Cardiac Arrest – The Science and Practice of Resuscitation Medicine 2nd Edition PDF
18.16 MB PDF
Death in the midst of life is the adversary of physicians. For millennia the loss of signs of life was considered the victory of death. Students were taught, and people believed, that once patients had succumbed they were beyond the healing arts. On a historical time frame, only relatively recently have physicians regularly attempted to wrest such patients back from death. We believe that the second edition of this text represents yet another step in resuscitative medicine’s coming of age.
There is a no more frightening experience for clinicians than a patient’s sudden loss of vital signs. The need to initiate multiple complex therapies, knowing that each minute that passes dramatically decreases the chances for a good outcome, makes sudden death the penultimate medical emergency.
It is difficult to obtain accurate numbers, but it is said that more than 300 000 persons die each year from sudden cardiac death in the United States alone. Worldwide the number is in the millions. Sudden death is not, however, caused by coronary artery disease alone. Hemorrhage and asphyxiation, among others, can kill physiologically competent patients without warning. Sudden death is not defined by etiology, but rather by the setting in which it occurs in a person with functional vital organ systems. It is not the natural ending of life, but death in the midst of life, and it is always tragic.
We are just beginning to appreciate the magnitude of this problem and the potential for therapy. Even a small improvement in outcomes of these patients – something that could be achieved in many communities by better application of established interventions-would save more lives than therapies that have received far more attention. The potential for good is astounding; the relationship of benefit to cost for some interventions is compelling.
If we acknowledge that sudden cardiopulmonary arrest may be among the most difficult conditions that confront rescuers, then remarkable improvement in the standardization of care has been achieved in a relatively short time through the efforts of national organizations which have developed evidence-based guidelines for resuscitative therapy. Their efforts have defined the current standard. This text is an attempt to disseminate the state-of-the-art. We believe that these efforts are complementary, as one cannot hope to enhance therapy to the patient’s benefit without international consensus on excellent basic care.
Remarkable progress has been made since the first edition. It has become clear that the treatment of lost hemodynamics is optimized by good and uninterrupted chest compression. A number of studies now indicate that simply removing interruptions can dramatically improve the rate of return of spontaneous circulation. At the same time, it appears that the application of mild hypothermia initiated after restoration of circulation can improve the neurologic outcome of cardiac arrest patients to a degree unanticipated only a few years ago. The combination of the improved chest compression and mild hypothermia has led to preliminary reports of intact survival in more than 50% of patients suffering out-of-hospital sudden death. We must admit that, even as enthusiasts of resuscitation medicine, we did not dream that improvements of this magnitude would occur for decades to come. Confirmation of this improvement in well-controlled clinical trials would mark an important event in medical history.
Our continued difficulty in treating cardiopulmonary arrest reflects ongoing limitations in our understanding of the pathophysiology of global ischemia and reperfusion. Yet the past few years have seen remarkable progress. Better understanding of the reperfusion event, reflected in delineation of phenomena such as programmed cell death, and the genomic and proteomic patterns during reperfusion, can only lead to even greater improvements in outcome. But we really do not understand fully the pathological processes that are taking place in these patients, and physicians are naturally uncomfortable in using therapies that are not fully understood and have not been clearly demonstrated to be effective. Nonetheless, the precarious status of these patients does not allow us the luxury of waiting for more definitive knowledge. We must apply all our skills, and our limited knowledge, immediately if persons with “hearts and brains too good to die” are not to be lost forever.
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