AND CARDIAC ARREST IN ADULTS:
From Physiological Concepts to Advances in CPR Performance
5th Congress of Cardiologists and Angiologists
of Bosnia and Herzegovina and
1st Congress of Cardiovascular Nursing
in Bosnia and Herzegovina
May 28, 2010
A. Maziar Zafari, M.D., Ph.D.
Associate Professor of Medicine
Emory University School of Medicine
Early Attempts at Resuscitation
Elisha's mouth to mouth resuscitation
(Bible, 2 Kings, IV, 34):
"...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."
Early Ages - Inversion Method
Early Ages - Heat Method
Early Ages - Flagellation Method
1530 - Bellows Method
1711 - Fumigation Method
1770 - Inversion Method
1803 - Russian Method
1812 - Trotting Horse Method
1856 - Roll Method
1892 - Tongue stretching
Hieronymus Bosch 1490, "The Ascent of the Blessed"
Scientific and Programmatic Highlights of the
Modern History of CPR
1740 The Paris Academy of Sciences officially recommends mouth-to-mouth resuscitation for drowning victims.
1767 The Society for the Recovery of Drowned Persons becomes the first organized effort to deal with sudden death.
1891 Dr. Friedrich Maass performs the first documented chest compression in humans.
1903 Dr. George Crile reports the first successful use of external chest compressions in human resuscitation.
1954 James Elam is the first to prove that expired air is sufficient to maintain adequate oxygenation.
1956 Peter Safar and James Elam invent mouth-to-mouth resuscitation.
1957 The United States military adopts the mouth-to-mouth resuscitation method to revive unresponsive victims.
1960 CPR is developed. The AHA starts a program to acquaint physicians with close-chest cardiac resuscitation.
1963 Cardiologist Leonard Scherlis starts the AHA's CPR Committee, and the same year, the AHA formally endorses CPR.
1966 Standardized training and performance standards for CPR are established.
1972 Leonard Cobb holds the world's first mass citizen training in CPR in Seattle, Washington called Medic 2.
1981 A program to provide telephone instructions in CPR begins in King County, Washington.
1984 A program with fire fighter EMTs using AEDs begins in King County, Washington
1991 The chain of survival is introduced in 1991 as a model of efficiency and synergy in resuscitation efforts.
2000 The world’s first international conference is assembled specifically to produce international resuscitation guidelines.
2005 ILCOR publishes the 2005 International Consensus on CPR and ECC Science with Treatment Recommendations.
2010 The International Consensus on CPR and ECC Science with Treatment Recommendations is planned for publication in October.
Adult Chain of Survival
The chain of survival was first introduced in 1991 as a
model of efficiency and synergy in resuscitation efforts
I. The 3-phase model in VT/VF arrest integrating and
characterizing specifically the time relationships of
the value of rapid defibrillation, CPR performance,
and the need for other measures.
Phase Time Intervention
I. Electrical 0-5 min Defibrillation
II. Circulatory 5-15 min Chest
III. Metabolic >15 min Hypothermia
Weisfeldt and Becker. JAMA 2002.
Important Changes in the 2005 AHA
Guidelines for CPR and
Emergency Cardiovascular Care
Ali and Zafari. Annals of Internal Medicine 2007.
II. The introduction of inexpensive, easy-to-
use Automatic External Defibrillators (AEDs).
Expected Survival According to the Interval
between Collapse and the Administration of
First Shock by the Defibrillator
Weaver et al. NEJM 2002.
Zafari, et al. J Am Coll Cardiol 2004.
The percentage of the arrest victims
presenting with pulseless ventricular
tachycardia or ventricular fibrillation
alive at discharge as a function of year.
The percentage of patients presenting
with life-threatening rhythms surviving
to discharge was greater after a program
encouraging early defibrillation was
instituted in 2001.
Percentage Arrest Victims Presenting with VT/VF
Alive at Discharge as a Function of Year
Public-Access Defibrillation and Survival after
Out-of-Hospital Cardiac Arrest
The Public Access Defibrillation Trial Investigators.
N Engl J Med 2004.
Kitamura T et al. N Engl J Med 2010.
III. The need to translate animal data on
CPR performance and effectiveness from
the laboratory into the clinical arena.
Coronary Perfusion Pressure
During Chest Compressions
Sanders, et al. J Am Coll Cardiol 1985.
Kern, et al. Resuscitation 1998.
Abella et al. JAMA 2005.
CPR Parameters and Resuscitation Outcomes
In a Cardiac Arrest Cohort (2002-2004)
IV. Introduction of devices that may improve
perfusion during cardiopulmonary resuscitation
and thus may improve survival.
Cooper, et al. Circulation 2006.
Techniques and Mechanisms of Cardiac Massage
Halperin, et al. J Am Coll Cardiol 2004.
Correlations between Heart and Brain Flows
for AutoPulse-CPR and Conventional CPR
Comparison of the Thoracic-Vest System
for CPR with Standard Manual CPR
Halperin, et al. N Engl J Med 1993.
V. Cardiocerebral resuscitation may be useful in
patients with out-of-hospital cardiac arrest.
“Why is it that every time I press on his chest he opens his eyes,
and every time I stop to breathe for him he goes back to sleep?”
A lay rescuer who had been given 9-1-1 dispatch telephone instructions in CPR
Ewy. Circulation 2005.Kern, et al. Circulation 2002.
Ewy, et al. J Am Coll Cardiol 2009.
Survival to Hospital Discharge of Patients With
Out-of-Hospital Cardiac Arrest Treated by
Different Emergency Medical Services Protocols
VI. Change in the characteristics of the
population suffering cardiac arrest and
registry-based information on
in-hospital and out-of-hospital CPR.
Zheng, et al. Circulation 2001.
The National Registry of
Chan, et al. N Engl J Med 2008.
Chan, et al. NEJM 2008.
Factors Associated with
Delayed Time to Defibrillation
Nadkarni, et al. JAMA 2006.
Outcomes of In-Hospital Pulseless Cardiac Arrest
by First Documented Pulseless Arrest Rhythm
Characteristics of Survivors and
Non-Survivors of Cardiac Arrest
Bloom, et al. American Heart Journal 2007.
Comparison of Cardiac Arrest Survivors
with and without Implantable Cardiac Defibrillators
Bloom, et al. Am Heart J 2007.
VII. The Post-Cardiac Arrest Syndrome and new
technologies that may impact on resuscitation.
Neumar, et al. Circulation 2008.
Neumar, et al. Resuscitation 2004.
Post–Cardiac Arrest Syndrome: Pathophysiology,
Clinical Manifestations, and Potential Treatments
Neumar, et al. Circulation 2008.
VIII. Moderate Hypothermia may be useful in
patients who after out-of-hospital cardiac arrest
have not awakened when they reach the emergency
Mechanisms of Action
• In the normal brain, hypothermia reduces the cerebral
metabolic rate for oxygen by 6% for every 1oC reduction in
brain temperature >28oC, in part by reduction in normal
• Mild hypothermia reduces free radical production, excitatory
amino acid release, and calcium shifts, which can in turn lead
to mitochondrial damage and programmed cell death.
• Hypothermia can also produce adverse effects, including
arrhythmias, infection, and coagulopathy. Perhaps the greatest
risk comes not from cooling itself but from rewarming, which
can sink blood pressure to life-threatening lows.
Four Trials of Mild Induced Hypothermia
after Cardiac Arrest
Foëx and Butler. Emerg Med J 2004.
After Cardiac Arrest
The Hypothermia after Cardiac Arrest Study Group. N Engl J Med 2002.
IX. New paradigms that may affect resuscitation.
Lloyd, et al. Circulation 2008.
Measurements from 36 Shocks
with Rescuer-Patient Contact
during External Defibrillation
Mean SD Range
5.8 5.77 0.280 - 14.1
283 140 18.9 - 907
24 12 0.070 - 95
60 15 36 - 87
2.27x104 1.4x104 1.09x103 to
Lloyd, et al. Circulation 2008.
Average Leakage Current
During Hands-on Defibrillation
in Relation to Electrical Safety
Automatic External Cardiac Defibrillation
This pilot study recorded
time to defibrillation and
investigated an operator-
external cardiac defibrillator
(AECD) on resuscitation
Ali, et al. Trials 2008.
Ali, et al. Trials 2008.
The AECD correctly
and delivered a 150
Joule shock after 47
seconds. The rhythm is
converted to sinus
rhythm but reverts to
after 10 seconds.
X. The state of consciousness
during cardiac arrest.
The AWAreness during Resuscitation Experiment
(AWARE) is an ongoing study run by the
Human Consciousness Project.
Flatliners, 1990 with Julia Roberts
and Kiefer Sutherland.
• Reports of Near Death Experiences in 1970’s
• Outcome of mind at point of death
• Cardiac arrest - closest model of dying process
• What is meant by near death?
Death: What Happens to Mind and Consciousness?
• First large scale study to examine claims to
“see” and “hear” and prove or disprove “out
of body experiences”
• Prospective international multicenter study of mind, brain and
consciousness during cardiac arrest
• Aim: To determine what happens to
human mind during clinical death
• Use of sophisticated technology to study the
relationship between brain oxygenation
during cardiac arrest and consciousness
Possible tool to study flow during cardiac arrest
The INVOS® Cerebral/Somatic oximeter is a noninvasive,
safe and effective oxygen monitor.
Near-infrared spectroscopy (NIRS) is used to provide real-
time monitoring of changes in regional oxygen saturation
(rSO2) of blood in the brain or other body tissues beneath
the sensor. It measures site-specific oxygen levels, rather
than systemic, whole body measures such as blood
pressure and pulse oximetry.
Brain oximetry will be studied as a potential real time
marker of cerebral resuscitation during in-hospital
Higher cerebral oxygen levels are associated with better
outcomes (60%) and lower values (40%) are associated
with worse survival in out-of-hospital cardiac arrest.
Newman, et al. Resuscitation 2004.
1. The occurrence of cognitive function and awareness
during cardiac arrest arises due to improved cerebral
resuscitation and is associated with reduced brain
2. Although seeming “real” to patients themselves, the
reports of consciousness and thought processes including
the ability to “see” and “hear” does not correspond with
an objective reality related to the period of cardiac arrest
but are rather experiences that are associated with an
individual’s previous social and cultural background.
1. Determine the relationship between consciousness and activity of the mind with cerebral
perfusion as measured by cerebral oximetry together with its impact on short and long term
neurological and cognitive outcomes in cardiac arrest survivors.
2. Determine the clinical usefulness of measuring brain perfusion by cerebral oximetry
during cardiac arrest in terms of predicting cognitive and neurological outcomes.
3. Identify physiological factors and clinical measures that lead to improved cerebral
resuscitation and their relationship with short and long term cognitive and neurological
4. Determine the association of cognitive function during cardiac arrest with physiological,
clinical and sociocultural variables as well as their impact on psychological and neurological
5. Qualitatively investigate consciousness, memories and perception during in-hospital
6. Objectively test memory and recall from the period of cardiac arrest. This study includes
an objective test that may demonstrate whether patients’ reported memories of ‘seeing and
hearing’ are false memories formed after the event or an actual awareness from the period
of cardiac arrest.
Ethical Issues in Resuscitation Research
Assess the views of cardiac arrest survivors on research conducted in emergency settings using the
federal exception from informed consent.
Serum Markers of Neuronal Damage
In almost all cardiac arrest cases patients will have routine blood samples sent to the laboratory by
the medical and nursing staff. Where serum samples have been routinely sent to the laboratory, the
excess serum that is not being used by the laboratory will be used to test for the levels of the two
brain parenchyma markers of damage (NSE and S100).
Excess blood samples and/or blood samples drawn for the purpose of this study will be stored for
later analysis of DNA and/or RNA. At present, there is no knowledge about possible genetic
variations that might be associated with better cognitive or neurological outcomes or the occurrence
of reported memories for the cardiac arrest period.
Summary and Conclusions
• Advances in resuscitative medicine are founded on the basic science
understanding of physiology and pathophysiology as well as advances
in understanding of the causal mechanisms involved in successful or
• Survival is correlated with the speed and quality with which definitive
therapies such as chest compressions and defibrillation are begun
after cardiac arrest.
Push hard, push fast, minimize interruptions.
• Automated detection algorithms and technological advances in early
defibrillation, chest compression, and post cardiac arrest care have
the potential to increase survival to discharge in patients with out-of-
hospital and in-hospital cardiac arrest.
Andrea G. Backscheider, PhD
Heather Bloom, MD
Matthew Certain, MD
Neal Dickert, MD, PhD
Samuel C. Dudley, MD, PhD
Vicki Heggen, RN
Akram Ibrahim, MD
Michael S. Lloyd, MD
Heather Miller, RN
Emeka Onuorah, PhD
Roger Phillips , RN
Kiran Reddy, BA
Maya Sternberg, PhD
Regina A. Taylor, RN
Lisa Williams, RN
Patricia Wilson, RN, MSN
Susan K Zarter, RN
and the CPR Committee
Sam Parnia, MD, PhD
Weill Cornell Medical Center, NY
Grady Memorial Hospital
Prasad Abraham, PharmD
Eric Honig, MD
Tze-chun V. Liao, PharmD
Antoine Trammell, MD