Resuscitation review article published in New England Journal of Medicine

April 26, 2001

The state-of-the-art in cardiac resuscitation is reviewed in an article by Mickey S. Eisenberg, MD, PhD, and Terry J. Mengert, MD, published in today's New England Journal of Medicine. According to a review of 10 years of data from King County, Washington, the average incidence of out-of-hospital cardiac (OHCA) arrest is 0.5/1,000. Two-thirds of OHCA victims (69 percent) are male. The average victim is 69-years-old. Most arrests (59 percent) are witnessed. Most victims receive bystander CPR (56 percent). OHCA occurs most often in the home (71 percent) and less frequently in public places (21 percent) and nursing homes (8 percent). A review of the literature suggests that national OHCA survival rates range from 4 to 33 percent. Reported rates of survival from cardiac arrest in hospitals range from 0 to 29 percent. The Chain of Survival (rapid access, rapid CPR, rapid defibrillation and rapid advanced care) remains the recommended approach to treatment for sudden cardiac arrest.

Key developments and controversies discussed by the authors are listed below.

An extra dose of CPR
While current protocols call for administration of defibrillation as quickly as possible, research suggests there may be instances (such as cases of unwitnessed or prolonged arrest) in which there are advantages to providing CPR before defibrillation.

Chest-compression-only CPR
While no human data support chest-compression-only CPR (an alternative method postulated by other authors), an observational study of OHCA patients has found similar rates of survival among those who received mouth-to-mouth ventilations and those who did not.

Increase in AED placement
Automated external defibrillators (AEDs) are becoming more widespread, thanks to efforts of the American Heart Assocation and other national organizations. While today's AEDs must be prescribed by a physician, the authors predict that in the next decade they will be sold as consumer devices. The role of AEDs in the home is yet unknown.

Implantable cardioverter defibrillators
Patients at highest risk for ventricular fibrillation should have implanted cardioverter defibrillators.

When to stop resuscitation efforts
In general, if a pulse has not returned after 30 minutes, resuscitation efforts are usually futile. Exceptions include hypothermia, submersion in cold water and drug overdose.

When to not to start resuscitation efforts
When death is not sudden, but expected, as in the case of terminal illness, resuscitation efforts are not always appropriate. Patients who do not wish to be resuscitated should have signed do-not-attempt resuscitation documents on the premises. As the authors note, "Death is, after all, inevitable. Only unexpected or sudden death is the enemy."

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