Journal of the New Zealand Medical Association, 07-May-2004, Vol 117 No 1193
A brief history of resuscitation
Three and a half millennia (3,500 years) ago, in Egypt, the inversion method of resuscitation was described, involving hanging the patient by the feet, applying chest pressure to assist expiration, and releasing pressure to assist inspiration.1 Old Testament prophets described accounts of resuscitation using terms such as ‘crouching over’, ‘mouth-to-mouth’, ‘breathing into’, and ‘pressing upon’.2
Nearly one millennium ago, authors recommended ventilating via a bellows and a tube in the trachea. In 1767, the Dutch Humane Society published guidelines for resuscitation of victims of drowning, stating: ‘keep the victim warm, give mouth-to-mouth ventilation, and perform insufflation of smoke of burning tobacco into the rectum’.1
Various other accounts of resuscitation include the use of flogging, bouncing on a trotting horse, rolling over a barrel, and sporadic descriptions of divine intervention. Interposed among these accounts of resuscitation is found the evolution of current concepts.2
External chest compression was first described by John Howard in the 18th century. In the early 20th century, Crile described an experimental method in animals combining chest compression, artificial respiration, and parenteral adrenaline. In 1956, Zoll published his accounts of defibrillation. Safer and Elam formally presented mouth-to-mouth ventilation in 1958, and (in 1960) Kouwenhoven, Jude, and Knickerbocker3 rediscovered external chest compression while testing defibrillation on an animal model of ventricular fibrillation. The paper describing this discovery (of chest compressions used to resuscitate) is widely attributed as being the usher of the modern era of cardiopulmonary resuscitation (CPR).
In the early 1960s, John F Kennedy proclaimed that America would put a man on the moon within 10 years and that ‘cardiopulmonary resuscitation would save thousands of hearts too good to die’.4 Some might argue that neither of these has been achieved. However, over the next four decades, we saw CPR evolve into a very sophisticated and highly resourced response to victims of out-of-hospital cardiac arrest. Part of this evolution has been the promulgation of the ‘chain of survival’ concept5—promoting bystander CPR, early call to the ambulance service, early defibrillation, and early advanced care.
Now the various international committees, councils, and associations provide consensus guidelines through an international liaison committee; and the New Zealand Resuscitation Council (NZRC) is an active participant in this process. In New Zealand, the guidelines are published and taught by the NZRC in a multi-tiered fashion—aimed at resuscitators with levels of expertise ranging from lay person to specialist resuscitator.
In this issue of the Journal are papers considering each end of this continuum. Larson and colleagues6 surveyed 400 adults about their knowledge and attitudes towards resuscitation. The results of the study are encouraging—74% had been taught CPR at some time, 73% wanted to know more, and 63% said they would perform mouth-to-mouth resuscitation on a stranger. International comparisons suggest that the willingness to do ‘mouth-to-mouth’ range from 43% in Australia, 15% in the USA, to 3% in Japan.
However, despite the willingness of New Zealanders to do CPR, the authors found that their ability to do it well has room for improvement. John F Kennedy’s enthusiasm for CPR focused on saving hearts; however, the modern teaching of CPR emphasises a generic approach to a collapsed person. The authors point out that if people learn the assessment and management of the airway of a person with impaired consciousness, as well as the control of external bleeding after trauma, then there is potential to save many victims, including in other circumstances apart from cardiac arrest.
Further along the chain of survival is the paper from the NZRC Defibrillation Advisory Group, helping us accommodate new defibrillation technology.7 History grows, and while we look back at how we got to this stage in cardiac arrest resuscitation, new things come upon us. Two of the more significant defibrillation developments in recent years have been the development of readily available automated external defibrillators (AEDs) and biphasic defibrillators. AEDs deliver defibrillating capacity without the need to interpret the cardiac rhythm. They are compact, easy to use, accurate, and are getting cheaper to buy. The distribution of this capacity to a variety of health professionals, and to lay resuscitators in some contexts (for example, at major sporting events, airports, etc—ie, so called ‘public access defibrillation’), is an issue we will entertain over the next few years.
Biphasic defibrillators, compared to traditional monophasic defibrillators, defibrillate at lower energy levels. However, not all biphasic defibrillators are the same, and the evidence base for the energy sequences to run through during resuscitation is not robust. Furthermore, the difference in machines and the uncertainty about energy doses has the capacity to confuse and distract operators during resuscitation. However, the advice from the NZRC Defibrillation Advisory Group is clearly explained and is sensibly simple, telling us that, no matter what defibrillator we come across, we do essentially the same thing.
In summary, the two papers (by Larson and colleagues) remind us that the work of the NZRC (in defining, promoting, and teaching what should be done in response to cardiac arrest) has been a particularly valuable addition to the recent history of resuscitation in New Zealand.
Author information: Professor Michael Ardagh, Emergency Department Christchurch Public Hospital and Christchurch School of Medicine, Christchurch
Correspondence: Professor Michael Ardagh, Emergency Department, Christchurch Hospital, Private Bag 4710, Christchurch. Fax: (03) 3640286; email: email@example.com
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