New horizons (Baltimore, Md.)
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Victims of out-of-hospital cardiac arrest in most communities are not the beneficiaries of an optimal healthcare system response capable of providing survivors who live to hospital discharge. The public at large, including family members and bystander witnesses of cardiac arrest, must be expected to participate in this optimal response capability. ⋯ Emergency medical services systems need to devise innovative approaches to rapid provision of automated external defibrillation, in many cases no doubt outside the boundaries of traditional means of delivery of this intervention. Finally, it is likely that targeted responders among the public will be participants in a public access defibrillation approach to dealing with sudden cardiac death.
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Researchers face a number of constraints to human resuscitation research. To overcome these constraints we must first recognize them and then work to develop solutions. The constraints include history, which tends to create a standard-of-care aura around practices that have not been confirmed by valid research. ⋯ Currently, human resuscitation research does not rank high on the funding priority list of our major funding agencies. This requires an organized approach to generate funding support and requires strong, coherent research proposals. Despite these constraints, we face many opportunities to improve survival from cardiopulmonary emergencies.
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Efforts to minimize hypoxic injury may gain insight from considering treatments directed at different levels of biological organization, from cellular physiology to societal norms. At the cellular level, it appears that cells do not actually die during ischemia, but rather during reperfusion or resuscitation. Free radicals are implicated because antioxidants reduce cell death from ischemia/reperfusion, but typically fail to protect when only given during reperfusion. ⋯ Bystander CPR suffers from poor quality of performance and from lack of initiation due to concern over disease transmission. The technology for rapid public defibrillation exists, yet is not commonly employed. Collectively, survival likelihood may be predicted with a multifactor equation which may be useful as we develop future therapies.
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The instruction of cardiopulmonary resuscitation (CPR) faces new challenges. With the current poor resuscitation outcomes of victims of sudden death syndrome, the impetus to include early defibrillation as a basic skill for laypersons imposes the need to simplify CPR instruction and reduce the time required to teach this technique. The exploration of an alternative paradigm has gained both public and academic interest. ⋯ Additional debate exists with respect to maintaining the current traditional training methods or the use of new media such as video-based instruction, interactive computer-based software, and public service announcements. To answer any one of these questions we are tasked with having to objectively document not only retention and performance of learned skills, but the ultimate impact that any of these elements have on survival and outcome. This has to balance against the ongoing scourge of sudden cardiac death, which claims the lives of 350,000 Americans each year.
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Early milestones of resuscitation research culminated in the 1950s in the documentation of modern external cardiovascular resuscitation (CPR) steps "ABC," followed by advanced and prolonged life support. Implementation of guidelines has been suboptimal. Self-training of the public in life-supporting first aid, including CPR-ABC-available since the 1970s-is only now being re-evaluated and hopefully implemented. ⋯ There was an appropriate emphasis on fully automatic external defibrillation by lay rescuers, which has the potential for a breakthrough effect. Wolf Creek V, which we recommend to be conducted around the turn of the millennium, should focus on the pathophysiology and therapeutics of respiratory, cardiac, and cerebral resuscitation in general, and on organ, cellular, and molecular level research into how cells, organs, and organisms die, and how acute dying processes might be reversed. What to teach whom and how should be left to guideline conferences of agencies.