Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
16 January 2008

CARDIOPULMONARY RESUSCITATION – WHAT IS IT?

            In the year 2005, national statistics indicate that there were approximately 2 ½ million deaths in the United States.  Of these, 800,000 people were estimated to have passed away from primary heart disease.  This amounts to roughly one-third of all deaths in the United States result from heart problems.  Approximately one-third of these 800,000 deaths will occur outside of the hospital.  The other two-thirds occur in hospital most commonly from a “heart attack”. 

            The final common pathway of most heart attacks is a condition called ventricular fibrillation in which the heart ceases to have an effective beat and instead quivers with no effective output of blood.  For many people, this abnormal electrical activity by the heart is the result of a stopped up artery, a very vital portion to the heart.  Thus, the thrust of care for people with heart attacks is to get the artery open to save the heart muscle that is being deprived of blood.  It is this blood-deprived heart muscle that causes the abnormal rhythm called ventricular fibrillation that results in the person’s actual death. 

            In 1947, a Dr. Beck learned that applying an electrical shock to the heart would stop the chaotic quivering rhythm that the heart had and re-establish an effective heart beat.  In 1960, the concept of pumping the person’s chest to simulate a heart beat was introduced to clinical medicine.  In the early 1970’s, the American Heart Association formalized a procedure of what to do when a person has a sudden death due to heart disease. This procedure was termed cardiopulmonary resuscitation or CPR for initials.

            Through the years, CPR was taught initially to healthcare professionals but is now taught to the lay public as a way to save a person’s life when sudden death occurs in the home or a shopping mall or an airport or a church or wherever a person might be. 

            The sequence of how to perform CPR is abbreviated to “the ABC’s”.  “A” is for being sure that he person has an airway.  “B” is checking to see that the person is breathing and “C” stands for starting chest compressions if the person has an airway and is not breathing.  Hopefully, more than one person will be present in a cardiac arrest and one person can check for the airway, etc. and another person can call for help.  Our metropolitan areas and small towns have emergency ambulance services that can often get to a fallen individual within a few minutes.  Arrival of emergency medical technicians or other healthcare professionals with adequate equipment may allow the institution of something called Advanced Cardiac

Life Support (ACLS) in which medications can be administered to the person intravenously and other medical steps taken to evaluate and treat the fallen person   

            Over the years, the method of performing “CPR” has evolved.  Initially, it was felt that the person should perform 5 cardiac compressions and then perform 1 mouth-to-mouth breathing step.  However, the mouth-to-mouth breathing step has always been difficult and often not acceptable to the lay public.  More recent statistics have indicated that simply performing chest compressions actually performs respiratory function for the person as well or better than mouth-to-mouth resuscitation.  Thus, the new standards for CRP are continuing to evolve. 

            A husband and wife recently came to the clinic to discuss “end of life” considerations.  They indicated that they were considering taking CPR training and wanted to know what the expectation was if they did this.  The real statistics are that only 1 of 20 people who pass away outside of the hospital and are treated with CPR survive.  In the hospital, greater than 40% of patients who have primary heart problems will survive if they receive a defibrillation shock within two minutes of the time that they have a cardiac arrest.  But the statistics fall off very quickly after that.  In the hospital, if the defibrillation is not achieved by six minutes after the cardiac arrest, only about 15% of patients will survive.  If the resuscitated procedure has been carried on for a full 15 minutes without re-establishment of an effective heartbeat, the likelihood of survival drops to less than 1%.  More depressing than that 1% survival is the state of those individuals who do survive.  They almost always have some substantial brain damage and restoration of normal function is not expected. 

            It needs to be emphasized that cardiopulmonary resuscitation is an orchestrated, well defined medical procedure.  The methods used, the sequence of their administration, and the use of a DC cardioverter are all well defined.  CPR is a medical treatment.  It should be recognized that there are situations in which CPR is indicated and useful and there situations in which a person expires and CPR is inappropriate and not useful. 

            Next week’s column will address the proliferation and growing number of electrocardiac defibrillators available in airports, malls, churches, and restaurants and when the use of these devices by the lay public is useful and helpful and when it is completely inappropriate.  I am often asked by nurses whether or not CPR should be considered for a given patient in the hospital.  In an uninformed situation, patients often say that they would like to have cardiopulmonary resuscitation carried out if they should happen to pass away.  When these patients have end-stage diseases such as untreatable cancers, the use of cardiopulmonary resuscitation may be inappropriate.  I tell healthcare professionals that if a person with an end-stage cancer passes away from that cancer, it would be inappropriate to perform an appendectomy on the person.  This is because doing an appendectomy would not bring the person back to life. By the same token, it would be equally inappropriate to perform cardiopulmonary resuscitation on that patient because it has no predictable likelihood of success and is a dehumanizing, degrading procedure to go through in a hopeless situation.  Details and further discussion of appropriate and inappropriate CPR will be the topic of next week’s column.

This and other columns available at www.macpierre.com.