CORRESPONDENCE How Much CPR is Enough CPR? To the Editor:

With regard to '~Cardiac Arrest in the Emergency Medical Services System: Guidel ines for Resuscita- tion" (JACEP, December 1977), cardiopulmonary resus- citation (CPR) survival rates (ie, percent discharged alive from the hospital) vary from zero ~ to 86% 2 for prehospital arrests and 4.6% 3 to 100% 4 for inhospital arrests. These wide ranges update the 1953 report of Stephenson and Hinton 5 which describes a successful resusci ta t ion percentage range of 8% to 75% from their l i t e ra ture search and a "permanent survival" average of 25% from their study of 1,000 cases of car- diopulmonary arrest. 5

As of J a n u a r y 1, 1978 a comprehensive retrospec- tive and prospective survey of cardiopulmonary arrest r e s u s c i t a t i o n ou t comes is needed to d e f i n i t i v e l y analyze factors such as pat ient age, sex, dura t ion of p r e r e s u s c i t a t i v e c a r d i o p u l m o n a r y ar res t , specific etiology of cardiopulmonary arrest, presence/absence of under ly ing disease, pat ient responsiveness to spe- cific therapeutic modalities, durat ion of active resusci- tation, effectiveness of individual resusci tat ionist con- tr ibutions dur ing each phase of resuscitation, and any other circumstances which contribute to ini t ia l resus- citation success, long-term success, unresponsiveness to resusci ta t ion, early demise, late demise, and ir- reversible organic derangement .

These studies require a uniform repor t ing sys- tem, 6 s tandard base determinat ions 7 and multihospi- tal collaboration to insure sufficient pat ient numbers for accura te s ta t i s t i ca l eva lua t ion . An es tab l i shed data collection center should first formulate str ict criteria for operational definitions of cardiopulmonary arrest, t rad i t iona l death, s resuscitat ion, dura t ion of arrest, dura t ion of resuscitation, and optimal emer- gency medical care tha t needs to be provided dur ing all phases. Only after accurate documentat ion can any statist ically supported tables be developed to guide physicians as to how long to resuscitate individual cases.

Duration of Resuscitation

A 3.5-hour resusci tat ion for cardiopulmonary ar- rest has been reported 9 from which the pat ient even- tual ly "survived with no detectable bra in damage." This same resusc i ta t ion group, successfully resusci- tated n ine other pat ients with cardiopulmonary resus- citations exceeding 20 minutes . 9 The Guinness Book of World Records 1° l is ts the longest recorded h u m a n hear t stoppage wi th subsequen t recovery at three hours in a 5-year-old boy who near-drowned in the ice-cold water of a fresh water river. He was under the water for an est imated 22 minutes , 1°,1~ required 120 minutes of cardiac compression, and ~'recovered with little if any neurological and intel lectual damage. ' '~ Jude et a112 reported a series of efforts at resuscitat ion from 2 to 120 minu tes and noted "successful re turn to the p rea r re s t c en t r a l ne rvous system and cardiac status occurred up to 90 minutes."

Successful resusci ta t ion (ie, discharged alive from

the hospital with no long-term evidence of brain dam- age) has occurred for the following durat ions of near- drowning submersion:

• 10 minutes (1964, 8-year-old, male, fresh water lake, 40 minute arrest un t i l ini t ial resuscitative re- sponse, body temperature 28 C) 15

• 17 minutes (1964, 21-year-old, male, brackish 'water [oceantidal reached River Yarra-water analysis: sod ium 128 mEq / l i t e r , p o t a s s i u m 4.6 mEq / l i t e r , chloride 200 mEq/liter], ? minu te arrest unti l ini t ial resuscitative response, body tempera ture 32 C) 16

• 20 minutes (1964, 3-year-old, male, fresh water stream, 55 minute arrest un t i l ini t ia l resuscitative re- sponse, body temperature 27 C) 15

• 20 minutes (1973, 33-year-old, male, swimming pool water, 50 minute arrest unt i l in i t ia l resuscitative response, body temperature 27.8 C) 17

• 22 minutes (1963, 5-year-old, male, fresh water river, 142 minute arrest un t i l resuscitative response, body temperature 24 C) 11

• 25 minutes (1977, 6-year-old, male, muddy liq- uid manure tank, 65 minute arrest unt i l ini t ia l resus- citative response, body temptera ture 31.8 C) is

• 30 minutes (1974, 5-year-old, male, fresh water river, 30 minute arrest unt i l in i t ia l resuscitative re- sponse, body temperature 27 C) 19

• 40 m i n u t e s (1975, 5-year-old, male, ice-cold fresh water river, 105-107 minu te arrest unt i l ini t ia l resuscitat ive response, body temperature 24 C). 2°

These and other data suggest the need for con- t inued individualized durat ions of resuscitat ion unti l sound statistical data, obtained with optimal resus- citative care, is available to support rigid numerical guidelines. It appears, however, that the economics of resuscitat ion will probably direct the decision-making before any reliable scientific tables are ever prepared in this country and published.

J.K. Sims, M.D. Honolulu, Hawaii

Mike Penick, EMT-A Aiea, Hawaii

1. Baker R, Waters JM: Cardiac Experience - - Jacksonville Rescue Branch - - February 1973, in Proceedings of the Na- tional Conference on Standards for Cardiopulmonary Resus- citation (CPR) and Emergency Cardiac Care (ECC), May 16-18, 1973. American Heart Association, Dallas, Texas, 1975, p 183.

2. Copley DA, Mantle JA, Russell RO Jr, et al: Reduction of morbidity and mortality with early cardiopulmonary resusci- tation via bystanders. Circulation II - - 225, 1976 (Abstract #0882).

3. Gilbert GJ: Cardiopulmonary resuscitation. JAMA 238:12, 1977.

4. Stephenson HE Jr (ed): Cardiac Arrest & Resuscitation. C V Mosby Co, St. Louis, 1974, pp. 809, 827.

5. Stephenson HE Jr, Hinton JW: Use of intra-aortic and in- tracardiac transfusions in cardiac arrest. JAMA 152:500-503, 1953.

6. Polnitsky CA, Capone RJ, Gagnon DE, et al: Prehospital coronary care - - proposal for a uniform reporting system. JAMA 237:134-137, 1977.

7:5 (May) 1978 JACEP 218/69

7. McManus WF, Darin JC: Can the well trained EMT- Paramedic maintain skills and knowledge? JACEP 5:984- 986, 1976.

8. Sims JK: Criteria for the pronouncement of death and the human brain death syndrome. Hawaii IVied J 35:11-14, 1976.

9. Sandoe E, Flensted-Jensen E, Dupont B: Long-term prog- nosis in patients resuscitated from cardiac arrest. Isr J Med Sci 5:769-771, 1969.

10. McWhirter N, McWhirter R: Guinness Book of World Rec- ords, Bantam Books - - Sterling Publishing Company, New York, 1977, p 42.

11. Kvittingen TD, Naess A: Recovery from drowning in fresh walter. Br Med J 1:1315-1317, 1963.

12. Jude JR, Kouwenhoven WB, Knickerbocker GG: Cardiac arrest - - report of application of external cardiac massage on 118 patients. JAMA 178:1063-1070, 1961.

13. Sims JK: Drowning and near-drowning, in Barry J (ed): Emergency Nursing. McGraw-Hill, New York, 1978, pp 377- 389.

14. Modell JH: The Pathophysiology and Treatment of Drowning and Near-Drowning. Charles C Thomas, Spring- field, Illinois, 1971, pp 8-12.

15. Ohlsson K, Beckman M: Drowning-reflections based on two cases. Acta Chir Scand 128:327-339, 1964.

16. King RB, Webster IW: A case of recovery from drowning and prolonged anoxia. Med J Aust 1:919-920, 1964.

17. DeVillota ED, Barat G, Petal P, et al: Recovery from pro- found hypothermia with cardiac arrest after immersion. Br Med J 4:394-395, 1973.

18. Theilade D: The danger of mis-judgement in hypother- mia after immersion. Anaesthesia 32;889-892, 1977.

19. Hunt PK: Effect and treatment of the "diving reflex" Can Med Assoc J 111:1330-1331, 1974.

20. Siebke H, Rod T, Breivik H, et al: Survival after 40 min- utes' submersion without cerebral sequelae. Lancet 1:1275- 1277, 1975.

To the Editor:

We concur with Dr. E l ias tam et al in "Cardiac Ar- r e s t in the E m e r g e n c y Medica l Se rv i ce Sys tem: G u i d e l i n e s for Resusc i t a t i on" ( J A C E P , December 1977) tha t the economic, physical and emotional costs of prolonged unsuccessful resusc i ta t ive efforts and main tenance of postresuscitat ion bra in damaged pa- t ients are so high, tha t earl ier t e rmina t ion of resus- citative efforts may be indicated. We commend Dr. El ias tam for a t tempt ing to establish guidelines for the complex and sensi t ive issue of resusci ta t ion in the emergency department.

However, we take exception to the second of the recommendations: "No response after more t han 30 minutes of ACLS, ( including ACLS administered in the field)." There are mi t iga t ing circumstances, eg, the young pat ient and the hypothermic pat ient , in which p ro longed c a r d i o p u l m o n a r y r e s u s c i t a t i o n (CPR), beyond 30 minutes, is clearly indicated. Our own experiences (unpublished data), as well as numer- ous cases in the l i t e ra tu re , 2 document successful resusci ta t ion long after one ha l f hour of resuscita- tive efforts.

Addi t ional ly , there are ins tances in which pa- t ients unresponsive to s tandard CPR techniques bene- fit from more aggressive in tervent ion such as emer- gency thoracotomy (unpublished data), eg, hypother- mia, res is tant arrythmias , pericardial tamponade, and tension pneumothorax.

We have other objections to the 30-minute cutoff which are philosophical. The decision to t e rmina te life support must be based on the physician's impression of the pat ient and his chance for survival, not on a time limit. The assessment stems from the physician's ex- perience.

In some instances, the experienced physician will curtail his efforts in less than half an hour. We are great ly concerned however, t ha t the inexper ienced physician will accept these guidelines as dictum and stop advanced cardiac life support (ACLS) at the 30- minute cutoff, thereby fai l ing to resuscitate some pa- t ients who might otherwise survive.

We feel there should be an addendum to the 30 minute guideline which will make it clear tha t there are instances, as mentioned above, where CPR should be continued for longer periods of time, possibly in- cluding modalities beyond s tandard ACLS.

Dr. El ias tam's efforts in es tabl ishing guidelines are a good beginning, but fur ther work is needed.

Marc J. Bayer, MD Joseph J. Bander, MD

Sanders Orent, MID Emergency Services

University of Oregon Health Sciences Center

1. Shockett E, Rosenblum-R: Successful open cardiac mas- sage. JAMA 200:157-158, 1967.

2. Russell ES: Cardiac arrest: survival after 2Vz hours open chest cardiac massage. Canad Med Assoc J 87:512-513, 1976.

Author's Reply I agree fully with the comments of both Dr. Bayer

and Dr. Sims. My recommendations are intended to serve as a first step in the process which will eventu- ally result in some reasonable guidelines tha t most physicians will be able to follow most of the time.

There is little doubt that there are specific cir- cumstances in which the suggested 30- minute l imit of ACLS should be ignored. These include the young pa- tient, the hypothermic patient, and possibly the pa- t ient bleeding from t raumat ic causes. The decision to hal t resuscitative efforts is made after the usual and customary measures have failed and physical exami- na t ion has not revealed a condition tha t might war- r an t more aggressive intervent ion. Thus, conditions such as hypothermia, res is tant ar rhythmias , pericar- dial tamponade, and tension pneumothorax should be excluded before any decision about ha l t ing resuscita- t ion is even considered. Since the references Dr. Bayer and his colleagues cite are their own unpubl ished works, I cannot comment on their validity.

I share Dr. Bayer's concern t ha t the inexperienced physician might use these guidelines as "dictum." I be- lieve tha t t ry ing to resuscitate everybody for as long as possible, irrespective of the clinical history, physi- cal examinat ion or response to therapy, does not rep- resen t a very a t t rac t ive a l t e rna t ive . Dr. Sims and pa ramed ic Pen ick are correct about the need for further study. I disagree with their view that the ab- sence of studies obligates us to continue doing what we are current ly doing, regardless of its futility.

I hope the recommendat ions in the article will begin to focus a t tent ion on those clinical conditions where aggressive the rapy is needed, and on those

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