In the Midst of Life

College Healthcare NHS Trust; former Chairman of the Resuscitation Committee, West Hertfordshire Hospitals NHS Trust; and former Vice-President of the British Cardiovascular Society.
     
     
    During the Second World War and in the Korean War the severe injuries inflicted led to surgeons having to extract bullets and shrapnel from many locations in the body including the heart. Previous medical teaching had assumed that any cardiac surgery would be fatal, but many foreign bodies were successfully extracted from the heart without mishap. This led to the dawn of modern heart surgery, and the recognition that many serious heart conditions could be treated. Doctors observed that ventricular fibrillation, a fatal abnormality in cardiac rhythm, could occur in certain circumstances such as during induction of anaesthesia or in the early stages of heart attacks in hearts that were otherwise healthy, ‘hearts that were too good to die’. It was also known that accidental electrocution could induce ventricular fibrillation, and that powerful electric shocks could reverse it. In 1947, the first successful internal defibrillation was performed during an open chest surgical procedure. The first successful external defibrillation was performed in 1955, and in the early 1960s portable defibrillators were developed. In 1967 mobile coronary care units were introduced in Belfast, with successful out-of-hospital defibrillation in patients with acute heart attacks. These developments led to the concept of Emergency Medical Services, to bring medical care to resuscitate the victim at the scene, rather than ‘scoop and run’ to the hospital.
    Ithas been known since the late 19th century that open chest cardiac massage could maintain an effective circulation. Closed chest cardiac massage by compressing the front of the chest against the vertebral spine resulting in compression of the heart and ejection of blood into the arteries was rediscovered in 1960. Mouth-to-mouth ventilation, often used to initiate breathing in a newborn, was shown to maintain oxygenation, and resulted in a switch from more cumbersome manual ventilation techniques. The combination of chest compression and mouth-to-mouth ventilation, or cardio-pulmonary resuscitation, became known as basic life support; this could maintain life for a short time until defibrillation or another definitive procedure was performed.
    Recent developments in cardio-pulmonary resuscitation
    It has long been recognised that the key elements of survival from cardio-respiratory arrest are early recognition and prompt call for help, early cardio-pulmonary resuscitation, early defibrillation and early advanced medical care. Recent developments to aid out-of-hospital resuscitation include Automated External Defibrillators (AED), which use electrode pads attached to the chest to diagnose the heart rhythm. If ventricular fibrillation is confirmed then both screen display and verbal advice is given to press a button and deliver a defibrillating electric shock. These devices have led to first responder defibrillation, public access defibrillation and home defibrillation. If an ambulance has been called, the dispatcher can provide telephone instructions to direct bystanders to initiate resuscitation while awaiting the arrival of the emergency medical services.
    Modern cardio-pulmonary resuscitation – A B C
    The Resuscitation Council (UK) * publishes various guidelines for cardio-pulmonary resuscitation, which are internationally accepted. If someone collapses or is found to be unresponsive, thestandard approach follows the pattern Airway, Breathing, Circulation or A B C. Detailed guidance and flow-chart posters can be found in various publications available from the Resuscitation Council website. * On discovering a collapsed or unresponsive person, the bystander or professional should call for immediate professional help if in hospital, or telephone the national emergency number if out of hospital. Resuscitation is a team effort, and cannot be performed effectively by an individual.
    The first action is to ensure the airway is clear of obstruction from the tongue, mucus or a foreign body. If the circulation is working adequately, the subject is placed in the lateral recumbent or recovery position on their side, which prevents the tongue from obstructing the airway. If there is cardiac arrest, and the patient should remain lying on their back to allow resuscitation, a short plastic tube known as a