Resuscitation


The term resuscitation, as used by medical personnel, means both trying to revive those who have gone into cardiac arrest (cardiopulmonary resuscitation or CPR) and any intense intervention that will prevent imminent death. Such interventions usually include helping people get oxygen and breathe, restoring the amount of fluid and blood in their system, keeping their hearts beating effectively, and halting any process that is interfering with their ability to survive. Some of these processes merge almost seamlessly with the process of "life support."

The simplest resuscitation procedure to assist oxygenation and breathing is to position the head and body so that the airway (e.g., nose, mouth, pharynx, and trachea) remains open. In some cases, clinicians may insert an oral or nasal airway device to help keep it open while patients continue breathing on their own. If the clinician believes that they may stop breathing, do not have control of their airway, may aspirate stomach contents, or have stopped breathing (apnea), he or she will usually put a tube into the trachea. These endotracheal tubes, made of clear polyvinyl, protect the airway or are used to attach patients to a mechanical ventilator (sometimes referred to as a respirator). In some cases, clinicians cannot pass the tube orally or nasally into the trachea because of damage to the area, swelling, or a person's unusual anatomy. In those cases, the clinician uses an emergency surgical technique, a cricothyrotomy, to pass the tube into the trachea through a hole made in the neck just below the thyroid cartilage (Adam's apple). An alternative surgical technique, more difficult to perform in emergencies, is the tracheotomy, in which physicians insert a smaller "trach" tube low in the neck.

Once the clinician places a tube in the trachea, patients may simply have humidified oxygen administered through the tube if they are still breathing adequately on their own. More commonly, they will first be "bagged" by hand, using a bag-valve mask, and then attached to a mechanical ventilator. These ventilators force oxygenated air into the lungs in the amount and at a pressure appropriate for each patient.

Sometimes, most frequently after trauma, one or both lungs collapse and may accumulate blood around them in the "pleural space." This often causes patients to have difficulty breathing. In some cases, it may decrease the oxygen getting into their systems and diminish the ability of their hearts to pump blood. In such cases, the clinician must immediately place a tube (chest tube or thoracostomy tube) into the pleural space through the chest wall. He or she then connects it to suction and removes the air and blood.

IVs, Fluids, Blood

Another common resuscitation measure is to administer fluids into a patient's veins. This helps improve the blood flow and thus the amount of oxygen and nutrients available to the body's tissues, thereby facilitating the cells' ability to discard waste products. Used for patients who are dehydrated, bleeding, or who simply cannot take adequate amounts of fluid orally, this procedure often includes inserting intravenous catheters with large internal diameters (large-bore IVs), into the arm, foot, neck, shoulder area, or groin. Through these IVs, medical personnel may administer large amounts of fluids, such as Normal Saline, Ringers Lactate Solution, plasma, or blood.

During resuscitations, medical personnel may place a large monitor/infusion catheter, such as Swan-Ganz or triple-lumen catheter, to assess a patient's state of hydration, heart functioning, and the amount of fluid in the lungs. Personnel may also place a catheter into the bladder to assess how the patient is producing urine, which is a simpler measure of how well the kidneys are functioning and an indirect measure of a patient's fluid status.

Heart

Clinicians often must concentrate on correcting cardiac (heart) abnormalities while resuscitating a patient. The most obvious and dramatic measure is cardiopulmonary resuscitation (CPR), in which clinicians pump on the sternum to generate circulation of blood. Resuscitation, however, may include many other activities before the clinician resorts to this procedure.

One of the most common resuscitative measures is to administer antiarrhythmic drugs to stop abnormal heart rhythms, such as overly rapid or slow heartbeats. In either case, the heart is not pumping effectively and so is not supplying enough blood to the brain and the rest of the body. The drugs may also be used when the heart is producing beats from an abnormal site, such as from the ventricle. This can either be an ineffective rhythm (not producing good blood flow) or a forewarning of cardiac arrest and so must be corrected. If the antiarrhythmic drugs prove ineffective, the patient may require an electrical shock to restore the heart to a normal rhythm. This can either be synchronized with the heartbeat (often at a relatively low voltage), called "cardioversion," or at higher energies and unsynchronized, called "defibrillation." Defibrillation is generally used to resuscitate patients in cardiac arrest.

Other measures to improve heart activity during resuscitations include inserting a temporary pacemaker, administering thrombolytics (clot busters), performing angiography, and doing pericardiocentesis. Temporary pacemakers, often placed through the same large IV sites as are used for fluid resuscitation, are inserted when the heart is beating too slowly to be effective, or to override an abnormally fast and life-threatening heart rate that they cannot stop any other way. Clinicians use thrombolytics, one of a class of medications, to help open coronary arteries during or immediately after a heart attack. If these drugs prove unhelpful (or sometimes even if they are working), physicians may take patients to the cardiac catheterization laboratory for coronary angiography. This procedure visualizes and opens coronary (heart) vessels and is particularly useful in patients in cardiogenic shock. In some patients, a sudden accumulation of blood or fluid around the heart (pericardial tamponade, often due to trauma) causes their heart to pump ineffectively. In those cases, physicians may need to put a needle into the sac around the heart to withdraw enough fluid, usually less than 50 cc, so that the heart can again pump normally. After this procedure, called pericardiocentesis, cardiac surgeons generally must take patients to the operating room for a definitive procedure.

Treating Underlying Problems

An essential step in resuscitations is for clinicians to definitively remedy underlying problems. Among other things, this may include stopping bleeding, halting or preventing infection, controlling blood pressure, and treating poisoning.

While external bleeding can be easily controlled with direct pressure, surgeons often need to operate on patients to halt bleeding in the chest, abdomen, or head. They may perform laparotomies (abdominal operations), thoracotomies (chest operations), and craniotomies (entering the skull) if bleeding does not stop spontaneously. Patients with continuing bleeding, such as from a torn artery, will die without such surgery. When necessary, neurosurgeons also perform craniotomies to relieve pressure on the brain from blood that has accumulated within the skull. In some cases, rather than operating, radiologists control bleeding with small pledgets of material that they put into the vessels through arterial catheters. In an even simpler procedure, orthopedic surgeons may slow or stop bleeding by stabilizing fractured bones (particularly the pelvis and femur). Physicians administer a variety of medications and clotting factors to reverse the process in patients bleeding due to hemophilia, liver failure, disseminated intravascular coagulation (DIC), platelet dysfunction, or other abnormalities related to the blood-clotting system. Unlike mechanical interventions, treatment for bleeding disorders may last for days until patients improve.

Infections still cause many deaths, and not all infections can be treated effectively. Yet, when possible, clinicians treat or try to prevent infections in patients undergoing resuscitations. For example, patients with perforated intestines may need broad-spectrum antibiotics administered both before and after surgery. Those with open fractures need similar antibiotic coverage, both to prevent and to treat infections. These patients, if they are not already immunized, also must receive immunizations against tetanus.

Patients undergoing resuscitation often have an altered blood pressure. Blood pressure is a measure of the effectiveness of cardiac activity (the pump), the distention and porosity of the blood vessels (the pipes), and the amount of blood in the circulatory system (fluid). The brain (control station) regulates these elements, directly or indirectly. When illness or injury alters any of these factors, blood pressure moves out of the safe and healthy range. Low blood pressure (hypotension) usually accompanies serious illness. Clinicians must frequently administer intravenous vasopressors to such patients to help elevate their blood pressure and to assure that adequate blood is flowing to their vital organs. In some cases, blood pressure is too high, a development that can be accompanied by or lead to strokes, heart attacks, dissecting aortas, and other life-threatening events. Physicians must use antihypertensive drugs to help resuscitate such patients.

Resuscitations often occur in patients who have taken overdoses of dangerous medications or illicit drugs, or who have come into contact with a dangerous poison. Treatment for such events includes using medications to reverse a drug's effect, when possible. There are few specific antagonists for common drugs, with the exceptions being narcotics, benzodiazepines (i.e., Valium) and Tylenol. Other antidotes also exist for some exotic poisons, such as cyanide, snake and insect toxins, heavy metals, and industrial chemicals similar to those used as warfare agents. Treatment for most drug overdoses, however, employs measures to support the affected systems, especially breathing, the heart and blood pressure, and the kidneys. Treatment often includes using charcoal to bind any of the medication still in the gut or washing off any toxin that is on the skin. Occasionally, clinicians must use renal dialysis or other supportive measures. Patients may also have severe reactions to a normal medication dose, an event termed "anaphylaxis," including a closed airway, impaired breathing, and falling blood pressure. Resuscitation involves supporting each of these systems.

Other resuscitations involve patients with severely abnormal temperatures (usually from environmental exposure or medications), acid-base and electrolyte abnormalities (sodium, potassium), and protracted seizures. These may occur alone, or in combination with other problems that also require resuscitative efforts and aggressive, organ-specific support while the clinician attempts to treat the problem's underlying cause.

Calling for Help, Viewing Resuscitations, and Stopping Resuscitative Efforts

In many U.S. jurisdictions, ambulance personnel must attempt resuscitation when patients are not clearly dead. Many people have received unwanted resuscitation attempts after their loved ones simply tried to notify authorities that the person had died. Most states have statutes or protocols whereby individuals can prevent unwanted resuscitation through an out-of-hospital Do Not Resuscitate (DNR) order or an advance directive that is recognized by ambulance personnel. Often referred to as "orange forms" because of their common color, prehospital advance directives allow medics to not begin resuscitative measures in cases of cardiac arrest. They are usually used for homebound, hospice, and nursing home patients.

The paramedic profession was formed primarily to implement new cardiac resuscitation methods and to "raise" the clinically dead from cardiac arrest. Yet, for patients on whom medics perform out-of-hospital CPR, only about 1 to 7 per every 100, on average, are discharged from hospitals alive. In those who have a cardiac arrest after trauma and are brought to a hospital, only about 5 per 200 survive, with only about 3 per 200 being able to function, meaning that many patients are pronounced dead on the scene, either after failed resuscitative efforts or where CPR was not begun because it would have been futile. As paramedic Mike Meoli wrote, "No matter how quickly we are summoned or how well we perform, the usual outcome of a CPR call is the same: death" (1993). While the phrase "dead on arrival" once meant that no resuscitation was attempted, the media now often use it for many patients who actually died in the emergency department, sometimes after a resuscitation attempt.

Family members who arrive during resuscitations should be allowed in the resuscitation area, if they wish. Senior staff (nurse, social worker, chaplain) should quickly brief them on what they will see and then accompany them throughout the procedure. When survivors witness resuscitative efforts, the resuscitations often run more smoothly (and more quietly), and the survivors have fewer problems accepting both the death and the notion that significant efforts were made to save their loved one. Studies show that they do not disrupt the resuscitative efforts. Subsequently, they also have lower levels of anxiety, depression, posttraumatic avoidance behavior, and grief. If the family is present when it is clear that resuscitative efforts have been unsuccessful, this should be explained to the family before supportive measures are discontinued, to provide them with a chance to "say goodbye" before death is pronounced.

Patients are dead when a physician declares them dead. Because errors are occasionally made, care must be taken to assure that patients declared dead are, in fact, dead. Such precautions also prevent implementing unnecessary resuscitative efforts. These errors can be avoided by checking vital signs and observing isoelectric cardiac activity in at least three ECG readouts (leads). This can be omitted when anatomical injuries (i.e., decapitation) are incompatible with life.

Prehospital personnel (EMTs, paramedics) should not begin or should halt resuscitative efforts if it would jeopardize their safety, if they cannot physically continue, or if there is a valid prehospital advance directive specifying not to resuscitate. This also applies when any of the following are present: rigor mortis, livor mortis, evidence of decomposition, bodies burned beyond recognition, or injuries clearly incompatible with life. Hospital personnel should not begin or should stop resuscitative efforts when the patient has declined them, in situations in which inadequate resources exist to treat all patients (e.g., disasters), or when appropriate resuscitative efforts have not been effective. Following resuscitation, physicians have two responsibilities: pronouncing the person dead and notifying the survivors.

See also: Advance Directives ; Do Not Resuscitate ; End-of-Life Issues ; Life Support System ; Necromancy ; Persistent Vegetative State

Bibliography

Iserson, Kenneth V. Death to Dust: What Happens to Dead Bodies?, 2nd edition. Tucson, AZ: Galen Press, 2001.

Iserson, Kenneth V. Grave Words: Notifying Survivors of Sudden, Unexpected Deaths. Tucson, AZ: Galen Press, 1999.

Iserson, Kenneth V. "Terminating Resuscitation." In Peter Rosen, Roger M. Barkin, Stephen R. Hayden, Jeffrey Schaider, and Richard Wolfe eds., The 5-Minute Emergency Medicine Consult. Philadelphia: Lippincott Williams and Wilkins, 1999.

Iserson, Kenneth V. "A Simplified Prehospital Advance Directive Law: Arizona's Approach." Annals of Emergency Medicine 22, no. 11 (1993):1703–1710.

Lombardi, Gary, John E. Gallagher, and Paul Gennis. "Outcome of Out-of-Hospital Cardiac Arrest in New York City: The Pre-Hospital Arrest Survival Evaluation (PHASE) Study." Journal of the American Medical Association 271, no. 9 (1994):678–683.

Meoli, Mike. "Supporting the Bereaved: Field Notification of Death." Journal of Emergency Medical Services 18, no. 12 (1993):39–46.

Robinson, Susan Mirian, Sarah Mackenzie-Ross, Gregor L. Campbell-Hewson, Conor Vincent Egleston, and Andrew T. Prevost. "Psychological Effect of Witnessed Resuscitation on Bereaved Relatives." Lancet 352 (1998):614–617.

KENNETH V. ISERSON



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