The Brief Time Period Available for Treat

CARDIAC ARREST REVIEW AND REPORT OF 12 CASES* W. ANDREW DALE, M.D. BIRMINGHAM, ALABAMA

FROM THE DEPARTMENT OF SURGERY OF THE UNIVERSITY OF ROCHESTER SCHOOL OF MEDICINE AND DENTISTRY, ROCHESTER, NEW YORK SUDDEN CARDIAC ARREST in the anesthe- resuscitation by massage following chloro- tized patient is an infrequent emergency, form arrest. Niehaus44 in 1889 made the first but because of its sudden occurrence, the unsuccessful attempt at cardiac massage in necessity for immediate treatment and high the human being. Tuffier and Hallion'03 con- mortality deserves consideration by every firmed Schiff's work in 1898 and reported physician who deals with anesthetized pa- an unsuccessful human case. Prevost and tients. It has received increasing attention Battelli86 in 1899 first reported the use of recently, as the diagnosis is more often electric shock and massage to treat ventric- made and treatment given. ular fibrillation. The brief time period available for treat- In 1901 the first successful restoration ment if death is to be prevented does not was done by Igelsrud.8 It was not reported permit consideration of therapy after arrest until 1904, and meanwhile in 1902 Starling occurs. This has been apparent in the man- and Lane97 recorded the first successful agement of 12 cases of cardiac arrest occur- case. ring in the University of Rochester hospi- Green44 in 1906 reviewed the literature tals, where the only two long-term survivals and reported two unsuccessful cases. He followed extremely prompt treatment. The found that of the 40 published cases, nine increasing incidence of diagnosis and treat- had survived with residual complications. ment of arrest by our staff prompted a re- The same year Crile and Dolley3' used res- view of others as well as our own experi- piratory assist and massage in dogs while ence in order to handle such cases more studying phenomena associated with car- adequately in the future. diac arrest, and commented on the longer This report concerns only sudden primary survival of young animals and the problem cardiac arrest, and not death after pro- of intravascular clotting. longed shock, toxicity or other primary Bost19 found 73 reported cases in 1923 cause. and added two; 16 of these survived. Lee and Downs68 in 1924 added 23 cases with HISTORY one personal report, for a total of 99 cases, of which 25 patients were successfully re- In 1848 the first death under anesthesia vived and lived. Further scattered case occurred,'6 and with similar following cases reports have occurred since then. Bailey's4-6 it provoked a storm of controversy as to report of 41 personal cases with six sur- cause, even resulting in legal inquiry. vivors, detailing his plan of treatment, stim- SchiffP in 1874 first demonstrated cardiac ulated interest, and his series still remains * Submitted for publication August, 1951. the largest general experience, excluding 376 Volume 135 Number 3 CARDIAC ARREST large series occurring during intrathoracic stimulation in dogs, although continued operations. cardiac arrest was not produced. Ziegler118 Negovski82 collected 290 cases of resusci- indicated that in all his terminal electrocar- tation to 1942, with 151 completely revived. diograms there was evidence of myocardial Wiggin, Saunders and Small113 in 1949 pre- anoxia prior to arrest. sented an excellent review of the literature Many causes of anoxia exist clinically. on resuscitation. Excessive sedative drugs, excessively deep anesthesia and blockage of the airway and INCIDENCE circulatory failure are common causes. Par- Table I indicates reports of cases found ticularly if the heart is already diseased, in the literature, excluding a few series not one or several of these or other causes may clearly analyzed. Undoubtedly many cases precipitate arrest. are not reported. Reports of single or small Vagal reflex inhibition is often impli- numbers of cases show a lower mortality, cated, although Sloan could not reproduce probably reflecting an emphasis upon re- arrest by this means in dogs unless hypoxia porting success rather than failure, while was present. Shumacker and Hampton94 the larger series emphasize total experi- reported five cases of sudden death due to ence. Mortality continues to be great. cardiac arrest as endotracheal extubation Arrest has occurred in most of the com- and suction were done. Whether this was mon operations as well as in unusual cir- due to a reflex or to hypoxia or to a combi- cumstances such as prior to operation and nation is unknown. It is recognized that dis- after the patient has returned to the ward. section in the mediastinum and about the It is most common in intrathoracic proced- lung roots and aortic arch may lead to ures but has occurred in abdominal, ortho- arrhythmias and arrest. pedic,83 neurosurgical,83 urologic,'04 dental,9 From the practical standpoint then, con- obstetric,40 and otolaryngologic40 cases. It ditions leading to anoxia and causing reflex has followed tonsillectomy under local inhibition may produce arrest. Excessive anesthesia.40 sedation, rapid induction and maintenance The present series also includes a variety of deep anesthesia, interference with the of cases-abdominal, thoracic, urologic, a airway, and previous cardiac disease ap- preoperative case, and one after the patient pear to be important contributing causes. was returned to the recovery ward. PATHOLOGIC PHYSIOLOGY ETIOLOGY The actual cause of cardiac arrest is Cardiac arrest results in anoxia as circu- usually difficult to discover in the individual lation ceases and available oxygen is used. patient. Two general causes appear impor- Cells vary in tolerance of anoxia, the neu- tant, anoxia and reflex inhibition. rons of the brain being earliest damaged Anoxia, or more accurately hypoxia, can and recovering last. Weinberger, Gibbon often be proved or logically assumed to be and Gibbon,'06 in their review, note that present. Experimental work bears out the Brown-Sequard in 1858 found that the cere- influence of anoxia. Sloan95 described re- brum, medulla, cord, and peripheral nerves cently the effects of low oxygen tension in were affected in that order by temporary dogs, finding that extreme hypoxia or as- interruption of blood supply. Stewart, phyxia often resulted in arrest while hyper- Guthrie, Burns and Pike98 in 1906 found capnia did not. Young, Sealy, Harris and complete recovery in dogs after five minutes Botwin117 found that hypercapnia increased interruption of cerebral blood flow, and and hypoxia decreased the effect of vagal one recovered fully after 15 minutes. None 377 Annals of Surgery W. ANDREW DALE March, 1952 recovered after 20 minutes. Cabat, Dennis one, and probably the same is true of human and Baker63 found eight minultes to be com- beings. Cooley27 however, reported that in patible with complete recoverry in dogs. children operated upon for pulmonic steno- Grant, Weinberger and C;ibbon43 and sis by the Blalock procedure, hypoxia is Weinberger, Gibbon and IGibbon,106' 107 already present, and that less than a minute stopped the circulation in cats3 by clamping of circulatory arrest may result in neuro- the pulmonary artery. If occliusion was less logic lesions under these circumstances. than three minutes ten seconids no neuro- Negovski,82 in a series of investigations, concluded that the most sensitive portions TABLE I.-Collected Cases of Ciardiac Arrest. of the central nervous system do not sur- Sur- Mor- vive without changes more than five to six Author Reference Year ICases vivors tality minutes of anoxia and that after ten min- Green 44 1906 40* 9 78% utes there is irreversible necrosis of cortical White 115 1909 10* 1 90% cells. Clinical experience bears out the Boat 19 1923 25* 6 76% Lee, Downs 68 1924 24* 9 63% brief time of circulatory arrest producing Negovski 82 1942 290t 11 permanent or Barber, Madden 8 1945 52% brain damage. After three Adams, Hand 1 1942 ...... four minutes neurologic residual changes Ruzicka, Nicholson 88 1947 may be regularly expected. Lahey, Ruzicka 66 1950 15 7 53% The heart itself is much more resistant to Nicholon 83 1942 7 2 71% most cases can Baileys 5,6 1947 41 6 85% anoxia and in be started if Dripp Kirby, the attempt is made within a few minutes. Johs, on, Erb. 36 1948 .... Johnsnsn, Kirby 60 1949 10io 5 50% Kountz65 perfused the coronary arteries of Cooleoy 27 1950 48 12 75% 127 hearts from patients dying within five Miscellaneous 3, 7, 9, 17, 20, 26,32,38,40, minutes to six hours and revived 65; 48 of 46,50,53,54, these beat for at least two hours. Since the 67,69,70,71, 78,84,90,96, heart is resistant to anoxia the brain is the 100, 102, 104, 1940- critical point in the time of circulatory 36 114, 116 1950 18 50% arrest. This series 1943- 1951 12 2 84% Totals 312 98 69% DIAGNOSIS

* Collected plus personal cases. t No information as to whether part included in other series. Because of the short time which may Figures not included in totals. elapse between circulatory arrest and re- logic disturbances occurred, but permanent sumption if brain damage is to be avoided, behavior alterations took place if the period rapid diagnosis is necessary. Lengthy pro- were three minutes 35 seconds or longer. cedures are useless and only simple meas- If the period were eight minutes 45 seconds ures are possible. or more, life could not be restored for more Pulse and blood pressure are the most than a few hours. The motor and visual obvious diagnostic criteria. The anesthetist areas sustained the earliest and greatest usually finds these absent at the time that damage. apnea occurs or shortly thereafter. If the Grenell45 studied the effects of temporary operative exposure allows, palpation of the circulatory arrest to the brain and pointed heart or a great vessel will lead to an imme- out that many factors such as narcosis and diate diagnosis. Otherwise the peripheral anesthesia affect the end result. After two vessels are used. The capillaries do not re- minutes they found cortical injury. The fill after pressure. brain of the young dog is more resistant to The electrocardiogram is useful but not complete anoxia than the brain of the old completely accurate, indicating arrhythmias 378 Volume 135 Number 3 CARDIAC ARREST but not the actual time of mechanical ar- thinks this may account for some of the re- rest. Negovski,82 reviewed the literature and ports of spontaneous defibrillation. reported his own animal experiments, indi- Occasionally as the chest wall or pleura cating that after the heart has ceased vis- is incised, respirations may suddenly re- ible pulsations the tracing may for a time sume and the heart is found to be contract- continue with but slight abnormalities. ing regularly. It appears likely that the Ziegler"18 found electrocardiographic activ- resumption is due to strong stimuli originat- ity after clinical arrest in seven patients ing in the incision, since other vigorous operated upon for pulmonic stenosis. He stimuli, such as sharply striking the pre- indicated its usefulness in warning of im- cordium, have been rarely successful in re- pending arrest by arrhythmias and brady- suscitation. cardia. If bradycardia of 50 or less did not TREATMENT respond to atropine or if it recurred after was it was often a pre-termi- atropine used, If the patient is to live without sequelae, nal sign in that series. immediate treatment is necessary. The brain Negovski believes the electro-encephalo- must receive oxygen within a few minutes, gram tracing is a more accurate indication three to four minutes being considered the of "clinical death," since its action currents maximum for asymptomatic survival,66 al- cease while animals still continue to breathe though occasional longer periods have been and while the electrocardiograph continues reported."15 Since an extremely brief inter- to record a tracing. val is allowable for a great many things to Ophthalmoscopic examination of the ocu- be done, it is evident that a previously con- lar fundi shows discontinuity of the col- sidered plan of action is necessary to cope umns of blood in the veins and non-visual- properly with the situation. Existing cir- ization of arterioles.'06 Salsburg and Mel- cumstances will modify the plan, but the vin89 describe the appearance of the veins benefit of previous consideration and organ- as a broken column of blood whose motion ization is great. Bailey4 strongly called for slowly ceases several minutes after the a plan, as have others since then, as experi- heart stops. ence in dealing with arrest has accumu- From the practical standpoint, diagnosis lated. With such a brief interval available ordinarily is based on lack of pulse and for therapy, it appears that few patients will be saved unless the surgeon blood pressure associated with apnea. If has previously considered some plan. this occurs when a great vessel is not imme- Organization of the available personnel diately at hand for palpation, a minimum of entails respiratory maintenance by time is available for stethoscopic ausculta- usually the anesthetist, cardiac massage by the sur- tion of the precordium. Valuable time may geon, insertion of an intravenous needle by be lost debating the possibilities of therapy. an assistant, and procurement of drugs by It may be necessary to open the chest or a nurse. If possible, some person should at abdomen upon the strong suspicion of car- once begin to record time, writing down diac arrest, confirming this by palpation. occurrences. If this can be done, there is at The heart will be motionless, contracting hand an accurate record of events to aid in very feebly, or fibrillating, the latter giving therapy as well as in later recollection. a sensation of a "bag of worms" in the hand. Oxygen must be delivered to the lungs in Fauteux39 points out that a bizarre ventric- high concentration, preferably 100 per cent, ular rhythm with auricular fibrillation may all anesthesia ceasing. An endotracheal tube be confused with ventricular fibrillation and is necessary to insure patency of the airway 379 Annals of Burgery W. ANDREW DALE March, 1952 and allow proper forced resuscitation. Some much less blood flow than when done trans- feel that automatic positive pressure respir- thoracically. It may be preferable to make atory machines of the Mautz,74 76 Craf- a new incision even though the abdomen is ford,-9 Rand,15 and Moerch79 types produce open. For this the left fourth interspace ap- a measured and constant volume of respir- proach is preferable, cutting adjacent car- ation that cannot be matched by the incon- tilages as needed to accommodate the hand stancy of manual methods.100 Other types within the thorax. The internal mammary of respiratory machines are being devised.2 vessels need not be clamped until return of Reicher87 reports that alternate mechanical circulation marks their position by a spurt suction and pressure resuscitation in dogs is of blood if they have been cut. A self-re- superior to either suction or pressure alone taining rib retractor aids the operator and or combined with massage. prevents uncomfortable and later painful Thompson, Quimby and Smith'0l showed pressure upon the wrist by the ribs. The with radio-active sodium that artificial res- pericardium need not be opened at once. If pirations alone will produce blood circula- it is done, it should be after initial massage.7 tion in dogs dead of asphyxia. Volpitto, Massage is best done with the apex of Woodberry and Abren,105 however, found the heart lying in the palm, fingers posterior no significant changes in systemic or pul- and thumb anterior to the organ. The monary blood pressures produced by any of heart should be squeezed firmly and rapidly seven methods of artificial respiration when to expel blood, then allowed to fill as the cardiac and respiratory arrest had occurred. fingers relax. A massage rate of 40 per min- Any blood flow which took place was ute has been used generally, but more rapid thought to go toward the extremities and rates have been advocated, such as 60,27 cutaneous areas rather than into the cere- 80,83 or even 120. The latter is based on dog bral and coronary circulations. experiments by Johnson and Kirby,"' who In any event, artificial respirations never found that the 120 rate was optimal to pro- replace cardiac massage, but supplement it, duce cerebral blood flow as indicated by an placing the oxygen in the lungs to be picked interposed bubble meter. What the best up by the blood moved past by cardiac rate is to initiate contractions is not known. massage. The rapid rates are fatiguing to the operator a Cardiac massage is begun at once to pro- and he usually needs relief after few duce circulation until spontaneous contrac- minutes. Beck and Rand15 have devised a tions resume and produce this. It has been suction cup apparatus to assist ifling the long known that circulation occurs, since heart and mechanically cause blood flow. dye is passed through the usual channels,47 Electrodes are arranged within the cups so although the circulation does not match the that electric shocks may be used if in- usual normal. dicated. If the chest is open, there need be no At intervals of a minute or so, or when delay. Otherwise, if the abdomen is open the tone of the heart increases, brief rests the diaphragm may be cut to allow mas- allow observation for spontaneous resump- sage, Bailey advocating detachment from tion. If arrest recurs, further massage is the left costal margin as described earlier indicated. by Bost,18 and Nicholson,83 preferring a Blood should be given rapidly to increase thumb-sized opening beneath the xiphoid. the circulating volume. Some advocate Massage through the intact diaphragm is intra-arterial transfusion directed centrally. inefficient. Johnson and Kirby6l found in Negovski,82 on the basis of his animal ex- dogs that this type of massage produced perience, warns that the transfusion should 380 Volume 135 Number 8 CARDIAC ARREST be changed to the venous side as soon as action.48 It cannot alone be counted upon massage begins. If intravenous cannulation to restore the beat. has been done, it will be started before an Procaine may be used to depress myocar- arterial infusion can be begun, so the dial irritability resulting from anoxia, in- method appears to have small use. jected epinephrine and massage. It in- Intracardiac injection may be used. Iok- creases the cardiac threshold to epineph- hveds58 revived one of his two patients by rine-produced fibrillation.23 24, 112 Because this combined with other measures. Gover- of its frequent use combined with epineph- nale and Rink42 report its use in a patient. rine it has been suggested that sterile bot- In the absence of previous blood loss, tles containing 0.5 cc. 1:1000 epinephrine caution must be used to avoid overloading plus 9.5 cc. 1 per cent procaine be available the circulation by transfusion. in operating rooms for intracardiac injec- Epinephrine is the classic cardiac stimu- tion.66' 88 Procaine may be used intrave- lant. Its use at present is controversial. It nously as prophylaxis against cardiac has been injected into various of the great arrhythmias21' 27 and during and after ar- vessels and chambers of the heart both rest on the same basis. In this hospital it is before, during and after arrest. It increases used for chest cases and elsewhere as in- cardiac irritability and may lead to ventric- dicated, in 0.1 per cent solution in 5 per ular fibrillation, as found in dogs by Mautz73 cent dextrose in water. and Fauteux39 and in human beings by Bar- Procaine amide has recently been re- ber and Madden.7 Auricular injection has ported as a substitute for procaine in been thought superior to ventricular be- prophylaxis and treatment of arrhyth- cause resulting fibrillation is less dangerous mias.59'72 While it may be used orally, there than in the ventricle. intravenous dosage is recommended preop- Hyman55 57 thought that successful res- eratively to avoid variability in level. toration by epinephrine was due to the Occlusion of the aorta by manual com- stimulus of needle puncture of the myocar- pression may be done to direct the available dium and recommended injection via the blood flow to the cerebral and coronary cir- right third interspace lateral to the sternum, culations. aiming inferiorly and medially to place the Head down position also increases cere- needle in the right auricle. Organe84 re- bral blood flow. ported two cases where auricular puncture Barium chloride'08 is suggested by Fau- alone resulted in restoration of beat, but teux39 to increase cardiac tone. He used 1 Beecher and Linton17 reported two cases to 2 cc. of 0.5 per cent solution injected into where repeated needle prick failed to start the auricular appendage in dogs. This was the heart while massage was done, and later used in a few patients in the series reported injection of epinephrine was successful in by Cooley.27 restoring the action. They warn against Heparinization has been suggested'0l to over-dosage of the drug and advise 0.2 to prevent intravascular thrombosis. However, 0.3 cc. 1:1000 epinephrine diluted ten times. with the circulation at a standstill it is not Beck recommended 0.5 cc. 1:1000 eineph- feasible, and when the circulation is re-es- rine in 5 cc. saline.15 tablished, its need ceases. Because of uncertain action, production Serial defibrillation is at present the best of cardiac irritability and brief time avail- method to stop ventricular fibrillation, able for all measures, the use of epinephrine which rarely41 93, 119 ceases spontaneously. seems to be best reserved for failure of Developed by Hooker, Kouwenhoven and response to massage or to strengthen weak Langworthy,52 Wiggers,109' 110 Mautz75 and

381 Annals of Surgery W. ANDREW DALE March, 1952 Beck11, 14 and applied to human beings by report four cases in which 2 to 4 cc. of 10 the latter, defibrillation entails the passage per cent calcium chloride was successful in of a series of electrical shocks through the restoring cardiac action after standstill or heart from electrodes on its surface. defibrillation. They prefer injection into the Wiggers'09 stated that ventricular fibrilla- left ventricle. tion in the hearts of larger animals is ir- An artificial pacemaker was described by revocable, no spontaneous recovery being Hyman56' 57 in 1932. In dogs and human found in 400 dogs. After 30 to 45 minutes, beings he found that a current could be as anoxia persists, all cardiac actions cease. passed through a needle electrode in the His method for defibrillation consisted of heart which would initiate extrasystoles, at passing three to seven shocks of 1 ampere, times going on to sinus rhythm. Callaghan lasting 0.1 to 0.5 seconds, with one- to two- and Bigelow25 have developed an artificial second intervals between shocks. The fibril- pacemaker and described its use in dogs lating muscle groups merge into consecu- where brief cardiac arrest has been induced tively larger areas until, with one final at normal and low body temperatures. shock, all action ceases. Massage is then nec- Coramine, Metrazol, alpha-lobeline, pic- essary to initiate cardiac motion. While the rotoxin, and other convulsant drugs are con- defibrillator apparatus is obtained and set demned,8' since animal experiments show up, massage should be done to prevent no respiratory stimulation and often an in- anoxia, which may not allow succesful de- crease in depression80 under deep anes- fibrillation. The heart can be successfully thesia. These drugs also elevate cerebral defibrillated after a longer period if massage metabolism and lead to cerebral anoxia.92 is done during that period.34 49 111 Gurvich Resuscitation may not restore cardiac and Yuniev48 49 have successfully used con- action. Fauteux39 classifies causes for this as denser discharges to debrillate animal follows: hearts rather than the alternating current 1. Hyperirritability: commonly described. a. ischemia Procaine injected into or dripped upon b. overstimulation the heart may allow defibrillation which 2. Absence of cardiac tone. fails without it.13 73 Beck advocates the in- 3. Increased myocardial temperature fol- jection of 5 cc. of 1 per cent procaine following defibrillation. Cool saline drip is lowed by brief massage, and then shocks suggested. (110 volt A.C., 1.5 amperes).15 He stated 4. Peripheral circulatory failure may oc- in 1949 that he had attempted defibrillation cur after cardiac action is restored. He sug- about 12 times, with temporary success in gests intracardiac injection of 500 cc. of each and two recoveries.15 blood into the auricular appendage in this Potassium chloride was used by Hooker5' situation. in 1929 by arterial injection to inhibit car- To this list should be strongly prefaced diac fibrillation, followed by calcium chlo- failure due to delay in treatment, the most ride to wash out the potassium and stimu- frequent cause of failure of survival. late a normal rhythm. One per cent potassium chloride may be used.9 CASE REPORTS Calcium chloride has been used to stim- Twelve cases have occurred in the Uni- ulate the heart by direct myocardial effect, versity of Rochester Hospitals since 1943, after either standstill or following defibril- when the first such diagnosis was made. lation.13' 50, 75, 110 Beck13 recommended 5 cc. Several other older cases were recalled but 1 per cent solution. Kay and Blalock" the records could not be located. 382 Volume 135 Number 3 CARDIAC ARREST

Case 1.-R. R., 34038, a 45-year-old white male, A hasty laparotomy was done and the heart found had 15 previous admissions for various acute le- motionless. Massage through the intact diaphragm sions, including operations for tonsillectomy and had no effect so it was opened. Massage now pro- twice for recurrent shoulder dislocation. There duced runs of weak contractions which gradually was known hypertension for 11 years with symp- ceased. Autopsy showed nothing not known clin- toms for 5 years, including recent dyspnea and ically. No cardiac lesions were found. The time orthopnea. The preoperative studies showed no between arrest and massage was about 2 to 3 evidence of renal damage and no symptoms of minutes. coronary insufficiency. On January 16, 1943, left lumbar dorsal sympa- Case 3.-E. T., 253374, a three-year-old white thectomy was done under gas-oxygen-ether. Post- female child, had patent ductus arteriosus with operative course was good. On January 27 the retarded development and progressive cardiac en- right side was to be done, following sedation with largement without endocarditis. On February 3, morphine .016 Gm. and atropine .0006 Gm. Fifty 1949, after .0002 Gm. atropine preoperatively, gas- milligrams of Avertin was placed in the rectum at oxygen-ether was given at 8:20 A.M. and operation 8:45 A.M., and at 9:25 A.M. gas-oxygen-ether was started at 8:55, a left third interspace anterior ap- begun. As the shoulders were elevated for endo- proach being used. The vagal and aortic areas tracheal intubation, apnea and pulselessness were injected with 1 per cent procaine as exposed. occurred. While posterior ductus dissection was being done at 11:08 A.M. the cardiac action became feeble, Manual respirations were begun with 100 per but upon ceasing dissection contractions became cent oxygen at once. One cubic centimeter of Cor- strong and regular. This recurred several times amine intravenously and 1 cc. 1:1000 epinephrine despite local injection of procaine as well as initia- intracardially at 5-minute intervals were of no tion of intravenous procaine. Complete arrest avail. At 10:00 A.M., after hasty laparotomy, mas- finally occurred and despite all efforts at massage sage through the intact diaphragm did not restore and electrical stimulation the heart did not beat action, so a small opening was made for the thumb, again. and after 2 squeezes cardiac action resumed. At Autopsy showed left ventricular hypertrophy 10:15 wound closure was done. The pulse was and dilatation, pulmonary congestion and atelec- regular and steady; blood pressure 100/60 (preoperative 198/130). tasis, lipoid pneumonia, nonspecific granulomata of the lungs and liver and visceral congestion. Postoperatively there were signs of cerebral damage. He did not regain consciousness and died Case 4.-M. B., 172397, a three-year-old girl, 13 hours postoperatively. Autopsy showed right was operated upon May 15, 1943, for acute non- coronary artery thrombosis with organizing myocar- perforated appendicitis with symptoms for one dial infarction and mural thrombosis of left the week. Preoperative medication was .0001 Gm. atro- ventricle. pine. During suture of the skin at the end of the operation, convulsions occurred suddenly while Case 2.-J. N., 133483, a 61-year-old white endotracheal suction was in progress. These stopped male, had had many previous admissions for treat- after 10 minutes and there was no respiration or ment of metastatic carcinoma of the nasopharynx, pulse. Intracardiac injection of 1 cc. 1:1000 including 3 local neck operations under general epinephrine produced no result. The left chest anesthesia for excision of metastases, the treat- was opened and the pericardium incised. During ment to the primary being radiation. On October the ensuing 90-minute period intermittent mas- 26, 1946, admission for study of episodes of loss of sage was done, the heart beating of itself during consciousness upon turning his head led to a diag- the intervals. However, strong regular contrac- nosis of right carotid sinus syndrome. The episodes tions were never maintained, and death occurred. continued. Autopsy showed atelectasis, cloudy swelling of On December 12, 1946, morphine .010 Gm. and the viscera and early interstitial pneumonia. atropine .0003 Gm. was given prior to Pentothal induction, with gas-oxygen-ether maintenance, for Case 5.-I. G., 309175, a 43-year-old white right radical neck dissection. This had proceeded female, was admitted with diabetic gangrene of the to a point 2 cm. above the carotid bifurcation when right great toe and bilateral cellulitis of the legs. sudden apnea and pulselessness occurred. An en- She also had congestive heart failure secondary to dotracheal tube was placed at once and 1 cc. hypertensive cardiovascular disease. The diabetes 1:1000 epinephrine injected into the exposed car- was mild and glycosuria never exceeded 2+ on diet otid artery and 1 cc. into the heart without effect. without insulin. Digitalization, fluid and salt re- 383 W. ANDR1EW DALE EWDALE ~~~~~~~~~AnnalsMnarc ofh, Surgory8195 2 striction and penicillin therapy with care of the region, exploration for possible branchial cyst infected areas was begun. Two days later, gas gan- was done. grene of the right lower leg appeared and she The preceding night at 10:00 P.M. he had re- became toxic. ceived .9 Gm. chloral hydrate and on April 26, At 6:30 P.M. March 7, 1950, ice refrigeration 1950, at 7:00 A.M., 12 cc. paraldehyde plus .100 to the mid-thigh was begun and a tourniquet Gm. Demerol and .0006 Gm. atropine preopera- placed tightly about the lower leg above the gas tively. At 11:00 A.M. Vinethene induction began area. Preoperative sedation the next morning con- and open drop ether was used for maintenance. At sisted of Nembutal 0.1 Gm., morphine .010 Gm. 11:15 endotracheal intubation was done. During and atropine .0006 Gm. at 10:25 A.M. Low thigh skin preparation at 11:25 some respiratory difficulty amputation was started under ice anesthesia. At was noted by the anesthetist and at 11:29 apnea 11:30 A.M., because of pain during fascial dissec- had been present 30 seconds. No peripheral pulse tion, morphine .008 Gm. was given intravenously could be found and auscultation of the chest and Pentothal anesthesia begun. The operation showed silence. was resumed at 11:40 A.M. When respirations The chest was opened through the left fourth ceased at 11:50 a total of 1.25 Gm. of Pentothal interspace, cutting the fourth and fifth costal car- had been used. One cubic centimeter of Coramine tilages. The heart was motionless. Massage at a was given intravenously at once without respiratory rate of 120 per minute was begun. Feeble action return. The pulse was present but weak and irreg- resulted within 15 seconds but ceased upon stop- ular. At 11:55 an endotracheal tube was placed ping the massage. However, after 90 seconds of and 1 cc. Coramine given intravenously. The pulse massage, contractions were strong and regular now disappeared and the diagnosis of cardiac (11:32 A.M.). Other measures consisted of 100 arrest was made. per cent oxygen by manual pressure, 250 cc. intra- Upon opening the left chest at the fourth venous plasma, and intracardiac injection of 9.5 cc.; interspace the heart was motionless. Massage was 1 per cent procaine plus 0.5 cc. 1:1000 epinephrine started at a rate of 90 per minute and 1 cc. (11:32 A.M.). At 11:41 A.M., spontaneous respir- epinephrine was injected into the heart. After ations resumed. The chest was closed in layers, about 5 minutes of massage spontaneous contrac- leading a catheter out posteriorly for suction. Five tions resumed. One cubic centimeter of 1:1000 cubic centimeters of Coramine were given after epinephrine was twice injected into the heart closure to stimulate respirations. At 12:40 noon within the next 45 minutes and at 12:45 noon, he was removed to the ward with vital signs stable, picrotoxin .006 Gm. was given. This was repeated pulse 70, blood pressure 85/50, respirations 18. at 1:30 P.M. in an effort to start respirations, which Electrocardiogram showed right bundle branch finally occurred at 2:00 P.M.; 1000 cc. blood trans- block. There were inverted T waves in V3 and fusion was completed, the chest was closed, and a prolonged QT interval, probably indicative of catheter was led out for suction. myocardial ischemia. By 10:30 P.M. the same day he responded to Convulsive motions of the extremities began at questioning and there was no evidence of central 3:25 P.M. and continued at intervals of a few nervous damage beyond that known preoperatively. minutes. Electrocardiogram showed myocardial ischemia with inverted T waves in leads I and The next day electrocardiogram was unchanged. and Chest film showed subcutaneous emphysema but aVL depressed ST segment in leads V4 and V5. good of the He She 4:20 A.M. expansion lung. convalesced well, survived until without regaining walking about the second day. The highest tem- consciousness or responding to any stimuli. perature was 38.60 C. The wound healed well. Autopsy showed extensive atelectatis and pul- His sensorium and motor powers were judged by monary edema with a small pulmonary embolus all observers to be the same as before operation. on the left. There were petechiae over the car- On the fifteenth postoperative day he was cysto- diac surface and focal myocarditis and hydroperi- scoped and on his twenty-fourth postoperative cardium. day the mass in the neck was explored under local anest'hesia, finding epidermoid carcinoma, primary Case 6.-B. L., 310687, an 86-year-old white site unknown. On June 12, 1950, he was placed in male, had no evidence of heart disease and his a psychiatric institution because of senile dementia blood pressure was 144/76. There was generalized and died there September 3, 1950. arteriosclerosis, arcus senilis and mental deterior- ation. Electrocardiogram April 23, 1950, showed Case 7.-J. T., 310387, an 8-week-old female left axis deviation and right bundle branch block. with congenital biliary ductal atresia, had preoper- After study of a fist-sized mass in the left cervical atively .0006 Gm. atropine followed by Vinethene 384 Volume 135 Number 3 CARDIAC ARREST induction at 8:15 A.M., June 3, 1950. Using opening 500 cc. clear fluid from the pleural space. The drop ether maintenance, the abdomen was explored heart was motionless. Massage 10 minutes after and as a catheter was being threaded through the arrest at a rate of 40-50 for 2 to 3 minutes resulted gallbladder into the common duct, respiratory in restoration of heartbeat. This became feeble, arrest occurred. Palpation of the heart through the however, and another operator then massaged at diaphragm showed no motion. One cubic centi- a rate of 120 without change. At 10:35 A.M., about meter of 1:1000 epinephrine was injected into the 17 minutes after massage was started, 9.5 cc. 1 per heart and massage through the intact diaphragm cent procaine plus 0.5 cc. 1:1000 epinephrine was was begun while the anesthetist did manual pres- injected into the left ventricle, with immediate sure resuscitation with 100 per cent oxygen. After increase in rate and force of the beat. At 10:45

7 minutes spontaneous cardiac motion resumed. A.M., 500 cc. of blood was rapidly transfused in-a Six minutes after this, 5 cc. Coramine was given 10-minute period. Blood pressure became obtain- intravenously and at 10:08 A.M., 38 minutes after able an hour after massage and respirations re- arrest, respirations began spontaneously. At 10:50 turned at a rate of eight. A.M. generalized twitchings and minor convulsive Electrocardiogram (Fig. 1) while the feeble seizures started and continued at short intervals. contractions were being aided by massage (10:35 The pulse continued to be rapid, up to 160. The A.M.) showed 35 ventricular complexes per minute, temperature varied, as high as 39.2'C. After re- the QRS complex being wide and totally disor- peated convulsions she died 34 hours postop- ganized. No definite P waves were found. At eratively. 10:45 A.M. when the heart began contracting Autopsy showed intrahepatic biliary ductal spontaneously the QRS became normal in config- atresia, generalized icterus, interstitial and broncho- uration, although the voltage was still low. At pneumonia and pulmonary congestion, and an un- 10:50 A.M. the rate was 110 and marked ST de- expected neuroblastoma of the adrenal gland. pression indicated coronary insufficiency. At 11:25 A.M. no changes were found. Case 8.-A. M., 37424, a 69-year-old white At noon he was returned to the ward with male, was admitted for study of heart disease and respirations 20, pulse 72-100 and blood pressure prostatic hypertrophy. Palpitation and exertional 80/40. He continued to show signs of severe cere- dyspnea with recent precordial and left shoulder bral damage, although the vital signs were stable. pain on exertion with evidence of generalized arte- At 4:30 P.M. there was again fibrillation by-elec- riosclerosis led to the clinical diagnosis of arterio- trocardiogram. ST depression was less marked, sclerotic heart disease. Chest film showed cardiac but otherwise the tracing was similar to the preoperative one. After 24 hours he died enlargement and an electrocardiogram (Fig. 1) without revealed auricular flutter-fibrillation with changing regaining consciousness. block and marked evidence of myocardial ischemia. Case 9.-H. K., 262276, a 60-year-old white Dysuria, frequency and nocturia had been increas- male, had had 9 previous operations for peripheral ing in severity. The prostate was large. While he vascular disease, including bilateral lumbar and was digitalized there was discussion concerning the dorsal sympathectomies, amputations of the right advisability of prostateetomy. After cardiac com- third finger and of the left index finger, and several pensation was restored was upon. it decided toe and foot amputations culminating in right mid- Preoperative sedation consisted sodium of calf amputation which failed to heal. Anesthesias phenobarbital .065 Gm. and atropine .0006 Gm. had included local, spinal, Pen-tothal and gas- at 8:50 A.M., November 25, 1950. At 9:45 A.M. oxygen-ether. There was no evidence of cardiac spinal anesthesia was induced with 5 mg. Nuper- disease clinically. caine with saddle block resulting after 10 min- In preparation for revision of the right mid-calf utes. Oxygen by mask was given and he was quiet amputation plus debridement of necrotic areas on as 2 per cent Pentothal intravenous drip was the left foot, preoperative sedation consisted of started. About four minutes later at 10:05 A.M. morphine .010 Gm. and atropine .0006 Gm. at apnea occurred which did not respond to manual 7:00 A.M. February 13, 1951. At 8:35 A.M. 2 per respiratory assistance or to changing from the cent Pentothal induction (to a total of 1.8 Gm.) lithotomy position. As the endotracheal tube was was followed by gas-oxygen-ether maintenance. passed, no pulse could be felt and no sound could Just after the Gigli saw had been passed about the be heard over the precordium. Two cubic centi- tibia an oro-pharyngeal airway was inserted at meters of 1:1000 epinephrine was injected into 9:05 A.M. Sudden apnea occurred and no pulse the heart without result. The chest was opened at or blood pressure could be obtained. There were 10:17 A.M. through the left fifth interspace, releas- no precordial heart sounds. 385 Annals of Surgery W. ANDREW DALE March, 1952 The chest was opened through the left fourth to 18 cm. revealed no finding except fixation of the interspace. As the pleura was incised he gasped rectal wall. Upon completion of this at 9:40 A.M., and sudden respirations resumed. The heart was the patient was sent to the recovery room, where then found to be beating regularly with good force. special nurses were in attendance. By 9:15 A.M. the blood pressure was 100/75 and At 9:50 A.M., because of apnea and pulseless- respirations 20. After closing the chest with ness, the surgeon was called from the dressing room. catheter drainage no further operative procedure He opened the left sixth interspace at 9:53 A.M., was done. He convalesced well, highest temper- finding a motionless heart. Massage at a rate of 50 ature being 38.50C., and the wound healed well. produced strong spontaneous contractions three Moderate hydrothorax absorbed spontaneously. minutes later and at 9:59 A.M. (6 minutes since Electrocardiogram two days postoperatively massage started) the radial pulse was fairly strong.

FIG.M1jCasej;eletrcrjrjj-jjjvTy II

FIG. Case 8; electrocardiograms pre- and postoperatively. Interpretation in text. showed borderline low voltage. On the tenth day it After 32 minutes spontaneous respirations resumed, was unchanged. an endotracheal tube having been placed and used On March 3, 1951, under Vinethene induction for respiratory resuscitation with 100 per cent with open drop ether maintenance, right supracon- oxygen. After chest closure about a catheter, the dylar and left great toe amputations were done. blood pressure was 85/70 and respirations 20 at Because of poor healing, revision of the stump was 10:50 A.M. Electrocardiogram showed regular done April 5, 1951, under spinal anesthesia. The rhythm with evidence of myocardial ischemia. patient is alive 5 months postoperatively. Chest film showed a wedge-shaped infiltration to the left of the heart. Case 1O.-R. P., 324910, a 29-year-old Negress, By 7:00 P.M. extensor spasms of the extrem- was studied for cause of lower abdominal pain ities were occurring regularly and there was with increasing distention and vomiting. Recto- Cheyne-Stokes type respiration. Bilateral Babinski vaginal examination showed a hard fixed mass an- signs and unsustained ankle clonus were noted. terior to the rectum. The clinical opinion was The next day, electrocardiogram showed ST carcinomatosis with ascites and partial obstruction, depression in leads, 1, 2, AVf, F2-6. T waves in pelvic primary site. Diagnostic sigmoidoscopy was leads 1 and AV2 were low. These changes were done March 28, 1951, after sedation with mor- interpreted as coronary insufficiency. Two days phine .010 Gm. and atropine .0006 Gm. At 9:10 after operation she was still unresponsive. The A.M., 2.5 per cent Pentothal solution to a total of electrocardiogram was unchanged. On the fifth 1.5 Gm. was given intravenously and sigmoidoscopy postoperative day there were some head and ex- 386 Volume 135 Number 3 CARDIAC ARREST tremity motions but she did not respond to stimuli. the left lower lobe and partially in the right lower, The temperature never was over 38.5°C. and the right hydrothorax and cerebral edema. wound was not remarkable. She died after five and a half days. No autopsy was permitted. Case 12.-J. J., 328455, a 36-year-old white male, was admitted for study May 24, 1951. He had Case 11.-J. R. 328060, a 36-year-old white had pneumonia in November, 1949, followed by a male, was admitted May 20, 1951, following diar- gunshot wound of the left chest and abdomen rhea and occasional melena for a month. Barium necessitating thoracotomy and splenectomy in Feb- enema was characteristic of chronic ulcerative ruary, 1950. He was hospitalized 3 times after that colitis, while stool cultures and examination did not for study and treatment of cardiac failure prior to show pathogenic organisms. Treatment consisted admission here. He had continued dyspneic and of rest, paregoric for diarrhea, sedation, several orthopneic and had aching upper abdominal pain antibiotics for a brief period without response, radiating through to the back. There was nausea atropinization and Banthine therapy. without vomiting at times and he was quite weak The course was irregularly febrile and diarrhea and listless. continued. Bleeding increased and the hemoglobin Admission physical findings included temper- fell as low as 6 Gm. per 100 cc. A 5-day course of ature 38°C., blood pressure 122/100, cyanotic nail- ACTH, 80 mg. per day, did not materially affect beds, dyspnea at rest, an enlarged heart and liver this. Over a 12-day period he required thirteen and distended neck veins. There was ascites. Elec- 500 cc. blood transfusions to prevent circulatory trocardiogram showed abnormal T waves and collapse and replenish the blood volume. An ileos- borderline low voltage, thought possibly to indicate tomy was planned. On the forty-seventh hospital an old myocardial infarction. The right femoral day he developed right lower quadrant pain and venous pressure was 180 mm. saline. Cine-angio- peritoneal signs with pneumoperitoneum by roent- cardiogram showed a dilated right auricle but the genogram, indicating perforation of the colon. After other chambers failed to become opaque. Cardiac further transfusions he was anesthetized with cyclo- catheterization was unsuccessful due to inability to propane plus ether. Endotracheal intubation was pass the catheter beyond the upper arm. Fluoros- done at 4:28 P.M., whereupon respirations ceased copy showed some diminution in pulsations of and cyanosis occurred. At 4:30 P.M. the pulse the heart. ceased. Immediate left sixth interspace thoraco- During a period of 2 months he was observed tomy was done and the heart found motionless. and studied without a definite diagnosis. Jaundice Massage at a rate of 90 per minute was done for occurred and persisted, icterus index being as high 90 seconds, after which spontaneous rhythm of 70 as 60. Mild edema of the lower extremities de- Needle liver was established. Ninety seconds later, arrest re- veloped. biopsy of the showed jaundice and passive congestion. curred. Massage was resumed and 0.5 cc. 1:1000 Because of the possi- bility of constrictive pericarditis, exploration was epinephrine with 9.5 cc. per cent procaine was at injected into the left ventricle. Within 15 seconds, length decided upon. On July 31, 1951, following preoperative preparation with morphine, .010 the heart at a resumed contractions rate of 120. Gm. and atropine .0006 Gm. subcutaneously plus The beats were forceful. After brief observation 450 mg. of quinidine intramuscularly, induction of without change the chest was closed. gas-oxygen-ether anesthesia was begun at 8:18 The condition at this point was fairly good and A.M. After eight minutes he gasped and became it seemed imperative to continue with laparotomy. apneic. An endotracheal tube was introduced and There was a great amount of gas and free feces manual resuscitation with oxygen started. The present within the peritoneum, issuing from a free pulse was palpable until 4 minutes later, when it perforation of the cecum 2.5 cm. in diameter. The ceased while the operator's hand was on the radial entire colon was inflamed with edematous walls. artery. The fifth anterior interspace was at once An ileostomy was done through a right lower opened and cardiac massage begun by compressing quadrant stab wound and the cecum marsupialized the heart from posteriorally against the sternum, about a tube at the lower end of the midline inci- since intrapleural adhesions prevented grasping the sion. The patient's condition was poor, blood pres- organ. After one minute feeble beats commenced. sure ebbing between 60 and 100 systolic and pulse The pericardium was opened, allowing the heart 150. The patient survived until 8:30 P.M., exhibit- to be enclosed by the hand. There was no evidence ing generalized twitching convulsive movements. of constrictive pericarditis. Further massage for 8 Autopsy showed acute and chronic ulcerative minutes was done and the heart, which beat feebly colitis with perforation and peritonitis. There was at times during this period, began firm, regular cardiac dilatation and hypertrophy, atelectasis of contractions. This occurred just after intracardiac 387 Annals of Surgery W. ANDREW DALE March, 1952

injection of 5 cc. 1 per cent procaine and 1 cc. was of definite benefit, as indicated by 1:1000 epinephrine and the operator's impression strengthened tontractions and resumption was that this resulted in immediate improvement of regular beats. In the fourth case the re- in cardiac action. Therefore the intracardiac injection was repeated at 8:41 A.M., 3 minutes after sponse to massage with simultaneous resumption of cardiac motion. At 8:47 spontaneous epinephrine injection was good. respirations occurred. The chest was closed about There were three transabdominal cardiac a catheter. massages done. In the first, after opening Three hours later anesthetic effects were ended. He moved about with irregular motions. The vital the diaphragm there was satisfactory re- signs were stable. There was evidence of severe sponse. In the second, after this was done cerebral damage and he did not respond to stimuli. there was only a brief response, which soon Death occurred 27 hours after massage. ended. The third is the single case where Autopsy showed severe coronary sclerosis with the heart responded to massage through the organized and recanalized thrombosis, diffuse myocardial scarring and myocarditis, mural thrombosis intact diaphragm. The nine transthoracic of the left ventricle, acute fibrinous pericarditis, massages produced seven resumptions of atelectasis and infarction of the left lower lobe and cardiac action, while two caused initial re- chronic passive congestion of liver and kidneys. turn of the beat followed by final cessation. Therefore, massage caused some resump- COMMENT tion of heart beat in all cases and in nine cases the heart resumed regular action for Analysis of these 12 cases shows that a period of hours as a minimum. Correlation three died almost at once despite treatment. of the time between arrest and massage is Seven died after an interval of four hours difficult because, in many instances, no rec- to five days, all showing evidence of severe brain damage. Two patients lived without ord was kept. An attempt was made to learn brain damage, one responding to prompt the probable time by comparison of the massage, the other apparently responding record with the memory of the operator in to the stimulation of thoracotomy and/or each case. The two surviving patients respiratory resuscitation. The mortality definitely had treatment in less than three rate therefore was 84 per cent. minutes. Other time intervals in the ones Six of these patients had factors thought who died ranged from less than three min- to predispose to arrest, namely two in- utes to more than ten. After checking the stances of excessive depressant drugs pre- time intervals it appears that six of the 11 operatively, one patient with known caro- had treatment within three to four minutes. tid sinus syndrome, one patient with de- In those who survived long enough for pleted blood volume and incipient shock infection to appear in the wound there was and two following myocardial infarction. never evidence of this. There was no in- Three of these patients and two others had stance of damage to lung or other visceral arrest as endotracheal intubation was per- organ in the course of rapid thoracotomy or formed, indicating reflex inhibition imposed laparotomy. upon probable anoxia. The patient who had arrest while in the recovery room fol- DISCUSSION lowing sigmoidoscopy under Pentothal anesthesia is the most puzzling. Certain practical questions arise in con- Epinephrine was used in every instance sideration of the management of cardiac except two. In no case of its use prior to arrest. In the light of previous experience massage was there any apparent response. and present knowledge these are discussed Four times it was injected after massage with the realization that many questionable was started. In three of these instances it points remain unsettled at present. 388 Volume 135 Number 3 CARDIAC ARREST What are the indications for cardiac instruments are not necessary. Massage massage? The anesthetized patient who is should be done at least initially without suddenly pulseless, apneic, and without opening the pericardium. peripheral blood pressure must be pre- Who should do massage? Any surgeon sumed to have cardiac standstill until must be prepared to massage. There is no proved otherwise. Palpation of a great ves- time after arrest occurs to plan proper pro- sel is indicated. If no vessel is at once avail- cedure or to call someone from several floors able through an incision already present, away. A poorly done incision with imme- thoracic auscultation is indicated, provided diate massage is better than a skillful ap- this can be done within a very short time. proach after brain damage has occurred. Otherwise, or if the sounds are absent by Should operation continue if the heart auscultation, an immediate rapid incision responds well? Circumstances may force for massage is indicated. When arrest oc- continuation of the procedure, guarding curs and exposure permits immediate pal- against anoxia or further reflex stimuli. In pation of the heart or a great vessel for most instances, staging, or deferment of the diagnosis, this at once makes clear the is since arrest necessity for cardiac resuscitation. procedure indicated, may recur. What is the preferable approach for mas- Should epinephrine be used? This is a sage? The procedure under way as well as controversial the operator's individual experience influ- point. Because it is rarely if ever successful alone in restoring cardiac ence decision for abdominal or thoracic ap- action, as well as because it may be toxic to proach. In general, access is more rapid the heart under anoxic conditions, its use and massage more efficient by the thoracic should be reserved until massage has been route. It is often preferable to make a sec- started. If no spontaneous action occurs, or ond incision in the chest for massage rather if the beat continues weak, a mixture of than covert an abdominal incision into one 0.5 cc. 1:1000 epinephrine with 9.5 cc. of through which the diaphragm may be -safely 1 per cent procaine should be injected. opened. Massage through the intact diaphragm is inefficient and often results in SUMMARY wasted time if an opening is made later. 1. The history and incidence of cardiac What are the landmarks for rapid thora- arrest indicates that it occurs not infre- cotomy? The fourth left interspace is the quently and may happen during or follow- preferable approach, but valuable time ing anesthesia for any procedure. Three should not be wasted counting this. Any hundred cases were found in the literature nearby interspace will allow adequate mas- and 12 new cases reported with a combined sage. The one just inferior to the nipple is mortality of 69 per cent. easily located. Several quick scalpel strokes 2. The importance of anoxia plus possible should open this from sternum to mid-axil- nervous reflexes in etiology is noted. lary line, nicking the pleura with care until 3. Study of the pathologic functional entering air results in the lung collapsing changes after cardiac arrest indicates that away from the incision. The finger then the brain is first damaged and that irrever- may be placed within to push away the sible changes there may preclude recovery, lung and allow rapid completion of the although the heart can usually be tempo- opening. Costal cartilages may be cut rarily revived. The period of circulatory above and below the interspace to allow arrest tolerated by human beings with full the ribs to be spread apart for the hand to recovery is about three or four minutes for enter. The knife cuts these easily and bone practical purposes. It is longer in young 389 W. ANDREWW.ANDREWDALE ~~~March,Annals of Sursgry1952 individuals and shorter in those with pre- 8 . : Historical Aspects of Cardiac Re- vious hypoxia. suscitation. Am. Ji Surg., 70: 135, 1945. 4. Diagnostic procedures are limited 9 Barclay, S.: Resuscitation by Cardiac Massage. by New Zealand M. J., 45: 446, 1946. the brief time available for treatment if 10 Barcroft, J., and W. E. Dixon: The Gaseous full recovery is to follow. Palpation of a Metabolism of the Mammalian Heart. J. great vessel or the heart is indicated at once Physiol., 35: 182, 1906. and an incision for this purpose may be 11 Beck, C. S.: Resuscitation for Cardiac Standstill necessary. and Ventricular Fibrillation Occurring Dur- ing Operation. Am. J. Surg., 54: 273, 1941. 5. Treatment is directed at maintenance 12 . : Discussion of 77. J. Thoracic Surg., of circulation to the brain and primarily 17: 283, 1948. consists of artificial respiratory maintenance 13 Beck, C. S., and F. R. Mautz: The Control of of high oxygen tension and massage of the the Heart Beat by the Surgeon. Ann. Surg., heart to maintain circulation and to stim- 106: 525, 1937. ulate the organ. Other therapeutic meas- 14 Beck, C. S., W. H. Pritchard and H. S. Feil: ures are secondary to these. Ventricular Fibrillation of Long Duration Abolished by Electric Shock. J. A. M. A., 6. The prognosis of the occasional case of 135: 985, 1947. ventricular fibrillation is extremely poor in 15 Beck, C. S., and H. F. Rand: Cardiac Arrest the best hands. Serial defibrillation by elec- During Anesthesia and Surgery. J. A. M. A., trical shocks has resulted in an occasional 141: 1230, 1949. recovery and should be further utilized and 16 Beecher, H. K.: The First Anesthesia Death investigated. with Some Remarks Suggested by It on the 7. Twelve cases of cardiac arrest with Fields of the Laboratory and the Clinic in the Appraisal of New Anesthetic Agents. two full recoveries are detailed as to course Anesthesiology, 2: 443, 1941. and management. Survival of an 86-year- 17 Beecher, H. K., and R. R. Linton: Epinephrine old man is the oldest reported case. in Cardiac Resuscitation. J. A. M. A., 135: 90, 1947. Dr. Paul N. G. Yu, Instructor in Medicine, the 18 Bost, T. C.: A New Technique of Cardiac Mas- University of Rochester School of Medicine and sage with a Case of Resuscitation. Lancet, Dentistry, reviewed and made final interpretation 2: 552, 1918. of all electrocardiograms, for which appreciation 19 ------: Further Observation of Heart Mas- is expressed. sage as a Final Resort for Resuscitating Heart BIBLIOGRAPHY Failing Under General Anesthesia. Surg., Gynec. & Obst., 36: 276, 1923. Adams, H. D., and L. V. Hand: Twenty Minute 20 Brantigan, C.: Cardiac Arrest With Complete Recovery. J. 0. Discussion of 39. A. M. A., 118: 133, 1942. 21 Burstein, C. L.: Treatment of Acute Arrhyth- 2 M. R. mias During Anesthesia by Intravenous Pro- Adelman, H., A. Berman and A. S. W. caine. Touroff: Automatic Controlled Respiration. Anesthesiology, 7: 113, 1946. Anesthesiology, 10: 673,1949. 22 ------: The Utility of Intravenous Procaine in 3 Anderson, R. M., W. G. Schoch and H. W. the Anesthetic Management and Cardiac Faxon: Cardiac Arrest. New England J. M., Disturbances. Anesthesiology, 10: 133, 1949. 243: 899, 1950.. 23 Burstein, C. L., and B. A. 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