Cardiac arrest may be defined as the abrupt cessation of cardiac function leading to a precipitous decrease in cardiac output and ensuing circulatory collapse. Sudden cardiac death is a leading cause of mortality, with three million annual deaths worldwide and more than 300,000 annual deaths just in the United States.1,2 One-quarter of these patients are younger than 65 years of age.3 The most common cause of sudden cardiac death remains out-of-hospital cardiac arrest (OHCA). Ventricular fibrillation (VF) is a common dysrhythmia that presents as cardiac arrest and is the most common malignant arrhythmia in adults with OHCA.2 As expected, diagnosis and management of this lethal disease has remained a priority for decades, with cardiopulmonary resuscitation (CPR) being advocated as a dependable treatment for OHCA. The CPR guidelines were established in 1966, and the most recent version was released in 2005.4-8 Nevertheless, the reality remains that survival rates from OHCA are abysmal, hovering around 1% to 7% in the major cities of the United States despite repeated changes in the emergency cardiac care (ECC) guidelines.
This chapter outlines our current state of understanding of the disease process and the management strategies that are currently available to us. We will also discuss a new therapeutic modality: cardiocerebral resuscitation (CCR), which has recently been shown in some reports to have improved outcomes compared with traditional CPR. CCR emphasizes uninterrupted chest compressions as a priority but offers an inclusive alternative that attempts to enhance survival from this lethal disease.
The initial attempts to treat cardiac arrest focused on chest compressions. Closed chest defibrillation and closed chest cardiac massage were first described in the 1960s.9-11 These initial reports suggested survival rates in excess of 70%; therefore, they were rapidly adopted for in-hospital cardiac arrests and OHCAs.4 Interestingly, in this initial publication, some patients were treated with chest compression without positive pressure.9 However, with time, ventilation gradually became ingrained as an essential pillar of cardiopulmonary resucitation.12 There were several reasons that positive-pressure ventilation was touted as being indispensable to CPR:
Volunteers who underwent respiratory arrest with temporary administration of paralytics were noted to have rapid deterioration of the blood gases.13
Gasping was not thought to be common in patients with cardiac arrest.
There was an assumption that the lay public could not reliably distinguish respiratory arrest from cardiac arrest (and would therefore fail to ventilate the victim who did undergo respiratory arrest).
Historical data derived from resuscitation attempts on drowning victims.12
Given the prevalence and lethality of the disease, the American Heart Association (AHA) spearheaded the dissemination of CPR and ECC information to health care professionals and the lay public in the 1970s. In 2000, the Guidelines for CPR and Emergency Cardiac Care were published by the AHA in collaboration with the International Liaison Committee on Resuscitation (ILCOR).6 It was the first time that national and international guidelines were ...