CARDIO -PULMONARY RESUSCITATION
Two Years Experience in a New Teaching Center -
HISHAM FARAG* AND MOHAMED NAGUIB**
Since the introduction of external cardiac massage in 1960 by Kouwenhoven et al.1, cardiopulmonary resuscitation (C.P.R.) services have been established in the majority of world hospitals. The concept, however, is still new for hospitals in Saudi Arabia.
King Fahd Hospital, inaugurated in 1981, is the teaching hospital for the Eastern Province of Saudi Arabia. It is a well equipped tertiary referral hospital. The need for a CPR policy was therefore obvious. A CPR Committee was founded to formulate policy, teach and supervise the CPR Team.
This is a retrospective report on the CPR project established at King Fahd Hospital in the initial period of two years (Sept. 82 - Sept. 84). The outcome of CPRs performed and evaluation of the quality of service offered will be presented.
The CPR Committee at King Fahd Hospital consists of an anesthesiologist, cardiologist, surgeon, intensive care nursing supervisor and a nurse tutor. The Committee adopted the recommendations of the American Heart Association2 for the execution of this project.
A detailed protocol was prepared to outline the duties and responsibilities of each member of the CPR team. The anesthesiologist, the team leader, is responsible for the patient's airway, ventilation and establishing IV line. The cardiologist manages the cardiac dysrhythmias. Experienced ICU nurse helped in preparing drugs and equipment. Nurses from the ward assist in applying external cardiac massage, recording medications and procedures on the CPR form.
The CPR form was made available and in triplicate. The original is kept in the patient's chart, a copy sent to the pharmacy for restocking used drugs, and a copy sent to the CPR Committee for review.
Nine mobile crash carts were distributed to strategic areas in the Hospital. One was permanently placed in each of the following units: Operating Room, Emergency Room, X-ray Department, Burn Unit, Intensive Care Unit and Delivery Room. The medical and surgical floors share carts. Crash carts were located in wards where cardiac arrests were more likely to occur. Vertical movements between floors were not allowed, but only between wards on the same floor. When a cart had to be shared between wards, the responsibility for maintenance and checking was defined and restricted to a particular ward. The carts were checked daily, and after use, restocked with drugs and other disposable items according to a checklist kept on the cart and signed every time a check was made.
Between Sept. 1982 and Sept. 1984, CPR was attempted on 120 cases of cardiac or respiratory arrest. Rarely, and upon the written order of the attending physician, was CPR withheld on medical grounds e.g. terminal cancer, brain death.
The teaching of CPR to doctors and nurses is another important target of the CPR Committee. Steps have already been taken towards the achievement of this goal. All nurses, as soon as they arrive, are given a course in basic life support. This is repeated annually. Anesthesia interns and residents get a course in both basic and advanced life support. Planning is underway to hold advanced cardiac life support for all Hospital doctors.
There were 146 calls for 120 patients in the two-year period under review. Of these patients, 49 (40.8%) were successfully resuscitated of which 8 (6.6%) were subsequently discharged home and 41 died in the Hospital. Table 2 shows details of the 8 patients who were successfully resuscitated. The mean age of all patients was 58.5 21 (S.D.) years. Children were not included, as the Pediatric Department runs an independent CPR team. The majority of resuscitations lasted less than 30 minutes. 34 calls lasted more than 30 minutes.
Details of Successful Resuscitations (8 patients)
AGE SEX DIAGNOSIS LOCATION CAUSE DURATION
OF ARREST OF RESUS-
30 M HEAD INJURY I. C. U. RESPIRATORY 40 MINUTES
19 F MYOCARDITIS I.C.U. V.F. 22 MINUTES
50 F C.H.F. I.C.U. RESPIRATORY 22 MINUTES
27 M C.H.F. I.C.U. V. T. 30 MINUTES
61 M CARDIAC FAILURE E. R. V.F. 35 MINUTES
33 M BLEEDING
ESOPHAGEAL VARICES O.R. ASYSTOLE 20 MINUTES
50 M C.A., ESOPHAGUS 0. R. V.F. 15 MINUTES
60 F C.V.A, X-RAY V.F. 28 MINUTES
The commonest cause of cardiac arrest was cardiovascular disease (40%) followed by head injury (19%) due to road traffic (Table 3).
As to location of CPR performance, 102 calls were in the ICU (Table 4).
Ventricular tachycardia and ventricular fibrillation were the presenting feature in 52 calls. Asystole and respiratory arrest were responsible for 41 % and 7% respectively (Table 2).
Recent reports of CPR had an overall survival of 8-32%4.5. In the present series, 6% (8 patients) were successfully managed and discharged home (Table 2). This relatively low incidence of success in our series could be due to the fact that resuscitation was attempted in 32 patients (26%) who had irreversible pathological conditions. The concept of <<not to resuscitate>> such patients had not evolved yet in our Institution, and doctors were therefore reluctant to withhold resuscitation. CPR has been practiced for more than 20 years and enough evidence, medical and legal, has accumulated to suggest that a specialist can decide to withhold resuscitation if the disease process is judged to be irreversible3.
Causes of Cardiac Arrest
No. of Patients
CARDIOVASCULAR DISEASE 49 (40.8%)
HEAD INJURY 23 (19%)
CEREBROVASCULAR ACCIDENTS 9
HEPATIC FAILURE 11
RESPIRATORY FAILURE 9
RENAL FAILURE 4
MALIGNANT DISEASE 15
Locations of CPR Calls
No. of Calls
INTENSIVE CARE UNIT 102 (69.8%,
GENERAL WARDS 25 (19%)
EMERGENCY ROOM 14 (9.5%)
X-RAY DEPARTMENT 2 (1.3%)
OPERATING ROOM 3 (2.0%)
Our results could have been better if nurses were allowed to take a more active part in the initiation of advanced cardiac resuscitation. Snoden et al6 noted that the best survival rates in their series was in patients who received prompt initial resuscitation and defibrillation by the nursing staff. Furthermore, it is important to note that high success rates in other series may be due to the inclusion of patient not suffering from true circulatory arrest7.
The survivors that were resuscitated in our series occurred in areas with high doctor-nurse / patient ratio, reflecting the importance of the closer surveillance given to such patients. All of the survivors had an intact mental status, and none of them had fractured ribs or any other complications due to CPR. Age alone did not appear to influence prognosis for survival following CPR4,5
The commonest cause of cardiac arrest in the present series was due to coronary heart disease (40.8%) (Table 3). Peatfield et al4 reported an incidence of 54% and Bedell et al.5, 39.9%. Asystole is associated with less favourable prognosis compared to ventricular tachycardia and ventricular fibrillation. Of the present survivors, only one patient had asystole whereas 5 patients had ventricular tachycardia and ventricular fibrillation (Table 2).
The mean age in our series is low (58.5 ± 21 mean ± S.D.) compared to other series of 70 years5 and 60.6 years6. This is probably related to the predominance of the young patients who came in with head injury due to the high prevalence of road traffic accidents in our community.
CPR has become an internationally accepted life-saving procedure and should be taught in every medical unit and first-aid facility. Provisions should be made in every medical institution for regular courses, repeated annually, for the medical and nursing personnel. Regardless of specialty, all physicians should be able to perform basic and advanced life support.
Doctors involved in hospital resuscitation teams should be properly trained in the use of the equipment available and the technique used must be carefully supervised.
Cardiac arrest calls at a new tertiary referral hospital are reviewed over a two-year period. The formation of a committee responsible for conducting and supervising the resuscitation team is outlined. There were 146 calls for 120 patients. 49 patients (40.8%) were initially resuscitated and 8 (6.66%) of these were discharged home. Age did not appear to influence the prognosis. Coronary heart disease was the commonest pathology (40%) and ventricular fibrillation and tachycardia were the leading causes of cardiac arrest.
1 . KOUWENHOVEN W.B., JUDE J.R.. KNICKERBOCKER G.G., Closed-Chest Cardiac Massage. JAMA 173:1064-7, 1960.
2 . MC INTYRE K.M., LEWIS A.J., Textbook of Advanced Cardiac Life Support. American Heart Association, 1983.
3 . MC INTYRE K.M., Medical Aspects of Cardiopulmonary Resuscitation and Emergency Cardiac Care.
In: Mc Intyre K.M., Lewis A.J., eds. Textbook of Advanced Cardiac Life Support. American Heart Association, 1983.
4 . PEATFIELD R.C., DEANNA TYLOR, SILLET R.W., Mc NICOL M.W., Survival after Cardiac Arrest in Hospital. The Lancet 1223-25, June 11, 1977.
5 . BEDELL S.E., DELBANCO T.L., COOK E.F., EPSTEIN F.H., Survival after Cardiopulmonary Resuscitation in the Hospital. N. Eng. J. Med. 309:569-76, 1983.
6 . SOWDEN G.R., ROBINS D.W., BASKET P.J.F., Factors Associated with Survival and Eventual Cerebral Status Following Cardiac Arrest. Anaesthesia 39:39-43, 1984.
7 . MESSERT B., OUGLIERI C.E., Cardiopulmonary Resuscitation: Perspective and Problems. Lancet 2:410-2, 1976.