Seven Effective Strategies of Highly Successful Resuscitations (or A New Look at an Ancient Practice)
Despite more intensive guidelines and advances in resuscitation research, the survival rate for victims of cardiopulmonary arrest remains virtually unchanged from forty years ago when modern cardiopulmonary resuscitation (CPR) was first described (1). Perhaps in part because the guidelines for ACLS set forth by the American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) have become so complex―and continue to increase in breadth and scope into topics well beyond cardiopulmonary arrest with each revision―the critical aspects of resuscitation have become diluted by unnecessarily difficult algorithms. Critical skill sets―such as proper performance of CPR and rapid defibrillation―have become dwarfed by less critical aspects of acute resuscitation. Remarkably common errors usurp the dual fundamental goals of ACLS: neurological preservation and prevention of early death. This review will address the historical context of resuscitation and then will focus on seven of the most essential, evidence-based strategies for improving outcomes in ACLS.
History of Resuscitation
The modern resuscitation era began in 1960 when Kouwenhoven, Jude, and Knickerbocker published a pair of landmark papers on the use of closed chest compressions (CCC) as a means to resuscitate patients in cardiopulmonary arrest (2,3). Interestingly, the culmination of their three and a half decades of work was initially motivated and sponsored by an electric company seeking to reduce the death rate of its linemen from ventricular fibrillation. While innovative, their technique built on millennia of creative, and sometimes bizarre ancient practices geared at reversing death. Given the lack of in-depth knowledge of anatomy and physiology combined with a rich overlap between shamanism and medicine, it is perhaps stunning to realize that the oldest recorded reasonably physiologic approach to resuscitation stems from over 3500 years ago. Egyptian hieroglyphs show the story of the healing goddess, Isis, reviving her husband Osiris using mouth-to-mouth ventilation (4). Still other Egyptian texts advocated hanging drowned victims upside down, compressing and releasing the thorax with the goal to ventilate and revive the patient (5). Hebrew midwives were documented as having performed mouth-to-mouth on deceased newborns as early as 1300 BCE (6). And even the Bible tells of the prophet Elishah’s successful resuscitation of a deceased child through artificial respiration:
…And he went up, and lay upon the child, and put his mouth upon his mouth, and his eyes upon his eyes, and his hands upon his hands; and he stretched himself upon the child; and the flesh of the child waxed warm (7).
One of the forefathers of modern medicine, the Greek physician Galen, was the first doctor to use an artificial ventilation strategy in 177, filling dead animals’ lungs with air from a bellows (8).
In 1628, physician William Harvey, the first to accurately describe circulation, used his newfound knowledge to successfully stop ventricular fibrillation in a pigeon using open heart massage (9 ). John Hunter created a bellows that could deliver positive and negative pressure ventilation, which he used to resuscitate dogs in 1755 (10). The Dutch Humane Society immediately tapped Hunter’s knowledge to help reduce the death rate of drowning victims (11). The resultant 1767 publication was the first ever to advocate the use of “artificial respiration”:
…the operator closed the patient’s nostrils, applied his mouth to the patient’s mouth, inflated the lungs and expanded the chest and belly, and produced expiration by compressing the abdomen with his free hand (12).
Despite giving ventilation equal measure with another popular technique at the time called fumigation―the use of tobacco smoke to fill the colon of drowned victims via a rectal tube―scientists rapidly began to use true physiologic practices to advance resuscitation.
