Closed chest cardiac resuscitation

Closed

Chest

Cardiac

Resuscitation*

L.AURENCEM. RIVKIN, M.D., BENSON B. ROE, M.D. AND RICHARD E. GARDNER, M.D.,

San Francisco, California From tbe Department oj Surgery (Cardiac), Mt. Zion Hospital and Medical Center, and tbe Department of Surgery, University of Calijoinia Medical Center, San Francisco, Calijornia. Tbis work was supported in part by U.S.P.H.S. Grant H-4461.

UDDENcirculatory arrest is a common mode death. When the cause of circulatory arrest is reversibIe or treatable, prompt and effective cardiac resuscitation can preserve life. For cardiac resuscitation to be prompt and effective, a simple and effkient technic must be available. One such technic is cardiac compression through the intact chest, recently reinstituted and described by Kouwenhoven et al. 111. With this technic many patients suffering from circuIatory arrest due to iIIness, injury or iatrogenic factors can be saved. During our First year of apphcation of closed chest cardiac resuscitation (CCCR) this technic has been used clinically in seventy patients and experimentally in ninety dogs.

S of

Fifteen other patients were successfully resuscitated one or more times, but died in the hospital. The cause of death was usually a progression of the original disease process. The most unusua1 patient in this group required ventricular defibrihation and cardiac compression more than IOO times during a five day period. In forty patients resuscitation was not successful. Since resuscitation was initiated by many different members of the hospita1 staff it has not been possible to analyze failures, or even keep an accurate tally of a11 unsuccessful attempts. C ar d’iac resuscitation was accomplished by nurses in three of the patients who survived. In most other patients, resuscitation was instituted by a house offrcer. Two patients were successfuhy resuscitated by the rescue squad of our Iire department. EXPERIMENTAL STUDIES

CLINICAL EXPERIENCE

Three types of experiments were performed. Initially, ventricmar IibriIIation was induced in dogs and the circulation was maintained with CCCR, foIlowed by deIibriIIation after ten to forty-Iive minutes. Consistent survival was accomplished in thirty consecutive animals. In a second study the technic was modihed with respect to the rate and Iength of compressions. In these animals the hemodynamics and efficacy of CCCR were studied and particuIar attention was paid to cardiac output, carotid blood flow and intracardiac pressures. In a third study several mechanical devices for Iong-term maintenance of CCCR were evaluated for their potentia1 usefumess in situations requiring Iong-term assisted circulation. All of these studies are stir1 in progress. In appIying CCCR to dogs, a systolic blood pressure of

In fifteen patients in whom sudden cardiac asystole or ventricmar fibrihation deveIoped, cardiac resuscitation was successfu1 and the patients were discharged from the hospital. (Table I.) One of these patients was resuscitated seven times and another patient twice. CircuIatory arrest developed in the operating room in only Iive of the patients. The other ten patients were resuscitated in other Iocations in the hospital. Five of the fifteen patients required externa1 cardiac defibriltation. No significant injuries occurred as a result of resuscitation. Several patients had evidence of mild costochondral separations, but no rib fractures occurred. One patient suffered a smaII second-degree burn at the site of the eIectrode following external defibrihation.

* Presented at the Annual Meeting of the Pacific Coast Surgical Association

283

American

at Portland, Oregon, Feb. Journal

of Surgery.

Volume

19-21,

104, Augur

1962. 1962

Rivkin,

Roe and Gardner TABLE

PATIENTS

Age b.;

HospitaI Location

RESUSCITATED

WITH

I

CLOSED CHEST CARDIAC

Circumstances of CircuIatory Arrest

Diagnosis

Sex

COMPRESSION

Duration of Cardiac Compressior (min.)

No

Operation

4

No

Apnea for 4 hr.

15

No

2

No

7 arrests in 12 hr.; 0Iiguria postoperatively Surgery deferred

3

No

. .

4

No

...

During bronchography

2

No

...

Stokes-Adams

attack

4

No

InternaI pacemaker inserted 3 days Iater

Hypoxia, puImonary hypertension During bronchoscopy

4

No

5

No

Hypoxia

5

Yes

40

Yes

,Quinidine intoxication

4

Yes

DigitaIis intoxication Postoperative eIectroIyte imbaIance

IO

Yes Yes

Gastric obstruction

65,M

Retina1 detachment

During gastroenterostomy During eye surgery

Hip fracture

During hip naiIing

HareIip

Induction

InguinaI hernia

Aspiration after completion of operation Hypoxia(?)

I,M 42,M 82,M 3,M 52,M

Operating room Operating room Admitting ward X-ray room Ward

52,F

Intensive care unit Intensive care unit Intensive care unit Conference room Ward

46,M 78,M

Ward Ward

46,F 38,F 739M 42,M

Pulmonary emphysema Bronchiectasis CompIete heart bIock Postoperative mitra1 vaIvotomy Amyotrophic IateraI scIerosis Pulmonary edema

anesthesia

Acute arrhythmia

Myocardial infarction ArterioscIerotic heart disease MitraI stenosis IntestinaI obstruction

Comments

2

65,M Operating

73J

DefibrilIation ~.

-_ room Operating room Operating room

WHO SURVIVED

4

compIeted

Two episodes of fibriIIation

80 to 100 mm. Hg was consistentIy maintained. The mean bIood pressure averaged 60 mm. Hg. The resuIts of cardiac compression at thirty strokes per minute and sixty strokes per minute were compared. No significant advantages were found in the faster rate in reIation to bIood pressure, cardiac output or bIood ffow. In some instances, significantIy better bIood flow occurred at the sIqwer rate. With technicaIIy satisfactory CCCR, cardiac output and cerebra1 bIood ffow ranged from 30 to 50 per cent of contro1 IeveIs. Associated with the faster rates of compression was an increase in trauma manifested by fractured ribs and hepatic laceration. FinaIIy, a mechanica piIe driver was utilized to simuIate cardiac compression. No advantages over manua1 compression were gained from this apparatus. However, the usefulness of such machines is dependent upon

the potentia1 vaIue of externa1 cardiac compression for long-term assisted circuIation. From this experience we have formuIated specific tech&a1 recommendations [2]. (Fig. I .) In the application of cardiac resuscitation, no deIay is possibIe. Therefore, a11 hospital personne1 directIy invoIved in the care of patients must be trained in the technic of initiating CCCR and artificia1 respiration at the onset of sudden circuIatory arrest. Competent Iaymen (such as firemen and poIicemen) shouId receive simiIar education. Except for patients with cardiac tamponade, we did not perform thoracotomy for circuIatory arrest. In the human subject, resuscitation through the intact chest is more effective, Iess traumatic to the heart and more easiIy and tireIessIy performed than thoracotomy with direct manual compression. Furthermore, it requires no surgical 284

CIosed Chest

Cardiac

Resuscitation

(Closed Chest Cardiac Compression) IS EFFECTIVE for Cardiac Standstill or Ventricular Fibrillation E SUSPICION of CARDIAC ARREST, DO NOT WAIT for confirmation. PATIENT SUPINE -OPERATOR For effective

compression

ABOVB

mount the bed or adpcent

PLACE HANGS ON STBRNUM.. the IIEEL

of OIW hand

chair.

.

DYBC the IOWW sternum,

the second

hand on the first.

RHYTHMICALLY

COMPRESS T&E HEART..

by exerting pressure

body

for

on fewer

‘h, MC. and

a min. STERNUM is applied.

weight

refea~.

SHOULD

DO NOT

Repeat

MOVE

.

sternum. MAINTAIN at

rate

the

of 30-40

3 to 5 cm when ‘pre~re

-.

exert Pressure on rib cage or epigostrium.

7’.

SIMULTANB@USLY ESTdkBlMH VENTlLATlON lb mouth to mouth or other owikrbie means. Call

anestbetid.

FEEL FOR PULSE and OBSERVE PUPILS If circulation is maintained, a pubs will be pupils will

cons&t.

(Pupils dilate

palpobie

circulatory

(head

DRUdS . . .

down)

to, increase

Give EPINEPHRINE

Combat

acidosis with

frequent

intervals.

cerebral

possible,

with

blood Raw and guard

(I.V. or tntracardiclc) I.V. SOblUM

Other

For VENTRICULAR

-

LACTATE

COAT

APPLY SHOCK lating,

CaCI~ (10%).

Only

Secure

EXTERNAL

MAINTAIN

with conductive

440V.A.C.

.

at 0.25 and

sec. If ineffec+ive,

alkali.

myocardium

The ECG may appear Epinrphtine,

norepinephrine,

to 20 cc). (Repeat

solut~ion pronestyl,

PRN,)

5 gms. Repeat

at

etc.

opsx,

If necessary

will

lactate,

normal

and other

the other

cww

the sternal

notch: see diagram.

jelly. repeat

apply

using 3 shocks in rapid

880

volt ihock

(0.25

. unt.1 I tmmediateiy

succession. If still fibril-

rec.). before

defibrillation

shock.

defibrillate.

CARDIAC COMPRESSION

tained,

1:lODO

defibrillator.

CARDIAC COMPRESSION

an oxygenated

(dilute

or NaHCd

FIBRILLATION:

give epinephrine

ALWAYS MAINTAIN

aspiration.

(40 cc 6f one Molar)

drugs as indicated:

the ECG.

ELECTRODES

against

4 cc of 1:20,000

APPLY ELECTRODES FIRMLY, oneoverthecardiac

DRUGS..

and

arrest.)

PATIENT in Trendlenberg position . . .

POSITlON

VERIFY,if

with

while drugs

AFTER DEFIBRILLATION the heart

beat

until a good pulse is main-

is ineffective.’

as above.

CONTINUE RESUSCiTATlON AS LONG AS THE PATIENT RESPONDS. DO NOT STOP PREMATURELY. I;Ic,. I. Poster showing instructions

for instituting

equipment or specialized ski& and does not introduce the probIems reIated to open thoracotomy. hloreover, the possibility of making an incorrect diagnosis is of no consequence. Nevertheless, violation of proper technic wiII result in faiIure of resuscitation. Unquestion-

closed chest cardiac

compression.

ably, many of the injuries attributed to CCCR itseIf are reahy the result of poor technic. When the diagnosis of circuIatory arrest is made, closed chest cardiac resuscitation (artificial circulation) and artificial respiration must be instituted immediateIy. The patient should 285

Rivkin,

Roe and

Gardner

FIG. z. Cross section of human thorax at the IeveI of the heart. Hands in position on sternum for cIosed chest cardiac compression. A, before cardiac compression. B. during cardiac compression. Note heart compressed between sternum anh verteb;aI body.

be in the supine position and the operator must be above him for proper Ieverage. This wiI1 require mounting the bed or a chair if the patient is not on the ffoor. AI1 pressure is appIied to the Iower third of the sternum mediated through the heeI of one hand; the second hand is placed on the first. Cardiac compression is instituted by shifting the body weight on the arms and appIying an effective force of 70 to go pounds on the sternum. The heart is then compressed between the sternum anteriorIy and the vertebra1 bodies posteriorIy. (Fig. 2.) The hands are not raised from the chest waI1 during the diastoIic phase. Pressure shouId be appIied thirty to forty times a minute and maintained for about haIf the pressure cycIe. With the proper appIication of force, the sternum wiI1 move 3 to 3 cm. Care in pIacement of the hands wiI1 Iimit pressure to the Iower sternum and guard against injury. Misdirected pressure over the ribs may resuIt in fracture, and pressure over the epigastrium can cause contusions or Iacerations of the Iiver. With proper technic the onIy injury noted has been minor costochondral or costosterna1 separation. The need for more rapid rates in the performance of cardiac compression has not been indicated by our cIinica1 or Iaboratory experience. On the other hand, a rapid rate of compression needs to be accompanied by an accejeration of force on the sternum, increasing the IikeIihood of trauma and increasing operator fatigue. The sIow rate aIIows for satisfactory resuscitation on a hospita1 bed. In chiIdren, force commensurate with the mobiIity of the sternum is utiIized.

Concomitant artiticia1 respiration is mandatory for successfu1 resuscitation; mouth to mouth or mouth to nose respiration is most readiIy appIicabIe. PIacement of the patient in the TrendeIenberg position prevents aspiration of vomitus and promotes maintenance of a cIear airway. The efficacy of cardiac compression can be confirmed by feeIing the puIse; a paIpabIe pulse is a concomitant of satisfactory resuscitation. The systoIic bIood pressure may be determinabIe by the paIpatory method. In addition, with efficient artificia1 circuIation, the pupiIs wiI1 constrict. With the re-estabIishment of circuIation and ventiIation by artificia1 respiration, spontaneous cardiac contractions are to be expected in the event of cardiac asystoIe. With the appearance of effective ventricuIar contractions, confirmed by a satisfactory puIse, cardiac compression can be discontinued. If spontaneous heartbeats do not occur, ventricujar fibriIIation or severe myocardia1 hypoxia is In either case, sodium bicarbonate present. soIution (3 gm.) or 40 cc. of sodium Iactate (I MoIar) shouId be given intravenousIy aIong with 4 cc. of I :20,000 epinephrine. Prior to defibriIIation, the presence of ventricuIar fibrilIation shouId be confirmed by an eIectrocardiogram. To effect ventricuIar defibriIIation an externa1 dehbriIIator is needed which dehvers up to goo voIts across the resistance of the chest. The defibriIIator shouId be connected to a waI1 receptacIe without an extension cord to aIIow for adequate current flow. The eIectrodes must be we11 coated with eIectrode jeIIy and then heId against the chest waI1 with pres286

CIosed Chest Cardia Resuscitation sure to achieve good contact. The eIectrodes are best applied in the verticaI axis of the chest, one over the cardiac apex and the second over the manubrium sterni. One shock of 440 volts a.c. for 0.25 second should be used. If defibriilation is not achieved, a second or repetitive series of shocks shouId be used. If unsuccessfu1, 880 volt shocks should be used. Cardiac compression must be maintained up to the moment of defibrillation and thereafter unti1 satisfactory spontaneous cardiac action is achieved. External cardiac compression is useful in shortterm assisted circuIation when cardiac action is weak. Thus, resuscitation shouId be maintained during the transitiona period foIIowing LTcntricuIar fibriIIation before a good heartbeat ensues. The electrocardiogram may be norma while the heartbeat is ineffective. Cardiac resuscitation should be maintained as long as circulation is maintained, as evidenced by pupillary constriction and arteria1 pulsation. Following resuscitation, diligent care may bc required to maintain good circulation and prevent recurrence of circuIatory arrest. The surviva1 of those patients with severe cardiac or respiratory disease may be diffIcuIt to achieve. SUMMARY

CIosed chest cardiac resuscitation has proved to be a most effective technic for emergency resuscitation or circuIation in the event of sudden circuIatory arrest. It is the method of choice in the treatment of this catastrophe. TechnicaI recommendations suggest a rate of thirty to forty strokes a minute as a nontraumatic technic of externa1 cardiac compression. UtiIizing this technic, survival has been effected foIIowing circulatory arrest in fifteen patients; five of these patients required ventricuIar defibrillation. REFERENCES I. KOUWENHOVEN,W. B., JUDE, J. R. and KNICKERBOCKER. G. G. Closed-chest cardiac massaee. J. A. n/r. A., 173: 1064, rg6o. 2. RIVKIN, L. M. and GARDNER, R. E. Cardiac resuscitation through the intact chest. Calijornia Med., 96: 75. 1962.

DISCUSSION

K. ALVIN MERENDINO (SeattIe, Rivkin,

Gardner

and

Roe

in this

Wash.): report

Drs. have

emphasized the importance of the contribution of closed chest cardiac compression. As this paper encompasses the breadth of the resuscitation probIem, one hardly knows to what aspect one should restrict his comments. CertainIy, there is nothing to disagree with and there is much which bears re-emphasis. Their choice of the term “closed chest cardiac compression” is an excelJcnt one; massage is an inappropriate term and should not be used in this connotation. The importance of anciIJary drugs, e.g. bicarbonate, seems well worth stressing in the patient in whom there may have been delay in initiating compression, or the patient who seems refractory to cardiac drugs and attempts at deJibriJIation. ObviousJy, no artificial method of maintaining circuJation is as effective as the normaI heart beat. In these artificia1 situations in which the cardiac output may be half or Jcss than normal, one must expect with time, a progressive metabolic acidosis. With acidosis “cardiac failure” may be reversed by drugs which in themselves arc alkaIotic or bind acid. In the acidotic patient whose heart is refractory to drugs and clcctrical dehbriliation, I have been impressed with the USC of THAM in restoring norma cardiac sensitivity to these resusitative measures. The drugs, advocated by the authors undoubtedIy are best for the case usuaIJy encountered outside the operating room. In the past, the average physician has been schizophrenic in his approach to the problem presented to him by the person who suddenIy keels over on the goIf course, football fieId or the like. If the vaIue of cIosed chest cardiac compression was soIeIy that it aIIowed the physician something to hide behind to avoid the necessity of considering an ill-advised thoracotomy, the vaIue of this alone wouId have been, in my opinion, worthwhiIe. However, the vaIue of cJosed chest cardiac compression goes far beyond this. I have not reviewed our total experience at the University HospitaI, but three iIIustrative cases immediately came to mind, as they occurred quite cIose together this past year. I wouJd Iikc to pesent these case histories which highlight the JIexibiIity and superiority of cIosed chest compression to the open methods. Patient R. B., a forty-eight year old white man, was admitted to the University HospitaI with progressive increase in shortness of breath, persistent edema, severe coughing and speIIs of orthopnea. Cardiac catheterization reveaIed severe pulmonary presumabIy secondary to tight hypertension, mitral stenosis and a mild amount of mitral insufficiency. He had one second vital capacity of I.9 liters. PreoperativeIy a total of approximately 3,000 cc. of serous pIeural JJuid was aspirated. Diuretics also helped account for a loss of 14.7 kg. in weight preoperativeIy. On September 14, 1961, mitra1 commissurotomy was performed. An opening measuring two fingerbreadths resuIted with-

Rivkin,

Roe and Gardner was given to the point of toxicity, and quinidine was given oraIIy. At 9 P.M. the patient was taIking, alert and without compIaints. BIood pressure was 104/74 mm. Hg and pulse 140 per minute. At 9:12 P.M. the patient suddenly became opisthotonic and emitted a crowing sound; head and eyes deviated to the right. An eIectrocardiographic tracing revealed ventricular fibriIIation. External cardiac compression was started immediateIy as we11 as mouth to mouth breathing. An oropharyngea1 airway was pIaced and the patient was bag-breathed with a mask in pIace. Skin coIor was good and periphera1 puIses strong. The eIectrocardiogram continued to show ventricuIar fibriIIation until 9:15 P.M., at which time externaI defibriIIation was performed. ExternaI compression was continued and an endotrachea1 airway inserted. At 9:17 P.M. a few SupraventricuIar compIexes were noted on eIectrocardiogram. ExternaI compression and bagassisted ventiIation were continued with persistence of good coIor and periphera1 puIses. At 9:18 P.M. a cutdown was pIaced on the right leg and at 9:19 P.M. eIectrocardiogram reveaIed more supraventricuIar contractions. At 9:20 P.M. an irreguIar rhythm at about 45 per minute was noted, with normaI-appearing QRS compIexes. BIood pressure was 70/40 mm. Hg. ExternaI compression was stopped at 9:21 P.M. and the endotrachea1 tube was removed, as the patient couId not toIerate it any Ionger. BIood pressure was 100/65 mm. Hg, spontaneous respirations were occurring and a mask with continuous oxygen was pIaced over the patient’s mouth and nose. At 9~22 to 9~24 P.M. a noda rhythm with independent sinus focus was present. BIood pressure was about 100/70 mm. Hg. Respirations continued reguIar with good color and at 9:25 P.M. normal sinus rhythm ensued with a rate of about 96 per minute. EIectrocardiographic tracing was discontinued at 9:25 P.M. and by 9:30 P.M. the patient was talking, asking pertinent questions and was oriented. He then feI1 into a deep sIeep for the next hour and a half. He eventuaIIy made an uneventfu1 recovery and was operated on successfuIIy eIsewhere with a diagnosis of subaortic stenosis, secondary to idiopathic Ieft ventricuIar hypertrophy. The third patient, a fifty-seven year oId white woman, R. J., had had rheumatic heart disease and signs and symptoms suggesting severe aortic stenosis. On May IO, 1961, hemodynamic studies were performed. An attempt to visuaIize the Ieft heart by injection of contrast material in the Ieft atrium by the transepta route was foIIowed in a matter of seconds by the onset of ventricular fibriIIation. ExternaI compression and mouth to mouth breathing were immediateIy performed. ExternaI shock with 450 voIts defibrillated the heart and restored sinus rhythm. It was obvious

out significant regurgitation before or after commissurotomy. His convalescence was prolonged and dragging, and was marked by oIiguria, periods of venous distention and some irrationa1 behavior. EarIy on October I I, the patient suddenIy sIumped over and was markedIy cyanotic. He was examined shortIy afterward by the surgica1 staff who noted markedly tense, distended neck veins, slow irregular respirations, grossIy audibIe raIes and no heart sounds. CIosed chest cardiac compression and mouth to mouth breathing were instituted immediately. A phIebotomy of 500 cc. was accompIished. ShortIy thereafter the bIood pressure rose to 106/80 mm. Hg and puIse increased to I IO per minute. PuImonary rales decreased during the next twenty-four hours and the patient’s confusion graduaIIy diminished. Early in the evening of October 12, the patient again had cardiac arrest. EIectroIytes were normaI. As before, external massage and mouth to mouth resuscitation were performed. He recovered, with normal bIood pressure and puIse. He was started on Levophed” drip in addition to other anciIIary maneuvers. At night, cardiac arrest again IO:30 P.M. the same deveIoped. AI1 efforts to re-estabIish the patient’s respirations or heart rate were unsuccessfu1. He was pronounced dead at 10:45 P.M. Resuscitation of this chronicaIIy iI postoperative patient on two occasions wouId have been practicaIIy impossibIe by open cardiac resuscitation. Left puImonary decortication in 1959 and the recent Ieft thoracotomy incision wouId have made resuscitation doubly diffrcuIt. Furthermore, not many wouId have opened the chest three times to attempt cardiac resuscitation, as wouId have been necessary here. The next two cases are exampIes of successfu1 resuscitation by the cIosed method in which there wouId have been IittIe chance of success by the open method. B. B., a thirty-one year oId singIe white maIe intern was admitted for the third time for eIective cardiac catheterization. He had been pIagued by intermittent chest discomfort and occasiona irreguIarities of rhythm associated with exertion. Prior to admission, at four years, eighteen months, three months, one month and three weeks, he had suddenly become weak with substerna pain, sweating and anxiety. During such attacks, atria1 fibriIIation has been documented with ventricular rates at times in excess of 200. With spontaneous reversion to norma sinus rhythm, these symptoms disappeared. On November 17 the patient underwent right then Ieft heart catherization, without event. He was awakened the next morning by miId anterior chest discomfort; his pulse was in excess of zoo. He was monitored by eIectrocardiograms; digoxin 288

CIosed Chest Cardia Resuscitation dangers, morbidity, mortaIity, risk of infection of thoracotomy and the secondary probIems of the placement of incisions for subsequent operations are avoided if the patient has surgica1 heart disease. These are only examples of what has been found possibIe in our hospita1. Undoubtedly, many of the members of the Association have had similar experiences. Since the need for thoracotomy no longer exists, there has been increased interest and activity in resuscitation throughout the Hospital on a11 services, all to the benefit of the patient. There is no doubt in my mind whether closed chest cardiac compression is as good as open cardiac compression. It is far superior. Arc there any instances in which open cardiac compression is superior? I can think of none, except in the operating room when the chest is aIready open and closed compression, impossibIe. Are there instances in which closed methods have failed and open methods succeeded? We have had one such experience, in a patient seven days after open heart correction of mitra1 insuffrciency. Closed chest massage and external defibriIIation were performecl without success. The chest was opened and compression performed with successfu1 defrbriIIation and reversion to normal sinus rhythm. A Iittle Iater, however, the patient had JibrilIation and died. The problem was related to a large baI1 valve Ieft atria1 thrombus, and the temporary success of open methods may have been reIated to mechanical probIcms created by displacement of the clot with changes in positions. Despite this experience, we do not now practice open methods when cIosed methods fai1 even in the postoperative patient with a chest incision readily avaiIabIe for reopening. Dr. Rivkin and his coIleagues are to be congratuIated on their contributions and their extensive experience and success with cIosed chest cardiac compression. EDMOND D. BUTLER (San Francisco, Calif.): Anyone at any time may be caIIed upon to administer artiJicia1 resuscitation. The responsibility for knowing these technics cannot be reIegated to “the other fellow” interested in this work. If Iives are to be saved, each of us must familiarize himself with the technics of mouth to mouth resuscitation, externa1 cardiac massage and the use of the externat deJibriIlator, as devised by Kouwenhoven and associates. Dr. Rivkin has made an exceIIent review of this subject and therefore, my remarks wiI1 be Iimited to emphasizing certain aspects of artihcia1 resuscitation which we have come to consider important. In the management of respiratory failure, regardless of cause, mouth to mouth resuscitation is indicated, and is superior to a11 other methods of artificia1 respiration in current use. With mouth to mouth resuscitation, tida1 air can be maintained

on recovery, however, that a right hemiplegia and speech impairment had developed. Later that evening, she had two additional episodes of ventricular fibrillation, each of which was combated by external compression, mouth to mouth breathing and external defibrillation. Despite her unstable cardiac status and her right-sided “stroke,” she gradually improved. An additiona finding was that the eIectrocardiograms had from the beginning shown evidence of Ieft axis deviation, Ieft bundIe branch block and prolongation of QRS intervaIs. These findings were suggestive of diffuse myocardial disease. Unfortunately, the coronaries were never adequately visualized on the angiocardiogram. Because of her precarious status following that study, no one exhibited an overwheIming ambition to further clarify by roentgenogram the status of the coronary vesseIs. She responded substantiahy to speech therapy and physiotherapy. I-lcmiparesis improved so that she was ambuIatory, and three weeks Iater she was considered a reasonable candidate for surgica1 treatment for aortic stenosis. This was performed on June 8, 1961. At surgery, she was cooIed to 3o”c. The aorta was occluded and the heart packed in sIush for anoxic coId arrest. The aortic valve itseIf was not .. badly caIcrfred, but there were bridges of calcium across a11 cusps. At the conclusion of debridement, one’s index linger could easily pass through the aortic vaIve without difficulty. The aorta was closed in the usual fashion, and patient resuscitated by means of rewarming and eIectrica1 delibriIIation; two shocks were necessary. She was in cardiac arrest for forty-three minutes and in ventricular fibrilIation requiring twenty-one additiona minutes of cardiac massage prior to eIectrica1 defibrillation. The ability of the heart to take this sort of treatment three weeks after cIosed chest resuscitation indicates that the method is reIativeIy atraumatic. A tracheostomy was necessary because of her inabiIity to cough up secretions as a result of the hemiparesis. She was discharged on the twentieth postoperative day, activeIy ambtdatory, after a relatively uneventfu1 convalescence. Both hearts had anatomic obstructions to the forward fIow of blood. In my experience, such hearts have been practicaIIy impossibIe to resuscitate by open methods unIess something is done at the same time to alIeviate the block. Obviously, this opportunity wouId be Iikely onIy if the catastrophe occurred in the operating room. In any other situation it wouId be practicaIIy hopeless. The fact that both patients recovered without the need for remova of the obstruction and without the need for thoracotomy incision is doubly impressive. It is abundantIy ciear that one can indeed under these adverse circumstances of the disease produce adequate circulation by closed chest methods. At the same time, the

289

Rivkin,

Roe and Gardner technic has proved practica1 from a physioIogic standpoint and is much Iess fatiguing to the rescuer, who is often cahed upon to administer artificia1 resuscitation over prolonged periods. In the technica appIication of externa1 cardiac massage, fracture of ribs, rupture of the liver and emesis of gastric contents are Iess Iikely to occur if pressure is applied upon the sternum just below its mid-point, rather than over the lowest portion of the sternum as is often recommended. In the management of cardiac arrest, use of the cardioscope or singIe Iead electrocardiogram tracings are invaIuabIe, if avaiIabIe, in differentiating cardiac standstih from ventricuIar IibriIIation. It must be made cIear that in patients suffering cardiac standstill rhythm may be converted to norma by continued efforts at mouth to mouth resuscitation and externa1 cardiac massage. However, patients suffering ventricuIar IibriIIation can only be sustained for a temporary period by these methods and wiI1 sureIy die unIess a defibriIIating counter-shock is administered. At times, one cannot be certain whether he is deaIing with cardiac standstiI1 or ventricuIar fibrillation. In instances in which a reasonabIe doubt exists, it is our poIicy to administer countershock therapy. A countershock of this voItage has IittIe effect upon the norma heart. On the other hand, onIy by administering counter-shock therapy wiI1 the patient with ventricuIar IibrilIation be saved. Successful defibrillation often depends upon correction of anoxia by vigorous resuscitating measures prior to administering the counter-shock therapy, and by correction of any acidosis which may exist by administration of sodium bicarbonate soIution intravenously. Once cardiac rhythm has been restored, the patient must be carefuhy and continuously monitored, and the rescuer and his equipment must be ready to reinstitute resuscitating measures at the first sign of a faiIing respiration or circulation. Much credit must be given to Dr. Kouwenhoven and his associates, and Gordon and others, for their pioneering efforts and invaIuabIe contributions in this long negIected beId. Again, may I commend the authors of this paper for their exceIIent presentation of this vita1 subject. CARLETON MATHEWSON, JR. (San Francisco, Calif.): AI1 this appears very simpIe in the film, and it sounds very simpIe, but the institution of closed resuscitation has many dangers. Nothing has been said about the dangers of using the so-caIIed externa1 defibriIIator. This instrument wiIl cause the heart to fibrilIate, therefore, it is not an instrument that can be used without some danger. Many years ago we were toId that if a puImonary embotus couId be removed within nine minutes the patient’s life couId be saved. I remem-

at approximateIy two and a haIf to three times the norma volume, and oxygen saturation of arterial bIood, as we11 as carbon dioxide content, can be maintained at norma levels, if circulation is adequate. It is obvious, however, that Iacking an adequate circuIation of bIood, mouth to mouth resuscitation, regardIess of its effectiveness, and a11 other methods of artificiaI respiration are doomed to faiIure. In those instances in which mouth to mouth resuscitation is not feasibIe, as may occur in patients suffering extensive facia1 wounds, artificial respiration may be administered by means of the SyIvester method. This method not onIy provides necessary ventiIation but may aIso be modified to alIow for external cardiac massage by a single rescuer, in those instances in which respiratory failure is associated with circuIatory faiIure. In patients whose circulation has faiIed as a resuIt of cardiac standstiI1 or ventricuIar hbrillation, and in whom the heart beat and puIse are not detectabIe, external cardiac massage is indicated and may be Iife-saving. External cardiac massage is capable of maintaining norma circuIation and bIood pressure for hours and when combined with mouth to mouth resuscitation, provides circulation and ventilation superior to that obtained with the open chest technic. In those instances of resuscitation in which the chest is not aIready opened, the combined use of mouth to mouth resuscitation and externa1 cardiac massage should obviate the need for opening the chest. It must be emphasized that externa1 cardiac massage is an adjunct to, and not a substitute for, respiratory methods of resuscitation. Gordon has shown that when externa1 cardiac massage is used aIone without artificia1 respiration, circuIation is adequate but tida1 air measures only 50 per cent of normal, and oxygen saturation of arteria1 bIood faIIs to 58 per cent in six minutes and to an anoxic IeveI of 20 per cent in twenty minutes. It becomes obvious, therefore, that some form of artificial respiration must be used in conjunction with externa1 cardiac massage. Mouth to mouth resuscitation and externa1 cardiac massage have been shown to be more effective when administered aIternateIy than when administered simuItaneously. OriginaIIy, it was recommended that externa1 cardiac massage be alternated with mouth to mouth resuscitation in a ratio of 5: I. From our own experience and on the recommendation of Dr. Gordon, we have come to adopt the foIlowing pIan. If the rescuer is working with assistance, externa1 cardiac massage and mouth to mouth resuscitation are aIternated in a ratio of 8: I. If the rescuer is working aIone, external cardiac massage and mouth to mouth resuscitation are aIternated in a ratio of I 5 : 2. This

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Closed Chest Cardia ber we were all standing around in a hailway as Professor Willkie was saying good-bye to a patient on whom he had performed an appendectomy a few days before, when suddenly the patient fell to the tloor. We had all been coached on how to remove a pulmonary rmboIus. Unfortunately, howc\er, the nine minutes passed before anybody thought of the correct diagnosis. I am afraid that this is what occurs, or is apt to occur in cardiac arrest, unless all peopIe invoived have been properIy instructed. If you intend to USC this method in your hospital, I think the procedure shouId be demonstrated on animals and all of the dangers shouId be emphasized. ROY COHN (Palo Alto, Calif.): Through the courtesy of Dr. Dean Clark, Mr. Lawrence Cohn and the Coroner’s office in Santa Clara County, I wish to record the results of tweIve autopsies in patients who underwent closed methods of cardiac resuscitation. Their injuries incIuded rupture of the spleen (one case) and vena cava (one case), multiple rib fractures, lacerated Iung and one lacerated Iiver. Now, you may say it is obvious that the peopIe who applied the method were not doing it properly. I am not sure that this is really the fact of the matter. Those of us who can remember, before the popularity of open heart massage, many instances in which patients ahegedly dead were resuscitated and recovered either by needling the heart, by which the Scandinavians seemed particularly impressed, a simpIe slap on the back or perhaps nothing at all. So when Dr. Rivkin mentions fifteen patients who recovered compIeteIy, unIess he had them connected to an electrocardiograph machine at the time, one couId reasonably expect that some of these people might have recovered with no treatment at aII. In the Iatest issue of the Journal of Circulation, there is an exceIIent study of the heart in patients who have undergone open massage, and the microscopic damage to the heart is astronomical. Even if this method is applied properly without damage to the ribs or sternum, it seems to me that compression of the myocardium between vertebrae and the posterior surface of the sternum must have a deIeterious effect on it, and there must be some patients with myocardia1 infarction in whom pour efforts are adverse ones. 1 am not too sure that mouth to mouth breathing is not the most important aspect of this whole probIem; however, I do agree with Dr. Merendino that the closed method does offer something, in that it gives the doctor something to do at the football stadium. RIC~IARD E. GARDNER (closing): I wouId like to mention something Dr. Stephens and I did about four years ago. We looked up the records of a11

Resuscitation

the patients during a five year period in whom open chest resuscitation had been attempted. Of the sixty-five patients in this group onIy seven survived. The onIy survivors were those in whom cardiac arrest occurred in the operating room; no patient subjected to attempted resuscitation by open chest technics on the wards or outside the operating theater survived. In the present one year period we have frad seventy such patients, fifteen of whom survived. This shows that we are now Iess hesitant to start external cardiac resuscitation than we arc to use the open technics. I wouId also like to remind you of some statistics that were presented by Dr. Beck and also by the group from Johns Hopkins Hospital, namely, that 50 per cent of patients with coronary thrombosis who die are probably resuscitable. In other words, these patients die from ventricuIar fibriIIation. An asystolic heart is a sick heart. When asystole occurs in surgery, it is usually due to poor oxygenation secondary to poor ventilation. A fibriilating heart is a healthy heart. Most of us who perform open cardiac surgery hnd that routinely fibrillating, the heart makes the operating procedure much easier and without complications, and it is easy to dehbriIIate the heart after we have tinished the specific operation. If we break the series down into asystolic and fibrillating hearts, we find that the highest incidence of successful resuscitation is in patients whose hearts were in ventricuIar fibrillation. The voltage used for defibriliation is 440 volts or 880 volts. Such a large voltage is used because any voltage over 90 to 100 voIts to the heart will cause asystole. Anything under 60 volts wiI1 routinely fibrillate the heart. The resistance of the skin requires this large amount of voItage to deliver 90 to IOO volts to the heart. The probIem of acidosis in these patients was discussed by Dr. Merendino. I would like to point out again that in our studies on cardiac output in dogs by the closed chest technic, the dogs were found to have a cardiac output of 50 per cent. The progression of metabolic acidosis with a 50 per cent output is rapid and quite surprising. The arterial pH in these animals wilI faI1 to as low as 6.9 or 7. We should emphasize then that sodium bicarbonate, which is avaiIabIe in vials of 50 cc., 44.6 mEq., should be given rapidly and without hesitation to any of these patients. One shouId aIso remember that IsupreI@ and adrenaIin are of value. It is important to remember, too, that the varied epinephrine derivatives will not have an ionatropic effect on the myocardium in an acidotic state. I wish to thank everyone who discussed our paper.