CARDIOPULMONARY RESUSCITATION: THE EGYPTIAN ALGORITHM

Hesham Salah Eldin MD, FACC, FSCAI

Professor of Cardiology, Faculty of Medicine, Cairo University

Egyptian hieroglyphs show the story of the healing goddess, Isis, reviving her husband Osiris using mouth-to-mouth ventilation. Still other Egyptian texts advocated hanging drowned victims upside down, compressing and releasing the thorax with the goal to ventilate and revive the patient.

In Quran, the human life is so precious and saving a Life has no equal “...We ordained for the Children of Israel that if any one slew a person - unless it be for murder or for spreading mischief in the land - it would be as if he slew the whole people. And if anyone saved a life, it would be as if he saved the life of the whole people....” (Qur’an 5:32).

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.

” In the sixteenth and seventeenth centuries reviving an arrested victim involved laying the casualty face down across a horse and encouraging it to trot, the movement of the horse causing the repeated application and release of pressure to the chest cavity.

However, it was not until 1874 when cardiac massage using the open chest method began, and although electrical defibrillation may have begun in 1775, it was not proven successful in animals internally until 1899. Modern resuscitation practice started in 1960 with the documentation of 14 patients who survived cardiac arrest with the application of closed chest cardiac massage. That same year, at the meeting of the Maryland Medical Society in Ocean City, the combination of chest compressions and rescue breathing was introduced. In 1966 the American Heart Association (AHA) developed the first cardiopulmonary resuscitation (CPR) guidelines, which have been followed by periodic updates.

Epidemiology of Cardiopulmonary Arrest In the United States an estimated 375,000 to 750,000 hospitalized patients suffer a cardiopulmonary arrest requiring advanced cardiac life support (ACLS) annually.

Data from 37 communities in Europe indicate that the annual incidence of EMS-treated out-of-hospital cardiopulmonary arrests (OHCAs) for all rhythms is 38 per 100,000 population. Based on these data, the annual incidence of EMS treated ventricular fibrillation (VF) arrest is 17 per 100,000 and survival to hospital discharge is 10.7% for all-rhythm and 21.2% for VF cardiac arrest.

There is, however, some evidence that long-term survival rates after cardiac arrest are increasing.

A study by Akahane et al suggested that survival rates may be higher in men but that neurologic outcomes may be better in women of younger age, though the reasons for such sex differences are unclear.

It has also been demonstrated that out-of hospital cardiac arrests occurring in public areas are more likely to be associated with initial ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) and have better survival rates than arrests occurring at home.

The reported incidence of in-hospital cardiac arrest is more variable, but is in the range of 1–5 per 1000 admissions.

Recent data from the American Heart Association’s National Registry of CPR indicate that survival to hospital discharge after in-hospital cardiac arrest is 17.6% (all rhythms).The initial rhythm is VF or pulseless VT in 25% of cases and, of these, 37% survive to leave hospital, while after PEA or asystole, 11.5% survive to hospital discharge.

The International Consensus on Cardiopulmonary Science The International Liaison Committee on Resuscitation (ILCOR)

was founded on November 22, 1992, and currently includes representatives from the American Heart Association (AHA), the European Resuscitation Council (ERC), the Heart and Stroke Foundation of Canada (HSFC), the Australian and New Zealand Committee on Resuscitation (ANZCOR), Resuscitation Council of Southern Africa (RCSA), the InterAmerican Heart Foundation (IAHF), and the Resuscitation Council of Asia (RCA).

Its mission is to identify and review international science and knowledge relevant to cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) and when there is consensus to offer treatment recommendations Since 2000, researchers from the ILCOR member councils have evaluated resuscitation science in 5-yearly cycles with the latest being the 2010 International Consensus Conference which involved 313 experts from 30 countries.

ILCOR member organizations publish resuscitation guidelines that are consistent with the science in this consensus document, but they also take into account geographic, economic, and system differences in practice; availability of medical devices and drugs, and ease or difficulty of training. High-lights of the 2010 ILCOR Consensus on Resuscitation Science and a Viewpoint Adult BLS There have been several important advances in the science of resuscitation since the 2005 ILCOR review.

The following is a summary of the most important evidence-based recommendations for performance of BLS:

• Lay rescuers should begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victim’s pulse.

• Rescuers should begin CPR with chest compressions rather than opening the airway and delivering rescue breathing.

• All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. A strong emphasis on delivering high quality chest compressions remains essential.

• Trained rescuers should also provide ventilations with a compression–ventilation ratio of 30:2.

• EMS dispatchers should provide telephone instruction in chest compression-only CPR.

Compressions only and compressions plus ventilations All rescuers should perform chest compressions for all patients in cardiac arrest.

Chest compressions alone are recommended for untrained laypersons responding to victims of cardiac arrest, and are reasonable for trained laypersons if they are incapable of delivering airway and breathing maneuver to cardiac arrest victims.

Providing chest compressions with ventilations is reasonable for trained laypersons who are capable of giving CPR with ventilations to cardiac arrest victims.

Professional rescuers should provide chest compressions with ventilations for cardiac arrest victims.

Compression–ventilation sequence In the 2005 International Consensus Conference recommendations, the recommended sequence of CPR actions was: airway, breathing, and circulation/chest compressions (ABC).

In the 2010 document, in an attempt to shorten the delay to first chest compressions for adult victims, experts came to the consensus that rescuers may consider starting CPR with chest compressions rather than ventilations (the sequence will then be “CAB”).

If a dispatcher suspects asphyxial arrest, it is reasonable to provide instructions for rescue breathing followed by chest compressions.

There are several reasons for this change:

Most survivors of adult cardiac arrest have an initial rhythm of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), and these patients are best treated initially with chest compressions and early defibrillation rather than airway management.

Airway management, whether mouth-to-mouth breathing, bagging, or endotracheal intubation, often results in a delay of initiation of good chest compressions.

Airway management is no longer recommended until after the first cycle of chest compressions -- 30 compressions in 18 seconds.

Only a minority of cardiac arrest victims receive bystander CPR. It is believed that a significant obstacle to bystanders performing CPR is their fear of doing mouth-to-mouth breathing. By changing the initial focus of resuscitation to chest compressions rather than airway maneuvers, it is thought that more patients will receive important bystander intervention, even if it is limited to chest compressions.

Defibrillation In general, the 2010 International Consensus Conference recommendations contain no major differences from the 2005 recommendations. CPR before defibrillation The theoretical rationale for performing CPR before shock delivery is to improve coronary perfusion and thereby the chances of achieving sustained return of spontaneous circulation (ROSC); however, there is inconsistent evidence to support or refute a delay in defibrillation to provide a period (90 s to 3 min) of CPR for patients in VF/pulseless ventricular tachycardia (VT) cardiac arrest.

If more than one rescuer is present, one rescuer should provide chest compressions while the other activates the emergency response system, retrieves the AED and prepares to use it. Defibrillation strategy All new defibrillators deliver shocks using a variety of biphasic waveforms.

Although it has not been demonstrated conclusively in randomised clinical studies that biphasic defibrillators save more lives than monophasic defibrillators, biphasic defibrillators achieve higher first-shock success rates.

Advanced Life Support The most important developments and recommendations in ALS since the 2005 ILCOR review have been:

• The use of capnography to confirm and continually monitor tracheal tube placement and quality of CPR.

• More precise guidance on control of glucose in adults with sustained ROSC. Blood glucose values >180mgdL-1 should be treated and hypoglycaemia avoided.

• Additional evidence, albeit lower level, for use of therapeutic hypothermia for comatose survivors of cardiac arrest initially associated with nonshockable rhythms.

• Recognition that many accepted predictors of poor outcome in comatose survivors of cardiac arrest are unreliable, especially if the patient has been treated with therapeutic hypothermia.

• The recommendation that implementation of a comprehensive, structured treatment protocol may improve survival after cardiac arrest.

• Electric pacing is not effective as a routine treatment in patients with asystolic cardiac arrest. The use of epicardial wires to pace the myocardium after cardiac surgery is effective.

•The routine use of cricoid pressure to prevent aspiration in cardiac arrest is not recommended. If cricoid pressure is used during cardiac arrest, the pressure should be adjusted, relaxed, or released if it impedes ventilation or placement of an advanced airway.

•The tracheal tube was once considered the optimal method of managing the airway during cardiac arrest.

There is considerable evidence that without adequate training or ongoing skills maintenance, the incidence of failed intubations and complications is unacceptably high. Alternatives to the tracheal tube that have been studied during actual and manikin CPR include the bag and mask and supraglottic airway devices such as the laryngeal mask airway (LMA), Combitube, the laryngeal tube, and the I-gel. No study has shown an effect of the method of ventilation on survival.

There are no data to support the routine use of any specific approach to airway management during cardiac arrest. There is inadequate evidence to define the optimal timing of advanced airway placement during cardiac arrest. •Despite the continued widespread use of epinephrine and increased use of vasopressin during resuscitation in some countries, at the time of publication of the consensus there was no placebo-controlled study that showed that the routine use of any vasopressor during human cardiac arrest increases survival to hospital discharge.

A study comparing the use of IV access and drugs (epinephrine, amiodarone, atropine, vasopressin, without isolating the effect of each individual drug alone), with no IV access and no drugs in adult out-of-hospital CPR demonstrated improvement in ROSC and survival to hospital and intensive care unit admission but no difference in survival to discharge or neurological outcomes at discharge and 1-year follow-up.However, this study was not powered to detect clinically meaningful differences in long-term outcome.

•After the publication of the guidelines and in the first randomized, double-blind, placebo-controlled trial of adrenaline in cardiac-arrest patients, researchers in Australia randomized 534 adults (mean age, 65; 73% men) with out-of-hospital cardiac arrest from any cause to receive 1 mL of either adrenaline 1:1000 (i.e., 1 mg) or normal saline every 3 minutes to a maximum of 10 mL. No other resuscitation drugs were given. Paramedics were allowed to use other standard methods of cardiopulmonary resuscitation, including defibrillation. Results showed that the rates of survival to hospital discharge -the primary outcome- did not differ significantly between the adrenaline and control groups (4.0% and 1.9%; odds ratio, 2.2), however, patients receiving adrenaline had significantly higher likelihood of prehospital return of spontaneous circulation (ROSC) than placebo recipients (23.5% vs. 8.4%; OR, 3.4) and of admission to the hospital from the emergency department (25.4% vs. 13.0%; OR, 2.3). Post-cardiac arrest care Cardio-respiratory arrest is the common pathway of death, but it isn’t in itself a diagnosis. The essential question to be answered is why did this happen. Organized post–cardiac arrest care with an emphasis on multidisciplinary programs that focus on optimizing hemodynamic, neurologic, and metabolic function (including therapeutic hypothermia) may improve survival to hospital discharge among victims who achieve ROSC following cardiac arrest either in- or out-of-hospital. Key objectives of post–cardiac arrest care include:

● Optimizing cardiopulmonary function and vital organ perfusion after ROSC.

● Transportation to an appropriate hospital or critical-care unit with a comprehensive post–cardiac arrest treatment system of care.

● Identification and intervention for acute coronary syndromes (ACS) patients.

● Temperature control to optimize neurological recovery.

● Anticipation, treatment, and prevention of multiple organ dysfunction.

Technology & CPR Use of ultrasound imaging during advanced life support Although no studies have shown that use of ultrasound imaging modality improves outcome, there is no doubt that echocardiography has the potential to detect reversible causes of cardiac arrest. Absence of cardiac motion on sonography during resuscitation of patients in cardiac arrest is highly predictive of death although sensitivity and specificity has not been reported.

The integration of ultrasound into advanced life support requires considerable training if interruptions to chest compressions are to be minimized. A sub-xiphoid probe position has been recommended.

Investigators in Austria performed a prospective observational study involving 42 adults with nontraumatic cardiac arrest. Of 10 patients with cardiac movement on initial echocardiography, 4 (40%) survived to hospital admission, and 1 survived to hospital discharge (with full neurological recovery).

Of 32 patients with cardiac standstill on initial echocardiography, 1 (3%) survived to hospital admission and died in the hospital. Cardiac standstill on initial echocardiography had a positive predictive value for death on the scene of 97%. CPR devices Although no circulatory adjunct is currently recommended as preferable to manual CPR for routine use, some circulatory adjuncts are being used in both out-of-hospital and in-hospital resuscitation attempts. If a circulatory adjunct is used, rescuers should be well trained and a program of continuous surveillance should be in place to ensure that use of the adjunct does not adversely affect survival. Many devices have been and are being investigated.

On the basis of case reports and case series it may be reasonable to consider load-distributing band or LUCAS CPR to maintain continuous chest compressions while the patient undergoes percutaneous coronary intervention (PCI) or computed tomography (CT) or similar diagnostic studies when provision of manual CPR would be difficult. Lund University cardiac arrest system (LUCAS) CPR The Lund University cardiac arrest system (LUCAS) is a gas driven sternal compression device that incorporates a suction cup for active decompression.

Although animal studies showed that LUCAS-CPR improves haemodynamic and short-term survival compared with standard CPR.

there are no published randomized human studies comparing LUCAS-CPR with standard CPR. Load-distributing band CPR (AutoPulse) The load-distributing band (LDB) is a circumferential chest compression device comprising a pneumatically actuated constricting band and backboard. Although the use of LDB-CPR improves haemodynamics,results of clinical trials have been conflicting. Evidence from one multicentre randomized control trial in over 1000 adults documented no improvement in 4-h survival and worse neurological outcome when LDB-CPR was used by EMS providers for patients with primary out-of-hospital cardiac arrest.

A non-randomized human study reported increased survival to discharge following OHCA. The Egyptian Algorithm The provision of effective resuscitation service for victims of cardiopulmonary arrest should have a priority within our health care system. Healthcare institutions have a responsibility to provide an effective resuscitation service and to ensure that their staff receives training for maintaining the required level of competence.

Egypt has its own peculiarities; access to EMS may be limited in remote areas, as well as in areas with heavy traffic, or rural and sub-urban areas with un-named streets. Hence, it is expected that the average time taken by the EMS for arrival to the scene will be in general more than that taken in the more developed countries.

The high rate of illiteracy among the population is also one of the barriers to effective implementation of resuscitation guidelines. Other limitations include the lack of appropriate statistics of resuscitation outcomes, as well as publications and research in the field.

The ethics of resuscitation and end-of-life decisions which are generally influenced by local cultural, traditional, legal, religious, and social factors, also need to be more thoroughly addressed The desire to reduce impediments to good CPR delivery should let us focus on teaching CPR guidelines in a simplistic and easy to remember way.

Lay person Basic Life Support (BLS) arabic programs should be available throughout the country if outcomes of resuscitation are to improve. A comprehensive nationwide database of in-hospital resuscitation events is important for comparison of resuscitation outcomes, to define the effect of resuscitation interventions, and to monitor compliance with the latest resuscitation guidelines. Finally, a need really exists to have a coordinating body that governs and overviews the cardiopulmonary resuscitation process nationwide and to foster and coordinate the practice and teaching of resuscitation, and advance research and publications in the field, in liaison with concerned authorities