The Terminal State Experimental Studies
Resuscitation and the Postresuscitation Syndrome
Fundamental Mechanisms of Rapid Dying and Resuscitation Alternatives to Tracheal Intubation
Other Airway Control Procedures Use of Open-Chest CPR
INTRODUCTION
The clinical practice of cardiopulmonary resuscitation (CPR) has been expanded to cardiopulmonary cerebral resuscitation (CPCR) ( 1). Its scientific basis,
“resuscitology” (2) or “reanimatology” (3), has also expanded to encompass a variety of acute dying processes, including the derangements of the entire organism.
Resuscitation potentials have also expanded beyond emergency resuscitation into prolonged life support, which is sometimes necessary with multiorgan system failure from postresuscitation disease. The derangements after cardiac arrest, in order of acute importance, involve the microcirculation, brain,
cardiovascular-pulmonary system, kidneys, and the gastrointestinal, hematologic, immune, and endocrine systems. This order of importance seems different after prolonged shock-trauma states, a condition in which the brain is less likely to suffer ischemic damage but kidneys and lungs frequently fail and endocrine
derangements are important. Sepsis has also gained recognition as a final common pathway in dying processes.
The scientific importance of resuscitology lies in its ability to establish the pathophysiologic mechanisms of the postresuscitation syndrome ( 4,5). This helps define the ultimate potentials and limitations of resuscitation for the treatment of cardiac arrest.
When CPR attempts inside or outside the hospital have succeeded in restoring some cerebral oxygenation within about 4 minutes of arrest, and adequate
spontaneous circulation was accomplished within minutes thereafter, one-half to two-thirds of patients so treated have recovered, with central nervous system (CNS) function grossly equivalent to the prearrest state (6,7,8 and 9). Most of the remaining patients died before leaving the hospital from complications secondary to coma or from underlying disease. Among the long-term survivors of all CPR attempts, including the delayed attempts, about 5 to 20% seem to have a permanent major neurologic deficit (6,7 and 8,10), depending on the type and quality of post-CPR life support. The use of selective hypothermia will likely alter the neurologic status.
Young, healthy people who suffer accidental deep hypothermia and circulatory arrest have shown little neurologic deficit even after prolonged time ( 10A).
CARDIAC ARREST
Death in the terminal stages of incurable disease does not result from sudden cardiac arrest. We define sudden cardiac arrest as “the clinical picture of abrupt cessation of circulation in a person who was not expected to die at that time” (1). Cardiac arrest is clinically diagnosed when the following four conditions coexist:
1. Unconsciousness (Fig. 1–1.1, Fig. 1–1.2, Fig. 1–1.3 and Fig. 1–1.4).
Figure 1–1.1. Phases and steps of cardiopulmonary-cerebral resuscitation. (See protocols for ACLS details) (Reprinted with permission from Safar P.
Cardiopulmonary cerebral resuscitation. Stavanger, Norway: Asmund S. Laerdal, 1981.)
Figure 1–1.2. Life-supporting first aid for an unconscious person (wallet card). If the patient is unconscious, control the airway (A). If the patient is not breathing, give mouth-to-mouth ventilation (B). If the patient is not breathing or is injured, use supported spine-aligned position (B). If the patient is unconscious and
breathing, use the stable side position (A). (Reprinted with permission from Caroline N. Life supporting resuscitation and first aid: a manual for instructors of the lay public. Geneva, Switzerland, prepared for the League of Red Cross Societies and the World Federation of Societies of Anesthesiologists, 1984.)
Figure 1–1.3. Positioning of the unconscious patient. Supported supine-aligned position—for resuscitation or for an injured person. Hold the head, neck, and chest aligned with slight traction. With both hands at the sides of the face, provide a jaw thrust, open the patient's mouth, and moderate backward tilt of the head. Prevent flexion and rotation of the head. (Reprinted with permission from Safar P. Cardiopulmonary cerebral resuscitation. Stavanger, Norway: Asmund S.
Laerdal, 1981.)
Figure 1–1.4. Stable side position—for the spontaneously breathing unconscious patient. A. Flex the leg closest to you. B. Put hand closest to you under the patient's buttocks. C. Gently roll the patient onto his side. D. Tilt the patient's head backward and keep his face low. Put his upper hand under his lower cheek to maintain head tilt and to prevent him from rolling onto his face. The lower arm behind his back prevents him from rolling backward. (Reprinted with permission from Safar P. Cardiopulmonary cerebral resuscitation. Stavanger, Norway: Asmund S. Laerdal, 1981.)
2. Apnea or gasping respirations (Fig. 1–1.5; in cases of choking).
Figure 1–1.5. Life-supporting first aid for choking (wallet card). If patient is choking, use back blows and clearing of mouth and throat. (Reprinted with
permission from Caroline N. Life supporting resuscitation and first aid: a manual for instructors of the lay public. Geneva, Switzerland, prepared for the League of Red Cross Societies and the World Federation of Societies of Anesthesiologists, 1984.)
3. Pulselessness in large arteries (carotid, femoral) (Fig. 1–1.6).
Figure 1–1.6. Life-supporting first aid for bleeding and shock (wallet card). If the patient is bleeding, elevate and compress (A). If the patient is in shock (and conscious), place him horizontally (face up) (B). (Reproduced with permission from Caroline N. Life supporting resuscitation and first aid: a manual for
instructors of the lay public. Geneva, Switzerland, prepared for the League of Red Cross Societies and the World Federation of Societies of Anesthesiologists, 1984.)
4. Deathlike appearance.
Examples of primary cardiac arrest include ventricular fibrillation (VF) (common) or asystole (less common) in patients with ischemic heart disease and in VF from electric shock (Fig. 1–1.7, conditions 1 and 2). Such sudden primary cessation of circulation in well-oxygenated persons results in unconsciousness within about 10 seconds and an isoelectric electroencephalogram (EEG) in about 30 seconds; agonal gasping may continue for 30 to 60 seconds; and apnea and maximal pupillary dilation begin at about 60 seconds. Oxygen stores are used up in 10 seconds (11,12 and 13).
Figure 1–1.7. Stages and reversibility of dying. Flow chart illustrating the development of circulatory arrest from eight basic variations of terminal states; clinical death with reversible brain failure, with its presently undefinable duration; and the various possible outcomes.
Examples of rapid secondary cardiac arrest include alveolar anoxia (e.g., inhalation of oxygen-free gas, fulminating pulmonary edema), asphyxia (airway obstruction, apnea), and exsanguination (Fig. 1–1.7, conditions 3 through 5; Table 1–1.1).
Table 1–1.1. Specific Mechanisms of Rapid Dying and Reanimation
Examples of slow secondary cardiac arrest include moderate hypoxemia, as in subacute pulmonary edema or consolidation, various shock states, and intracranial pathology (Fig. 1–1.7, conditions 6 through 8), any of which may stop the circulation within minutes, hours, or days.
Although the basic steps of CPR (airway, breathing, circulation) are applicable in most cases of sudden death ( 1), definitive therapeutic measures (CPR steps D, E, and F) and prolonged life support differ with the different mechanisms of terminal states (14) (Fig. 1–1.2, Table 1–1.2). The addition of G, H, and I includes the additional focus on monitoring, cerebral resuscitation, and intensive care. The need for rapid airway control requires positioning and manual clearing of the airway (Fig. 1–1.8, Fig. 1–1.9, Fig. 1–1.10 and Fig. 1–1.11). The issue of health care professionals reduced willingness to perform mouth-to-mouth resuscitation (less than 50%) has not been adequately addressed (14A).
Table 1–1.2. Phases, Steps, and Measures of Cardiopulmonary-Cerebral Resuscitationa
Figure 1–1.8. Backward tilt of head. A. Hypopharyngeal obstruction by the tongue in coma with head in midposition or flexed. B,C. Backward tilt of the head stretches anterior neck structures and thereby lifts the base of the tongue off the posterior pharyngeal wall. B. Neck lift, which is easier to teach; and C. chin support, which better controls opening of the mouth. (Reproduced with permission from Safar P. Cardiopulmonary cerebral resuscitation. Stavanger, Norway: Asmund S. Laerdal, 1981.)
Figure 1–1.9. Techniques for backward tilt of head. Backward tilt of the head, by neck-lift, plus positive pressure inflation by mouth-to-mouth (left) and mouth-to-nose (right) exhaled air inflations. (Reproduced with permission from Safar P. Cardiopulmonary cerebral resuscitation. Stavanger, Norway: Asmund S. Laerdal, 1981.)
Figure 1–1.10. Triple airway maneuver. Tilt the head backward, displace the mandible forward, and open the mouth. A. Operator at the patient's vertex (for spontaneously breathing patients.) B. Operator at side of the patient for direct mouth-to-mouth ventilation. Seal the nose with your cheek for mouth-to-mouth breathing. Seal the mouth with your other cheek for mouth-to-nose breathing. C. Modified triple airway maneuver by the thumb-jaw lift method (for relaxed patient only). (Reproduced with permission from Safar P. Cardiopulmonary cerebral resuscitation. Stavanger, Norway: Asmund S. Laerdal, 1981.)
Figure 1–1.11. Three methods force the mouth open for clearing, finger sweeping, suctioning, and inserting of airways or laryngoscope. A. “Crossed-finger”
maneuver, for the moderately relaxed jaw. B. “Finger behind teeth” maneuver, for the tight jaw. C. “Tongue-jaw lift” maneuver, for the relaxed jaw. (Reproduced with permission from Safar P. Cardiopulmonary cerebral resuscitation. Stavanger, Norway: Asmund S. Laerdal, 1981.)