Resuscitation

Resuscitation signifies the act of returning an individual to life from an unconscious or death-like condition. The fundamental distinction between life and death is universally acknowledged, but the notion of reversibility of death varies greatly across cultures and time. The spirituality of many cultures frequently incorporates ideas of the immortality of the soul and occasionally the body as well. Western civilization's emphasis on the opposing duality of spirit versus body has determined that resuscitation be relegated to the realm of physical phenomena. Resuscitation is best understood in its historical, medical, cultural, legal, and ethical contexts.

The dependence of life on the flow of air and blood has been recognized in many cultures for thousands of years. There is evidence that resuscitative techniques, including attempts to restore circulation and breathing, were utilized at least back to biblical times in the Near East. Resuscitation in modern societies is viewed principally within a medical framework. Progressive scientific understanding and manipulation of normal and abnormal human physiology have achieved the reversibility and prevention of many diseases. The development of cardiopulmonary resuscitation (CPR) in the 1950s was based on decades of research using animal models. Initially CPR was intended for patients in hospital settings, but its use has been expanded to out-of-hospital settings as well. Medical resuscitation began with basic mechanical restorative interventions, but it has grown to encompass sophisticated electrical and pharmacological modalities.

Resuscitation Procedures

Currently there are widely agreed upon resuscitation procedures for witnessed and unwitnessed [Page 847]cardiopulmonary arrests. Initial efforts include (a) chest compressions to approximate the pumping of the heart and (b) mouth-to-mouth breathing to provide oxygen and allow exhalation of carbon dioxide. These procedures restore, at best, 60#x0025; of normal physiological function. Trials of mechanical chest compression devices have not demonstrated significant improvement over chest compressions performed manually. Mechanical ventilation with oxygen-enriched air after placement of a tube in the trachea, however, clearly has advantages over mouth-to-mouth breathing. The interdependence of respiratory failure and cardiac standstill requires that resuscitative efforts be directed toward concurrent restoration of respiration and circulation.

Scientific investigation into the immediate causes of cardiopulmonary collapse has revealed several potential antecedents: inability to move or exchange oxygen and carbon dioxide, cessation of electrical activity within the heart, ventricular fibrillation (disorganized electrical activity leading to ineffective heart pumping), and mechanical interference with the pumping action of the heart. For out-of-hospital cardiorespiratory collapse, the most common cause is disordered ventricular electrical activity. Reversal of the cause is currently the goal of advanced life support. Ventricular fibrillation, for example, may be reversed by electric shock applied externally to the chest. Because of the rapid accumulation of noxious metabolic products during periods of absent or inadequate cardiopulmonary function, pharmacological interventions are also required. Asystole (absence of cardiac electrical activity) and electromechanical dissociation (pulseless cardiac electrical activity) have proven more resistant to current therapeutic modalities.

Outcomes of Cardiopulmonary Resuscitation

The original intention of CPR was restoration of adequate respiration and circulation as a temporizing measure, allowing treatment of the underlying condition(s) causing the arrest. Ultimately, cessation of respiration and circulation is the final event in all dying processes, but underlying conditions have significant influence on the success of resuscitative efforts. Coronary artery disease and associated cardiac electrical disturbance are the most common underlying diagnoses resulting in cardiopulmonary arrest. Modification of certain risk factors such as elevated cholesterol and hypertension has been demonstrated to delay or prevent coronary artery disease and concomitant decrease in arrests. Installation of permanent antifibrillatory devices has lowered the risk of arrest in many patients.

...