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Key Clinical Questions

  • image What are the fundamental goals of cardiopulmonary resuscitation?

  • image Which components of resuscitation are considered vital to success?

  • image How can the common pitfalls of resuscitation be surmounted?

  • image What treatments should be instituted immediately upon successful resuscitation?

  • image How should outcomes in resuscitation shape the discussion of advanced directives?

Cardiopulmonary resuscitation is a time-dependent, team-based effort to reverse physiologic events that may culminate in a patient’s imminent death. Biblical and ancient Egyptian hieroglyphic texts allude to mouth-to-mouth ventilation in divine contexts, but other texts indicate Jewish midwives used mouth-to-mouth resuscitation as early as 3300 years ago to revive stillborn children.

In the United States an estimated 375,000 to 750,000 hospitalized patients suffer in-hospital cardiac arrest (IHCA) requiring advanced cardiac life support (ACLS) annually. The incidence of IHCA is estimated to be as high as 1% to2% of all patients admitted to academic hospitals with a prevalence of approximately 65 people per 100,000 nationally.

In-hospital cardiac arrest encompasses a spectrum of disorders from insufficient cardiac output to generate appreciable cerebral perfusion such as arrhythmia or shock to complete cessation of cardiac activity. Vital sign anomalies may often herald impending inpatient cardiac arrest by minutes to hours, but many cardiac arrests occur suddenly and without warning. Acute pulmonary arrest (very common in pediatric populations, often due to airway obstruction; but much less common in adults) may precede IHCA and may occur from sedative or opiate analgesic overdose.

This chapter focuses on (1) the techniques that are essential to successful cardiopulmonary resuscitation especially with attention to good neurologic recovery (as defined by the cerebral performance category of zero or one), and (2) decision making based on patient resuscitation status.


Since standardization of closed chest cardiac massage (CCCM)—that is, chest compressions—was first described systematically in the medical literature in 1960, CCCM has remained the only reliable means of reviving a patient in cardiopulmonary collapse. It is an effective and powerful intervention that, when unnecessarily delayed, may lead to poor patient outcomes. In one study, survival dropped from 34% to 14% if CCCM was delayed even as little as 60 to120 seconds from the time the patient collapsed. Therefore, clinicians must recognize and respond to cardiac arrest immediately for resuscitation measures to be effective.

Advanced cardiac life support combines basic life support (BLS) measures with specific interventions, such as medication, defibrillation, transthoracic pacing, and advanced airway management.

While often considered adequate for institution credentialing purposes, completion of American Heart Association (AHA) courses fails to result in long-term meaningful skill performance. Health care providers’ capabilities to demonstrate appropriate technique for CCCM and capabilities to successfully navigate the steps of cardiopulmonary resuscitation begin to degrade just weeks following course completion. Therefore, for the whole medical team to respond concisely and in a coordinated fashion, clinicians must have extensive medical knowledge, training, ...

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