Thread by @CritCareReviews

➡️The history of resuscitation in cardiac arrest is long and fascinating
➡️Over time, four components have emerged to provide the central basis for saving an apnoeic, pulseless person just minutes from death

A thread.....

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➡️Perhaps the earliest reference to artificial breathing comes from the Egyptian Goddess Isis
➡️She resuscitated her dead husband (who was also her brother...) by breathing into his mouth

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➡️The Greek physician Galen was the first to describe artificial ventilation with his famous quote:
➡️"If you take a dead animal & blow air through its larynx through a reed, you will fill its bronchi and watch its lungs attain the greatest distention"

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➡️Over time scientific focus was misplaced, with attempts at supported breathing becoming less insightful
➡️Efforts at artificial ventilation with tobacco smoke, using a bellows placed in the anus, proved disappointing

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➡️In 1732, the British surgeon William Tossach resuscitated coal miner James Blair using mouth-to-mouth ventilation
➡️"there was not the least pulse in either Heart or Arteries, & not the least Breathing could be observed"
➡️By 4 hours, the miner was conscious & walking

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➡️In 1782, the Royal Humane Society advocated the use of bellows to replace mouth-to-mouth ventilation, which was deemed "vulgar" by the English members
➡️Their recommendation included the use of cricoid pressure to prevent gastric aspiration

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➡️In 1958, Peter Safar and James Elam, two American anesthesiologists, demonstrated the efficacy of mouth-to-mouth ventilation by performing it on paralysed volunteers.

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➡️In 1628, the English physician William Harvey published his treatise de Motu Cordis describing the circulation
➡️The heart pumped blood to organs via arteries, which returned via veins
➡️As this contradicted the centuries old paradigm of Galen, Harvey was ridiculed

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➡️Attempts to provide an artificial circulation included placing a patient over a barrel and rolling it, or over a horse, which ran generating episodic vertical force on the chest
➡️However, these manoeuvres were likely intended to produce chest movement for ventilation

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➡️In 1883, Franz Koenig described external cardiac massage by pressing at the expected site of the apex beat at 30-40 beats per minute 
➡️This restored spontaneous circulation in a patient who had cardiac arrest accidentally induced by chloroform anesthesia

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➡️Mechanical chest compression devices first appeared in the early 1960s, beginning with the “electro-pneumatic machine” of Harkins & Bramson
➡️It was quickly followed by other machines, including the “Beck-Rand external cardiac compression machine” of Safar in 1963

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➡️Luigi Galvani, an Italian physicist in the late 1700s, thought he had discovered a means of restoring life
➡️Using electrical currents, he stimulated amputated frog legs to move
➡️Galvani envisioned a means of resuscitating the dead with electricity

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➡️In 1802, Galvani's nephew, Giovanni Aldini, promoted his uncle's work in London
➡️He acquired the body of a recently hung man & applied electrical currents
➡️Aldini astounded his audience by stimulating eye opening, facial movements, head turning and a clenched fist

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➡️After opening the deceased's chest, Aldini tried to restart the heart with directly applied electricity, but was unsuccessful
➡️One member of the audience was reported as dying that night at home from shock

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➡️Mary Shelly, the author of Frankenstein, was influenced by these report of electrically induced movements of the dead.
➡️Anthony Carlisle, a medic who attended these exhibitions, was a good friend of her father
➡️Shelly hid under the table to hear these stories

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➡️In 1940, the American physiologist Carl Wiggers, demonstrated the how an externally applied electrical current could stop a heart fibrillating

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➡️In 1947, American cardiac surgeon Claude Beck successfully internally defibrillated a 14-year-old boy who suffered ventricular fibrillation during a thoracoplasty for a congenital chest deformity
➡️This occurred after 45 minutes of cardiac massage

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➡️In 1956, American Cardiologist Paul Zoll reported the first successful closed-chest external defibrillation in a man with recurrent syncope that caused ventricular fibrillation

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➡️Belfast cardiologist Frank Pantridge, working at the Royal Victoria Hospital, was the first to introduce a mobile defibrillator (1965) and out-of-hospital cardiac resuscitation service (1966)
➡️The defibrillator weighed 70 lbs & was powered by the ambulance engine

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➡️In 1885, George Oliver and Edward Schäfer of the University of London discovered an adrenal gland extract which acted on the blood vessels & heart, causing arteriolar constriction & increases in heart rate, ventricular contraction & blood pressure

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➡️In 1897, the active compound was isolated by John Abel, at John Hopkins University, & called epinephrine
➡️In 1900, Japanese biochemist Jōkichi Takamine also purified an adrenal compound he named adrenalin
➡️British physiologist Starling used the term adrenaline

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➡️Thus began the old trans-atlantic naming debate
➡️Interestingly, the derivations of the names differ too
➡️adrenaline derives from the latin roots “ad” and “renes” (near the kidney)
➡️epinephrine from the Greek roots “epi” and “nephros” (on the kidney).

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➡️The administration of adrenaline in cardiac arrest was first attributed to Crile and Dolley in 1906
➡️Pearson and Redding described perhaps the first animal study demonstrating the effectiveness of adrenaline for the management of canine cardiac arrest in 1963

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➡️Despite a long history of the development of the various elements of modern CPR, global outcomes for people suffering out-of-hospital cardiac arrest remain poor
➡️Just 29.7% survive to hospital admission
➡️8.8% survive to hospital discharge

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➡️In 2015, Bernard reported the results of the observational CHEER study, describing an incredible 54% survival with good neurological recovery in 26 patients with prolonged cardiac arrest
➡️Were the 4 key elements of resuscitation going to be added to?

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The intervention consisted of
➡️mechanical CPR
The intervention consisted of
➡️mechanical CPR
➡️intra-arrest induced hypothermia
➡️ECMO
➡️early reperfusion PCI strategy

➡️ECMO commenced at a median of 56 mins post collapse
➡️96% obtained ROSC

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➡️In 2020, Yannopoulos reported the randomised controlled ARREST trial, comparing ECMO facilitated resuscitation with standard ACLS treatment in 30 patients with OHCA & refractory ventricular fibrillation
➡️1/15 ACLS vs 6/14 ECMO survived to hospital discharge

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➡️Despite the encouraging results, these two studies were small
➡️Enter the Prague OHCA study, investigating mechanical chest compression, intra-arrest head cooling, transport to hospital, extracorporeal life support and immediate coronary reperfusion

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Survival with good neurological outcome at 180 days occurred in
➡️31.5% in the invasive strategy group
➡️22.0% in the standard resuscitation group
Odds ratio 1.63; 95% CI, 0.93 to 2.85

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➡️Will eCPR be the latest addition to our choice of interventions to manage OHCA?

➡️Join us at #CCR22 to hear Jan Belohlavek (@jan_belohlavek) present the Prague OHCA study and find out!

➡️criticalcarereviews.com/meetings/ccr22

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@jan_belohlavek CCR22 is supported by:

 ➡️@MyIntensiveCare
 ➡️@norsomedical
➡️@VisitBelfast
 ➡️@belfastcc
 ➡️@TourismNIreland

@jan_belohlavek @MyIntensiveCare @norsomedical @VisitBelfast @belfastcc @TourismNIreland References