Saturday, August 30, 2008

A Brief History of Time: CPR (Cardiopulmonary Resuscitation)

In April, my good friend the cardiologist in California received an email from one of his friends on the subject of “New AHA rules for CPR finally released to the general public”.

It read:

Thanks to you, I'd had a two year head start on this subject that's only this week published in the popular press. When you first advised me on it, I'd forwarded that info to all my friends. Believe it or not, a GI friend of mine actually saved a life at a wedding last year. Some elderly gent at his table suddenly collapsed to the floor without a pulse. He remembered the article I'd forwarded him and began vigorous CPR without giving mouth to mouth. That gent survived to thank him. Indirectly, of course, he's thanking you.”

My good friend has been interested in the subject of CPR for many years and provided me with some interesting material on the history of CPR, which I share with you below.

History in the Western World

1891: The first external cardiac massage in the Western world was reported to be done successfully by Friedrich Maass.

1960: Kowenhoven and Knickerbocker reported their method in JAMA that chest compression was accepted as a method of resuscitation for cardiac arrest.

1966: The first guideline for CPR was published.

1970: Teaching the lay public to do CPR was started.

1974: American Heart Association (AHA) formally promoted the practice involving the combination of rescue breathing and external cardiac massage for cardiac arrest in a ratio of 2:15.

2005: Ewy in Arizona showed that hands-only CPR, at a rate of 100 per minute until the emergency crew armed with automated cardiac defibrillators arrive, was superior to the traditional method of CPR.

My friend immediately drew the attention of his colleagues in Hong Kong to Ewy's work and suggested that the lay public should be taught this simplified method of CPR to encourage bystanders to give aid to victims of cardiac arrest. Many bystanders would otherwise be reluctant to help for fear of contracting AIDS through traditional mouth-to-mouth resuscitation to these strangers.

The AHA was hesitant to accept Ewy's idea in their new guidelines for CPR in 2005, but as a compromise, recommended a ratio of 2 breaths to 30 chest compressions instead.

2007: In March The Lancet reported a Japanese study on a series of over 4000 cases in Tokyo, comparing traditional CPR to hands-only CPR by bystanders. The results showed that the latter was more successful in the resuscitation of cardiac arrest with preservation of neurological function.

2008: In April, the AHA finally gave its approval on hands-only CPR from bystanders. The link has a video demo.

To date I could not find any hands-only CPR in NICE and the St John’s Ambulance site is still in the 2/30 era.

Luckily for the wedding guest, his friend did not wait for the AHA recommendation nor any British ones.

History in Traditional Chinese Medicine

403-221 BC: (Warring Kingdoms period) External cardiac massage was practised as a method of resuscitation for victims of suicide by hanging. Some credited this to Bian Que.

6 BC - 221 AD: (Eastern Han Dynasty) The first description of CPR for resuscitation of victims of hanging came from Zhang Zhongjing.

In his Essence of the Golden Chest, miscellaneous therapy #23, he described the method as follows: "Lower the victim gently, don't just cut the rope, and lie him on the blankets. One person should put his feet against the shoulders of the victim and pull on his hair, rendering it taut (to open the airway). One person should put his hands on the victim's chest and compress rhythmically (external cardiac massage). One person should flex and extend the victim's limbs (to promote venous return). One person should press on the victim's abdomen (to enhance intrathoracic pressure during external cardiac massage). ....This method is the best and usually successful."

Zhang Zhongjing's writings were handed down and read by Chinese physicians through the centuries.

1186-1249 AD: (Sung Dynasty) The above passage in Essence of the Golden Chest was cited by Sung Ci in his book on forensic medicine “Washing Away of Wrongs (Xi Yuan Ji Lu)”, which is recognized as the first book of forensic medicine in the world and has been translated into many languages both in Asia and Europe.

There is much we can learn from the past. One may even save a life.

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