A Brief History of Resuscitation After Cardiac Arrest
Cardiopulmonary resuscitation (CPR) is a relatively recent medical innovation, but the history of attempts at resuscitation dates back at least as far as the second century1, when the Greek physician Galen first recorded his failed attempts to inflate a dead animal’s lungs with a bellows. Many centuries passed with little or no progress in resuscitation until the 18th century, when death by drowning became a major public concern, and interest in resuscitation was renewed.
Mouth-to-mouth resuscitation for drowning victims was first recommended by the Paris Academy of Sciences in 1740, and in 1767, a group of concerned citizens in Amsterdam formed the Society for Recovery of Drowned Persons and issued the first set of recommendations for reversing death. Historically, suggested procedures have included the inflation of the victim’s lungs using mouth-to-mouth breathing or a bellows, applying pressure to the abdomen, warming the victim’s body, stimulating the body internally via rectal fumigation with tobacco smoke, and bloodletting. By the early 19th century, the role of electricity in restarting a heart was recognized, and in 1809, the Scottish surgeon Allan Burns first suggested the combination of electrical shock and ventilation as a means to reverse death.
The following century saw the first external defibrillation, and the first successful use of “closed chest cardiac massage,” now commonly referred to as chest compressions. In 1903, the surgeon George Washington Crile introduced the use of epinephrine (adrenaline) during cardiac arrest. Over the next 55 years, stepwise refinements in ventilation, defibrillation, and chest compressions were ultimately codified as cardiopulmonary resuscitation in a seminal paper2 published in the Journal of the American Medical Association.
CPR aims to oxygenate and circulate blood to all organs—especially the brain—while attempting to restart the heart as quickly as possible. Chest compressions and rescue breathing are the familiar core components of CPR. These basic techniques have been augmented by the use of external defibrillators, which deliver electrical shocks that can restart or restore a normal rhythm to a heart that is beating abnormally, along with drugs such as epinephrine (adrenaline), which can help increase blood flow to the heart and brain.
However, with all of these systems in place, CPR is still very limited in its efficacy. Even when expertly performed, CPR can only pump about 25 percent of the blood that the heart normally pumps around the body and only about 20 percent of the normal blood flow to the brain. Since oxygen is carried on hemoglobin molecules around the body, without sufficient blood flow the body and vital organs remain deprived of oxygen and lose function rapidly within minutes. Due to the significant limitations of CPR, many people won’t survive cardiac arrest unless a different approach to resuscitation is developed that goes beyond conventional CPR.
A Need for Innovation Beyond Cardiopulmonary Resuscitation
Treatments for infections, cancer, heart disease, and countless other conditions have been transformed by the adoption of new technologies, techniques, and medications over the past several decades, yet implementation of new practices in the field of resuscitation science has not kept pace. In many cases, resuscitation is managed with a one-size-fits-all approach—namely, CPR—which belies the reality that cardiac arrest patients are extremely heterogeneous. Few other medical conditions impact such a wide range of people, yet treatment approaches are not always customized to individual patient circumstances. A 25-year-old athlete is unlikely to warrant the same approach to resuscitation as an elderly patient with a terminal cancer diagnosis, yet both may receive similar treatment.
Another complicating factor is that cardiac arrest is a rapidly-changing condition that quickly ushers in a range of other complex medical issues as it progresses. By comparison, a fast-moving cancer may change over the course of weeks or months. A rapidly worsening infection may progress in hours or days. Cardiac arrest is a condition that begins as an emergency and changes on a timescale of seconds and minutes, affecting every organ system in the body and becoming more difficult to reverse with each passing minute.
Improvement in patient survival with brain recovery requires more widespread understanding of how cardiac arrest’s complications evolve. It similarly requires implementation of strategies above and beyond CPR to attempt to reverse the condition and its impact on the body.