In reviewing all of the factors contributing to cardiac arrest, hypoxia seems to play a very significant role. On the basis of the major diagnoses and clinical data, nearly half the patients probably had a significant reduction in oxygenation due to chronic lung disease, congestive failure, acute pneumonia, depression of the central nervous system respiratory center, chest wall trauma, and postoperative pain in thoracic and abdominal cases. As a means of attempting to predict which patients have a predisposition to cardiopulmonary arrest, the cases are shown by primary diagnosis in Figure 3. By far the greatest number of arrests occurred in patients with acute myocardial infarction. The second large group of patients are those with heart failure, including those whose failure was due to valvular heart disease or to myocardial damage from previous, usually multiple, infarctions. Many of those in the remaining groups are of particular interest to surgeons. Thirty per cent of the entire series were primarily under the care of a surgeon. 204

Some of the calls obviously should not have been made, as in the twelve patients whose primary diagnosis was malignancy, most with widespread metastases, none of whom survived the arrest. Only 8 per cent of the calls for the entire group were judged to have been ill advised or not in the best interest of the patient. The only harm done by these ill advised calls, except for the commotion caused by the resuscitative effort, was to prolong a terminal illness in one patient for two days and for three days in another. Comments

The study of these 302 cardiopulmonary resuscitations reveals a common factor among many or most of these patients: an anoxic heart. The heart has been made anoxic either regionally in the case of coronary occlusion or generally from pulmonary insufficiency. Recognizing this, any patient with an anoxic heart or generalized hypoxia should be placed in a unit where he can be monitored closely. The improvement in survival statistics at our hospital seems directly related to the development of a coronary care training program for nurses. Many of the nurses throughout the hospital have taken this course, have become very astute at patient monitoring, both electrocardiographically and clinically, and have learned effective resuscitative measures which they are not afraid to use. Most of the resuscitative procedures have TheAmerican

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been started by the nurses before the doctors arrive. Although previously nearly every patient with ventricular fibrillation from an acute myocardial infarction died, now in the coronary care unit about 45 per cent survive and about half the defibrillations are carried out by the nursing staff. It is quite obvious that by increasing and improving the various parameters of patient monitoring and by extending the training program for nurses throughout the rest of the hospital, further significant gains can be attained. Summary

Cardiopulmonary resuscitation efforts in response to an emergency call are analyzed as to effectiveness in 302 patients. Over a seven year period there had been a marked improvement in the success rate of resuscitation. The reasons for this are the recognition of the patients most likely to suffer cardiac arrest and the monitoring of these patients closely in special units where nurses trained in resuscitation are constantly in attendance. References 1. Hollingswotth

JH: The results of cardiopulmonary resuscia 3-year university hospital experience. Ann intern Med 71: 459, 1969. 2. Jeresaty RM, Godar TJ, Liss JP: External cardiac resuscitation in a community hospital. Arch Intern Med 124: tation:

588, 1969. Discussion THOMAS K. HUNT (San Francisco, Calif) : Doctor Stiles is an old schoolmate, a foxhole buddy. The last time we worked together was when we were in the Army. He was already an impressively skillful surgeon. I am pleased to welcome him to the Society, and I am pleased that the Society has recognized his abilities. In my opinion the ‘important points of his paper are: (1) the recent improvement in results ; (2) the attribution of this improvement to increased capability of paramedical staff; (3) the emphasis on monitoring for early detection or prevention of cardiopulmonary arrest; and (4) the very useful and practical knowledge that the team is not being overused and is not unnecessarily prolonging life of poor quality. Throughout the country we have approximately 60 to 75 per cent survival after arrest in the operating room, 40 to 60 per cent survival in coronary care units, and now with his statistics, up to perhaps about 25 per cent survival in the general ward area. Obviously, early resuscitation has the greatest chance for even-

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tual success, and it has, across the board, a very great chance of success. Therefore, it is simple to deduce that to improve survival in the ward and the intensive care unit, we must train the first echelon, that is, the paramedical personnel. In San Francisco General Hospital our experience parallels that of the Good Samaritan group. A significant number of resuscitations are either successfully started or actually completed by the nurses even before the doctors arrive. The emphasis on hypoxia as a cause of arrest is extremely important. From 1964 to 1967 cardiopulmonary arrest on our surgical wards decreased sharply. Unanticipated arrests on the ward are now a rarity. In my opinion the most important reason for this striking change has been the use of blood gas electrodes. We now measure blood gases in all patients suspected of being a risk for either acute or chronic pulmonary failure. Those who do not pass the test are moved postoperatively into the intensive care unit with respiratory support until we have objective proof of adequate pulmonary reserve, along the lines which Dr Olcott discussed. We believe that the majority of arrests in surgical patients are due to hypoxia. A new California law, the first of its kind in the country, provides that rescue teams outside the hospital or owners or operators of authorized emergency vehicles are protected from liability. This is important to allow us to put the emphasis on early treatment of arrest. “No act or omission of any rescue team operating in conjunction with an authorized emergency vehicle while attempting to resuscitate any person who is in immediate danger of loss of life shall impose any liability upon the rescue team or the owners or the operators of any authorized emergency vehicle if good faith is exercised . . .” This is an important precedent because it must eventually include paramedical personnel who do the resuscitation. ALBERT HALL (San Francisco, Calif) : I would like to congratulate the authors on bringing this important subject to our attention and to endorse the concept that the precardiac arrest state should be accepted as a legitimate reason for calling the cardiac arrest team in certain cases in which it may be impractical to obtain immediate interdisciplinary consultation for a patient whose condition has unexpectedly deteriorated. We would be the last to criticize a nurse who called a cardiac arrest team before the patient actually lost his pulse or had become unconscious. One further point concerns the feasibility in very selected instances of using peripheral oxygenation for patients who are failing to respond to conventional, external cardiac massage. We have had experience with this in six patients and have had one long-term survivor after four hours of peripheral oxygenation. This patient had totally inadequate cardiac contractility for the first three hours. We think he survived because the perfusion pressure

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at the aortic root was higher than could be obtained with external cardiac compression because of severe coronary artery disease. In those hospitals that have the capability of using emergency extracorporeal perfusion and oxygenation, it is a reasonable technic to use in selected cases. We have used retroperitoneal exposure of the iliac artery and vein to perfuse these patients at flows up to 4 L a. minute, producing excellent perfusion pressure and oxygenation. THOMAS T. WHITE (Seattle, Wash) : I was interested .that only twenty-two of the patients reported on had general surgical problems. I see a very high incidence of both hiccup and cardiac arrest in patients with biliary-pancreatic disease or recurrent ulcers, often with accompanying pulmonary problems. We have been trying to prevent complications by keeping the patients from smoking for several days preoperatively and by teaching them to use the positive pressure ventilation apparatus. When the patient starts to hiccup on the operating table, we are afraid of arrest. A celiac-ganglion block with an anesthetic agent will usually abruptly stop the hiccup. The blood will suddenly become less black. Ritalin@, 10 mg four times a day, will promptly stop most hiccups that occur postoperatively. This will reduce cardiorespiratory effort. Just before Christmas I had five patients at one time, in four of whom the hiccup stopped with this treatment. We gave the other patient a celiac-ganglion block at a later point because we did not seem to be able to stop the hiccup. It is my impression and that of my associates both in anesthesia and in other areas that patients who hiccup have poorer ventilation and oxygenation than others. I would like to recommend that a celiac-ganglion block be used in patients who have hiccup at the time of surgery to stop the hiccup and to prevent immediate operative and postoperative poor oxygenation. JOHN R. BENFIELD (Torrance, Calif) : About three years ago we reported our experience with a similar program at the University of Wisconsin. As I recall, 12 per cent of our patients with bona fide cardiac arrest were ultimately discharged from the hospital. I would like to comment on some of the organizational problems that we encountered at that hospital, which are probably common to other hospitals, and to ask Dr Stiles if he had similar obstacles to overcome. One problem was the need to convince the directors of the nursing staff to allow the nurses on the floors and on the wards to initiate cardiac resuscitation. This was ultimately accomplished successfully but it required rewriting the nursing bylaws of the hospital. It is important that papers such as Doctor Stiles’ get into the literature so as to give nursing directors and administrators precedent on which to rewrite thei,r rules and regulations. The second point that we learned is that the elevator

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was a very great deterrent to getting the team to the patient. It was necessary to find a key which could commandeer the elevator at any minute and rapidly transport the team and the proper equipment to the patient. Finally, I would like to comment on a program that is currently operational within Los Angeles County under the direction of D,r J. Michael Criley who is the Chief of Cardiology at our hospital. A group of firemen have been trained to initiate cardiopulmonary resuscitation in ambulances. These firemen are in constant communication with a doctor in the coronary care unit of our hospital, and by telemetric communication they can transmit information about the patient to the doctor who in turn can help them in initiating this resuscitation. We are currently studying the feasibility of extending this kind of remote control cardiopulmonary resuscitation to other types of emergency problems encountered outside the hospital. I believe this approach has ,considerable future. CARLETON MATHEWSON, JR (San Francisco, Calif) : There have been a number of papers on this excellent program that call our attention to the many sophisticated methods now available to prolong life. Unfortunately, they are concentrated in a very small number of hospitals. As I commented yesterday, not many good things come out of war; however, we have learned from our experience in Vietnam that proper care at the scene of an accident and rapid transport of the seriously injured to a center where all of these sophisticated methods of resuscitation are available have saved innumerable lives. Unfortunately, little has been done in civilian life to organize a system of care that will compare with that which has proved so successful in Vietnam. Too often, civilian casualties are managed at the scene of an accident by inexperienced personnel, transportation facilities are inadequate, and more often than not the injured are taken to the closest medical facility rather than to one properly equipped to manage serious injuries. In San Francisco we have been able to save numerous lives because most serious casualties are transported by a city-wide, properly manned ambulance service directly to the San Francisco General Hospital, where casualty teams are on twenty-four hour duty and most facilities for immediate and sophisticated treatment are available. I would urge each and every member of this society to help organize similar facilities in all sections of the Pacific Coast. The Armed Services have trained innumerable technicians who are returning to civilian life and who can be of great service provided we offer them the opportunity. We must not forget that accidents are the greatest cause of death in persons under the age of thirty-five and it is within our power and therefore our responsibility to do something about it. QUENTIN R. STILES (closing) : When I originally

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started looking through all these charts, reviewing them to get these statistics, I had rather a negative opinion of this whole program. I wanted to find just what the batting average was and I was very amazed and very pleased to see that there is a definite trend toward improvement. What is the make-up of our team? It is a chaotic make-up. The operator just calls out: “Dr Heart, Room 305.” Then, whatever appears is the team. It is usually about ten times the number of doctors that are needed, and there is a tremendous commotion. It needs much better organization than we presently have. Doctor Hunt also asked about the make-up of the hard equipment that we have present on the wards. The special units, that is, the intensive care and coronary care units, are all self-contained. There is another crash cart that is kept in the operating room where there is someone on duty all the time with the key to the elevator. Doctor Benfield asked if we had trouble getting the nursing supervisor to agree to allow the nurses to carry out these procedures which traditionally have been left

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up to the physicians. Yes, we did, which is really one of the reasons that I felt very strongly that this type of material should appear in print to give support to these nurses. They need this kind of support from the medical staff. Doctor White, you thought that 22 per cent was a small number to have for general surgical patients. The number was actually higher. When a postoperative patient had a pulmonary embolus or myocardial infarction, he was placed in these groups. The group listed as postoperative general surgery is a somewhat miscellaneous group. We need better monitoring of patients. Our need now is not only electrocardiography, which we are using now, but some type of oxygen monitoring such as an electrode. We need a pC0, monitor which, I think, will be very helpful. Our medical friends have taken a giant step in training nursing personnel for coronary care, the whole coronary care concept. I think surgeons should take advantage of this and support this concept more than we have.

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