Abstract
We analyzed the outcomes of the patients with out-of-hospital cardiac arrest in Japan and make proposals for improving the results in the early 21st century by systemizing a so-called “chain of survival” which includes hypothermic brain protection. The 1-year survival rate of witnessed arrest of cardiac etiology out of hospital is as low as 2.6% in Japan and this poor score was attributed to delays in making ambulance calls, a low rate of layrescur's cardiopulmonary resuscitation (CPR), and low success rate of on-site defibrillation done by emergency life-saving technicians (ELST). Interval between the call and defibrillation is proved to be a problem in Japan. Although advanced life support done by doctors in E. R. may increase the temporary survivors, their long-term morbidity and mortality is worse than that of those who are resuscitated before arriving at a hospital. This result also proves the importance of early defibrillation. We usually go on applying cardiopulmonary bypass in combination with intraaortic balloon pumping, coronary reperfusion, and mild hypothermia of 34°C as an advanced cardiopulmonary cerebral resuscitation. Hypothermic brain protection for post-resuscitative state is still controversial but our non-randomized non-controlled study of twenty-three cases resulted in 52% of good recovery. With all these results we propose the followings as a strategy to obtain good recovery.
1. In the field; promotion of immediate ambulance calls from witnesses by using a mobil phone, popularization of chest-compression-only CPR by laypersons, and spread of public access, automated external defibrillator in hands of trained laypersons are needed.
2. In the hospital; advanced post-resuscitation care to stabilize cardiovascular system, to preserve brain function, and to prevent multiple organ dysfunction and serious infection are needed.
The guideline 2000 for CPR which was based on the latent evidence in the 20th century categorized the efficacy of both cardiopulmonary bypass and resuscitative hypothermia as the Class Indeterminate, but we expect from our clinical experience that new randomized controlled trials in the 21st century will be promising.
