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PubMed1985

Expired PCO2 as an index of coronary perfusion pressure.

Presently, there is no reliable noninvasive method of assessing the adequacy of cardiopulmonary resuscitation (CPR). Studies of animals have shown that during prolonged arrest the coronary perfusion pressure (CPP) is correlated with successful resuscitation. During previous studies it appeared that expired PCO2 correlated with CPP. To investigate this relationship, eight mongrel dogs (mean weight, 22.7 +/- 5.8 kg) were anesthetized with pentobarbital. Catheters were placed in the thoracic aorta and right atrium of each dog. Each animal was electrically fibrillated, and CPR was started using mechanical resuscitator. The PCO2 was determined at end expiration using a Hewlett Packard 47210A Capnometer with the electrode attached to the endotracheal tube. After 10, 15, 20, or 25 minutes of ventricular fibrillation and closed-chest massage, a thoracotomy was performed, and internal massage was begun. Coronary perfusion pressure was calculated at least each minute and correlated with the PCO2 values. A correlation coefficient of 0.78 was calculated based on 368 data points for eight dogs (P less than 0.01). The results of this study indicate that expired PCO2 is positively correlated with CPP in the canine model of CPR. Inasmuch as CPP correlates with survival in prolonged CPR, the noninvasive measurement of PCO2 may be a useful method of assessing the adequacy of CPR.

Animals↗
PubMed1985

Central venous and mixed venous oxygen saturation: comparison during canine open-chest cardiopulmonary resuscitation.

Mixed venous oxygen saturation (MVO2) is a valuable parameter in monitoring critically ill patients because it serves as an index of the adequacy of the oxygen delivery system. Mixed venous oxygen saturation as reflected by the easily obtainable central venous oxygen saturation (CVO2) may prove useful during cardiopulmonary resuscitation (CPR) as an indicator of both the adequacy of varying CPR regimens and the efficacy of pharmacological interventions. This study investigates the relationship between CVO2 and MVO2 and its clinical usefulness during CPR. Swan-Ganz and central venous catheters were placed in 20 mongrel dogs. Ventricular fibrillation was then induced and, after predetermined downtimes ranging from 5 to 60 minutes, thoracotomy was performed, and open-chest bimanual cardiac massage was started. Central venous and mixed venous blood-gas samples were drawn every five minutes during a 30-minute period of CPR. The correlation between CVO2 and MVO2 was 0.8719 (P less than 0.001) before arrest but deteriorated at all times during CPR with values ranging from 0.1589 (P = 0.542) to 0.5781 (P = 0.024). Although statistically significant at times, the correlation between CVO2 and MVO2 during CPR is not consistently high enough to enable the routine substitution of CVO2 for MVO2 in assessing the oxygen delivery system.

Animals↗
PubMed1984

Recording of diastolic slope with catheters during junctional rhythm in humans.

Junctional diastolic slopes were recorded in 11 of 15 patients (73.3%) with junctional rhythm that occurred spontaneously, after intravenous administration of atropine (1 mg), or during carotid sinus massage. The diastolic slopes were recorded through a unipolar lead consisting of a terminal of an electrode catheter placed in the His bundle area paired with an indifferent terminal on the superior vena cava. The slope of these diastolic deflections -0.18 +/- 0.06 m V/sec (mean +/- SD). Overdrive atrial and ventricular stimulations were followed by slowing of the junctional rate and decrease in the diastolic slope. Strong negative correlations (r values from -.71 to -.95) were found between the junctional cycle lengths and the diastolic slopes after atrial or ventricular pacing. Carotid sinus massage decreased the junctional rate and the junctional diastolic slope, whereas atropine increased the junctional rate and the junctional diastolic slope. Since prolongation of junctional cycle lengths after atrial pacing did not depend on frequency of impulse penetration into the His bundle, we postulate that the junctional pacemaker responsible for the junctional rhythm in some of our patients was in the N region of the AV node. Application of this recording method should help in the identification and characterization of automatic junctional pacemakers.

Aged↗
PubMed2001

Prehospital use of minimally invasive direct cardiac massage (MID-CM): a pilot study.

BACKGROUND: Internal cardiac compressions are more efficient than closed chest compressions (CCC) in cardiac arrest (CA). AIM OF THE STUDY: To evaluate the prehospital feasibility of performing a new method of minimally invasive direct cardiac massage (MID-CM TheraCardia Inc.). METHODS: Prospective non-randomized open study, after ethical committee approval. Inclusion of 18-85 years old patients in witnessed CA if BLS>5 min and unsuccessful ACLS>20 min after CA. The MID-CM is an atraumatic manual cardiac pumping system deployed in the thoracic cavity through a small incision. Evaluation of: ease of insertion and performing MID-CM, complications, end-tidal CO(2) (PETCO(2)), non invasive arterial blood pressure (NIBP) and return of spontaneous circulation (ROSC). Values are mean+/-SD (min-max). RESULTS: Twenty-five patients included. Mean age 59+/-16 years (26-85); BLS started at 8+/-5 min (0-20), compressions started at 47+/-10 min (29-74) after CA. Dissection and insertion was fast and easy (<1 min). Deployment of the MID-CM was difficult in two patients because of pericardium adhesions and cardiomegaly. In six patients compressions were more difficult because of a 'stone heart' phenomenon. Compressions were possible during ambulance transport of four patients. There was a good palpable carotid pulse in all patients receiving internal compressions. There was a trend in increase of PETCO(2) compared to CCC. NIBP could be measured during MID-CM compressions in 9 patients (systolic>85 mmHg), never during CCC. Seven patients had a ROSC, but only four patients were admitted alive. There was no long term survival. One patient had a serious complication (heart rupture). DISCUSSION: Prehospital use of MID-CM is possible, but it is not comparable to any other resuscitation technique. Training of medical teams is mandatory to obtain good skills and to avoid complications. Further studies are necessary to evaluate efficiency and survival compared to closed chest compressions.

Adult↗
PubMed1981

[Assessment of external cardiac massage efficiency or Kouwenhoven revisited (author's transl)].

The external cardiac massage mechanism is commonly related to the ventricles compression between the vertebral block and the sternum. This over-simple explanation must be reconsidered. Following recent data, the intra thoracic pressure changes take probably a major part in it efficiency. Six patients have been studied by hemodynamic intra aortic measurements and Doppler carotidian velocimetry. Intra thoracic pressure have been recorded by an oesophageal catheter. Results are in agreement with the prominent part of the intra thoracic pressure variations. Various external cardiac methods are investigated following this monitoring. Some aspects of the classical management of the cardiac arrest have to be discussed.

Heart Massage↗
PubMed2001

Community attitudes towards performing cardiopulmonary resuscitation in Western Australia.

OBJECTIVE: to determine the attitudes of the Western Australian community towards performing cardiopulmonary resuscitation, and the factors affecting these attitudes. METHODS: telephone survey of a randomly selected sample of people from suburban Perth and rural Western Australia; practical assessment of a sub-sample of volunteers from those surveyed, to correlate survey answers with practical skills. RESULTS: of 803 people surveyed, the majority (90.7%) definitely would give mouth-to-mouth ventilation to a friend or relative, but less than half (47.2%) would to a stranger. The reluctance was mostly (56%) because of health and safety concerns, particularly related to HIV infection. Higher percentages of people would definitely provide cardiac massage for a friend or relative (91.4%) or stranger (78.1%). People were more likely to give mouth-to-mouth and cardiac massage if they had been trained in cardiopulmonary resuscitation (CPR), trained several times, trained recently, and used their CPR skills in real life. There were no significant differences between city and country people in whether they would provide CPR, but older people were less willing to provide mouth-to-mouth or cardiac massage. On practical assessment of 100 volunteers, there were significant errors and omissions in airway assessment, mouth-to-mouth resuscitation and cardiac massage. Volunteers with better practical scores were more prepared to provide CPR. DISCUSSION: our results indicate a significant reluctance of the Western Australia public to perform mouth-to-mouth, except to a friend or relative. Earlier CPR training, practice and use seemed to diminish this reluctance. Practical CPR skills were not well executed. Those with better skills were less reluctant to use them. We recommend increasing CPR training in the community, greater frequency of refresher courses and public education on the risks of CPR to improve rates of bystander CPR.

Attitude to Health↗
PubMed2000

Minimally invasive direct cardiac massage versus closed-chest cardiopulmonary resuscitation in a porcine model of prolonged ventricular fibrillation cardiac arrest.

Open chest cardiac massage has been shown to be superior to closed-chest cardiopulmonary resuscitation for both hemodynamics produced during resuscitation and ultimate resuscitation success. The inexperience of many rescuers with emergency thoracotomy, along with the associated morbidity contributes to the continued reluctance in the use of invasive cardiopulmonary resuscitation techniques. A device has been developed for performing 'minimally invasive' direct cardiac massage. This technique was compared to standard closed-chest CPR for resuscitation results in 20 swine during prolonged ventricular fibrillation cardiac arrest. Minimally invasive direct cardiac massage was superior to closed-chest CPR for return of spontaneous circulation (7/10 vs. 2/10; P<0.02) and coronary perfusion pressure at 30 min of CPR (17+/-9 vs. 6+/-6 mmHg; P<0.05). No significant injuries altering outcome were found with the invasive device. Throughout most of the time course of the study no significant differences in end-tidal expired carbon dioxide levels were noted. Nor were there any differences in 24-h survival. Improvements in assuring proper placement of the device on the epicardium should make this technique a potent advanced cardiac life support adjunct.

Analysis of Variance↗
PubMed1981

External cardiovascular resuscitation of the anesthetized pony.

External cardiac massage and concomitant respiratory support were used successfully 6 of 8 anesthetized ponies sustaining unexpected cardiac arrest while being used in a study of shock. Approximately 20 thoracic compressions/min maintained systolic and diastolic aortic blood pressures in excess of 50% of the corresponding base-line values in 5 ponies. The high success rate was attributed to early recognition of the problem, the small size of the patient, and the relatively short duration of cardiopulmonary resuscitation (average, 2.9 minutes). It was concluded that external cardiac message can be effective for cardiopulmonary resuscitation in selected equine patients that have sustained cardiac arrest.

Anesthesia↗
PubMed1997

[Coronary gas embolism after laparoscopic surgery].

Gas embolism is a severe complication of laparoscopic surgery. We report two cases: one with lethal peroperative cardiac arrest from massive coronary artery gas embolism recognized during open-chest cardiac massage; the second case, also associated with coronary artery gas embolism, resulted in severe but transient abnormal left ventricular anterior wall motion, subepicardial ischaemia and injury in ECG leads V1 to V5, but unremarkable coronary arteriography and full recovery. The pathophysiology of gas embolism occurring during a laparoscopic procedure, the mechanisms of gas entry into the systemic vascular bed, the clinical, ECG, pulse oximetry, end-tidal CO2 concentration changes and alarm signs are discussed. The diagnostic value of Doppler transoesophageal echocardiography when possible is underlined, and emergency management of gas embolism is considered.

Aged↗
PubMed1998

[Successful emergency coronary artery bypass grafting after use of a percutaneous cardiopulmonary support system in a patient with cardiopulmonary arrest secondary to acute myocardial infarction].

A 37-year-old woman was taken to a hospital because of sudden chest pain. She lapsed into shock, and the ECG indicated acute myocardial infarction. The ECG later showed ventricular fibrillation, and the patient was given cardiac massage while being transported to our hospital, where she was resuscitated with a percutaneous cardiopulmonary support system. Emergency coronary angiography revealed 99% stenosis of the left main coronary artery. PTCA was performed, and the stenotic lesion was released, but dissection and rapid formation of a thrombus were detected in the LAD. Re-PTCA was performed, but the hemodynamics did not improve, and emergency CABG of the LAD, D1, and LCx was performed. Postoperative max CPK was 18,957 IU/L. Although postoperative MRSA pneumonia developed as a complication, weaning from the respirator was performed 17 days after the operation. The patient was discharged, ambulatory, 74 days after the operation.

Adult↗
PubMed1997

Emergency pulmonary embolectomy with percutaneous cardiopulmonary bypass.

BACKGROUND: The management of patients with acute pulmonary embolism remains difficult, particularly when cardiogenic shock is involved. The preoperative incidence of cardiac arrest compromises the results of emergency pulmonary embolectomy. In an attempt to reduce the operative mortality rate, we applied percutaneous cardiopulmonary bypass support to restore vital organ perfusion before the surgical intervention. METHODS: Percutaneous cardiopulmonary bypass support was preoperatively instituted in 3 patients with acute cardiopulmonary collapse caused by massive pulmonary embolism. In each patient, cardiac massage and endotracheal intubation were necessary due to loss of consciousness, hypotension, and severe cyanosis. Transesophageal echocardiography was performed to detect any evidence of thrombus in the main pulmonary artery, and each patient underwent the emergency pulmonary embolectomy using conventional cardiopulmonary bypass through a median sternotomy. RESULTS: Percutaneous cardiopulmonary bypass support immediately provided effective cardiopulmonary resuscitation. Transesophageal echocardiography clearly demonstrated any evidence of thrombus located in the pulmonary artery. Each patient was discharged from the hospital without any postoperative complication. CONCLUSIONS: The use of percutaneous cardiopulmonary bypass support immediately resuscitated and stabilized the cardiopulmonary function and allowed for successful emergency pulmonary embolectomy. In each patient, transesophageal echocardiography was useful for prompt and noninvasive diagnosis.

Adult↗
PubMed1983

Prolonged hypoperfusion in the cerebral cortex following cardiac arrest and resuscitation in dogs.

Increasing cerebral vascular resistance and brain perfusion failure occur within 90 minutes following cardiac arrest and resuscitation. This study followed cortical perfusion for 18 hours after a 15-minute cardiac arrest. Six dogs were anesthetized with ketamine and gallamine and then mechanically ventilated. They were instrumented for arterial pressure, central venous pressure, and regional cerebral cortical blood flow (rCCBF) determined by thermodilution. A left thoracotomy and pericardiotomy were done. Two dogs served as non-arrest controls. Cardiac arrest was produced in four dogs with an intravenous bolus of KCl at 1 mEq/kg. After 15 minutes of cardiac arrest, the animals were resuscitated with internal massage, NaHCO3, epinephrine, and internal defibrillation. Cortical blood flow was followed for 18 hours. Arterial core temperature was never less than 35 C. Pre-arrest cortical blood flows were 0.86 cc/min/g (+/- 0.11). The two control animals had stable rCCBF (0.74 +/- 0.17) for all determinations during the 18-hour follow-up period. Determinations of rCCBF from 6 to 18 hours in post-arrest animals were 7% to 14% of pre-arrest values. We conclude that the post-resuscitation perfusion failure in the cortex is prolonged. Any potential for neuronal recovery, unless perfusion is protected, would not be realized given this phenomenon.

Animals↗
PubMed1989

[A portable manual sternal compressor for cardiac massage of a patient under transportation--1. Evolution after trials and errors].

Difficulties of external cardiac massage during transportation of a patient on a litter or stretcher prompted us to develop a new portable manual sternal compressor. A seemingly good idea of sternal compression with an inflatable balloon placed between the sternum and a chest band engaged us in a long ordeal of trial and error until we retreated from this preconception. A practical sternal compressor has finally been created by applying two hydraulic pistons, one as a sternal compressor and the other as its push-pull energizer incorporated into a manual lever system. In this paper, one of the serial reports on this new device, all our errors are described lest some one in the future meet the same problems. Details of this new apparatus and the results of our experimental study and clinical application will soon follow this paper.

Equipment Design↗
PubMed1990

The mechanism of blood flow during closed chest cardiac massage in humans: transesophageal echocardiographic observations.

Despite years of research, the mechanism of forward blood flow during closed chest cardiac massage remains controversial. Two theories have been suggested: the cardiac pump theory and the thoracic pump theory. Transesophageal echocardiography offers a new approach for study of the flows and cardiac morphologic features during chest compressions in humans. Case reports are presented to illustrate the use of transesophageal echocardiography during cardiopulmonary resuscitation. The findings included right and left ventricular compression, closure of the mitral valve during compression, opening of the mitral valve during the release phase, and atrioventricular valvular regurgitation during compression, indicating a positive ventricular-to-atrial pressure gradient. These findings suggest that direct cardiac compression was the predominant mechanism of forward blood flow during cardiopulmonary resuscitation in these patients. An understanding of the actual mechanisms involved is necessary if improved cardiopulmonary resuscitative techniques or adjuncts are to be rationally developed for enhancing the outcome of resuscitation.

Aged↗
PubMed1994

Rib fractures in children--resuscitation or child abuse?

The autopsy reports of 233 babies and children aged between 5 days and 7 years, including 190 cases of non-traumatic and 43 cases of traumatic death, were reviewed. In 94 out of 190 cases of death due to natural causes, attempted resuscitation (closed-chest massage) was performed and only in 2 cases could fractures of the ribs localized on both sides in the midclavicular line be observed. In 15 of the 43 cases of death due to traumatic events, fractures mainly of the posterior ends of the ribs occurred. These observations support the published findings of other authors which indicate that fractures of ventral parts of the thorax can occur during resuscitation. Fractures localized in particular in dorsal parts of the chest wall of infants without metabolic bone diseases, however, must be interpreted as a strong indication of physical child abuse. It was observed that relevant injuries due to resuscitation are caused much more frequently or almost exclusively by physicians than by non-medical persons. This finding refutes any possible claims that rib fractures were caused by inexpert resuscitation in a panic-like reaction.

Cause of Death↗
PubMed1979

Relative importance of alpha and beta adrenergic receptors during resuscitation.

Successful resuscitation from cardiac arrest in the asphyxiated dog model has been ascribed to the use of artificial ventilation, closed chest cardiac massage, and administration of a vasopressor. Controversy remains over whether the most commonly employed vasopressor, epinephrine, exerts its effects primarily by elevating diastolic pressure and reestablishing coronary flow, or by exciting cardiac pacemaker cells and enhancing myocardial contractility. To observe pure alpha and beta adrenergic receptor influences during resuscitation, three groups (alpha-blocked, beta-blocked, unblocked) of dogs were studied. beta-blocked dogs resuscitated with phenylephrine and unblocked dogs resuscitated with epinephrine experienced 100% successful resumption of spontaneous circulation after 5 min of asphyxia-induced arrest. Only 27% of alpha-blocked animals resuscitated with isoproterenol were successfully revived. The appearance of the ECG during cardiac arrest and resuscitation could in no way be used to predict the outcome of resuscitation attempts. Results suggest that, initially, alpha receptor stimulation with concomitant diastolic pressure elevation is more important to the success of resuscitation than beta receptor stimulation.

Animals↗
PubMedDate not supplied

Use of open chest cardiopulmonary resuscitation after failure of standard closed chest CPR: illustrative cases.

Compared to standard closed chest CPR, open chest cardiac massage improves vital organ perfusion and survival in animal models of medical cardiac arrest. Yet its use is essentially limited to the treatment of traumatic arrest. Three cases of medical cardiac arrest are presented in which open chest compression was used after failure of external chest compression. These cases illustrate the range of potential outcomes and how this therapy can be optimally applied. Approaches we have used to prevent application of futile intensive therapy in patients unlikely to be neurologically intact survivors are described. Replacement of open chest CPR by closed chest CPR as the standard of care for the in-hospital cardiac arrest was not justified by experimental data. The circumstances of refractory cardiac arrest make it unlikely that well controlled human studies will be able to demonstrate the superiority of open chest CPR in selected patients. The decision to use this therapy will likely remain within the art of medicine.

Adult↗
PubMed1981

Lidocaine levels during CPR: differences after peripheral venous, central venous, and intracardiac injections.

Drug administration via peripheral vein, central vein, and intracardiac routes is generally assumed to be equally effective during cardiopulmonary resuscitation (CPR). Experiments were performed in an animal model to evaluate this assumption. Twelve mongrel dogs weighing greater than 20 kg were studied. Arterial blood pressure and electrocardiogram were monitored continuously. Cardiac outputs were evaluated before CPR to determine control. After thoracotomy and fibrillation of the heart, cardiac massage was started and the rate of compression adjusted to give 30% of control cardiac output. A lidocaine bolus of 1.5 mg/kg was given via peripheral vein in four dogs, central vein in four dogs, and intracardiac (left ventricle) in four dogs. Drug levels were sampled through an aortic catheter at the level of the coronary artery ostia every 20 sec for five min, every 30 sec for 10 min, and every 60 sec for 15 min. There was no significant difference in the appearance of effective levels or time of peak levels in the three groups. The peak levels were highest in the central venous group, while peripheral venous and intracardiac peak levels were 63% and 31%, respectively, of the central venous peak. Duration of effective levels was 20 min in the intracardiac group, 14.5 min in the central venous group, and 9.6 min in the peripheral venous group. Further studies are needed to determine whether changes are needed in drug administration during CPR in man.

Animals↗