Building a Chinese CPR survival environment

Survival is an important task facing human society, which runs through the entire life cycle of "birth, aging, illness and death". Cardiopulmonary resuscitation (CPR), the protagonist in the fight against death, has become a powerful weapon in the game with the god of death. For half a century, CPR, as a rescue method for patients with cardiac arrest (CA), has been represented by the guidelines issued by the American Heart Association, forming a chain of treatment for survival after patients with CA according to different time periods. However, whether it is the continuous optimization of the process from rescue to rescue (OHCA and IHCA) or the continuous improvement of the technology from rescue to rescue, the survival rate of CA patients around the world has not increased significantly; recent data show that the success rate of out-of-hospital cardiopulmonary resuscitation in my country is ≤1%, and the success rate of in-hospital cardiopulmonary resuscitation is <10%, indicating that there is still room for improvement and development in the survival chain that only runs through rescue as the main line. The "Guidelines for Cardiopulmonary Resuscitation in China" divides CA into early, middle and late stages for the first time based on the occurrence and development of CA and the entire cycle of cardiac arrest, and gives the connotations and extensions of "three preventions" (prevention, pre-recognition and early warning), "three transformations" (standardization, diversification and individualization), and "three lives" (resurrection, super-birth and prolonged life) accordingly. This lays the foundation for people to improve the survival chain that cannot meet the needs of CA, and the cardiopulmonary resuscitation survival circle formed by connecting the "three stages" in sequence is about to emerge.

The cardiopulmonary resuscitation survival loop is based on the feedback from clinical CA patients. The needs of CA patients reflected in clinical surveys can be summarized into three aspects: First, patients who have successfully undergone CPR asked whether there are any signs to identify before CA occurs, and what warnings can be given to prevent it. Second, patients who have successfully undergone CPR asked if there are any techniques that can replace chest compressions during the resuscitation process. Third, the family members of patients who have not been successfully resuscitated by CPR asked whether there are any ways to fulfill the deceased's long-cherished wish of tissue and organ donation after death. It is precisely based on the "three what?" clinical problem-oriented CA patients that we have a "heart" understanding of the different stages of CA, and further triggered our reflection on the survival chain. How to break through the current limitation of CA treatment period to carry out CPR is urgent! That is, on the basis of expanding the CA treatment link, the CA checkpoint is moved forward and extended, so that the narrow sense of CPR for rescue is expanded to the broad sense of CPR from treatment to prevention, and the survival loop of the closed loop of CPR lifeline is constructed (Figure 1).

Figure 1: China CPR Survival Circle

I. The “front ring” of the CPR survival cycle

The "pre-circle" of the CPR survival circle refers to the period before the patient's heart beats or breathes suddenly stop before cardiac arrest. It usually refers to the extremely short period of precursor symptoms before CA occurs, which is often only a few minutes to a few hours. The pre-CA period also refers to the entire time process before the patient actually develops CA. During this period, from individuals to families, communities, medical and health service systems and even the entire society, the composition of each relevant factor will become the key to determining whether the CA patient survives or not. The main thing is to move the prevention, treatment and rescue concept of CA forward. CA often occurs suddenly. Any mistakes and delays in the rescue process can lead to a poor prognosis. Therefore, the "three preventions" policy of prevention, foresight and warning should be emphasized before CA occurs. Prevention includes building a stronghold of the "heart" (home residence, 120-999, community and village), targeting the enemies of the "heart" (enemies that are not yet ill, enemies that are about to get sick, enemies that are already ill), and measures to attack and defend the "heart" (long-term attack and defense, medium-term attack and defense, and short-term attack and defense); foreknowledge includes grasping the "heart"'s cognitive situation (life and destiny, survival situation, and life trend), using the "heart"'s cognitive method (tracing back to the past, based on the present, and changing the future), and serving the "heart"'s cognitive body (personal physique, family sports, and social system); for early warning, it includes the permanent "heart" level (level I response, level II response, and level III response), always thinking of the "heart"'s call (physical call, pathological call, and psychological call), and always being the "heart"'s messenger (care for the heart in normal times, protect the heart at the right time, and save the heart in emergencies). (Figure 2)

Figure 2: CA early stage "three pre-" front ring

II CPR Survival Ring "Center"

The "middle ring" of the CPR survival ring refers to the period of primary or advanced life support for patients during cardiac arrest and respiratory arrest in the middle stage of cardiac arrest. With clinical CA patients as the core, the "three-dimensional" method of standardization, diversification and individualization should be adopted to maximize the success rate and survival rate of CPR rescue. Under complex and changing clinical conditions, in order to obtain the best resuscitation treatment and resuscitation effect, it is necessary to adopt the most practical integrated prevention, treatment and rescue methods that are adapted to local conditions and vary from person to person. Standardized methods include basic CPR (open airway, artificial respiration, chest compression), instrumental CPR (electric shock defibrillation, ventilation support, circulatory assistance), and drug CPR (positive inotropy, cardiac rhythm correction, acid-base balance); diversified methods include chest CPR (chest lifting and compression, open chest compression, transthoracic pacing), abdominal CPR (abdominal lifting and compression, subdiaphragmatic lifting and compression, arterial occlusion), and other CPR (extracorporeal membrane oxygenation, limb compression, chest-abdomen combination); individualized methods include applicable procedures (rescue objects, rescuers, rescue environment), applicable methods (methods according to time, place, and disease), and applicable time limits (special causes, special groups, and special conditions). (Figure 3)

Figure 3: CA mid-term "three changes" central ring

Ⅲ The “back ring” of the CPR survival ring

The "post-circle" of the CPR survival cycle refers to the period after the CA patient in the late stage of cardiac arrest has undergone primary or advanced life support ROSC or the termination of resuscitation. The "three life" strategies of resuscitation, super life and extension of life should be followed to enable CA patients to obtain the best life outcome. Resuscitation includes stabilizing the circulation of the "heart" (ensuring perfusion, vascular expansion, and adjusting heart rate), optimizing the indicators of the "heart" (cardiopulmonary function, oxygen and index, vital signs), and eliminating the cause of the "heart" (airway management, identification of 5H5T, cardiogenic CA); super life includes super "heart" support (balloon counterpulsation, extracorporeal membrane lung, blood purification), surpassing the management of the "heart" (temperature management, fluid management, acid-base management), and extending the time limit of the "heart" (differences in causes, differences in patients, and differences in disease conditions); extension of life includes extending the life of the "heart" (organ transplantation, tissue transplantation, cell transplantation), improving the three tables of the "heart" (body donation table, organ donation table, charity donation table), and returning to the home of the "heart" (returning to planting trees, returning to a good life, and returning to a kind heart). (Figure 4)

Figure 4: CA late "three-life" back ring

Indeed, the 2016 Chinese Expert Consensus on Cardiopulmonary Resuscitation guidelines reflect that the CPR survival cycle (CA) in the early stage "front ring" is based on the word "prevention", changing passive rescue to active forward prevention and control, striving to prevent and save lives, predict and know life, and warn and save lives; highlighting the CPR survival cycle (CA) in the middle stage "middle ring" is based on the word "transformation", closely integrating CPR science and technology with clinical practice, accurately grasping the common standards and individual characteristics of CA patients and CPR technology, dialectical rescue and scientific resolution, striving for standardized lifesaving, diversified life preservation, and individualized life; strengthening the CPR survival cycle (CA) in the late stage "post ring" is based on the word "life", fully demonstrating the CPR development concept of respecting and expanding life, optimizing the entire process of post-CPR management, so that life can be restored and continued, striving to revive and restore life, transcend life and protect life, and prolong life, inheriting the Chinese classic "the best doctor treats the disease before it occurs, the middle doctor treats the disease that is about to occur, and the lower doctor treats the disease that has already occurred", and highlighting the closed-loop life concept of "preventing the heart, treating the heart that is about to occur, and saving the heart that has already occurred" (Figure 5). Undoubtedly, the survival circle is a spatial expansion of the previous CPR survival chain from points, lines, surfaces and bodies by Chinese scholars. We believe that with the in-depth development of the China CPR Training (China CPR 4.0) national continuing education project supported by the theory of cardiopulmonary resuscitation survival circle, through the implementation of the overall clinical plan throughout the entire peri-cardiac arrest period, it will surely interpret the connotation and extension of CPR with Chinese characteristics in an all-round, full-process and three-dimensional manner; weaving the cardiopulmonary resuscitation survival circle of "coming back to life" front circle, "resurrection from the dead" middle circle and "regeneration from death" back circle is of great significance to guiding the theoretical research and clinical practice of CPR. There is still a long way to go to jointly forge the Chinese cardiopulmonary resuscitation survival circle!

Figure 5: China’s CPR three-cycle

Author: Wang Lixiang, Liu Zhongmin

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