The New CPR

Attempts at resuscitating a victim of cardiac arrest have a long and colorful past – and recent literature and thinking leaves no doubt that a new chapter is soon to be written.

Since the beginning of man, there have been endeavors to figure out how to resuscitate a person who has died. The first recorded attempt at resuscitation was contained in the Old Testament, when the Prophet Elijah performed mouth-to-mouth on Elisah: “…And we 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 warmed” (2 Kings 4:3). In 400 B.C., the writings of Hippocrates described intubation of the trachea to support ventilation.

Very early man realized the human body becomes cold when lifeless and is warm when a person is alive. When a person was dying, early man placed warm ashes and hot water directly on the body to keep it warm – thus attempting to prevent death. Other attempts with early man actually included flagellation, where the victim was whipped, in order to elicit some type of response.

In the 1500s, people attempted to breathe life into another person by using the bellows from a fireplace to blow air into the victim’s mouth. Apparently, there was some success with this method, as it was used for about 300 years and some have argued that a bellow was a precursor for today’s bag-valve mask. There may have even been more success with using bellows, but medical experts at the time did not have a clear understanding of anatomy and the respiratory system and did not know of the need to hyperextend the victim’s neck in order to open the airway.

In the 1700s, another method of resuscitation involved blowing smoke tobacco into an animal’s bladder, and then into the victim’s rectum. In 1829, the French physician Leroy d’Etiolles, in a demonstration showed an animal’s lungs could be overextended using bellows, so the practice was discontinued.

In 1770, the Inversion Method was developed in response to drowning, which was a leading cause of death in Europe at the time. The method involved hanging the victim by their feet. Raising and lowering the victim created pressure to aid expiration and inspiration.

In 1773, in a move to force air in and out of the victim’s chest, a rescuer would place the victim onto a large barrel and alternately roll him or her back and forth. By this action, the victim’s chest was compressed, forcing air out, and then a release of pressure allowed the chest to expand, resulting in air being drawn in. In 1803, the Russian Method included reducing the body’s metabolism by freezing the body under a layer of snow and ice. In 1812, lifeguards used a trotting horse to attempt to resuscitate a drowning victim. The victim was hoisted onto a horse and the horse was run up and down the beach. The bouncing on the horse resulted in alternate compression and relaxation of the chest cavity. However, the procedure was banned in 1815 as a result of complaints by “Citizens for Clean Beaches.”

Other methods of resuscitation around 1892 included stretching the rectum, rubbing the body, tickling the throat with a feather and waving strong salts such as ammonia under the victim’s nose. Another method described by French doctors included stretching the victim’s tongue. The procedure included holding the victim’s mouth open while pulling the tongue forcefully and rhythmically.

Mouth-to-mouth resuscitation as we know it today was advocated by the military in World War II. In the 1950s, the American Red Cross began a nationwide education campaign to educate the American public on mouth-to-mouth procedures. In the 1960s, the procedure was extended to lifeguard training and included using flotation devices to perform the procedure while still in the water.

In the 1960s, closed-chest massage was introduced to circulate blood throughout the body. Combined with the technique of mouth-to-mouth, cardiopulmonary resuscitation (CPR) as we know it today came about. During the Vietnam War, the U.S. Army officially introduced CPR. In 1973, the American Red Cross and the American Heart Association started a nationwide campaign to teach CPR to the general population.

Which brings us to the 21st century. You would think we’d have it right by now. I have always been taught, “Air goes in; blood goes round and round; anything different is a bad thing,” but apparently this is no longer the case.

There is now an emerging trend of thinking that it is not necessary to oxygenate the victim right away. Instead, some physicians and researchers are advocating chest compressions only. The theory is based on the hypothesis that when the heart stops beating, the body still contains enough of oxygen-rich blood. According to those advocating chest compressions only, it is actually more important to get blood flowing to vital organs. This new line of thinking is more for the general public than it is for firefighters and rescue medical personnel.

Over the years, there has been a general decline in bystanders willing to perform CPR on unknown victims. Some have theorized this is because of fear of disease or fear of lawsuits. Therefore, there is a new move afoot to have untrained bystanders skip mouth-to-mouth and only do chest compressions until help arrives.

In a study published in May 2000 in the New England Journal of Medicine, researchers from the University of Washington analyzed the results of 241 patients who received chest-compression-only CPR and 279 who received mouth-to-mouth along with chest compressions when treated at the scene. Survival rates were actually better, up to the time of discharge from the hospital among the compression-only group. A total of 14.6% of the compression-only group survived compared to 10.4% of those who also received mouth-to-mouth and chest compressions.

In another study, a survey of more than 4,000 people showed that a person is more comfortable performing compression-only CPR on someone he or she does not know. The survey showed that only 15% would do CPR if they had to do mouth-to-mouth against 68% who said they would do chest compressions only.

As a result of these studies and others, the American Heart Association (AHA) has changed its standards and says chest compressions alone should be administered by anyone unwilling or unable to also perform mouth-to-mouth resuscitation. The AHA also said emergency dispatchers may also want to give only instructions on chest compressions.

Some 911 dispatching centers are switching to new directives for providing pre-arrival instructions. Cities such as Chicago, Dallas, Los Angeles, New York City, Philadelphia, Richmond, San Francisco and Seattle are telling callers to start chest compressions only as opposed to trying to teach the caller breathing steps and chest compressions over the telephone.

But before you throw your ACLS book into the trash, the AHA still recommends conventional CPR be taught in classes and that anyone trained in the procedure should be utilizing it as a method of resuscitation.