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Cardiac Arrest

The Science and Practice ofResuscitation Medicine

Second edition

Cardiac Arrest is the definitive and most comprehensivereference in advanced life support and resuscitation medi-cine.

This new edition brings the reader completely up-to-date with developments in the field, focusing on practicalissues of decision making, clinical management and pre-vention, as well as providing clear explanations of thescience informing the practice. The coverage includesinformation on the latest pharmacotherapeutic options,the latest chest compression techniques and airwaymanagement protocols, all backed by clearly explained,evidence-based scientific research. The content is consis-tent with the latest guidelines for practice in this area, asdetailed by the major international governing organiza-tions.

This volume is essential reading for all those working inthe hospital environments of emergency medicine, criticalcare, cardiology and anesthesia, as well as those providingcare in the pre-hospital setting, including paramedics andother staff from the emergency services.

Norman A. Paradis is Adjunct Professor of Surgery,University of Colorado Health Sciences Center.

Henry R. Halperin is Professor of Medicine, Radiology, andBiomedical Engineering at the Johns Hopkins UniversitySchool of Medicine, Baltimore, USA.

Karl B. Kern is Professor of Medicine at the Sarver HeartCenter, University of Arizona, USA.

Volker Wenzel is Associate Professor of Anesthesiologyand Critical Care Medicine in the Department ofAnesthesiology and Critical Care Medicine of InnsbruckMedical University, Innsbruck, Austria.

Douglas A. Chamberlain CBE is Honorary Professor ofResuscitation Medicine at the School of Medicine, CardiffUniversity, Wales and Visiting Professor of Cardiology at theUniversity of Brighton, Sussex, UK.

© Cambridge University Press www.cambridge.org

Cambridge University Press978-0-521-84700-1 - Cardiac Arrest: The Science and Practice of Resuscitation Medicine, Second EditionEdited by Norman A. Paradis, Henry R. Halperin, Karl B. Kern, Volker Wenzel and Douglas A. ChamberlainFrontmatterMore information

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From reviews of the first edition:

. . . It is a tribute to the editors of this book, and the con-tributors they have selected, that they have managed toproduce a book of enormous quality on the science ofresuscitation medicine. The Lancet

The excellent book, the first of its kind in the field of cardiacarrest, provides a balance of theoretical and clinical infor-mation. It achieves a level of authority and sophisticationwell beyond that of the advanced cardiac life supportguidelines and will be of considerable use to all those prac-ticing or teaching clinical resuscitation.

The New England Journal of Medicine

The book has virtually everything one would ever want toknow about the causes of cardiac arrest, the applied phys-iology, and its treatment. Physicians and nurses involved inthe management of critically ill or injured patients shouldhave Cardiac Arrest in their personal libraries for ready ref-erence. Resuscitation






Cardiac ArrestThe Science and Practice ofResuscitation Medicine

Second edition

Editors

Norman A. Paradis, M.D.University of Colorado, Denver, USA

Henry R. Halperin, M.D., M.A.Johns Hopkins University School of Medicine, Baltimore, MD, USA

Karl B. Kern, M.D.University of Arizona, Sarver Heart Center, Tucson, AZ, USA

Volker Wenzel, M.D., M.Sc.Innsbruck Medical University, Innsbruck, Austria

Douglas A. Chamberlain CBE, M.D.School of Medicine, Cardiff University, Wales, UK

Senior Associate Editor

Max Harry Weil, M.D.Weil Institute of Critical Care Medicine, Rancho Mirage, CA, USA

Associate Editors

Scott M. Eleff, M.D.William Beaumont Hospital, Royal Oak, MI, USA

Terry L.Vanden Hoek, M.D.University of Chicago, IL, USA

Vinay M. Nadkarni, M.D.Children’s Hospital of Philadelphia, PA, USA

Development Editor

Pamela Talalay, Ph.D.Johns Hopkins University School of Medicine, Baltimore, MD, USA






cambridge university press

Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo

cambridge university press

The Edinburgh Building, Cambridge CB2 8RU, UK

Published in the United States of America by Cambridge University Press, New York

www.cambridge.org

Information on this title: www.cambridge.org/9780521847001

© Norman A. Paradis, Henry R. Halperin, Karl B. Kern, Volker Wenzel and

Douglas A. Chamberlain 2007

This publication is in copyright. Subject to statutory exception

and to the provisions of relevant collective licensing agreements,

no reproduction of any part may take place without

the written permission of Cambridge University Press.

First published 2007

Printed in the United Kingdom at the University Press, Cambridge

A catalogue record for this book is available from the British Library

ISBN 978-0-521-84700-1 hardback

Cambridge University Press has no responsibility for the persistence or accuracy

of URLs for external or third-party internet websites referred to in this publication,

and does not guarantee that any content on such websites is, or will remain,

accurate or appropriate.

Every effort has been made in preparing this publication to provide accurate and

up-to-date information which is in accord with accepted standards and practice at

the time of publication. Although case histories are drawn from actual cases, every

effort has been made to disguise the identities of the individuals involved.

Nevertheless, the authors, editors and publishers can make no warranties that the

information contained herein is totally free from error, not least because clinical

standards are constantly changing through research and regulation. The authors,

editors and publishers therefore disclaim all liability for direct or consequential

damages resulting from the use of material contained in this publication. Readers

are strongly advised to pay careful attention to information provided by the

manufacturer of any drugs or equipment that they plan to use.






In memory of Harold Paradis, M.D., without whose

inspiration this effort would never have been under-

taken, and for Christine, without whose patience it

would never have been completed. N.A.P.

To my wife, Sharon Tusa Halperin, and children,

Victoria and Eric Halperin, whose patience and

support inspired me to complete my contributions to

this work. In memory of Victor Halperin, D.D.S., who

inspired me to undertake a career in academic med-

icine and complete this work. H.R.H.

To Martha, my wife, who always understood that the

most worthwhile books are written with friends, and

that true friendship develops best while fly fishing,

and to Matt, my youngest son, who has helped me

keep my perspective that each day is wonderful and

full of promise. K.B.K.

To my daughter Katharina, whose love from

Innsbruck to the moon and back keeps me going on

good days and especially on bad days, and in

memory of Gunther and Ute Wenzel. And to my

friends worldwide providing ideas, critique, encour-

agement, and hard work. V.W.

To my wife Jennifer, who continues to be incredibly

tolerant of a husband who is forever ensconsed in

his study and who offers no help with the washing

up. D.A.C.






Contents

List of contributors xiForeword – Myron L. Weisfeldt M.D. xxviiPreface xxxi

Part I Introduction

1 A history of cardiopulmonary resuscitation 3Mickey S. Eisenberg, Peter Baskett, and DouglasChamberlain

2 The epidemiology of sudden death 26Graham Nichol and David Baker

Part II Basic science

3 Global cellular ischemia/reperfusion duringcardiac arrest: critical stress responses and thepostresuscitation syndrome 51Kimm Hamann, Dave Beiser, and Terry L. Vanden Hoek

4 Genetics, genomics and proteomics in suddencardiac death 70Lesley A. Kane, Silvia G. Priori, Carlo Napolitano, Dan E.Arking, and Jennifer E. Van Eyk

5 Intracellular signaling during myocardialischemia 90Peter H. Sugden

6 Electrophysiology of ventricular fibrillation anddefibrillation 101Wei Xiong and Gordon F. Tomaselli

7 The neuroendocrine response to global ischemiaand reperfusion 128Martin W. Dünser, Stefan Jochberger, Karl-HeinzStadlbauer, and Volker Wenzel

vii






8 Inflammatory and Immunologic responses toischemia and reperfusion 163Jason S. Haukoos, Ronald J. Korthuis, and James T.Niemann

Resuscitation research

9 Methodology of laboratory resuscitation research 179Menekhem Zviman and Henry R. Halperin

10 The methodology of clinical resuscitation research 206Johan Herlitz, Anouk van Alem, Volker Wenzel, and KarlWegscheider

11 The special problem of consent for resuscitationresearch 216Henry R. Halperin and Douglas Chamberlain

Part III The pathophysiology of global ischemiaand reperfusion

12 The etiology of sudden death 229Sunil K. Sinha, Arthur J. Moss, and Hugh G. Calkins

13 Global brain ischemia and reperfusion 236Brian J. O’Neil, Robert W. Neumar, Uwe Ebmeyer, andGary S. Krause

14 Reperfusion injury in cardiac arrest andcardiopulmonary resuscitation 282Thomas Aversano

15 Visceral organ ischemia and reperfusion incardiac arrest 298Kevin R. Ward and Andreas W. Prengel

16 Mechanisms of forward flow during external chest compression 326Henry R. Halperin

Perfusion pressures

17 Hemodynamics of cardiac arrest 347Michael P. Frenneaux and Stig. Steen

18 Coronary perfusion pressure duringcardiopulmonary resuscitation 369Karl B. Kern, James T. Niemann, and Stig Steen

19 Methods to improve cerebral blood flow andneurological outcome after cardiac arrest 389Uwe Ebmeyer, Laurence M. Katz, and Alan D. Guerci

20 Pharmacology of cardiac arrest and reperfusion 395Tommaso Pellis, Jasmeet Soar, Gavin Perkins, and Raúl J.Gazmuri

21 Analysis and predictive value of the ventricularfibrillation waveform 417Trygve Eftestøl, Hans-Ulrich Strohmenger, and ColinRobertson

22 Etiology, electrophysiology, and myocardialmechanics of pulseless electrical activity 426Tom P. Aufderheide

Part IV Therapy of sudden death

23 Prevention of sudden cardiac death 449Catherine Campbell, Ty J. Gluckman, Charles Henrikson,Dominique M. Ashen, and Roger S. Blumenthal

24 Sequence of therapies during resuscitation:application of CPR 463Leonard A. Cobb

25 Transthoracic defibrillation 470Richard E. Kerber, Charles D. Deakin, and Willis A. Tacker, Jr.

26 Automated external defbrillators 482Rudolph W. Koster, Douglas Chamberlain, and Dianne L.Atkins

27 Public access defibrillation 496Roger D. White, Mick Colquhoun, Carys Sian Davies, MaryAnn Peberdy, and Sergio Timerman

28 The physiology of ventilation during cardiacarrest and other low blood flow states 506Ahamed H. Idris and Andrea Gabrielli

29 Airway techniques and airway devices 550Jerry P. Nolan and David A. Gabbott

External chest compression: standard andalternative techniques

30 Manual cardiopulmonary resuscitationtechniques 571Henry R. Halperin and Barry K. Rayburn

31 Mechanical devices for cardiopulmonaryresuscitation 585Henry R. Halperin

32 Invasive reperfusion techniques 600Mark G. Angelos

33 Routes of drug administration 614Thomas Kerz, Gideon Paret, and Holger Herff

viii Contents






Vasopressor therapy during cardiac arrest

34 Adrenergic agonists 639Max Harry Weil, Shijie Sun, and Wanchun Tang

35 Vasopressin and other non-adrenergic vasopressors 647Anette C. Krismer, Martin W. Dünser, Karl H. Stadlbauer,Karl H. Lindner, and Volker Wenzel

36 Antiarrhythmic therapy during cardiac arrestand resuscitation 667Markus Zabel, Douglas Chamberlain, Paul Dorian, PeterKudenchuk, Edward Platia, and Hans-Richard Arntz

37 Acid–base considerations and buffer therapy 674Gad Bar-Joseph, Fulvio Kette, Martin von Planta, andLars Wiklund

38 Cardiac arrest resuscitation monitoring 698Kevin R. Ward and Joseph Bisera

39 Special considerations in the therapy of non-fibrillatory cardiac arrest 725Tom P. Aufderheide, Todd M. Larabee, and Norman A.Paradis

40 Cardiocerebral resuscitation: a new approach toout-of-hospital cardiac arrest 747Gordon A. Ewy and Michael J. Kellum

41 Thrombolysis during resuscitation from cardiac arrest 757Fabian Spöhr and Bernd W. Böttiger

42 Percutaneous coronary intervention (PCI) aftersuccessful reestablishment of spontaneouscirculation and during cardiopulmonary resuscitation 764Marko Noc, Bjørn Bendz, and Karl B. Kern

43 Emergency medical services systems and out-of-hospital cardiac arrest 772Matthias Fischer, Thomas Krafft, Luis García-CastrilloRiesco, Freddy Lippert, Jerry Overton, and IainRobertson-Steel

44 In-hospital resuscitation 782Mary Ann Peberdy, Johan Herlitz, and Michelle Cretikos

45 Complications of CPR 792Michael Baubin, Walter Rabl, and Robert Sebastian Hoke

46 Bringing it all together: state-of-the-art therapyfor cardiac arrest 809Max Harry Weil and Wanchun Tang

Part V Postresuscitation disease and its care

47 Postresuscitation syndrome 817Erga L. Cerchiari

48 Prevention and therapy of postresuscitationmyocardial dysfunction 829Raúl J. Gazmuri, Max Harry Weil, Karl B. Kern, WanchunTang, Iyad M. Ayoub, Julieta Kolarova, and JeejabaiRadhakrishnan

49 Prevention of postresuscitation neurologicdysfunction and injury by the use of therapeuticmild hypothermia 848Wilhelm Behringer, Stephen Bernard, Michael Holzer,Kees Polderman, Risto Roine, and Marjaana Tiainen

50 Postresuscitation neurologic prognosticationand declaration of brain death 885Romergryko G. Geocadin, Daniel F. Hanley, and Scott M.Eleff

51 Bringing it all together: brain-orientedpostresuscitation critical care 902Uwe Ebmeyer, Laurence M. Katz, Kevin R. Ward, andRobert W. Neumar

Part VI Special resuscitation circumstances

52 Prevention of sudden death in patients at risk:channelopathies and arrhythmic syndromes inthe structurally normal heart 921Alan Cheng, Gordon F. Tomaselli, and Ronald D. Berger

53 Pediatric cardiopulmonary resuscitation 937Robert A. Berg and Vinay M. Nadkarni

54 Resuscitation in elder persons 960Arthur B. Sanders

55 Asphyxial cardiac arrest 969Peter Safar†, Norman A. Paradis, and Max Harry Weil

56 Hemorrhagic shock and hypovolemic cardiac arrest 994James L. Atkins, Michael T. Handrigan, and David Burris

57 Cardiopulmonary resuscitation in hypothermicpatients 1014Peter Mair, Birgit Schwarz, Beat Walpoth, and Tom Silfvast

58 Cardiac arrest due to poisoning 1028Kenneth Heard and Norman A. Paradis

Contents ix

†Deceased






59 Cardiac arrest during anesthesia 1043Wolfgang Ummenhofer, Andrea Gabrielli, Quinn H.Hogan, Eldar Soreide, and Mathias Zuercher

60 Resuscitation of the pregnant patient sufferingsudden cardiac death 1076Mark Stacey and Stephen Morris

61 Drowning 1088Joost Bierens, Robert A. Berg, Peter Morley, DavidSzpilman, and David S. Warner

62 Anaphylactic shock 1103Richard Pumphrey

63 High altitude resuscitation 1118Philip Eisenburger, Benjamin Honigman, SusanNiermeyer, Robert Roach, and Wolfgang Voelckel

64 Electrical injuries 1136Wolfgang Lederer, Erga Cerchiari, and Norman A. Paradis

65 Rare syndromes, commotio cordis, suddendeath in athletes 1148Tommaso Pellis, Mark Link, Charles Antzelevitch, andPeter Kohl

Part VII Special issues in resuscitation

66 The ethics of resuscitation and end of life decisions 1201Peter Baskett, Arthur B. Sanders, and Petter Andreas Steen

67 The economics of treating sudden cardiac arrest 1212Alastair Fischer and Graham Nichol

68 Medicolegal aspects 1226Richard Pawl

69 The near-death experience, long-termpsychological outcomes and support of survivors 1244Sam Parnia, K. Spearpoint, and P.B. Fenwick

70 CPR training 1258Michael Shuster, Walter Kloeck, Edward R. Stapleton, Ulrik Juul Christensen, and Allan Braslow

71 Consensus development in resuscitation: thegrowing movement towards internationalemergency cardiovascular care guidelines 1278Jerry P. Nolan, Douglas Chamberlain, William H.Montgomery, and Vinay M. Nadkarni

Index 1289

x Contents






Contributors

Mark G. AngelosDepartment of Emergency MedicineThe Ohio State University146 Means Hall1654 Upham DriveColumbus OH 43220USA

Charles AntzelevitchMasonic Medical Research laboratory2150 Bleecker StreetUtica NY 13501–1787, USA

Dan E. ArkingMcKusick-Nathans Institute of Genetic MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA

Hans-Richard ArntzDivision of CardiologyHumboldt UniversityCampus Benjamin FranklinCharité BerlinHindenburgdamm 30Berlin D-12200Germany

M. Dominique AshenBlalock 524 C – CardiologyThe Johns Hopkins CiccaronePreventive Cardiology Center600 North Wolfe StreetBaltimore MD 21287USA

xi






Dianne L. AtkinsDivision of Pediatric CardiologyChildren’s Hospital of IowaDepartment of PediatricsCarver College of MedicineUniversity of IowaIowa CityUSA

James L. AtkinsDivision of Military Casualty ResearchWalter Reed Army Institute of ResearchSilver SpringMDUSA

Tom P. AufderheideDepartment of Emergency MedicineMedical College of Wisconsin9200 West Wisconsin AvenueFEH Room 1870Milwaukee WI 53266USA

Thomas AversanoJohns Hopkins UniversityBaltimoreMDUSA

Iyad M. AyoubMedical ServiceNorth Chicago VA Medical Center3001 Green Bay RoadNorth Chicago IL 60064USA

David BakerUniversity of WashingtonClinical Trial Center 1107 NE 45th StreetSuite 505Seattle, WA 98105USA

Gad Bar-JosephPediatric Intensive CareMeyer Children’s HospitalRambam Medical CenterPO Box 9602Haifa 31096Israel

Peter BaskettFormerly Department of AnaesthesiaFrenchay Hospital and the Royal InfirmaryBristol UK

Michael BaubinDepartment of Anaesthesia and Critical Care MedicineInnsbruck Medical UniversityAnichstrasse 35Innsbruck A-6020Austria

Wilhelm BehringerDepartment of Emergency MedicineVienna General HospitalWaehringer Guertel 18–201090 ViennaAustria

Dave BeiserDepartment of Emergency MedicineUniversity of Chicago5841 South Maryland Avenue MC5068Chicago IL 60637USA

Bjørn BendzDepartment of CardiologyRikshospitalet University HospitalOslo 0027Norway

xii List of Contributors






Roger S. BlumenthalBlalock 524 C – CardiologyThe Johns Hopkins CiccaronePreventive Cardiology Center600 North Wolfe StreetBaltimore MD 21287USA

Bernd W. BöttigerDepartment of AnaesthesiologyUniversity of HeidelbergIm Neuenheimer Feld 110D-69120 HeidelbergGermany

Allan Braslow45 Greenwich Hill DriveGreenwichCT 06831, USA

David BurrisNorman M Rich Department of SurgeryUniformed Services University of the Health SciencesBethesda MDUSA

Hugh G. CalkinsCarnegie 520Johns Hopkins University600 North Wolfe StreetBaltimore MD 21287-0409USA

Catherine CampbellBlalock 524 C – CardiologyThe Johns Hopkins CiccaronePreventive Cardiology Center600 North Wolfe StreetBaltimore MD 21287USA

List of Contributors xiii

Robert A. BergUniversity of Arizona College of MedicineDepartment of PediatricsP O Box 245017Tucson AZ 85721-5017USA

Ronald D. BergerJohns Hopkins Medical InstitutionsCarnegie 592600 North Wolfe StreetBaltimore MD 21287USA

Stephen BernardDepartment of Epidemiology and Preventive MedicineMonash UniversitySt Kilda RoadPrahran VIC 3181Australia

Joost BierensDepartment of AnesthesiologyVU University Medical CentreP O Box 7057Amsterdam 1007 MBThe Netherlands

Joseph BiseraInstitute of Critical Care Medicine35–100 Bob Hope DriveRancho Mirage CA 92270USA






Erga L. CerchiariDepartment of Anaesthesiology and Intensive TherapyMaggiore HospitalLargo Nigrisoli 240131 BolognaItaly

Douglas ChamberlainPrehospital Research UnitSchool of MedicineCardiff UniversityUK

Alan ChengJohns Hopkins HospitalCarnegie 568600 North Wolfe StreetBaltimore MD 21287USA

Ulrik Juul ChristensenSophus Medical ApSCopenhagenDenmark

Leonard A. CobbMedic One Support GroupHarborview Medical Center325 9th AvenueBox 359748Seattle WA 98112USA

Mick ColquhounResuscitation Council5th FloorTavistock House NorthTavistock SquareLondon WC1H 9HRUK

Michelle CretikosSimpson Centre for Health Services ResearchLiverpool Health ServiceUniversity of New South WalesSydneyAustralia

Carys Sian DaviesDepartment of HealthArea 407133–155 Waterloo RoadLondon SE1 8UGUK

Charles D. DeakinShackleton Department of AnesthesiaSouthampton University Hospitals NHS TrustTremona RoadSouthampton SO16 6YDUK

Paul DorianDivision of CardiologySt Michael’s HospitalRm 7051, Queen Wing30 Bond StreetToronto ON M5B 1W8Canada

Martin W. DünserDepartment of Anesthesiology and Critical Care MedicineInnsbruck Medical UniversityAnichstrasse 35Innsbruck 6020Austria

Uwe EbmeyerKlinic for Anaesthesiologie und IntensivtherapieOtto-von-Guericke UniversityMagdeburgLeipsiger Str 44Magdeburg D-39120Germany

Trygve EftestølDepartment of Electrical and Computer EngineeringStavanger University CollegeStavanger N-4036Norway

xiv List of Contributors






Mickey S. EisenbergDepartment of MedicineUniversity of Washington, Seattle,WA, USAKing County EMS999 Third Avenue, Suite 700Seattle WA 98104USA

Philip EisenburgerUniversitatsklinik furNotfallmedizinAllgemeines Krankenhaus der StadtWienWahringer Gurtel 18–20/6/DWien A-1090Austria

Scott M. EleffDepartment of Emergency MedicineWilliam Beaumont HospitalRoyal OakMIUSA

Gordon A. EwySarver Heath Center Department of CardiologyUniversity of Arizona TucsonAZUSA

P.B. FenwickConsciousness Research GroupUniversity of SouthamptonSouthamptonUKandCritical Care DepartmentHammersmith Hospitals NHS TrustLondonUK

Alastair FischerSt. George’s HospitalUniversity of LondonCranmer TerraceLondon SW17 0REUK

Matthias FischerDepartment of Anaesthesiology and Intensive Care

MedicineKlinik am EichertEichertstrasse 3Göppingen 73035Germany

Michael P. FrenneauxDepartment of Cardiovascular MedicineThe Medical SchoolUniversity of BirminghamEdgbastonBirmingham B15 2TTUK

David A. GabbottDepartment of AnaestheticsGloucester Royal HospitalGreat Western RoadGloucester CL1 3NNUK

Andrea GabrielliDivision of Critical Care MedicineUniversity of Florida1600 SW Archer RoadGainesville FL 32610-0254USA

Luis García-Castrillo RiesgoUniversidad de CantabriaHospital Universitario Marqués de CaldecillaSantanderSpain

Raúl J. GazmuriMedical ServiceNorth Chicago VA Medical Center3001 Green Bay RoadNorth Chicago IL 60064USA

List of Contributors xv






Romergryko G. GeocadinDepartment of NeurologyThe Johns Hopkins HospitalMeyer 8-140600 North Wolfe StreetBaltimore MD 21287USA

Ty J. GluckmanBlalock 524 C – CardiologyThe Johns Hopkins CiccaronePreventive Cardiology Center600 North Wolfe StreetBaltimore MD 21287USA

Alan D. GuerciDepartment of Medicine,St. Francis Hospital100 Port Washington Blvd.Roslyn, New York 11576, USA

Henry R. HalperinJohns Hopkins UniversityBlalock 524ABayview Campus600 North Wolfe StreetBaltimore MD 21287USA

Kimm HamannDepartment of Emergency MedicineUniversity of Chicago5841 South Maryland Avenue MC5068 Chicago IL 60637USA

Michael T. HandriganDepartment of Resuscitation MedicineNaval Medical Research CenterSilver Spring MD 20910USA

Daniel F. HanleyDepartment of NeurologyNeurosurgery and Anesthesiology-Critical Care

MedicineJohns Hopkins University School of MedicineBaltimore MDUSA

Jason S. HaukoosDepartment of Emergency MedicineDenver Health Medical Center777 Bannock StreetMail Code 0108Denver CO 80204USA

Kenneth HeardUniversity of Colorado School of Medicine, Department

of Surgery (Emergency Medicine)4200 E 9th Avenue, 4215Denver CO 80262USA

Charles HenriksonBlalock 425 C – CardiologyThe Johns Hopkins CiccaronePreventive Cardiology Center600 North Wolfe StreetBaltimore MD 21287USA

Holger HerffDepartment of Anesthesiology and

Critical Care Medicine Innsbruck Medical University Anichstr. 35, 6020 Innsbruck,Austria

Johan HerlitzDepartment of Metabolism and Cardiovascular ResearchSahlgrenska University HospitalSE-413 45 GoteborgSweden

Quinn H. HoganMedical College of WisconsinDepartment of Anesthiology8701 Watertown Plank RoadMilwaukee, WI 53226-0509, USA

xvi List of Contributors






Robert HokeDepartment of Cardiology-AngiologyUniversity of LeipzigJohannisallee 3204103 LeipzigGermany

Michael HolzerUniversity Klinik fur NotfallmedizinAKH WienWaehringer Guertel 18–20Vienna A-1090Austria

Benjamin HonigmanEmergency Medicine B2154200 East 9th AvenueDenver CO 75390-8579USA

Ahamed H. IdrisUniversity of Texas SouthwesternMedical Center at Dallas5323 Harry Hines BoulevardDallas TX 75390-8579USA

Stefan JochbergerDepartment of Anesthesiology and Critical Care MedicineInnsbruck Medical UniversityAnichstrasse 356020 InnsbruckAustria

Janice JonesDepartment of Physiology and BiophysicsGeorgetown UniversityWashingtonDCUSA

Lesley A. KaneDepartment of Biological ChemistryJohns Hopkins UniversityBayview CampusMason F Lord BuildingCenter Tower, Room 601Baltimore MD 21224USA

Laurence M. KatzDepartment of Emergency MedicineUniversity of North Carolina School of MedicineNeuroscience HospitalGround Floor101 Manning DriveChapel Hill NC 27599USA

Michael J. KellumDepartment of EmergencyMercy Walworth Medical CenterLake GenevaWIUSA

Karl B. KernSarver Heart CenterUniversity of Arizona1501 North Campbell AvenueTucson AZ 85724USA

List of Contributors xvii






Thomas KerzDepartment of Neurosurgery Intensive Care UnitJohannes Gutenberg-Universität KlinikumLangenbeckstr 1Mainz D-55131Germany

Fulvio KetteEmergency Department and Intensive Care UnitS. Vito al Tagliamento HospitalVia Savorgnano 233078 San Vito al TagliamentoItaly

Walter Kloeck72 Sophia StreetFairland2195 JohannesburgSouth Africa

Peter KohlUniversity Laboratory of PhysiologyThe Cardiac Mechano-Electric Feedback LabOxford OX1 3PT

Julieta Kolarova21730 Boschome DriveKildeer IL 60047USA

Ronald J. KorthuisDepartment of Medical Pharmacology and PhysiologySchool of MedicineOne Hospital Drive, MA415University of Missouri-ColumbiaColumbia MO 65212USA

Rudolph W. KosterDepartment of CardiologyAcademic Medical CenterUniversity of AmsterdamRoom F-239Meibergdreef 9Amsterdam 1105 AZThe Netherlands

Thomas KrafftGeographisches InstitutUniversitat KölnAlbertus-Magnus-PlatzD-50923 KölnGermany

Gary S. KrauseDepartment of Emergency MedicineWayne State University550 East Canfield Avenue51.2 Lande BuildingDetroit MI 48201USA

Anette C. KrismerDepartment of Anesthesiology and Critical Care MedicineInnsbruck Medical UniversityAnichstrasse 35Innsbruck A-6020Austria

Peter KudenchukUniversity of Washington Medical CenterCampus Box 3564221959 NE Pacific StreetSeattle WA 98195USA

Todd M. LarabeeDivision of Emergency MedicineUCHSC B2154200 East 9th AvenueDenver CO 80262USA

xviii List of Contributors






Wolfgang LedererDepartment of Anaesthesiology and Critical Care

MedicineUniversity of InnsbruckAnichstrasse 25A-6020 InnsbruckAustria

Howard R. LevinDepartment of SurgeryDivision of Cardiothoracic SurgeryCollege of Physicians and SurgeonsColumbia UniversityNew York, NY 10032, USA

Karl H. LindnerDepartment of Anesthesiology and Critical Care MedicineInnsbruck Medical UniversityAnichstrasse 35Innsbruck A-6020Austria

Mark LinkTufts University School of MedicineNEMC Box #197750 Washington StreetBoston MA 02111USA

Freddy LippertCopenhagen Hospital CorporationCopenhagen University HospitalDenmark

Peter MairDepartment of Anaesthesia and Intensive Care MedicineInnsbruck Medical UniversityAnichstrasse 35Innsbruck A-6020Austria

James MennegazziUniversity of Pittsburgh School of MedicinePittsburgh PAUSA

William H. MontgomeryDepartment of AnesthesiologyStraub Clinic and HospitalUniversity of Hawaii School of Medicine888 South King StreetHonoluluHawaii 96813USA

Peter MorleyIntensive Care UnitRoyal Melbourne HospitalGrattan StreetParkville VIC 3050Australia

Stephen MorrisDepartment of AnaesthesiaLlandough HospitalPenarthCardiff CF64 2XXUK

Arthur J. MossUniversity of Rochester Medical CenterDepartment of MedicineRochester, New York, USA

Vinay M. NadkarniDepartments of Anesthesia, Critical Care and PediatricsThe Children’s Hospital of Philadelphia34th Street and Civic Center BlvdPhiladelphia PA 19104-4399USA

Carlo NapolitanoDepartment of Medicine and Department of Biomedical

EngineeringJohns Hopkins UniversityBaltimoreUSA

List of Contributors xix






Robert W. NeumarDepartment of Emergency MedicineUniversity of Pennsylvania School of MedicineHospital of the University of Pennsylvania3400 Spruce StreetPhiladelphia PA 19104-4283USA

Graham NicholUniversity of WashingtonClinical Trial Center1107 NE 45th StreetSuite 505Seattle WA 98105USA

James T. NiemannDepartment of Emergency MedicineHarbor-UCLA Medical Center1000 West Carson Street, Box 21Torrance CA 90509USA

Susan NiermeyerDivision of NeonatologyUniversity of ColoradoSchool of MedicineThe Children’s Hospital4200 East 9th AvenueDenver, CO 80218, USA

Marko NocUniversity Ljubljana Medical CenterCenter for Intensive Internal MedicineZaloska Cesta 7Ljubljana 1000Slovenia

Jerry P. NolanAnaesthesia and Intensive Care MedicineRoyal United HospitalCombe ParkBath BA1 3NDUK

Brian J. O’NeilDepartment of Emergency MedicineWilliam Beaumont Hospital3601 W Thirteen Mile RoadRoyal Oak MI 48073USA

Joseph P. OrnatoDepartment of Emergency MedicineVirginia Commonwealth University401 N 12th StreetRichmond, VA 23298USA

Jerry OvertonRichmond Ambulance AuthorityRichmond VAUSA

Norman A. ParadisUniversity of ColoradoDenverColoradoUSA

Gideon ParetDepartment of Pediatric Critical CareThe Chaim Sheba Medical CenterSafra Children’s HospitalTel Hashomer, Israel

Sam ParniaConsciousness Research GroupUniversity of SouthamptonSouthamptonUKandCritical Care DepartmentHammersmith Hospitals NHS TrustLondonUK

Richard PawlDepartment of Emergency MedicineMedical College of Georgia1120 15th StreetAF 2014Augusta GA 30912-2800USA

Mary Ann PeberdyDepartment of Medicine and Emergency MedicineVirginia Commonwealth University Health System1200 East Broad Street,West Hospital, 10th FloorRoom 1042, P O Box 980204Richmond VA 23298USA

xx List of Contributors






Tommaso PellisCardiac Mechano-Electric Feedback LabThe University Laboratory of PhysiologyOxford OX1 3PT

Gavin Perkins26 Hollie Lucas RoadKings HeathBirminghamB13 0QL, UK

Edward PlatiaCardiac Arrhythmia CenterWashington Hospital Center DC110 Irving StreetWashington DC 2010USA

Kees PoldermanDepartment of Intensive CareVU University Medical CenterAmsterdamThe Netherlands

Andreas W. PrengelDepartment of Anesthesiology, Critical Care Medicine,

and Pain TherapyRuhr University Hospital BochumIn der Schornau 23–2544892 BochumGermany

Silvia G. PrioriDepartment of Molecular CardiologyIRCCS Fondazione Salvatore MaugeriVia Maugeri 10 / 10a27100 PaviaItaly

Richard PumphreyDepartment of ImmunologyManchester Royal InfirmaryManchester M13 9WLUK

Walter RablInstitute of Legal MedicineInnsbruck Medical UniversityMuellerstrasse 44Innsbruck A-6020Austria

Jeejabai RadhakrishnanDepartment of MedicineRosalind Franklin University of Medicine and Science3333 Green Bay RoadNorth Chicago ILUSA

Barry K. RayburnSchool of MedicineUniversity of AlabamaTinsley Harrison Tower THT 3211530 3rd Avenue SBirmingham AL 35294-0006USA

Robert RoachDivision of NeonatologyUniversity of Colorado School of MedicineThe Children’s Hospital4200 East 9th AvenueDenver, CO 80218, USA

Colin RobertsonDepartment of Accident and EmergencyThe Royal Infirmary of Edinburgh51 Little France CrescentEdinburgh EH16 4SAScotlandUK

Iain Robertson-SteelWest Midlands Ambulance Service NHS TrustDudleyWest MidlandsUK

Risto O. RoineDepartment of Neurology, Turku University Hospital,Finland

Peter Safardeceased

List of Contributors xxi






Arthur B. SandersDepartment of Emergency MedicineUniversity of ArizonaP O Box 2450571501 N Campbell AvenueTucson AZ 85724-5057USA

Birgit SchwarzDepartment of Anaesthesia and Intensive Care MedicineInnsbruck Medical UniversityAnichstrasse 35Innsbruck A-6020Austria

Michael ShusterDepartment of Emergency MedicineMineral Springs HospitalBox 1050Banff AB T1L 1H7Canada

Tom SilfvastDepartment of Anaesthesia and Intensive Care MedicineMeilhati HospitalHelsinki University HospitalP O Box 340FIN-00029HelsinkiFinland

Michiel SinaasappelLaser CenterAcademic Medical CenterUniversity of AmsterdamMeibergdreef 91105 AZAmsterdamThe Netherlands

Sunil K. SinhaThe Johns Hopkins HospitalCarnegie 530600 North Wolfe StreetBaltimore MD 21287-1345USA

Jasmeet SoarAnaesthetics and Intensive CareSouthmead HospitalN. Bristol NHS TrustWestburg-on-TrymBristol BS10 5NBUK

Eldar SoreideIntensive Care UnitDivision of Acute Care MedicineStavanger University HospitalPB 81004068 StavangerNorway

K. SpearpointDepartment of Anaesthetics and Intensive Care5th Floor, Hammersmith HouseHammersmith HospitalDu Cane RoadLondon W12 0HSUK

Fabian SpöhrDepartment of AnaesthesiologyUniversity of HeidelbergIm Neuenheimer Feld 110D-69120 HeidelbergGermany

Mark StaceyAnaesthetics DepartmentLlandough HospitalPenarthCardiff CF64 2XXUK

xxii List of Contributors






Karl-Heinz StadlbauerDepartment of Anesthesiology and Critical Care MedicineInnsbruck Medical UniversityAnichstrasse 35Innsbruck A-6020Austria

Edward R. StapletonDepartment of Emergency Medicine080, Level 4, Health Science CenterState University of NY

at Stony Brook, Stony BrookNew York 11794-8350USA

Petter Andreas SteenDepartment of AnaesthesiologyUlleval University HospitalOslo N-0407Norway

Stig SteenDepartment of Cardiothoracic SurgeryUniversity Hospital of LundLund UniversityBox 117Lund S-22100Sweden

Hans-Ulrich StrohmengerDepartment of Anaesthesiology and Critical Care

MedicineMedical University InnsbruckAnichstrasse6020 InnsbruckAustria

Peter H. SugdenImperial College LondonNHLI Division (Cardiac Medicine)Flowers Building (4th Floor)Armstrong RoadLondon SW7 2AZUK

Shijie SunWeil Institute of Critical Care Medicine1696 North Sunrise WayBuilding 3Palm Springs CA 92262USA

David SzpilmanIntensive Care UnitHospital Miguel CoutoAv das Americas 3555Bloco 2, Sala 302Barra da TijucaRio de Janeiro 22631-004Brazil

Willis A. Tacker JrBasic Medical SciencesPurdue University625 Harrison StreetWest Lafayette IN 47907-2006USA

Wanchun TangWeil Institute of Critical Care Medicine1696 North Sunrise WayBuilding 3Palm Springs CA 92262USA

Marjaana TiainenDepartment of Neurology, Helsinki University

Hospital, FinlandFinland

Sergio TimermanResuscitation DepartmentHeart Institute of Sao PaoloAv Dr Eneas de CarvalhoAguiar 44Sao Paulo 05403-900Brazil

Gordon F. Tomaselli Cardiovascular Clinical Research CenterJohns Hopkins University School of Medicine600 North Wolfe StreetBaltimore MD 21287USA

List of Contributors xxiii






Wolfgang UmmenhoferDepartment of AnaesthesiaUniversity Hospital21 Spital StrasseCH-4031 BaselSwitzerland

Anouk Van AlemDepartment of CardiologyAcademic Medical CenterRoom B2-238Meibergdreef 91105 AZ AmsterdamThe Netherlands

Terry L. Vanden HoekDepartment of Emergency MedicineUniversity of Chicago5841 South Maryland Avenue MC 5068Chicago IL 60637USA

Jennifer E. Van EykJohns Hopkins University – Bayview Campus5200 Eastern AvenueMason F Lord BuildingCenter Tower, Room 602Baltimore MD 21224USA

Wolfgang VoelckelDepartment of Anaesthesiology and Critical CareInnsbruck Medical UniversityAnichstrasse 35Innsbruck A-6020Austria

Martin von PlantaDepartment of Internal MedicineUniversity of BaselSt Johanns-Vorstadt 44CH-4056 BaselSwitzerland

Beat WalpothCardiovascular ResearchService of Cardiovascular SurgeryUniversity HospitalGeneva 1211Switzerland

Kevin R. WardDepartment of Emergency MedicineVirginia Commonwealth University401 N 12th StreetRichmond VA 23298USA

David S. WarnerDepartments of Anesthesiology, Neurobiology and

SurgeryDuke University Medical CenterBox 3094Durham NC 27710USA

Karl WegscheiderInstitute for Statistics and EconometryUniversity of HamburgVon-Melle-Park 520146 HamburgGermany

Max Harry WeilWeil Institute of Critical Care Medicine35-100 Bob Hope DriveRancho Mirage CA 92270USA

Myron WeisfeldtJohns Hopkins University Medical CenterDepartment of Medicine1830 E. Monument St., 9th FloorBaltimore, MD 21287, USA

Volker WenzelDepartment of Anesthesiology and Critical Care MedicineInnsbruck Medical UniversityAnichstrasse 35Innsbruck A-6020Austria

xxiv List of Contributors






Roger D. WhiteMayo Clinic College of Medicine200 First Street SWRochester MinnUSA

Lars WiklundDepartment of Surgical SciencesUppsala University Hospital75185 UppsalaSweden

Wei XiongCardiovascular Clinical Research CenterJohns Hopkins University School of Medicine600 North Wolfe StreetBaltimore MD 21287USA

Markus ZabelDivision of CardiologyUniversity of GöttingenGermany

Mathias ZuercherDepartment of AnaesthesiaUniversity Hospital21 Spital StrasseCH-4031 BaselSwitzerland

Menekhem ZvimanCardiovascular Clinical Research CenterJohns Hopkins University School of Medicine600 N. Wolfe St.Baltimore, MD 21287, USA

List of Contributors xxv






Foreword

Myron L. Weisfeldt, M.D.

This monograph on cardiac resuscitation medicine is thestandard reference in the field. This Second Edition adecade later presents an entirely changed and dynamicfield. Advances in resuscitative medicine encompass thebasic science understanding of physiology and pathophys-iology as well as advances in understanding of the causalmechanisms involved in successful or non-successfulresuscitation. There are new programs and approaches ata practical and real-world level that improve survival andthe quality of survival from cardiac arrest. I would maintainthat these prerequisites relate to the need for this updatedmonograph. It is important that this text be acquired andused by providers of emergency cardiac care in both theout-of-hospital and in-hospital settings. It will be of valueuniversally in the emergency departments. Clinical inves-tigators will find this text of tremendous value when pur-suing the improvement of survival from cardiac arrest, aswell as laboratory-based clinical investigators attemptingto identify and justify approaches to improving theoutcome of cardiac arrest. As the underlying science ofresuscitation deepens, basic scientists will value thesestate-of-the-art discussions. Resuscitation Science hasbroadened the focus from mechanics to reperfusion injury,post-resuscitation inflammation and programmed celldeath.

To substantiate my statements about this update and itsvalue to the medical and resuscitative community, I haveidentified what I consider to be the eight major advancesin resuscitative medicine over the last decade.1. The advent of inexpensive, easy-to-use Automatic

External Defibrillators (AEDs) for use by the lay public.Ten years ago, industry was just beginning to producethese revolutionary devices. The FDA considered use ofthese AEDs by other than physicians, nurses andtrained Emergency Medical Technicians (EMTs) as“illegal,” off label, over-the-counter use of an approved

xxvii






device. Ten years ago, only one or two states referred todefibrillation as being covered by the Good Samaritanlaw. Now all states consider such resuscitative efforts bymembers of the lay public to be encompassed by theGood Samaritan statutes. Ten years ago there were noconvincing data that AEDs are effective in improvingthe outcome of resuscitation. Perhaps the most remark-able result was in the casinos of Las Vegas where TerryValenzuela and his colleagues measured time from col-lapse to defibrillation precisely (on video cameras).Security guards could defibrillate with an average timeof 4.4 minutes and survival of 59% in 90 subjects. Ifdefibrillation was performed within 3 minutes (n�20),survival was over 70%. As well, in the Public AccessDefibrillation study (PAD), we now have data to supportthe value of the AEDs in the public arenas when addedto CPR instruction. Ten years ago we had no conscien-tious programs to implement AEDs in full public view inairports and other transportation facilities, on-boardairlines, in exercise facilities, or recently by governmentmandate in large public buildings. Although these pro-grams clearly have had little impact on the overallpublic health survival rate from cardiac arrest, theyhave produced some of the most rewarding survivalsbecause of the promptness of resuscitation and theclear ability of those resuscitated very quickly to recoverfully and rapidly.

2. Change in the characteristics of the population sufferingcardiac arrest. Ten years ago, broad population studiesshowing that 70% or so of people suffering cardiacarrest have ventricular fibrillation (or ventricular tachy-cardia) as the first documented electrocardiographicrhythm. Now, multiple large population studies notethat 20% to 30% of those suffering a cardiac arrest haveventricular tachycardia (VT) or ventricular fibrillation(VF) as their initial rhythm. The majority now have anabsence of electrical activity, or occasionally will haveelectromechanical dissociation. The reason for thismajor change, one can only speculate. One possibility isthat, in fact, modern drug treatment of coronarydisease and heart failure combined with implantationof automatic defibrillators in their target populationhas led to this change. For survivors of cardiac arrestcaused by ventricular tachycardia or fibrillation,implantation of defibrillators has provided an increas-ing standard of care. This is also true for patients withcongenitally inherited causes of sudden death, andmany individuals with reduced left ventricular functiondue to previous myocardial infarction or cardiomyopa-thy. It is possible that we are implanting defibrillatorscurrently at sufficient rate to have an impact in the

United States on the overall public health’s incidence ofcardiac arrest from these arrhythmias. Drug and proce-dural treatment strategies for chronic coronary diseaseand heart failure may also be impacting on the inci-dence of sudden death from VT/VF. It is very clear that,in these broad populations, beta-blocking agents aswell as angiotensin II receptor blockers, and anti-platelet drugs (for coronary disease), and aldosteroneantagonist improve survival from these chronic cardiacstates. It is less clear that they reduce the incidence ofsudden death particularly sudden death from VF or VT.That is a likely possibility. A final speculation is thatcardiac arrest in advanced age is more likely not VT/VF.With the striking decline in age-adjusted mortality fromcardiovascular disease, we have less incidence of deathand perhaps less sudden death from VT/VF in youngerindividuals on a population basis.

This change in the initial arrhythmia has a number ofsignificant impacts. First, survival of this group ofpatients who do not have VT/VF is much lower and weknow little about what are effective ways of resuscitat-ing this population. We also know less about the long-term management and care of these patients that mayresult in their survival since it is likely that placing auto-matic implantable defibrillators in these patients willnot improve their long-term outcome even if theysurvive their initial arrest. These, and a whole host ofother theoretical and practical problems, emanate fromthis change in population suffering cardiac arrest.

3. In recent years there has been recognition of the needto extend animal data on CPR performance andeffectiveness from the laboratory into the clinical arena. Itis very clear from animal studies that all interruptions ofchest compressions are detrimental to the hemodynam-ics of CPR, particularly coronary blood flow. It has longbeen recognized that indices of coronary blood flow arevery closely related to human survival. Interruptionsfrom repeated looks at the electrocardiogram, multipledefibrillation attempts, or procedures such as inefficientintubation, have been minimized on the basis of thesedata. In addition, it has been demonstrated in animalmodels very convincingly that hyperventilation or even“usual” ventilation during resuscitation is too much ven-tilation and is detrimental. Related to these issues, per-formance of cardiopulmonary resuscitation in thereal-world situation, both in the hospital by healthcareprofessionals and out-of-the hospital by EMTs, is char-acterized by multiple, prolonged and repeated interruptsof chest compression and hyperventilation. Monitoringsystems, feedback systems, and other systems for con-trolling or at least documenting the way resuscitation is

xxviii Foreword






performed, are beginning to change the policies andpractices of CPR performance. It is very clear that, frompoint “2” above, we come to the realization that in 70% ofarrest in which the initial electrocardiogram is not VT/VF,it is only the quality of CPR and its performance that canlead to return of spontaneous circulation and ultimatelythe possibility of survival.

4. In VT/VF Arrest, Dr. Lance Becker and I proposed a three-phase model to integrate and characterize specificallythe time relationships of the value of rapid defibrillation,the performance of cardiopulmonary resuscitation, andthe need for other measures focused on the metabolicfactors that decrease survival after prolonged cardiacarrest. Phase 1 of the three-phase model identifies thefirst 4 or 5 minutes as a time when initial defibrillationhas a remarkable survival benefit. It next identifies thatbetween 4 minutes and 10 minutes, optimal survival isvery poor if there is no CPR performed. Shock at thistime may be detrimental in addition to the time wasted.During Phase 2 from 4 to 10 minutes after arrest, it maybe critical to perform cardiopulmonary resuscitation toachieve even a 20–30% survival rate. Finally in Phase 3,after 10 minutes without resuscitation, the model iden-tifies the possibility that drugs and pharmacologicalagents as well as subsequent treatment strategies suchas hypothermia may be required to reach reasonablesurvival.

5. We are beginning to see devices that may improve perfu-sion during cardiopulmonary resuscitation and thusmay improve survival. It is understood that the hemo-dynamics of CPR are not excellent with regard to restor-ing and maintaining brain and particularly myocardialblood flow. Fluctuating intra-thoracic pressure to agreater degree (both positive during compression or the“systolic” phase of the CPR cycle and increasing nega-tive intra-thoracic pressure during the “diastolic”phase) in animal models seems to show very convinc-ing benefit in improving blood flow as well as animalsurvival. There are initial studies in man suggestingfavorable hemodynamic changes occur. To date, thevest-like devices that increase intra-thoracic pressureduring the systolic phase are cumbersome. Motivationto use devices is important. There have been variableresults in humans – none that are convincing. A smallairway valve device that decreases intra-thoracic pres-sure between compression cycles improves blood flowin animals and humans. This device is associated withimproved short-term survival and we await largerstudies which are ongoing to see whether this devicewill improve long-term and meaningful survival.

6. Moderate hypothermia may be useful in patients who

after out-of-hospital cardiac arrest have not awakenedwhen they reach the emergency department. Two studiesappear to show benefit of 12 to 24 hours of 32 ° to 33 °C,hypothermia in terms of improving survival and brainfunction following such episodes of out-of-hospitalcardiac arrest. This benefit has been accepted in AHAguidelines, but is not accepted by the FDA. Much is hap-pening in the experimental arena to develop devicesthat induces easy controllable hypothermia. There areinitial studies to potentially bring hypothermia earlierin the course of resuscitation. Again, animal studiessuggest that broad implementation of early hypother-mia after cardiac arrest may improve survival remark-ably.

7. Registry-based information on in-hospital and out-of-hospital CPR. Detailed performance data with resultsare now available for thousands of in-hospital resusci-tations. There are also increasing numbers of epidemi-ological studies and other out-of-hospital registrystudies that have identified correlates of survival fromcardiac arrest as related to resuscitation strategies,maneuvers and approaches. We are beginning to define“best” practices and (if you will) the “worst” practices.

8. There is a new horizon of technology that will certainlyimpact on resuscitation This technology revolution Ipredict will include patient sensors that identify futilityof cardiac resuscitation. Diagnosis of death is inade-quately made in many individuals with current clinicalcriteria. Perhaps more importantly, we will use sensorsthat will identify patient status from the point of view ofmetabolism blood flow and oxygen delivery. They willprovide an assessment of the current status of thepatient and/or what the resuscitative maneuvers haveaccomplished. This type of information will dictate carepatterns and strategies to improve survival from thepoint of view of drug administration as well as deviceand hemodynamic strategies. The strategies are likely tobe complex and therefore it is highly likely that deviceswill integrate the clinical status of the patient with theinformation obtained with sensors into a care and man-agement. These will emerge particularly as metabolicphase markers lead to specific therapeutic strategies.Information will likely be used at the scene and in theemergency department that is ultimately going toreceive the patient. Similar devices and approaches willalmost certainly change in-hospital and ED manage-ment of the arrest occurring in that circumstance.

9. In summary, this new volume on the science and prac-tice of resuscitative medicine is extraordinarily timely.The depth and breadth of new material and chaptersare remarkable and valuable. The new authors include

Foreword xxix






the current generation of the most contributory andthoughtful leaders of the field. The text should beembraced by a broad and deep audience of those inter-ested in this exciting and forward-moving field and

branch of medicine. The worldwide authorshipreflects the fact that sudden death is a worldwideproblem that is increasingly gaining true worldwideattention!

July 12, 2006

xxx Foreword






Preface to the first edition

O, that I could but call these dead to life!

King Henry VI

William Shakespeare

There is a no more frightening experience for a clinicianthan a patient’s sudden and complete loss of vital signs.The need to initiate multiple complex therapies, all thewhile knowing that each minute that passes dramaticallydecreases the chances for a good outcome, makes suddendeath the penultimate medical emergency.

Premature death is the adversary of physicians. For mil-lennia, the loss of life signs was considered the victory ofdeath. Students were taught that once patients had suc-cumbed they were beyond the healing arts. Only relativelyrecently have physicians regularly attempted to wrest suchpatients back from death.

Accurate numbers are difficult to obtain. It is said thatmore than 300,000 persons die each year from suddencardiac death in the United States alone. Worldwide thefigure is in the millions. Sudden death is not, however,caused by coronary artery disease alone. Hemorrhage andasphyxiation, among others, can kill physiologically com-petent patients without warning. Sudden death is notdefined by etiology; it is the circumstance of cardiopul-monary arrest in a person with functional vital organsystems. It is death in the midst of life, and it is alwaystragic.

We are just beginning to appreciate the magnitude ofthis problem and the potential for therapy. Just a 5%improvement in outcome – something that could beachieved in many communities by better application ofstandard care – would save more lives than therapies thathave received far more attention. The potential for good isastounding; the relationship of cost to benefit compelling.

Sudden cardiopulmonary arrest is the most difficultdisease state to treat. Remarkable improvement in the






quality of care has been achieved in a relatively short timeby the American Heart Association’s and the EuropeanResuscitation Council’s guidelines to therapy. Their effortsdefine the standard; this text is an attempt to delineatestate-of-the-art. Our efforts are complementary. Onecannot hope to individualize therapy to the patient’sbenefit without excellent basic care, and internationalconsensus provides this basis.

Our difficulty in treating cardiopulmonary arrest reflectsa limited understanding of the pathophysiology of globalischemia and reperfusion. Physicians are naturallyuncomfortable in using therapies that are poorly under-stood and that have not been clearly demonstrated effect-ive. However, these patients do not allow us the luxury ofwaiting for more definite knowledge. We must apply all ourskill and limited knowledge immediately if persons with“hearts and brains too good to die” are not to be lostforever.

This text is for clinicians who wish to practice both thescience and the art of resuscitation. Every physician will atsome time attempt to resuscitate a patient from suddendeath, but few will have had the opportunity to learn fromteachers dedicated to this skill. That is the purpose of thisbook. In each chapter, a recognized authority has beenasked not only to review present knowledge, but also todescribe the state of their art. Cardiac arrest patients do nothave the luxury of seeking out experts. You must bring thatexpertise to the bed or curb side.

This is intended to be a comprehensive text incorporat-

ing critical analysis of material not readily available else-where. The text begins with chapters that place our currentknowledge into context, describing the magnitude of theproblem. The next two sections describe the basic scienceof ischemia and reperfusion at the cellular, organ system,and organismal levels and the pathophysiology of cardio-pulmonary arrest and resuscitation. The fourth and fifthsections focus on state-of-the-art therapy for cardiopul-monary arrest, first without respect to etiology and thenunder specific circumstances. Contributors were asked toprovide insights that complement widely disseminatedguidelines. The sixth section focuses on the pathophysiol-ogy and therapy of postresuscitation syndrome, a complexdisease state that is increasingly believed to underlie themorbidity and death following resuscitation. The therapysections conclude with summaries intended to bringtogether concepts discussed throughout the chapters oncardiopulmonary resuscitation and postreperfusion syn-drome.

We are at the beginning of what will be a rapid expansionin our knowledge of the pathophysiology and therapy ofsudden death, global ischemia, and reperfusion injury.This text is intended not only to reflect the field, but also toaffect it. We hope to convince the reader that there is arteven in the management of this, the most dire medicalemergency. “Life is short and the art is long.” Consideringthe millions of lives that are cut short and the limits of ourknowledge, the art must be very long indeed.

The Editors

xxxii Preface to the first edition






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