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Cardiopulmonary Resuscitation.

Section Editor(s): Ellison, NorigHogue, Charles W. Jr MD

Book and Multimedia Reviews: Media Review

Department of Anesthesiology Washington University School of Medicine St. Louis, MO hoguec@notes.wustl.edu

Cardiopulmonary Resuscitation. Ornato JP, Perberdy MA, eds. Totowa, NJ: Humana Press, 2005. ISBN 1-58829-283-5. 764 pages, $185.

Approximately 460,000 people die from heart disease annually in the either in an emergency department or before reaching the hospital. The majority of these deaths are due to coronary artery disease and most are sudden cardiac death. Remarkable progress has been made in resuscitation from cardiac arrest over the last 50 years. A textbook summarizing this progress would be a welcome addition to the library of most physicians. The basic aim of Cardiopulmonary Resuscitation is to provide physicians, nurses, paramedics and other health professionals with the latest information of the science and practice of CPR. The aim is addressed with 37 chapters covering a broad range of relevant topics.

Overall, the strengths of this book are not the reviews of basic treatment algorithms for various causes of cardiac arrest. The reader might be better served in fact by referring to other publications such as those from the American Heart Association on advanced cardiac life support. Any value that Cardiopulmonary Resuscitation might bring to students of CPR is due mostly to the chapters that provide information on ancillary topics of this subject. An example is provided in the first chapter, which is an enjoyable synopsis of the history of resuscitation beginning with the Age of Enlightenment when the view of resuscitation of the dead as only within the realm of God was transformed to a view that scientific discovery could be applied to all facets of nature and life. Seminal events in the evolution of artificial ventilation, CPR, and defibrillation are covered. Likewise, the reader might find chapter 3 useful since it summarizes data from large randomized trials that have evaluated multiple therapies for preventing sudden cardiac death. A nice summary of trials of implantable cardioverter defibrillators (ICDs) for primary and secondary prevention of sudden cardiac death is included. There are other examples of chapters covering topics related to CPR that may not be available from standard publications.

Ventilation and airway management are critical topics in any book on CPR. A concise summary of the physiology of gas exchange during cardiac arrest is well provided in chapter 4. The basis for controversies such as “no-ventilation” CPR for adults is included, as are arguments for and against initial ventilation versus initial chest compression CPR. In contrast, most practicing anesthesiologist and critical care physicians will find the discussion of airway management in chapter 5 superficial. They may further take issue with many statements, such as the assertion that a clinical history should be the guide for choosing a particular laryngoscope blade in cardiac arrest and that nasal intubation requires a spontaneously ventilating patient. A particular concern is that there is no discussion of the American Society of Anesthesiologists’ difficult airway management algorithm. Mention of approaches to preventing and treating pulmonary aspiration would seem appropriate.

Physiologic aspects and controversies about current theories on chest compression are covered in chapters 9 and 10. Frankly, the author of chapter 9 uses a rather informal style in challenging the dogma behind current CPR recommendations about compression rate, depth, hand placement, and pauses for ventilation. Chapter 10 is a more scholarly written chapter that outlines different alternative CPR devices and techniques, including piston chest compression, active compression-decompression, vest CPR, and other techniques. This is followed several chapters later by a discussion about theoretic aspects of defibrillation waveform. Chapter 13 is a particularly strong chapter that addresses public access to automatic external defibrillators (AEDs). The topic is covered extremely well and includes a well organized and informative summary of steps needed to implement community-based and work-based models of AED programs.

There are five chapters on pharmacologic therapy during cardiac arrest. Several of these chapters are well written and informative while others seem to prolong the discussion of some sub-topics that could be easily summarized AND are highly redundant. The information provided, particularly related to how cardiac arrest alters the pharmacokinetics of drugs, is good, but editing errors including statements such as “drugs binding to the adrenergic receptors located inside the cell” are distracting. Chapter 19 provides a thorough discussion of the use of vasopressors in cardiac arrest, including a concise summary of laboratory and clinical studies that have investigated α-adrenergic and ß-adrenergic receptor agonist drugs and vasopressin in cardiac arrest.. Chapter 21 is a good contribution that provides the rationale for current recommendations for antiarrhythmic drugs for cardiac resuscitation, including ample discussion of the data favoring amiodarone and possibly procainamide but not lidocaine in certain circumstances. The discussion of treatment of life-threatening ventricular arrhythmias in patients with cocaine intoxication or with other clinical conditions such as an ICD is useful.

There are several chapters in this book on topics of cardiac arrest under extenuating circumstances due to environmental factors. Chapter 23 provides an overview of cardiac arrest during pregnancy including a summary of the important physiologic changes associated with pregnancy and causes of cardiac arrest unique to the parturient. Included are fetal considerations during CPR and the consideration for emergency C-section to salvage a potentially viable baby. The next three chapters address issues of cardiac arrest due to drowning, lightning strike, and hypothermia. While the chapters discussing the two former topics are very informative yet concise, coverage of environmentally induced hypothermia has deficiencies, including the discussion of acid-base management during hypothermia and rewarming. Cardiac arrest in the trauma victim is appropriately reviewed (chapter 27) from the perspective of providing an update of contemporary topics and not a comprehensive review that would not be possible in a single chapter. Topics covered include volume resuscitation of the patient with hemorrhagic shock, emergency department thoracotomy, and the 3-phase approach of “damage control” surgery for the patient with life-threatening hemorrhagic injuries.

While there has been progress in the survival from cardiac arrests to hospital admission, rates of survival to hospital discharge remain abysmally low (Morbidity and Mortality Weekly Report. CDC/NCHS, 2002, Vol 51, No 6). Myocardial dysfunction and CNS damage are the two primary etiologies of postresuscitation mortality. In chapter 29, experimental and clinical data regarding myocardial dysfunction after cardiac arrest are reviewed. Proposed risk factors for this often transient myocardial dysfunction include duration of cardiac arrest, number of defibrillation shocks, dose and wave form of the shocks, epinephrine dose, and use of buffers.

At first one might question whether the topic of pediatric CPR could be appropriately addressed in a single chapter, especially in a text with primary focus on adults. Chapter 31 successfully provides a summary of unique aspects of cardiac arrest in pediatric patients, including physiologic considerations, epidemiology, manifestations of presentation, drug therapy, and postresuscitation considerations. Another interesting chapter follows providing a critical appraisal of the deficiencies with application of the “chain of survival” approach to “in-hospital” CPR. In addition to pointing out deficiencies with rapid CPR response for “in-hospital” cardiac arrest, the author provides an organizational framework for implementation of recommendations to improve early access and treatment. The next to last chapter addresses ethical considerations related to CPR and discusses withholding of CPR and postresuscitation treatment withdrawal. The author provides debate regarding other contemporary ethics topics, ranging from patient advance directives to the principle of medical futility and family presence during CPR.

The critical reader will find many chapters in Cardiopulmonary Resuscitation frustrating to read. There is much redundancy in addition to the examples already highlighted. While some subjects are certainly of enough importance to cover more than once, there are far too many instances where this is not the case. A second edition would further benefit from better organization of the chapters. For example, chapter 11 well describes novel approaches for CPR training specifically tailored to current theory on adult learning. The placement of this chapter between alternative CPR devices and external defibrillation seems inappropriate.

The authors of Cardiopulmonary Resuscitation are ambitious in attempting to provide a single text for a broad range of readers with differing backgrounds. In reading the text I asked myself the question of what role this book would have for the practicing anesthesiologist or critical care physician? The books strengths, as pointed out, are as a quick reference to ancillary topics of CPR and not so much as a source on the basics of the subject. There are many areas of redundancies, use of informal language, typographical errors, and use of nonstandard abbreviations that are distracting. Furthermore, there is a large variation between chapters in the depth that the individual topics are reviewed. Several of the chapters, though, are outstanding and would serve as a useful reference. Nonetheless, while it is easy to be critical in a review, one must acknowledge the authors’ efforts in the compilation of a comprehensive set of topics relevant to the practice of cardiopulmonary resuscitation.

© 2005 International Anesthesia Research Society