Closed-chest Massage Research Articles

Fulfilling the Promise of “Anyone, Anywhere” to Perform CPR

Closed-chest cardiac massage for the treatment of cardiac arrest was first described in the medical literature in 1960. The report provided the basis to revolutionize care for one of the leading causes of death. In a statement filled with hope and promise, the authors wrote that “Anyone, anywhere, can now initiate cardiac resuscitative procedures. All that is needed are two hands.” Prior to closed-chest massage, the only recourse to achieve artificial circulation was open-chest massage involving emergency thoracotomy. Today the procedure widely known as cardiopulmonary resuscitation (CPR) has been shown to double or triple the odds of survival from cardiac arrest.2

Retrograde flush is more protective than heparin in the uncontrolled donation after circulatory death lung donor

BackgroundFormation of microthrombi after circulatory arrest is a concern for the development of reperfusion injury in lung recipients from donation after circulatory death (DCD) donors. In this isolated lung reperfusion study, we compared the effect of postmortem heparinization with preharvest retrograde pulmonary flush or both. MethodsDomestic pigs (n = 6/group) were sacrificed by ventricular fibrillation and left at room temperature for 1 h. This was followed by 2.5 h of topical cooling. In control group [C], no heparin and no pulmonary flush were administered. In group [R], lungs were flushed with Perfadex in a retrograde way before explantation. In group [H], heparin (300 IU/kg) was administered 10 min after cardiac arrest followed by closed chest massage for 2 min. In the combined group, animals were heparinized and the lungs were explanted after retrograde flush [HR]. The left lung was assessed for 60 min in an ex vivo reperfusion model. ResultsPulmonary vascular resistance at 50 and 55 min was significantly lower in [R] and [HR] groups compared with [C] and [H] groups (P < 0.01 and P < 0.001) and at 60 min in [R], [H], and [HR] groups compared with [C] group (P < 0.001). Oxygenation, compliance, and plateau airway pressure were more stable in [R] and [HR] groups. Plateau airway pressure was significantly lower in [R] group compared with the [H] group at 60 min (P < 0.05). No significant differences in wet–dry weight ratio were observed between the groups. ConclusionsThis study suggests that preharvest retrograde flush is more protective than postmortem heparinization to prevent reperfusion injury in lungs recovered from donation after circulatory death donors.

Assessment of emergency medicine residents' cardiopulmonary resuscitation team in imam reza hospital.

Cardiopulmonary resuscitation (CPR) is practiced widely since the first practical report on the efficacy of closed chest massage in 1960.1 Delay in CPR after cardiac arrest could be associated with poor outcome.2 A hospital CPR discharge rate of 13–14% was reported from the studies in the 1990s3,4 which has been confirmed by the recent Canadian study.5 Therefore, we decide to study our CPR team which includes emergency residents, nurses, anesthesia technicians and the staff that are involved in resuscitating patients in all hospital wards. Reports of survival after discharge following in-hospital CPR are variable between 7% and 26%.6-8 In our research, most of arrests happened in the morning and asystole rhythm was the most common rhythm; a 40 percent survival rate showed that we can improve our CPR team performance. Recent data have recommended that the successful resuscitation efforts could be prevented by insufficient performance of CPR.8 To increase safety and reduce errors, effective team performance in dynamic and complex environments such as critical care units are required in where decisions are made .9 There is supporting evidence that suboptimal team performance can have damaging effects. In the context of ACLS training, poor ACLS performance is associated with inefficient leadership and impaired task distribution between the resuscitation team members.10 We studied 422 patients in our research from which 59.5% and 40.5% were male and female respectively. The median age of the patients was 68 (SD: 17.284) years old (mode: 73, oldest: 95, youngest: 1). The mean time of CPR performance was 30 minutes with the minimum of 3 minutes and maximum of 60 minutes. We found that most of our patients who arrested (36%) were admitted in pulmonary ward and after that (18.5%) were admitted in gastroenterology ward. Most of patients (51.7%) had arrested in the morning. 44.3% of patients did not have any definitive diagnosis; however, 5.5% of them had ESRD, 5.2% pneumonia, and 4.3% GI Bleeding. Among patients asystole was the most common pattern (94.3; Figure 1), the other observed patterns are presented in Figure 1. Our CPR team had to intubate 24.4% of the patients while 75.6% were intubated prior to CPR team arrival. Just 40% of the patients could be saved following successful resuscitation. Figure 1 Therefore, based on the obtained data from the present study, it seems that our CPR team work is effective; however, for being more effective and achieving better results, better organization is essential. By having more experienced and efficient team, and also by paying attention to those wards and times that have the most arrests we can be more prepared and therefore perform resuscitation more successfully than before.

Intra-arrest hypothermia: Both cold liquid ventilation with perfluorocarbons and cold intravenous saline rapidly achieve hypothermia, but only cold liquid ventilation improves resumption of spontaneous circulation

BackgroundRapid intra-arrest induction of hypothermia using total liquid ventilation (TLV) with cold perfluorocarbons improves resuscitation outcome from ventricular fibrillation (VF). Cold saline intravenous infusion during cardiopulmonary resuscitation (CPR) is a simpler method of inducing hypothermia. We compared these 2 methods of rapid hypothermia induction for cardiac resuscitation. MethodsThree groups of swine were studied: cold preoxygenated TLV (TLV, n=8), cold intravenous saline infusion (S, n=8), and control (C, n=8). VF was electrically induced. Beginning at 8min of VF, TLV and S animals received 3min of cold TLV or rapid cold saline infusion. After 11min of VF, all groups received standard air ventilation and closed chest massage. Defibrillation was attempted after 3min of CPR (14min of VF). The end point was resumption of spontaneous circulation (ROSC). ResultsPulmonary arterial (PA) temperature decreased after 1min of CPR from 37.2°C to 32.2°C in S and from 37.1°C to 34.8°C in TLV (S or TLV vs. C p<0.0001). Coronary perfusion pressure (CPP) was higher in TLV than S animals during the initial 3min of CPR. Arterial pO2 was higher in the preoxygenated TLV animals. ROSC was achieved in 7 of 8 TLV, 2 of 8 S, and 1 of 8C (TLV vs. C, p=0.03). ConclusionsModerate hypothermia was achieved rapidly during VF and CPR using both cold saline infusion and cold TLV, but ROSC was higher than control only in cold TLV animals, probably due to better CPP and pO2. The method by which hypothermia is achieved influences ROSC.

Liquid ventilation with perfluorocarbons facilitates resumption of spontaneous circulation in a swine cardiac arrest model

Induced external hypothermia during ventricular fibrillation (VF) improves resuscitation outcomes. Our objectives were twofold (1) to determine if very rapid hypothermia could be achieved by intrapulmonary administration of cold perfluorocarbons (PFC), thereby using the lungs as a vehicle for targeted cardiopulmonary hypothermia, and (2) to determine if this improved resuscitation success. Part 1: Nine female swine underwent static intrapulmonary instillation of cold perfluorocarbons (PFC) during electrically induced VF. Part 2: Thirty-three female swine in VF were immediately ventilated via total liquid ventilation (TLV) with pre-oxygenated cold PFC (-15 degrees C) or warm PFC (33 degrees C), while control swine received no ventilation during VF. All swine in both Parts 1 and 2 underwent VF arrest for 11 min, then defibrillation, ventilation and closed chest massage until resumption of spontaneous circulation (ROSC). The endpoint was continued spontaneous circulation for 1h without pharmacologic support. Static intrapulmonary instillation of cold PFC achieved rapid cardiopulmonary hypothermia; pulmonary artery (PA) temperature of 33.5+/-0.2 degrees C was achieved by 10 min. Nine of 9 achieved ROSC. Hypothermia was achieved faster using TLV: at 6 min VF, cold TLV temperature was 32.9+/-0.4 degrees C vs. cold static instillation temperature 34.3+/-0.2 degrees C. Nine of 11 cold TLV swine achieved ROSC for 1h vs. 3 of 11 control swine (p=0.03). Warm PFC also appeared to be beneficial, with a trend toward greater achievement of ROSC than control (ROSC; warm PFC 8 of 11 vs. control 3 of 11, p=0.09). Targeted cardiopulmonary intra-arrest moderate hypothermia was achieved rapidly by static intrapulmonary administration of cold PFC and more rapidly by total liquid ventilation with cold PFC; resumption of spontaneous circulation was facilitated. Warm PFC showed a trend toward facilitating ROSC.

Is internal massage superior to external massage for patients suffering a cardiac arrest after cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether open chest cardiac massage is superior to closed chest compressions in patients suffering cardiac arrest following cardiac surgery. Using the reported search, 527 papers were identified. Fifteen papers represented the best evidence on the subject and the author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. The quality and level of evidence was assessed using the International Liaison Committee on Resuscitation guideline recommendations. We conclude that over 18 good quality animal studies have consistently demonstrated the superiority of open chest cardiac massage, with the cardiac index and coronary perfusion pressures often more than doubling. There are fewer human studies but they have shown that closed chest massage generates a cardiac index of around 0.6 l/min/m(2) which rises to 1.3 l/min/m(2) or more with open-chest-CPR, accompanied by even bigger improvements in coronary perfusion pressure. ILCOR recommends prompt conversion to open-chest-cardiac massage in patient's shortly post-cardiac surgery, and we would support this intervention if simple resuscitative efforts such as defibrillation, pacing or atropine fail, in order to significantly improve the quality of cardiopulmonary resuscitation.

Pericardial effusion—A life saver!

HE USE OF interventional cardiac catheterization in children with congenital cardiac defects has grown dramatically in the last two decades, comprising more than 40% of all catheterizations in children and posing a new challenging environment for the anesthesiologist.l Two cases are reported to present the role of the anesthesiologist during pediatric cardiac catheter interventions and to emphasize the impact of collaborative efforts of the cardiologist and the anesthesiologist on patient outcome. CASE 1 A 3-day-old male neonate, weighing 3.5 kg, was born at 41 weeks gestation through normal vaginal delivery. At birth, the baby had low Apgar scores and, despite multiple resuscitation maneuvers, continued to be increasingly cyanotic. A transthoracic echocardiogram showed severe hypoplasia of the left ventricle and the ascending aorta, with mitral atresia, a patent ductus arteriosus, and a restrictive atrial septal defect. He was started on a prostaglandin E1 infusion, 50 ng/kg/min, and taken to the pediatric cardiac catheterization laboratory for a balloon atrial septostomy to improve intracardiac mixing. After induction with 2 mg/kg of ketamine intravenously, the airway was secured using a 3.5-ram internal diameter endotracheal tube, and a fight radial arterial catheter was placed. Through a 6F right femoral venous sheath, a 5F Numed Balloon Septostomy catheter (Braun, Inc, Bethlehem, PA) was introduced, advanced across the atrial septal defect, and the balloon was inflated to its 2-mL capacity. On withdrawal of the inflated balloon to enlarge the septal defect, the baby became progressively hypotensive and bradycardic. A transthoracic echocardiogram showed a rapidly accumulating pericardial effusion with marked cardiac compression (Fig 1). Immediate cardiopulmonary resuscitation was started, with closed-chest massage and multiple doses of epinephrine, 10 ~tg/kg, while awaiting the arrival of blood products and a cardiac surgeon. The cardiologist placed a 20-G catheter into the pericardial space through the subxiphoid approach and, using intravenous tubing, a three-way stopcock, a 170-pro filter, and a male-to-male adapter, the anesthesiologist was able to continually withdraw blood from the pericardial sac and retransfuse it to the patient through a peripheral intravenous line (Fig 2), thus maintaining hemodynamic stability by reinfusion of 60 mL of blood to the patient. The cardiac surgeon was able to perform a sternotomy, evacuate the pericardium, and identify a tear at the upper pole of the right atrium, which he successfully repaired. The baby was taken to the pediatric intensive care unit in stable condition and had an uneventful stage I Norwood repair 2 days later. CASE 2 A 13-year-old, 31-kg boy with a history of truncus arteriosus, repaired at 3 months of age, with a revision of the pulmonary artery homograft at the age of 5 years, presented to the cardiac catheterization laboratory with a calcified pulmonary artery homograft, a stenosed right pulmonary artery (Fig 3), and right ventricular hypertension (right ventricular systolic pressure, 95 mmHg). He was scheduled for stenting of the right pulmonary artery and possible balloon dilatation of the calcified homograft.

No-reflow after cardiac arrest: Intensive Care Med 1995; 21/2 (132–141)

Successful resuscitation of the brain requires unimpaired blood recirculation. The study addresses the question of the severity and reversibility of no-reflow after cardiac arrest. Adult normothermic cats were submitted to 5, 15 and 30 min cardiac arrest by ventricular fibrillation. The extent of no-reflow was assessed in each cardiac arrest group after 5 min closed chest cardiac massage in combination with 0.2 mg/kg epinephrine or after successful resuscitation followed by 30 min recirculation. Reperfusion of the brain was visualized by labelling the circulating blood with FITC-Albumin. Areas of no-reflow, defined as absence of microvascular filling, were identified by fluorescence microscopy at 8 standard coronal levels of forebrain, and expressed as percent of total sectional area. During cardiac massage, noreflow affected 21±5%, 42±38% and 70±27% of forebrain after 5, 15 and 30 min cardiac arrest, respectively. After 30 min spontaneous recirculation following successful resuscitation of the heart, no-reflow significantly declined to 7±11% after 5 min cardiac arrest (p<0.05) but persisted in 30±11% and 65±21% of forebrain after 15 and 30 min cardiac arrest, respectively (n.s.). Our observations demonstrate that resuscitation of the heart by closed chest massage causes severe (and after prolonged cardiac arrest irreversible) no-reflow of the brain. This suggests that no-reflow is an important cause of postresuscitation brain pathology.

No-reflow after cardiac arrest

Successful resuscitation of the brain requires unimpaired blood recirculation. The study addresses the question of the severity and reversibility of no-reflow after cardiac arrest. Adult normothermic cats were submitted to 5, 15 and 30 min cardiac arrest by ventricular fibrillation. The extent of no-reflow was assessed in each cardiac arrest group after 5 min closed chest cardiac massage in combination with 0.2 mg/kg epinephrine or after successful resuscitation followed by 30 min recirculation. Reperfusion of the brain was visualized by labelling the circulating blood with FITC-Albumin. Areas of no-reflow, defined as absence of microvascular filling, were identified by fluorescence microscopy at 8 standard coronal levels of forebrain, and expressed as percent of total sectional area. During cardiac massage, no-reflow affected 21 +/- 5%, 42 +/- 38% and 70 +/- 27% of forebrain after 5, 15 and 30 min cardiac arrest, respectively. After 30 min spontaneous recirculation following successful resuscitation of the heart, no-reflow significantly declined to 7 +/- 11% after 5 min cardiac arrest (p < 0.05) but persisted in 30 +/- 11% and 65 +/- 21% of forebrain after 15 and 30 min cardiac arrest, respectively (n.s.). Our observations demonstrate that resuscitation of the heart by closed chest massage causes severe (and after prolonged cardiac arrest irreversible) no-reflow of the brain. This suggests that no-reflow is an important cause of post-resuscitation brain pathology.

Rib fractures in children--resuscitation or child abuse?

The autopsy reports of 233 babies and children aged between 5 days and 7 years, including 190 cases of non-traumatic and 43 cases of traumatic death, were reviewed. In 94 out of 190 cases of death due to natural causes, attempted resuscitation (closed-chest massage) was performed and only in 2 cases could fractures of the ribs localized on both sides in the midclavicular line be observed. In 15 of the 43 cases of death due to traumatic events, fractures mainly of the posterior ends of the ribs occurred. These observations support the published findings of other authors which indicate that fractures of ventral parts of the thorax can occur during resuscitation. Fractures localized in particular in dorsal parts of the chest wall of infants without metabolic bone diseases, however, must be interpreted as a strong indication of physical child abuse. It was observed that relevant injuries due to resuscitation are caused much more frequently or almost exclusively by physicians than by non-medical persons. This finding refutes any possible claims that rib fractures were caused by inexpert resuscitation in a panic-like reaction.

A new proposal of CPR based on coronary perfusion pressure

Closed chest massage and tracheal intubation are not enough. The 70% success rate promised by Kouwenhoven 31 years ago is not realised. Coronary perfusion pressure is the main goal. To achieve this a proposal of a combined new CPR is advocated which encompass the following items besides closed chest massage and tracheal intubation: (a) use of high dose methoxamine (instead of epinephrine), (b) use of continuous abdominal pressure (instead of intermittent pressure), (c) unloading the pump, which means no use of any intravenous fluids, and (d) intracardiac injection of medications until restarting of spontaneous circulation.

End-Tidal CO2 Measurement in the Detection of Esophageal Intubation During Cardiac Arrest

Measurement of end-tidal carbon dioxide (ETco 2 ) has been used to detect accidental esophageal tube placement in noncardiac arrest situations. The purpose of our study was to determine whether ETco 2 measurement could distinguish tracheal from esophageal tube placement during closed-chest massage (CCM). Twelve large dogs were anesthetized, and endotracheal tubes were placed in both the trachea and the esophagus. Placement was verified by fiberoptic endoscopy. Ventricular fibrillation was induced by a 60-Hz discharge through a right ventricular pacemaker. After four minutes of cardiac arrest, CCM was initiated and continued for 20 minutes. The dogs were divided into two groups: Group A was ventilated through the tracheal tube, and group B was ventilated through the esophageal tube. Unused tubes were removed. ETco 2 was recorded continuously beginning two minutes before arrest until the end of the experiment. There were no significant between-group differences in mean arterial pressure, weight, blood loss, IV fluid volume administered, or prearrest arterial blood gases. ETco 2 differed significantly between the two groups throughout CCM ( P = .001). In group A, ETco 2 ranged from 13 to 34 mm Hg (median, 20 mm Hg). In group B, ETco 2 ranged from 2 to 11 mm Hg (median, 3 mm Hg). In this experimental model, measurement of ETco 2 reliably distinguished esophageal from tracheal intubation during cardiac arrest and CCM. If confirmed in human beings, this may prove to be a quick, reliable method of detecting esophageal intubation during cardiac arrest.

Splenic Laceration Secondary to Closed Chest Massage

Closed chest massage can be a lifesaving act. Performed incorrectly or by untrained individuals it can lead to life-threatening complications. Successful recognition and treatment of a lacerated spleen secondary to cardiopulmonary resuscitation is reported. All patients surviving CPR should be screened for potential complications.

End-tidal CO 2 measurement in the detection of esophageal intubation during cardiac arrest

Measurement of end-tidal carbon dioxide (ETCO2) has been used to detect accidental esophageal tube placement in noncardiac arrest situations. The purpose of our study was to determine whether ETCO2 measurement could distinguish tracheal from esophageal tube placement during closed-chest massage (CCM). Twelve large dogs were anesthetized, and endotracheal tubes were placed in both the trachea and the esophagus. Placement was verified by fiberoptic endoscopy. Ventricular fibrillation was induced by a 60-Hz discharge through a right ventricular pacemaker. After four minutes of cardiac arrest, CCM was initiated and continued for 20 minutes. The dogs were divided into two groups: Group A was ventilated through the tracheal tube, and group B was ventilated through the esophageal tube. Unused tubes were removed. ETCO2 was recorded continuously beginning two minutes before arrest until the end of the experiment. There were no significant between-group differences in mean arterial pressure, weight, blood loss, IV fluid volume administered, or prearrest arterial blood gases. ETCO2 differed significantly between the two groups throughout CCM (P = .001). In group A, ETCO2 ranged from 13 to 34 mm Hg (median, 20 mm Hg). In group B, ETCO2 ranged from 2 to 11 mm Hg (median, 3 mm Hg). In this experimental model, measurement of ETCO2 reliably distinguished esophageal from tracheal intubation during cardiac arrest and CCM. If confirmed in human beings, this may prove to be a quick, reliable method of detecting esophageal intubation during cardiac arrest.

Open-chest cardiac massage

Open-chest cardiac massage was widely and successfully used for many decades before its virtual abandonment 25 years ago. Both experimental evidence and basic physiologic evidence indicate that it has many advantages over closed-chest massage (especially increased cardiac output). Both resuscitation techniques have specific and unique advantages and disadvantages: They are not mutually exclusive. However, significant increases in rates of survival after cardiac arrest cannot be expected with variations of closed-chest cardiac massage and standard advanced life support services. Therefore, physicians must be willing to support controlled human studies that can definitively determine the proper role of each in resuscitation after cardiac arrest.

Anaphylactoid Reactions to Protamine

Protamine is used routinely at our institution during arterial surgery to reverse the anticoagulant effect of heparin. Adverse fatal reactions to protamine are generally believed to be rare. However, major anaphylactoid reactions occurred in 11 of the last 1150 patients receiving this drug at our institution. Nine of these reactions occurred in 325 insulin-dependent diabetic patients (incidence, 3%), whereas only two occurred in the 825 patients not receiving insulin (incidence, 0.2%) (p less than 0.001). Ten of these reactions occurred within 10 minutes of protamine administration (15 to 35 mg), whereas one reaction occurred immediately after administration of a 5 mg test dose of protamine. Systolic blood pressure fell below 60 mm Hg in all of the 11 patients, and three patients had to be resuscitated with closed-chest massage. Initial treatment with epinephrine and steroids was successful in seven cases. Four patients required further resuscitative measures, including closed-chest massage. However, one of the patients died as a result of ventricular fibrillation resistant to treatment. Ten of the 11 patients, including the patient who died, had significant preexisting cardiac disease; six of the surviving 10 patients (60%) had perioperative myocardial infarctions and three died. Thus the total mortality rate was 36% (4/11). These data support the implication that neutral protamine Hagedorn (NPH) insulin produces an adverse reaction through immunologic presensitization of the patient. These data also show that, in the older vascular surgery population with a high incidence of significant cardiac disease, protamine reactions can be potentially lethal. Thus routine use of protamine should be avoided in diabetic patients receiving insulin.

Anaphylactoid reactions to protamine: An often lethal complication in insulin-dependent diabetic patients undergoing vascular surgery

Protamine is used routinely at our institution during arterial surgery to reverse the anticoagulant effect of heparin. Adverse fatal reactions to protamine are generally believed to be rare. However, major anaphylactoid reactions occurred in 11 of the last 1150 patients receiving this drug at our institution. Nine of these reactions occurred in 325 insulin-dependent diabetic patients (incidence, 3%), whereas only two occurred in the 825 patients not receiving insulin (incidence, 0.2%) (p < 0.001). Ten of these reactions occurred within 10 minutes of protamine administration (15 to 35 mg), whereas one reaction occurred immediately after administration of a 5 mg test dose of protamine. Systolic blood pressure fell below 60 mm Hg in all of the 11 patients, and three patients had to be resuscitated with closed-chest massage. Initial treatment with epinephrine and steroids was successful in seven cases. Four patients required further resuscitative measures, including closed-chest massage. However, one of the patients died as a result of ventricular fibrillation resistant to treatment. Ten of the 11 patients, including the patient who died, had significant preexisting cardiac disease; six of the surviving 10 patients (60%) had perioperative myocardial infarctions and three died. Thus the total mortality rate was 36% (4/11). These data support the implication that neutral protamine Hagedorn (NPH) insulin produces an adverse reaction through immunologic presensitization of the patient. These data also show that, in the older vascular surgery population with a high incidence of significant cardiac disease, protamine reactions can be potentially lethal. Thus routine use of protamine should be avoided in diabetic patients receiving insulin.

Open chest cardiac massage: an overview.

Open-chest cardiopulmonary resuscitation has been shown to produce better blood flow in man than closed-chest massage. It therefore should be taught as part of the protocol for all hospital CPR teams.

Neurologic benefits from the use of early cardiopulmonary resuscitation

The efficacy of bystander CPR in resuscitation from cardiac arrest when defibrillation is available within five to six minutes has been questioned. Epidemiologic studies from different cities have shown conflicting results. We conducted a study to determine the effect of early CPR versus no CPR on resuscitability, 24-hour survival, and neurologic deficit in an animal model of cardiac arrest. Twenty-two mongrel dogs were subjected to five minutes of electrically induced ventricular fibrillation. In 11 dogs, closed-chest massage and ventilation with room air was begun immediately and was continued for five minutes. The other 11 dogs received no CPR. At five minutes defibrillation was attempted and advanced cardiac life support (ACLS) protocols were followed until the animal was resuscitated or died. No statistical difference in resuscitability or 24-hour survival between the two groups was demonstrated. Eight of 11 "early CPR" animals were resuscitated and survived 24 hours; six of 11 "no CPR" dogs were resuscitated, and five lived for 24 hours. A significant difference was demonstrated by the Student t test in neurologic deficit and ease of resuscitation. "Early CPR" dogs had no neurologic deficit, while "no CPR" dogs had a 41% deficit (P less than .01). "Early CPR" dogs were resuscitated in significantly less time once ACLS was started (29 versus 317 seconds), and required less electrical energy (100 versus 560 J), fewer countershocks (1.3 versus 4.0), and less epinephrine (0.1 versus 1.7 mg) than did "no CPR" animals. In this animal model of cardiac arrest, early CPR was shown to be beneficial to neurologic function and ease of resuscitation, even when ACLS was provided within five minutes.

Factors influencing outcome of cardiopulmonary resuscitation in children.

We evaluated 47 pediatric patients after cardiopulmonary arrest. Patients entered the study with the onset of advanced life support. We followed them until death, or discharge from the hospital, occurred. We identified three groups of patients: long-term survivors, who survived to discharge, short-term survivors, who survived longer than 24 hours after CPR but not until discharge, and nonsurvivors, who died within 24 hours of their arrest. All of the long-term surviving patients were discharged from the hospital without gross neurologic deficit attributable to the arrest or resuscitation effort. Twenty-seven (57%) children were successfully resuscitated. Eighteen (38%) were long term-survivors, while nine (19%) were short-term survivors. Favorable outcome is associated with the following factors: inhospital arrest, extreme bradycardia as the presenting arrhythmia, successful resuscitation with only ventilation, oxygen and closed chest massage, and a duration of CPR of less than 15 minutes. Age, sex, and race, as well as pupillary reaction and motor response at the onset of advanced life support, did not correlate with long-term survival.