Wang Lixiang and Liu Zhongmin: Reflecting on Abe's cardiopulmonary resuscitation after his heart and lungs stopped

According to previous reports, at 10:30 a.m. Beijing time on July 8, 2022, former Japanese Prime Minister Shinzo Abe was shot in the left chest and neck while delivering a campaign speech on the streets of Nara City, causing cardiopulmonary arrest. Japanese rescuers performed cardiopulmonary resuscitation such as chest compressions and AED at the scene, but the rescue continued for more than 50 minutes without success. He was sent to the hospital for rescue and was announced dead by NHK at 16:48 p.m. on the same day. It took 6 hours from Abe being shot to cardiac and respiratory arrest, and then to the scene and hospitalization for treatment. Through a retrospective analysis of Abe's on-site emergency cardiopulmonary resuscitation, people can know that traumatic cardiac arrest caused by shooting is very different from the non-traumatic cardiac arrest that people are familiar with, and the strategies, processes, and methods used in cardiopulmonary resuscitation are very different. Trauma is a major threat to human life. According to the World Health Organization (WHO), it causes 10% of deaths and 16% of disabilities in the world. In my country, more than 700,000 people die from various types of trauma each year. The key link that determines the mortality rate of trauma depends on cardiopulmonary resuscitation (CPR) of fatal complications of cardiac arrest caused by trauma. Traumatic cardiac arrest (TCA) usually refers to the clinical cardiac arrest syndrome caused by external violence on the human body, resulting in mechanical damage and blood loss and hypoxia, which leads to the cessation of heartbeat, breathing, and consciousness. It is also called the state of near death. CPR, which establishes artificial circulation and breathing, has become the main means of rescuing patients with traumatic cardiac arrest. Focusing on the characteristics of traumatic cardiac arrest and combining the pre-hospital CPR case of Abe's traumatic cardiac arrest caused by shooting, the construction of the CPR system for traumatic cardiac arrest is strengthened to get out of the dilemma of only 0~3.7% survival rate of traumatic cardiac arrest.

Reflection 1: Strengthen the prevention and control of cardiopulmonary resuscitation in the early stage of traumatic cardiac arrest

It refers to the period before traumatic cardiac arrest occurs (peri-cardiac arrest period) when external violence causes mechanical damage and blood loss and hypoxia to the human body. According to the peak moments of the "three deaths" of traumatic pathology, early recognition, early warning, and early prevention of high-risk factors that cause cardiac arrest are adopted. Cardiopulmonary resuscitation measures are taken to reduce the incidence of traumatic cardiac arrest by moving the "gateway" forward and "building a dam" to control reversible causes. Whether intervention measures can be taken actively and accurately for patients with severe trauma is the key to reducing the mortality rate of patients. Research statistics on combat casualty rescue in the United States show that the leading cause of death in combat casualties is massive bleeding, accounting for 60% of all deaths. Acute blood loss is the primary preventable cause of death in trauma patients. Therefore, doing a good job of stopping bleeding on the spot can effectively reduce most traumatic deaths. Special attention should be paid to the following three aspects: (1) Prevent and control the first peak of death from trauma. Traumatic cardiac arrest may occur within a few minutes after trauma, and 50% of patients will die immediately. At this moment, we are racing against death. We should focus on preventing and controlling traumatic cardiac arrest caused by damage to important organs and large blood vessels of the heart and brain. (2) Prevent and control the second peak of death from trauma. Traumatic cardiac arrest may occur within a few minutes after trauma. We should know how to control the "golden time" of trauma rescue. We should focus on preventing and controlling hypovolemic shock, asphyxia, tension pneumothorax, pericardial tamponade, crush syndrome, craniocerebral injury, and brain hernia. (3) Prevent and control the third peak of death from trauma. Traumatic cardiac arrest may occur a few weeks after trauma. Although the injuries of trauma patients have been controlled after rescue, based on many factors such as the complexity of the patients' injuries and decreased resistance, we should focus on preventing and controlling traumatic cardiac arrest caused by severe infection or organ failure.

Reflection 2: Strengthening the integrated view of mid-term cardiopulmonary resuscitation in traumatic cardiac arrest

It refers to the period of cardiac arrest caused by external violence acting on the human body, resulting in mechanical damage and blood loss and hypoxia. It targets the "three types" of primary traumatic cardiac arrest, secondary traumatic cardiac arrest, and induced traumatic cardiac arrest, and adopts standardized, individualized, and diversified cardiopulmonary resuscitation precision integration measures, which reflects the multi-dimensional cardiopulmonary resuscitation integration concept to improve the success rate of traumatic cardiac arrest rescue. The electrocardiogram characteristics of mid-term traumatic cardiac arrest are ventricular asystole, electrocardiogram dissociation, and ventricular fibrillation, which reveal the three types of cardiac arrest caused by different causes of cardiac arrest. Whether cardiopulmonary resuscitation can be accurately performed on patients with traumatic cardiac arrest to achieve restoration of spontaneous circulation (ROSC) is an important basis for improving the survival rate of patients. Many previous literature reports showed that the initial heart rate of cardiac arrest patients was ventricular fibrillation in 80%, but this was not the case for patients with traumatic cardiac arrest. The initial heart rhythm of traumatic cardiac arrest was ventricular fibrillation in 3% and pulseless electrical activity (PEA) in 30% to 60%, which then deteriorated into cardiac asystole. Obviously, this is completely different from the initial heart rhythm sequence of patients with non-violent cardiac arrest. Therefore, most patients with traumatic cardiac arrest are not suitable for the use of AED.

How to understand the "sad" reasons for traumatic cardiac arrest, especially pay attention to grasping three aspects: (1) Cardiopulmonary resuscitation for primary traumatic cardiac arrest, CPR performed when external violence directly hits the human heart and blood vessels to cause cardiac arrest, common heart penetration injuries, heart and large blood vessel ruptures, standard chest compression CPR should not be used, because people cannot press on an "empty heart". In addition to choosing open-chest CPR, thoracotomy exploration, and bleeding control and other heart-saving integrated methods, open-chest subdiaphragmatic lifting and compression CPR can come in handy. (2) Cardiopulmonary resuscitation for secondary traumatic cardiac arrest, CPR performed when external violence directly hits the human body's non-heart and blood vessels to cause cardiac arrest, often secondary to severe damage to organs other than the heart and blood loss. Due to cardiac arrest caused by hypovolemia, cardiac tamponade, tension pneumothorax or chest trauma, the effect of chest compression is not as good as that of normal blood volume cardiac arrest, and abdominal compression CPR (ACD-CPR) came into being. Abdominal lifting and compression cardiopulmonary resuscitation originated from the clinical restrictions and poor effects of traditional chest compression for cardiac arrest. In addition, about 30% to 80% of the complications of rib or sternum fractures and separation of the bone-cartilage junction during the implementation of traditional chest compression cardiopulmonary resuscitation lead to damage to the lungs, pleura and heart, which limits the implementation of traditional chest compression technology and affects the success rate of cardiopulmonary resuscitation. Therefore, a new cardiopulmonary resuscitation method of "abdominal resuscitation when the chest is blocked" was explored. (3) Cardiopulmonary resuscitation for traumatic cardiac arrest: cardiopulmonary resuscitation for cardiac arrest caused by external violence directly hitting the human body and inducing traumatic stress and psychological changes. Trauma not only causes damage to people's body tissues but also has a certain impact on their mental health. Trauma-induced traumatic cardiac arrest is mainly divided into sympathetic nervous system imbalance emotional disorder type, respiratory center regulation abnormal emotional disorder type, and cardiovascular event-induced emotional disorder type. Through scientific and effective self-emotional management, individuals and groups can recognize, coordinate, guide, interact and control their own emotions and the emotions of others, actively and consciously adjust, relieve and stimulate emotions, so as to maintain appropriate emotional experiences and behavioral responses, and avoid or alleviate practical activities of inappropriate emotions and behavioral responses. This is crucial to preventing cardiac arrest caused by traumatic emotional disorders, and will help prevent the occurrence of trauma-induced traumatic cardiac arrest.

Reflection 3: Strengthen the concept of cardiopulmonary resuscitation and regeneration in the late stage of traumatic cardiac arrest

It refers to the period after external violence acts on the human body, causing mechanical damage and cardiac arrest due to blood loss and hypoxia. After the spontaneous circulation is restored or resuscitation is terminated with the support of primary or advanced cardiopulmonary resuscitation, the "three lives" cardiopulmonary resuscitation strategy of resuscitation, super-life and prolongation of life is followed to enable patients with traumatic cardiac arrest to obtain the best life outcome. The resuscitation after traumatic cardiac arrest is the primary goal after the restoration of spontaneous circulation, including the period of life support that stabilizes the hemodynamics after resuscitation, optimizes vital parameters, and eliminates the causes and inducements of traumatic cardiac arrest; the super-rebirth after traumatic cardiac arrest refers to the "super-rebirth" period of "super life support" from the resuscitation stage to the recovery of organ function; the extension of life after traumatic cardiac arrest is the period when a person's life is in danger, after active treatment has failed, or after a series of life support, there is no possibility of survival and is destined to die. The organ (heart) that still has enough vitality is "grafted" to others, that is, organ donation and organ transplantation, so that the life of the deceased can be continued to varying degrees with the help of other people's bodies. This kind of life relay can be regarded as the broad connotation of cardiopulmonary resuscitation after traumatic cardiac arrest. The concept of regeneration of cardiopulmonary resuscitation after traumatic cardiac arrest, from "resurrection from the dead" to "life towards death", presents a benign outcome of the life cycle of "birth, aging, illness and death". In recent years, we have advocated the "black gold" time, which refers to the period of time after the termination of cardiac arrest to continue to provide artificial circulation and breathing support to the organs, tissues, and cells of the body, minimizing the damage to the organs, tissues, and cells. Appropriate rescue measures should be taken for organs that have terminated cardiac arrest within 10 minutes of the "black gold" time to meet their needs for transplantation and regeneration, and to improve the transition from "saving lives" to "saving organs" to achieve the purpose of cardiopulmonary resuscitation to continue life and regenerate from death.

References:

[1] Wang Lixiang and Liu Zhongmin: Views on cardiopulmonary resuscitation in patients with traumatic cardiac arrest [J] Chin J Orthop Trauma, April 2022, Vol. 24, No. 4

[2] Wang Lixiang and Liu Zhongmin. Overview of the construction of cardiopulmonary resuscitation in China. Chin Crit Care Med, September 2021, Vol. 33, No. 9.