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How much CPR is enough CPR?
CORRESPONDENCE How Much CPR is Enough CPR?
the hospital with no long-term evidence of b r a i n damage) has occurred for the following durations of neardrowning submersion: • 10 m i n u t e s (1964, 8-year-old, male, fresh water lake, 40 m i n u t e arrest u n t i l initial resuscitative response, body t e m p e r a t u r e 28 C) 15 • 17 m i n u t e s (1964, 21-year-old, male, brackish ' w a t e r [oceantidal reached River Yarra-water analysis: s o d i u m 128 m E q / l i t e r , p o t a s s i u m 4.6 m E q / l i t e r , chloride 200 mEq/liter], ? m i n u t e arrest until initial resuscitative response, body t e m p e r a t u r e 32 C) 16 • 20 m i n u t e s (1964, 3-year-old, male, fresh water stream, 55 m i n u t e arrest u n t i l initial resuscitative response, body t e m p e r a t u r e 27 C) 15 • 20 m i n u t e s (1973, 33-year-old, male, s w i m m i n g pool water, 50 m i n u t e arrest u n t i l i n i t i a l resuscitative response, body t e m p e r a t u r e 27.8 C) 17 • 22 m i n u t e s (1963, 5-year-old, male, fresh water river, 142 m i n u t e arrest u n t i l resuscitative response, body t e m p e r a t u r e 24 C) 11 • 25 m i n u t e s (1977, 6-year-old, male, muddy liquid m a n u r e tank, 65 m i n u t e arrest u n t i l initial resuscitative response, body t e m p t e r a t u r e 31.8 C) is • 30 m i n u t e s (1974, 5-year-old, male, fresh water river, 30 m i n u t e arrest u n t i l i n i t i a l resuscitative response, body t e m p e r a t u r e 27 C) 19 • 40 m i n u t e s (1975, 5-year-old, male, ice-cold fresh water river, 105-107 m i n u t e arrest u n t i l initial resuscitative response, body t e m p e r a t u r e 24 C). 2° These and other data suggest the need for cont i n u e d individualized d u r a t i o n s of resuscitation until sound statistical data, obtained with optimal resuscitative care, is available to support rigid n u m e r i c a l guidelines. It appears, however, that the economics of resuscitation will probably direct the decision-making before any reliable scientific tables are ever prepared i n this country and published.
To the Editor: With regard to '~Cardiac Arrest in the Emergency Medical Services System: Guidelines for Resuscitation" (JACEP, December 1977), cardiopulmonary resuscitation (CPR) s u r v i v a l rates (ie, percent discharged alive from the hospital) vary from zero ~ to 86% 2 for prehospital arrests and 4.6% 3 to 100% 4 for inhospital arrests. T h e s e wide ranges update the 1953 report of Stephenson and H i n t o n 5 which describes a successful r e s u s c i t a t i o n p e r c e n t a g e r a n g e of 8% to 75% from their l i t e r a t u r e search a n d a " p e r m a n e n t survival" average of 25% from their study of 1,000 cases of cardiopulmonary arrest. 5 As of J a n u a r y 1, 1978 a comprehensive retrospective and prospective survey of cardiopulmonary arrest r e s u s c i t a t i o n o u t c o m e s is n e e d e d to d e f i n i t i v e l y analyze factors such as p a t i e n t age, sex, d u r a t i o n of p r e r e s u s c i t a t i v e c a r d i o p u l m o n a r y a r r e s t , specific etiology of c a r d i o p u l m o n a r y arrest, presence/absence of u n d e r l y i n g disease, p a t i e n t responsiveness to specific therapeutic modalities, d u r a t i o n of active resuscitation, effectiveness of i n d i v i d u a l resuscitationist contributions d u r i n g each phase of resuscitation, and a n y other circumstances which contribute to i n i t i a l resuscitation success, long-term success, unresponsiveness to resuscitation, early demise, late demise, a n d irreversible organic d e r a n g e m e n t . These studies r e q u i r e a u n i f o r m r e p o r t i n g system, 6 s t a n d a r d base d e t e r m i n a t i o n s7 and multihospital collaboration to insure sufficient p a t i e n t n u m b e r s for a c c u r a t e s t a t i s t i c a l e v a l u a t i o n . An e s t a b l i s h e d data collection c e n t e r should first formulate strict criteria for operational definitions of cardiopulmonary arrest, t r a d i t i o n a l death, s resuscitation, d u r a t i o n of arrest, d u r a t i o n of resuscitation, and optimal emergency medical care t h a t needs to be provided d u r i n g all phases. Only after accurate documentation can a n y statistically supported tables be developed to guide physicians as to how long to resuscitate i n d i v i d u a l cases.
J.K. Sims, M.D. Honolulu, Hawaii Mike Penick, E M T - A Aiea, Hawaii 1. Baker R, Waters JM: Cardiac Experience - - Jacksonville Rescue Branch - - February 1973, in Proceedings of the National Conference on Standards for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC), May 16-18, 1973. American Heart Association, Dallas, Texas, 1975, p 183. 2. Copley DA, Mantle JA, Russell RO Jr, et al: Reduction of morbidity and mortality with early cardiopulmonary resuscitation via bystanders. Circulation II - - 225, 1976 (Abstract #0882). 3. Gilbert GJ: Cardiopulmonary resuscitation. J A M A 238:12, 1977. 4. Stephenson HE Jr (ed): Cardiac Arrest & Resuscitation. C V Mosby Co, St. Louis, 1974, pp. 809, 827.
Duration of Resuscitation A 3.5-hour resuscitation for cardiopulmonary arrest has been reported 9 from which the patient eventually "survived with no detectable b r a i n damage." This same r e s u s c i t a t i o n group, successfully resuscitated n i n e other p a t i e n t s with cardiopulmonary resuscitations exceeding 20 minutes. 9 The Guinness Book of World Records 1° lists the l o n g e s t recorded h u m a n h e a r t stoppage w i t h s u b s e q u e n t recovery at three hours in a 5-year-old boy who near-drowned in the ice-cold water of a fresh water river. He was u n d e r the water for an estimated 22 minutes, 1°,1~ required 120 minutes of cardiac compression, and ~'recovered with little if any neurological a n d intellectual damage. ' ' ~ Jude et a112 reported a series of efforts at resuscitation from 2 to 120 m i n u t e s and noted "successful r e t u r n to the p r e a r r e s t c e n t r a l n e r v o u s s y s t e m a n d cardiac status occurred up to 90 minutes." Successful resuscitation (ie, discharged alive from
7:5 (May) 1978
5. Stephenson HE Jr, Hinton JW: Use of intra-aortic and intracardiac transfusions in cardiac arrest. JAMA 152:500-503, 1953. 6. Polnitsky CA, Capone RJ, Gagnon DE, et al: Prehospital c o r o n a r y care - - proposal for a uniform reporting system. JAMA 237:134-137, 1977.
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7. McManus WF, Darin JC: Can the well trained EMTParamedic maintain skills and knowledge? JACEP 5:984986, 1976.
We have other objections to the 30-minute cutoff which are philosophical. The decision to t e r m i n a t e life support must be based on the physician's impression of the patient and his chance for survival, not on a time limit. The assessment stems from the physician's experience. In some instances, the experienced physician will curtail his efforts in less t h a n half an hour. We are g r e a t l y concerned however, t h a t the i n e x p e r i e n c e d physician will accept these guidelines as dictum and stop advanced cardiac life support (ACLS) at the 30m i n u t e cutoff, thereby failing to resuscitate some patients who might otherwise survive. We feel there should be an a d d e n d u m to the 30 m i n u t e guideline which will make it clear t h a t there are instances, as mentioned above, where CPR should be continued for longer periods of time, possibly including modalities beyond s t a n d a r d ACLS. Dr. E l i a s t a m ' s efforts in e s t a b l i s h i n g guidelines are a good beginning, b u t f u r t h e r work is needed.
8. Sims JK: Criteria for the pronouncement of death and the human brain death syndrome. Hawaii IVied J 35:11-14, 1976. 9. Sandoe E, Flensted-Jensen E, Dupont B: Long-term prognosis in patients resuscitated from cardiac arrest. Isr J Med Sci 5:769-771, 1969. 10. McWhirter N, McWhirter R: Guinness Book of World Records, Bantam Books - - Sterling Publishing Company, New York, 1977, p 42. 11. Kvittingen TD, Naess A: Recovery from drowning in fresh walter. Br Med J 1:1315-1317, 1963. 12. Jude JR, Kouwenhoven WB, Knickerbocker GG: Cardiac arrest - - report of application of external cardiac massage on 118 patients. JAMA 178:1063-1070, 1961. 13. Sims JK: Drowning and near-drowning, in Barry J (ed): Emergency Nursing. McGraw-Hill, New York, 1978, pp 377389. 14. Modell JH: The Pathophysiology and Treatment of Drowning and Near-Drowning. Charles C Thomas, Springfield, Illinois, 1971, pp 8-12.
Marc J. Bayer, MD Joseph J. Bander, MD Sanders Orent, MID Emergency Services University of Oregon Health Sciences Center
15. Ohlsson K, Beckman M: Drowning-reflections based on two cases. Acta Chir Scand 128:327-339, 1964. 16. King RB, Webster IW: A case of recovery from drowning and prolonged anoxia. Med J Aust 1:919-920, 1964. 17. DeVillota ED, Barat G, Petal P, et al: Recovery from profound hypothermia with cardiac arrest after immersion. Br Med J 4:394-395, 1973. 18. Theilade D: The danger of mis-judgement in hypothermia after immersion. Anaesthesia 32;889-892, 1977.
1. Shockett E, Rosenblum-R: Successful open cardiac massage. JAMA 200:157-158, 1967. 2. Russell ES: Cardiac arrest: survival after 2Vz hours open chest cardiac massage. Canad Med Assoc J 87:512-513, 1976.
19. Hunt PK: Effect and treatment of the "diving reflex" Can Med Assoc J 111:1330-1331, 1974.
Author's Reply
20. Siebke H, Rod T, Breivik H, et al: Survival after 40 minutes' submersion without cerebral sequelae. Lancet 1:12751277, 1975.
I agree fully with the comments of both Dr. Bayer and Dr. Sims. My recommendations are i n t e n d e d to serve as a first step in the process which will eventually result i n some reasonable guidelines t h a t most physicians will be able to follow most of the time. There is little doubt that there are specific circumstances i n which the suggested 30- m i n u t e limit of ACLS should be ignored. These include the young patient, the hypothermic patient, and possibly the pat i e n t bleeding from t r a u m a t i c causes. The decision to halt resuscitative efforts is made after the u s u a l and customary measures have failed and physical examin a t i o n has not revealed a condition t h a t m i g h t warr a n t more aggressive i n t e r v e n t i o n . Thus, conditions such as hypothermia, r e s i s t a n t a r r h y t h m i a s , pericardial tamponade, and tension p n e u m o t h o r a x should be excluded before any decision about h a l t i n g resuscitation is even considered. Since the references Dr. Bayer and his colleagues cite are their own u n p u b l i s h e d works, I cannot comment on their validity. I share Dr. Bayer's concern t h a t the inexperienced physician m i g h t use these guidelines as "dictum." I believe t h a t t r y i n g to resuscitate everybody for as long as possible, irrespective of the clinical history, physical e x a m i n a t i o n or response to therapy, does not repr e s e n t a very a t t r a c t i v e a l t e r n a t i v e . Dr. Sims and p a r a m e d i c P e n i c k are correct a b o u t t h e n e e d for further study. I disagree with their view t h a t the absence of studies obligates us to continue doing what we are c u r r e n t l y doing, regardless of its futility. I hope the r e c o m m e n d a t i o n s in the article will begin to focus a t t e n t i o n on those clinical conditions where aggressive t h e r a p y is needed, a n d on those
To the Editor:
We concur with Dr. E l i a s t a m et al in "Cardiac Arrest in the E m e r g e n c y Medical Service System: G u i d e l i n e s for R e s u s c i t a t i o n " ( J A C E P , D e c e m b e r 1977) t h a t the economic, physical and emotional costs of prolonged u n s u c c e s s f u l r e s u s c i t a t i v e efforts a n d m a i n t e n a n c e of postresuscitation b r a i n damaged patients are so high, t h a t earlier t e r m i n a t i o n of resuscitative efforts may be indicated. We commend Dr. E l i a s t a m for a t t e m p t i n g to establish guidelines for the complex a n d sensitive issue of r e s u s c i t a t i o n i n the emergency department. However, we take exception to the second of the recommendations: "No response after more t h a n 30 m i n u t e s of ACLS, (including ACLS administered in the field)." There are m i t i g a t i n g circumstances, eg, the y o u n g p a t i e n t a n d the hypothermic patient, in which prolonged cardiopulmonary resuscitation (CPR), beyond 30 minutes, is clearly indicated. Our own experiences (unpublished data), as well as n u m e r ous cases i n the l i t e r a t u r e , 2 d o c u m e n t successful r e s u s c i t a t i o n long after one h a l f hour of resuscitative efforts. A d d i t i o n a l l y , t h e r e are i n s t a n c e s in which patients unresponsive to s t a n d a r d CPR techniques benefit from more aggressive i n t e r v e n t i o n such as emergency thoracotomy (unpublished data), eg, hypothermia, r e s i s t a n t a r r y t h m i a s , pericardial tamponade, and tension pneumothorax.
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the hospital with no long-term evidence of b r a i n damage) has occurred for the following durations of neardrowning submersion: • 10 m i n u t e s (1964, 8-year-old, male, fresh water lake, 40 m i n u t e arrest u n t i l initial resuscitative response, body t e m p e r a t u r e 28 C) 15 • 17 m i n u t e s (1964, 21-year-old, male, brackish ' w a t e r [oceantidal reached River Yarra-water analysis: s o d i u m 128 m E q / l i t e r , p o t a s s i u m 4.6 m E q / l i t e r , chloride 200 mEq/liter], ? m i n u t e arrest until initial resuscitative response, body t e m p e r a t u r e 32 C) 16 • 20 m i n u t e s (1964, 3-year-old, male, fresh water stream, 55 m i n u t e arrest u n t i l initial resuscitative response, body t e m p e r a t u r e 27 C) 15 • 20 m i n u t e s (1973, 33-year-old, male, s w i m m i n g pool water, 50 m i n u t e arrest u n t i l i n i t i a l resuscitative response, body t e m p e r a t u r e 27.8 C) 17 • 22 m i n u t e s (1963, 5-year-old, male, fresh water river, 142 m i n u t e arrest u n t i l resuscitative response, body t e m p e r a t u r e 24 C) 11 • 25 m i n u t e s (1977, 6-year-old, male, muddy liquid m a n u r e tank, 65 m i n u t e arrest u n t i l initial resuscitative response, body t e m p t e r a t u r e 31.8 C) is • 30 m i n u t e s (1974, 5-year-old, male, fresh water river, 30 m i n u t e arrest u n t i l i n i t i a l resuscitative response, body t e m p e r a t u r e 27 C) 19 • 40 m i n u t e s (1975, 5-year-old, male, ice-cold fresh water river, 105-107 m i n u t e arrest u n t i l initial resuscitative response, body t e m p e r a t u r e 24 C). 2° These and other data suggest the need for cont i n u e d individualized d u r a t i o n s of resuscitation until sound statistical data, obtained with optimal resuscitative care, is available to support rigid n u m e r i c a l guidelines. It appears, however, that the economics of resuscitation will probably direct the decision-making before any reliable scientific tables are ever prepared i n this country and published.
To the Editor: With regard to '~Cardiac Arrest in the Emergency Medical Services System: Guidelines for Resuscitation" (JACEP, December 1977), cardiopulmonary resuscitation (CPR) s u r v i v a l rates (ie, percent discharged alive from the hospital) vary from zero ~ to 86% 2 for prehospital arrests and 4.6% 3 to 100% 4 for inhospital arrests. T h e s e wide ranges update the 1953 report of Stephenson and H i n t o n 5 which describes a successful r e s u s c i t a t i o n p e r c e n t a g e r a n g e of 8% to 75% from their l i t e r a t u r e search a n d a " p e r m a n e n t survival" average of 25% from their study of 1,000 cases of cardiopulmonary arrest. 5 As of J a n u a r y 1, 1978 a comprehensive retrospective and prospective survey of cardiopulmonary arrest r e s u s c i t a t i o n o u t c o m e s is n e e d e d to d e f i n i t i v e l y analyze factors such as p a t i e n t age, sex, d u r a t i o n of p r e r e s u s c i t a t i v e c a r d i o p u l m o n a r y a r r e s t , specific etiology of c a r d i o p u l m o n a r y arrest, presence/absence of u n d e r l y i n g disease, p a t i e n t responsiveness to specific therapeutic modalities, d u r a t i o n of active resuscitation, effectiveness of i n d i v i d u a l resuscitationist contributions d u r i n g each phase of resuscitation, and a n y other circumstances which contribute to i n i t i a l resuscitation success, long-term success, unresponsiveness to resuscitation, early demise, late demise, a n d irreversible organic d e r a n g e m e n t . These studies r e q u i r e a u n i f o r m r e p o r t i n g system, 6 s t a n d a r d base d e t e r m i n a t i o n s7 and multihospital collaboration to insure sufficient p a t i e n t n u m b e r s for a c c u r a t e s t a t i s t i c a l e v a l u a t i o n . An e s t a b l i s h e d data collection c e n t e r should first formulate strict criteria for operational definitions of cardiopulmonary arrest, t r a d i t i o n a l death, s resuscitation, d u r a t i o n of arrest, d u r a t i o n of resuscitation, and optimal emergency medical care t h a t needs to be provided d u r i n g all phases. Only after accurate documentation can a n y statistically supported tables be developed to guide physicians as to how long to resuscitate i n d i v i d u a l cases.
J.K. Sims, M.D. Honolulu, Hawaii Mike Penick, E M T - A Aiea, Hawaii 1. Baker R, Waters JM: Cardiac Experience - - Jacksonville Rescue Branch - - February 1973, in Proceedings of the National Conference on Standards for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC), May 16-18, 1973. American Heart Association, Dallas, Texas, 1975, p 183. 2. Copley DA, Mantle JA, Russell RO Jr, et al: Reduction of morbidity and mortality with early cardiopulmonary resuscitation via bystanders. Circulation II - - 225, 1976 (Abstract #0882). 3. Gilbert GJ: Cardiopulmonary resuscitation. J A M A 238:12, 1977. 4. Stephenson HE Jr (ed): Cardiac Arrest & Resuscitation. C V Mosby Co, St. Louis, 1974, pp. 809, 827.
Duration of Resuscitation A 3.5-hour resuscitation for cardiopulmonary arrest has been reported 9 from which the patient eventually "survived with no detectable b r a i n damage." This same r e s u s c i t a t i o n group, successfully resuscitated n i n e other p a t i e n t s with cardiopulmonary resuscitations exceeding 20 minutes. 9 The Guinness Book of World Records 1° lists the l o n g e s t recorded h u m a n h e a r t stoppage w i t h s u b s e q u e n t recovery at three hours in a 5-year-old boy who near-drowned in the ice-cold water of a fresh water river. He was u n d e r the water for an estimated 22 minutes, 1°,1~ required 120 minutes of cardiac compression, and ~'recovered with little if any neurological a n d intellectual damage. ' ' ~ Jude et a112 reported a series of efforts at resuscitation from 2 to 120 m i n u t e s and noted "successful r e t u r n to the p r e a r r e s t c e n t r a l n e r v o u s s y s t e m a n d cardiac status occurred up to 90 minutes." Successful resuscitation (ie, discharged alive from
7:5 (May) 1978
5. Stephenson HE Jr, Hinton JW: Use of intra-aortic and intracardiac transfusions in cardiac arrest. JAMA 152:500-503, 1953. 6. Polnitsky CA, Capone RJ, Gagnon DE, et al: Prehospital c o r o n a r y care - - proposal for a uniform reporting system. JAMA 237:134-137, 1977.
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7. McManus WF, Darin JC: Can the well trained EMTParamedic maintain skills and knowledge? JACEP 5:984986, 1976.
We have other objections to the 30-minute cutoff which are philosophical. The decision to t e r m i n a t e life support must be based on the physician's impression of the patient and his chance for survival, not on a time limit. The assessment stems from the physician's experience. In some instances, the experienced physician will curtail his efforts in less t h a n half an hour. We are g r e a t l y concerned however, t h a t the i n e x p e r i e n c e d physician will accept these guidelines as dictum and stop advanced cardiac life support (ACLS) at the 30m i n u t e cutoff, thereby failing to resuscitate some patients who might otherwise survive. We feel there should be an a d d e n d u m to the 30 m i n u t e guideline which will make it clear t h a t there are instances, as mentioned above, where CPR should be continued for longer periods of time, possibly including modalities beyond s t a n d a r d ACLS. Dr. E l i a s t a m ' s efforts in e s t a b l i s h i n g guidelines are a good beginning, b u t f u r t h e r work is needed.
8. Sims JK: Criteria for the pronouncement of death and the human brain death syndrome. Hawaii IVied J 35:11-14, 1976. 9. Sandoe E, Flensted-Jensen E, Dupont B: Long-term prognosis in patients resuscitated from cardiac arrest. Isr J Med Sci 5:769-771, 1969. 10. McWhirter N, McWhirter R: Guinness Book of World Records, Bantam Books - - Sterling Publishing Company, New York, 1977, p 42. 11. Kvittingen TD, Naess A: Recovery from drowning in fresh walter. Br Med J 1:1315-1317, 1963. 12. Jude JR, Kouwenhoven WB, Knickerbocker GG: Cardiac arrest - - report of application of external cardiac massage on 118 patients. JAMA 178:1063-1070, 1961. 13. Sims JK: Drowning and near-drowning, in Barry J (ed): Emergency Nursing. McGraw-Hill, New York, 1978, pp 377389. 14. Modell JH: The Pathophysiology and Treatment of Drowning and Near-Drowning. Charles C Thomas, Springfield, Illinois, 1971, pp 8-12.
Marc J. Bayer, MD Joseph J. Bander, MD Sanders Orent, MID Emergency Services University of Oregon Health Sciences Center
15. Ohlsson K, Beckman M: Drowning-reflections based on two cases. Acta Chir Scand 128:327-339, 1964. 16. King RB, Webster IW: A case of recovery from drowning and prolonged anoxia. Med J Aust 1:919-920, 1964. 17. DeVillota ED, Barat G, Petal P, et al: Recovery from profound hypothermia with cardiac arrest after immersion. Br Med J 4:394-395, 1973. 18. Theilade D: The danger of mis-judgement in hypothermia after immersion. Anaesthesia 32;889-892, 1977.
1. Shockett E, Rosenblum-R: Successful open cardiac massage. JAMA 200:157-158, 1967. 2. Russell ES: Cardiac arrest: survival after 2Vz hours open chest cardiac massage. Canad Med Assoc J 87:512-513, 1976.
19. Hunt PK: Effect and treatment of the "diving reflex" Can Med Assoc J 111:1330-1331, 1974.
Author's Reply
20. Siebke H, Rod T, Breivik H, et al: Survival after 40 minutes' submersion without cerebral sequelae. Lancet 1:12751277, 1975.
I agree fully with the comments of both Dr. Bayer and Dr. Sims. My recommendations are i n t e n d e d to serve as a first step in the process which will eventually result i n some reasonable guidelines t h a t most physicians will be able to follow most of the time. There is little doubt that there are specific circumstances i n which the suggested 30- m i n u t e limit of ACLS should be ignored. These include the young patient, the hypothermic patient, and possibly the pat i e n t bleeding from t r a u m a t i c causes. The decision to halt resuscitative efforts is made after the u s u a l and customary measures have failed and physical examin a t i o n has not revealed a condition t h a t m i g h t warr a n t more aggressive i n t e r v e n t i o n . Thus, conditions such as hypothermia, r e s i s t a n t a r r h y t h m i a s , pericardial tamponade, and tension p n e u m o t h o r a x should be excluded before any decision about h a l t i n g resuscitation is even considered. Since the references Dr. Bayer and his colleagues cite are their own u n p u b l i s h e d works, I cannot comment on their validity. I share Dr. Bayer's concern t h a t the inexperienced physician m i g h t use these guidelines as "dictum." I believe t h a t t r y i n g to resuscitate everybody for as long as possible, irrespective of the clinical history, physical e x a m i n a t i o n or response to therapy, does not repr e s e n t a very a t t r a c t i v e a l t e r n a t i v e . Dr. Sims and p a r a m e d i c P e n i c k are correct a b o u t t h e n e e d for further study. I disagree with their view t h a t the absence of studies obligates us to continue doing what we are c u r r e n t l y doing, regardless of its futility. I hope the r e c o m m e n d a t i o n s in the article will begin to focus a t t e n t i o n on those clinical conditions where aggressive t h e r a p y is needed, a n d on those
To the Editor:
We concur with Dr. E l i a s t a m et al in "Cardiac Arrest in the E m e r g e n c y Medical Service System: G u i d e l i n e s for R e s u s c i t a t i o n " ( J A C E P , D e c e m b e r 1977) t h a t the economic, physical and emotional costs of prolonged u n s u c c e s s f u l r e s u s c i t a t i v e efforts a n d m a i n t e n a n c e of postresuscitation b r a i n damaged patients are so high, t h a t earlier t e r m i n a t i o n of resuscitative efforts may be indicated. We commend Dr. E l i a s t a m for a t t e m p t i n g to establish guidelines for the complex a n d sensitive issue of r e s u s c i t a t i o n i n the emergency department. However, we take exception to the second of the recommendations: "No response after more t h a n 30 m i n u t e s of ACLS, (including ACLS administered in the field)." There are m i t i g a t i n g circumstances, eg, the y o u n g p a t i e n t a n d the hypothermic patient, in which prolonged cardiopulmonary resuscitation (CPR), beyond 30 minutes, is clearly indicated. Our own experiences (unpublished data), as well as n u m e r ous cases i n the l i t e r a t u r e , 2 d o c u m e n t successful r e s u s c i t a t i o n long after one h a l f hour of resuscitative efforts. A d d i t i o n a l l y , t h e r e are i n s t a n c e s in which patients unresponsive to s t a n d a r d CPR techniques benefit from more aggressive i n t e r v e n t i o n such as emergency thoracotomy (unpublished data), eg, hypothermia, r e s i s t a n t a r r y t h m i a s , pericardial tamponade, and tension pneumothorax.
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