ADVANCES IN

CARDIOPULMONARY

RESUSCITATION

WOLF CREEK CONFERENCE ON CARDIOPULMONARY RESUSCITATION

October 30, 31,1975

/

Front: James Jude , David Leighninge r, Louis Del Guercio, Guy Knickerbocke r, Charles Guildner, Don Dembo; Middle : Christopher Rattenborg, Robert Huber, Peter Safar, Robert Oswald, Joseph Redding, Hugh Stephen­son , Jr., Archer Gordon, Leon Resnekov, Gerald Modell, Leonard Scherlis, James Elam, James Evans ; Back: Keith Thwaites, Paul Zoll , Edwin Nemoto, Larry Birch , Eugene Nagel, Asmund Laerdal.

(The following are the signatures of these participants, not in any particular order.)

t- ;rJ'- ,!du~ .--#...I7~'~ 0-/./(1'0-,-- ~~~

~/.~d//~

#~·~fl: ~~

q~f£- ~~-~~A?~t\"'.~~;; ;tZ,£-~~~

ADVANCES IN CARDIOPULMONARY

RESUSCITATION Peter Safar, Editor

James Elam, Associate Editor

with 92 illustrations

SPRINGER-VERLAG New York Heidelberg Berlin

Peter Safar, M.D., Dr. hon. causa Professor and Chairman Department of Anesthesiology/Critical Care Medicine University Health Center of Pittsburgh Pittsburgh, Pennsylvania 15261

James O. Elam, M.D. Professor of Anesthesiology University of Chicago Chicago lying-in Hospital Chicago, Illinois 60637

This monograph issues from: The Wolf Creek Conference, 1975.

library of Congress Cataloging in Publication Data

Main entry under title:

Advances in cardiopulmonary resuscitation.

Proceedings of a conference held at Wolf Creek lodge, Ga., Oct. 30-31, 1975. Bibliography: p. Includes index. 1. Resuscitation-Congresses. 2. Critical care medicine-Congresses. I. Safar, Peter, 1924-. II. Elam, James a., 1918- III. Title: Cardiopulmonary resuscitation.

RC682.A385 615'.8'043 77-10510

All rights reserved.

No part of this book may be translated or reproduced in any form without written permission from Springer-Verlag.

© 1977 by Springer-Verlag New York Inc. Softcover reprint of the hardcover 1st edition 1977

9 8 7 6 5 4 3 2 1

ISBN-13: 978-1-4612-6340-1 e-ISBN-13: 978-1-4612-6338-8 001: 10.1007/978-1-4612-6338-8

To the memory of

WILLIAM B. KOUWENHOVEN Jan. 13, 1886-Nov. 10, 1975

(See Chapters 37 and 43)

THOMAS K. BURNAP June 7, 1924-Aug. 24, 1975

(American Heart Association CPR Committee Chairman

1971-1972)

Since the late 19505, revolutionary devel­opments of basic knowledge, techniques, teaching, and practice of cardiopulmonary resuscitation (CPR) have resulted in the saving of uncountable lives from conditions that previously led to certain death. The 1950s brought breakthroughs in respiratory resuscita­tion, the 1960s, breakthroughs in cardiac resuscitation, and the 1970s have begun to show breakthroughs in resuscitation of the arrested brain.

Mobilization of large-scale public involve­ment in life-saving efforts is essential. But the challenges and opportunities of implementing new knowledge in CPR on a large scale have brought agencies and politics into the field, unnecessarily complicating initially clear con­cepts and simple techniques. Because of this and because of the need for a fresh look at the past, present, and futu re trends and prior­ities, 24 of the initiators of modern CPR met on October 30 and 31, 1975 in the solitude of Georgia's mountains to discuss recent advances

PREFACE

in and the potential future of emergency resuscitation. This meeting was initiated by james Elam. james jude, owner of the Wolf Creek Lodge (Blairsville, Georgia 30512), acted as host.

The Program Committee invited primarily clinician-scientists from the United States, solicited synopsis papers and predistributed the 37 papers selected to the participants. We were spared formal paper presentations and thus could devote ourselves to two full days of informal, stimulating, provocative discus­sions. This led to cross-fertilization of ideas among individuals with different specialty backgrounds.

The participants included old friends and collaborators, as well as currently active re­searchers. There were the first generation resuscitation researchers (DelGuercio, Elam, Gordon, Jude, Knickerbocker, Leighninger, Rattenborg, Redding, Safar, Stephenson, and Zoll), some representatives of the second (Modell, Nagel, Resnekov), and third (Guildner,

viii

Preface

Nemoto) generations of investigators. By "generation" we actually mean "decades," starting with the 1950s. There were innovators in training and implementation (Laerdal and others); members of the first American Heart Association CPR Committee (Birch, Dembo, Elam, Gordon, Huber, Jude, Safar, Scherlis); a link with neonatology (Evans); and represen­tatives of the American Heart Association (Thwaites), and the American Red Cross (Oswald). Bjorn Lind, Henning Ruben, Joel Nobel, Bernard Lown, and Hugh Day were also invited, but could not attend.

The discovery and rapid development and implementation of modern resuscitation are an example of how a mix of targeted, basic and applied, laboratory and clinical research can quickly benefit the public without sacri­ficing quality and the freedom of investigators. I ndividuals with small research teams proved to be an effective form of conducting innova­tive research in resuscitation. Several of the groups have interacted and even collaborated

since the 1950s in spite of geographic separa­tion. All this may suggest patterns for present day "research centers or institutes" in general.

Although the reader will find in the 37 papers some heretofore unpublished and clinically relevant data, the principle value in publishing this Conference was meant to be the individual opinions, visions, syntheses, re­views, and memories of both old-timers and "young turks." Historic perspective, which the young generation sometimes lacks, is fostered by the "historic vignettes."

This volume concerns itself with scientific, clinical, and educational aspects of respiratory, circulatory, and cerebral resuscitation. How­ever, if we are to promote the future develop­ment of resuscitation in a sound and reasonable manner, supportive of human evolution, we must concern ourselves also with the public health issues and philosophic, sociologic, and economic problems created by the potentials of modern resuscitation.

P. S.

ACKNOWLEDGMENTS

Our special gratitude goes to Asmund Laerdal, innovative benefactor of resuscitation since 1960, whose generosity made publication of this Conference possible. We also want to thank our host and owner of the Wolf Creek Lodge, james jude. To james Evans we are particularly grateful for the local arrangements, recording, and transcribing. In Pittsburgh, Patricia Sands helped with editing, and Vicki Shidel with typing and final preparation of the manuscripts. Without the collaboration of the staff of Springer-Verlag, New York, publica­tion of this volume would not have been possible.

P. S.

THE PREARREST PERIOD 1

1 CLASSIFICATION OF ETIOLOGY, PREVENTION, AND TREATMENT OF CARDIAC ARREST 3

james R. jude

2 PHYSIOLOGIC BASIS FOR PREDICTION OF IRREVERSIBLE CARDIAC ARREST 8

Louis R.M. Del Guercio

3 DYSRHYTHMIA SURVEILLANCE Prevention of Ventricular Fibrillation and Ventricular Tachycardia 13

Leon Resnekov

II AIRWAY OBSTRUCTION AND RESPIRATORY ARREST 21

4 SEQUENTIAL STEPS OF EMERGENCY AIRWAY CONTROL 23

Peter Safar

5 RESUSCITATION-OPENING THE AIRWAY Comparative Study of Techniques for Opening the Airway Obstructed by the Tongue 33

Charles W. Guildner

CONTENTS

6 EMERGENCY MANAGEMENT OF FOREIGN BODY AIRWAY OBSTRUCTION Comparison of Artificial Cough Techniques, Manual Extrication Maneuvers, and Simple Mechanical Devices 39

Archer S. Gordon, M. Kathleen Belton, Paul F. Ridolpho

7 EMERGENCY MANAGEMENT FOR AIRWAY OBSTRUCTION BY FOREIGN MATERIAL 51

Charles W. Guildner, Douglas Williams, Thomas Subitch

8 IMPROVED ESOPHAGEAL OBTURATOR AIRWAY (EOA) AND NEW ESOPHAGEAL GASTRIC TUBE AIRWAY (EGTA) 58

Archer s. Gordon

9 AIRWAY MANAGEMENT WITH THE ESOPHAGEAL PHARYNGEAL AIRWAY 65

james o. Eiam, Phebe Lim-Tan, Mohamad Shafieha, Marjorie Robert

10 BAG-VALVE-MASK O 2 VENTILATION Efficiency versus Convenience; O 2 versus Valve Lock 73

james O. flam

xii

Contents

III CIRCULATORY ARREST 81

11 INVESTIGATIONS IN PREHOSPITAL SUDDEN CARDIAC DEATH 83

Eugene L. Nagel, Richard R. Liberthson, Jim C. Hirschman, Sidney R. Nussenfeld

12 PRECORDIAL THUMPING DURING CARDIAC RESUSCITATION 87

Joseph S. Redding

13 MECHANICAL EXTERNAL CARDIAC COMPRESSION AND VENTILATION DURING CARDIOPULMONARY RESUSCITATION 94

Larry H. Birch

14 PRELIMINARY OBSERVATIONS DURING MECHANICAL EXTERNAL HEART COMPRESSIONS 99

Eugene L. Nagel, Jerome SchoHerman

15 PRESENT PLACE OF OPEN-CHEST CARDIAC RESUSCITATION 102

Hugh E. Stephenson, Jr.

16 PROPOSED NEW EMERGENCY MEDICAL TECHNICIAN PROCEDURES FOR MANAGEMENT OF HYPOVOLEMIA 107

Eugene L. Nagel

IV DRUGS IN CARDIOPULMONARY RESUSCITATION 111

17 DRUG THERAPY DURING CARDIAC ARREST 113

Joseph S. Redding

18 VASOACTIVE CARDIAC SUPPORTIVE DRUGS 118

Leon Resnekov

19 ELECTROPHYSIOLOGIC PRINCIPLES OF ANTIARRHYTHMIC DRUGS 122

Donald H. Dembo

20 EFFECT OF BICARBONATE AND THAM ON APNEA-INDUCED HYPERCARBIA 128

Christen C. Rattenborg

21 THE INTRAPULMONARY ROUTE FOR CPR DRUGS 132

James O. Elam

V ELECTROCARDIOGRAPHY, PACING, AND DEFIBRILLATION 141

22 ELECTROCARDIOGRAPHY IN CARDIAC ARREST 143

Joseph S. Redding

23 EXTERNAL CARDIAC STIMULATION 152

Paul M. Zoll

24 DEFIBRILLATION ENERGY AND WAVE FORMS 156

G. Guy Knickerbocker

25 SPONTANEOUS VENTRICULAR DEFIBRILLATION AND REFRACTORY DEFIBRILLATION 161

Hugh E. Stephenson, Jr.

26 ESOPHAGEAL ELECTROCARDIOGRAPHY AND LOW-ENERGY VENTRICULAR DEFIBRILLATION 167

James O. Elam, Enrique Via Reque, Christen C. Rattenborg

VI THE IMMEDIATE POSTRESUSCITATIVE PERIOD 175

INTRODUCTION TO CHAPTERS 27-29, RESUSCITATION OF THE ARRESTED BRAIN 177

Peter Safar

27 AMELIORATION OF POSTISCHEMIC-ANOXIC BRAIN DAMAGE BY REF LOW PROMOTION 182

Peter Safar, William Stezoski, Edwin M. Nemoto

28 AMELIORATION OF POSTISCHEMIC-ANOXIC BRAIN DAMAGE BY THIOPENTAL 187

Edwin M. Nemoto, Achiel L. Bleyaert, Wi11iam Stezoski, Nisantha Bandaranayake, John Moossy, Ra;asekhara G. Rao, Peter Safar

29 CARDIOPULMONARY-CEREBRAL RESUSCITATION (CPCR) Postresuscitative Intensive Therapy Recommendations and Patient Trial Protocols 195

Peter Safar

30 MICROCIRCULATION IN CARDIOPULMONARY RESUSCITATION 208

Hugh E. Stephenson, Jr.

VII SPECIAL CONSIDERATIONS 219

31 CARDIOPULMONARY RESUSCITATION AND MASSIVE HEMORRHAGE 221

Hugh E. Stephenson, Jr.

32 NEAR-DROWNING 226

Jerome H. Modell

33 INTRAUTERINE FETAL RESUSCITATION 231

James A. Evans

34 QUANTITATIVE GOALS IN THE TEACHING OF CARDIOPULMONARY RESUSCITATION 239

Asmund S. Laerdal

35 LEGAL CONSIDERATIONS OF CARDIOPULMONARY RESUSCITATION 246

Robert Huber

VIII HISTORIC VIGNETTES 251

36 EIGHTEENTH CENTURY RESUSCITATION 253

Leon Resnekov

37 CONTRIBUTIONS OF WILLIAM B. KOUWENHOVEN-REMINISCENCES 255

Guy Knickerbocker

38 CONTRIBUTIONS OF CLAUDE BECK 259

David S. Leighninger

xiii

Contents

39 REDISCOVERY OF EXPIRED AIR METHODS FOR EMERGENCY VENTILATION 263

James O. Elam

40 FROM BACK-PRESSURE ARM-LIFT TO MOUTH-TO-MOUTH, CONTROL OF AIRWAY, AND BEYOND 266

Peter Safar

41 HISTORIC ViGNETTES CONCERNING RESUSCITATION FROM DROWNING 276

Joseph S. Redding

42 THE FIRST SUCCESSFUL EXTERNAL CARDIAC STIMULATION AND A-C DEFIBRILLATION 281

Paul M. loll

43 REDISCOVERY OF EXTERNAL HEART COMPRESSION IN DR. WILLIAM KOUWENHOVEN'S LABORATORY 286

James R. Jude

44 FIFTEEN YEARS' EXPERIENCE WITH MECHANICAL CARDIOPULMONARY RESUSCITATION 292

Larry H. Birch

CONCLUDING STATEMENT BY THE HOST 295

James R. Jude

CONCLUDING STATEMENT BY THE EDITOR 296

Peter Safar

INDEX 299

Larry H. Birch, M.D. Director, Cardiovascular laboratory Baptist Memorial Hospital Jacksonville, FL 32207

Louis R. M. Del Guercio, M.D. Professor and Chairman Department of Surgery New York Medical College Flower and Fifth Avenue Hospital New York, NY 10029

Donald H. Dembo, M.D. Head, Division of Cardiovascular Medicine Maryland General Hospital Baltimore, MD 21201

James O. Elam, M.D. Professor of Anesthesiology University of Chicago, Chicago Lying-in Hospital Chicago, IL 60637

James A. Evans, M.D. Chattahoochee Anesthesia Associates P.O. Box 2748 Columbus, GA 31902

CONTRIBUTORS

Archer S. Gordon, M.D., Ph.D. Clinical Professor of Anesthesiology University of California, Los Angeles Los Angeles, CA 90027

Charles W. Guildner, M.D. Medical Anesthesia Associates, Inc. Everett, WA 98201

Robert Huber, Esq. Hassard, Bonnington, Rogers & Huber 44 Montgomery Street San Francisco, CA 94104

James R. Jude, M.D. Clinical Professor of Surgery University of Miami School of Medicine Miami, FL 33133

G. Guy Knickerbocker, Ph.D. Emergency Care Research Institute 5200 Butler Pike Plymouth Meeting, PA 19462

xvi

Contributors

Asmund S. Laerdal, P. O. Box 377 4001 Stavanger Norway

David Leighninger, M.D. Edgewater Hospital 5700 N. Ashland Avenue Chicago, Il 60660

Jerome H. Modell, M.D. Professor and Chairman Department of Anesthesiology University of Florida College of Medicine Gainesville, Fl 32610

Eugene L. Nagel, M.D. Professor and Chairman Department of Anesthesiology Johns Hopkins School of Medicine Baltimore, MD 21205

Edwin M. Nemoto, Ph.D. Assistant Professor of Anesthesiology/

Critical Care Medicine (Research) University of Pittsburgh School of Medicine Pittsburgh, PA 15261

Robert Oswald American National Red Cross National Headquarters Washington, DC 20006

Christen C. Rattenborg, M.D. Professor of Anesthesiology University of Chicago Chicago, Il 60637

Joseph S. Redding, M.D. Professor of Anesthesiology Director of Respiratory Therapy Medical University of South Carolina Charleston, SC 29401

Leon Resnekov, M.D. Professor of Medicine (Cardiology) University of Chicago Chicago, Il 60637

Peter Safar, M.D., Dr. h.c. Professor and Chairman Department of Anesthesiology/

Critical Care Medicine University Health Center of Pittsburgh Pittsburgh, PA 15261

Leonard Scherlis, M.D. Director, Division of Cardiology University of Maryland Hospital Baltimore, MD 21201

Hugh E. Stephenson, Jr., M.D. Professor of Su rgery University of Missouri School of Medicine Columbia, MS 65201

Keith Thwaites American Heart Association National Office Dallas, TX 75231

Paul M. Zoll, M.D. Clinical Professor of Medicine Harvard Medical School Beth Israel Hospital Boston, MA 02215