24 - Sequence of therapies during resuscitation: application of CPR

Summary

Introduction

Intuitively, the order in which therapies are applied seems likely to be important for the treatment of many conditions. In the emerging field of cardiac resuscitation such ordering was initially established on the basis of empiricism and on interpretation of animal experiments. In this chapter, a reexamination of two long accepted therapies addresses the possibility that changes might be considered for the sequence of actions in carrying out basic CPR and in the delivery of precordial shocks for ventricular fibrillation.

The worldwide acceptance of the ABC sequence (airway, breathing, circulation) for CPR is impressive. Similarly the emphasis on rapid defibrillation would seem to be logical and has borne the test of time. On the other hand, there is scant evidence for the strict adherence to treatment guidelines in terms of what comes first.

An important reason for reexamining the sequence of steps is that the ground rules have changed over the course of some 40 plus years. CPR was initially developed for use by physicians,nurses,and specially qualified emergency rescue workers. However, resuscitation is nowcommonly initiated outside the hospital, often by persons with minimal—or even no—formal training in the application of CPR.Notably, the widespread use of automated defibrillators (AEDs) has provided opportunities for new approaches. And clearly, the call for evidence-based medicine is increasingly heard.

The ABC sequence for basic CPR

Prior to 1960, attempts to alter the outcome of cardiac arrest entailed thoracotomy, direct cardiac compression, and internal defibrillation. Whereas open-chest resuscitation could be effective in controlled environments, survivors of such an approach were uncommon.