LORING S. FLINT, Jr., MD, MBA

THE CHAIN OF SURVIVAL was initially presented during the Citizens CPR Conference in 1988. The links in the chain symbolize early access, early CPR, early defibrillation, and early advanced care. On the left and the right of the chain are half chains symbolizing early intervention. As is obvious from this diagram, cardiopulmonary resuscitation (CPR) is only one of many interlocking links in the challenge to improve survival from cardiovascular disease. This interesting concept highlights the fact that emergency cardiac care in a community is a continuum of multiple interdependent forces. With the increased emphasis on early recognition, early access, and automated defibrillators, emergency cardiac care stresses the fact that these components are as important and may be even more important than the early CPR step. The strength of the chain is that it stands together. It is incumbent upon all of us as health care providers to strengthen and support not just one aspect of this chain but to support all aspects of this continuum. It is well known that any chain is only as strong as its weakest link; and this is especially true in the fight against heart disease.

The challenge that the American Heart Association (AHA) and all of us in the field of emergency cardiac care face is to decrease morbidity and mortality from cardiovascular disease. Diseases of the heart and blood vessels are still the leading cause of death in the United States (Figure 2).¹ Deaths due to heart attack are still estimated to be approximately 500,000 per year. Most impressive, however, is the cumulative percent decline in age-adjusted death rates during the past decade (Figure 3).^l Certainly the increased emphasis on diet, exercise, and prevention have had a major impact leading to this decline in death from cardiovascular disease.

The first link in the chain of survival is early access. The half chain leading to this link is suggestive of the important role that early recognition has in the emergency cardiac care system.

Prevention is the first step in any effort to controlling the morbidity and mortality for cardiovascular disease. Practicing a prudent life-style that encourages a balanced approach to nutrition and exercise are events that must start in childhood. Controlling those risk factors that can be changed is an additional key factor. For too many of us, we grew up smoking and had high- cholesterol and high-fat diets with lack of exercise. As heart disease is often silent, it may already be too late. However, many risk factors can be changed, and there may still be benefit from a prudent life-style.

When somebody collapses, the most important actions a bystander can take are to recognize the critical nature of the situation and call an emergency service number. For many years, the AHA has attempted to introduce in its CPR training programs, education concerning the importance of recognizing the signs and symptoms of an acute myocardial infarction and stroke and the action plan for survival.

A community-wide response system, called an emergency medical system, is critical to be able to respond to individuals in crises. Fortunately, in the United States most communities do have a planned emergency medical system at this time. It will take additional information and clinical research to determine what is the most appropriate system to have in place based on the needs of the population. There are controversies and logistical issues concerning the roles of one-tiered versus two-tiered paramedic systems. The decision is primarily related to geography, transportation, and the size of the population.

Unfortunately, all communities do not have a simple emergency telephone number. In the United States, "911" is utilized by approximately 60% of the country. However, for the other 40%, a local, seven-digit, emergency telephone number is utilized to access emergency help. Surprisingly, in spite of the large amount of public information, there are still significant delays by individuals in calling the emergency medical system. Some of this is explainable. The event is often unexpected and not planned. Family members or other individuals may be emotionally paralyzed and have not familiarized themselves with a formal emergency action plan.

Additionally, individuals fail to recognize the signs and symptoms of a significant cardiac event. A lot of time is spent looking up the emergency telephone number. Many individuals feel it is appropriate to call their private physician, hospital emergency room, friend, or relative. Unfortunately, these steps delay the response of the emergency medical system. For somebody who has suddenly collapsed, it is unlikely that advise from a friend, relative, or even the local emergency room will be very helpful. A few communities in the United States have trained their dispatchers in emergency rooms to perform telephone-directed CPR. In these situations, there have been many reports that individuals have been successfully resuscitated without using the pure standards that are propagated by the AHA for the performance of CPR. The critical factors seem to be accessing of the emergency medical system, maintaining the airway, and performing some compressions and ventilations. Other problems in delay include dispatcher response times. Dispatchers must continually be trained to recognize a true emergency call and dispatch the emergency medical team to the scene as quickly as possible.

An important issue that needs to be addressed in the area of early access is educating the community to "phone first." There has been extensive campaigning in the state of Iowa in the United States to educate the population concerning this concept. A number of items supporting the concept were reported from this statewide study.² Of the individuals who presented with an out-of-hospital cardiac arrest with an initial rhythm of ventricular fibrillation, it was noted that the survival rate was directly related to the total down time an individual experiences. The total was defined as the time from collapse until defibrillation and includes the components of call time, access time, and shock time. They reported that for individuals, who had a total down time greater than 6 minutes, only 5% survived to be discharged from the hospital to home. When the down time was less than 6 minutes, the survival rate improved to 28%. They further reported that in those individuals who survived, the call time was less than 2 minutes versus almost 3 minutes for those who did not survive. There was an additional 2-minute delay from the time of collapse to the initiation of CPR for those who did not survive. Also, there was an additional minute and a half increase to ambulance response time for those who did survive versus those who did not survive. The total down time for survivors, adding all components, was approximately 3 minutes shorter for survivors.

A very important observation in this study was that for individuals who are CPR-trained, less than 40% accessed the emergency medical system within one minute. Greater than 50% called within 5 minutes. The average time CPR was performed prior to activating the emergency medical system was 4 minutes. This raises the important question, how long does it take to do a minute of CPR? The AHA's CPR educational materials have consistently enforced the fact that individuals should perform one minute of CPR and then immediately call the emergency medical system. If our resuscitation efforts are to be successful, acknowledging that the total down time includes approximately 2 minutes to defibrillate and 3 to 4 minutes for an ambulance to respond to the scene, then that 1 minute of CPR may very well have to be the fastest 1 minute of an individual's life. There are significant questions as to the benefit of that initial minute of CPR, especially if it really is 4 minutes of CPR. Perhaps all individuals should "phone first." For those individuals who are not CPR-trained, this is essential.

The phone-first campaign in the state of Iowa was adopted as a community-wide program. It was first aimed at the local ambulance and first responder services and, subsequently, supported by the Iowa State Hospital Association. A media campaign was initiated. There was training for all CPR instructors and a number of service groups, as well as training and media campaigns for the hospitals. The results of this campaign are under study. The unresolved and controversial issue raised by the campaign is: should an individual phone first or perform the first minute of CPR? To date the AHA Basic Life Support Subcommittee has decided to continue its existing recommendations, educating trainers that they should continue to do a minute of CPR, and access the emergency medical system if no one else has responded who is able to call for help. This issue will be revisited during the upcoming 1991 AHA Standards and Guidelines Conference.

The second link in the chain of survival is early CPR. Research confirms that victims who receive early CPR are more likely to survive than those who received delayed CPR.³ Brain death is reported to occur sometime between 4 to 6 minutes after an individual is clinically dead. The importance of early CPR is evident. What isn't known is why early CPR is effective. Is CPR prolonging ventricular fibrillation (which is treatable) or are other factors important? With a new perspective on early access and the next link, early defibrillation, it is clear that CPR cannot stand alone as the sole important link to increased survival.

The third link in the chain of survival is early defibrillation. Most victims of a cardiac arrest will not be revived if electrical therapy is not administered. Early defibrillation has evolved from an experimental treatment to a community-wide standard of care.

During the 1985 AHA Standards Conference, the issue of early defibrillation was addressed: "Tbe use of defibrillation by the EMTs who have been trained in the recognition of ventricular fibrillation has been shown to improve survival significantly in areas without paramedic service, or where the response time for paramedics is relatively long. This concept has been proved and it should be implemented in many areas."⁴

The 1987 textbook of Advanced Cardiac Life Support further supports the principle: "In the last decade we have under emphasized the role of prompt defibrillation ... efforts to provide a cadre of less trained first responders with the training and equipment to administer early defibrillation have been initiated and should be aggressively supported."⁵ Furthermore, "a national EMT defibrillation training curriculum should be developed ... precise protocols must be developed so that units (automatic defibrillators) are used properly with minimal interruption of CPR... local regional or statewide advanced training programs, if available, can be of assistance."⁴

The importance of early defibrillation was first reported by Eisenberg in 1980.⁶ Patients with ventricular fibrillation who were defibrillated had a 50% chance of being admitted to the hospital and a 26% chance of being discharged from the hospital. Those who were in the control group had a 21% chance of being admitted to the hospital and a less than 12% chance of ultimately being discharged from the hospital.

This study was repeated in Iowa and the results were even more dramatic.⁷ Of those individuals who were in ventricular fibrillation versus the control group, 18% were discharged to home. For those who did not receive early defibrillation, there was less than 4% survival. These studies were conducted in two different populations, one with a very close geographic and well dispersed emergency medical system and one in rural communities. Early defibrillation was very successful and led to increased survival in both areas. Other studies in the United States included those in southeast Minnesota, northeast Minnesota, and Wisconsin; all demonstrated an increased odds ratio for improved survival after an early defibrillation program was instituted.^8-10

Recently, automated external defibrillators (AEDS) have become available. The automation aspect in terms of being able to recognize ventricular defibrillation, without requiring arrhythmia-training by the person using the equipment, has made it possible to further decrease the response time to deliver the first counter shock. Less trained individuals can function very well as first responders. In a recent study,¹¹ there was a 30% survival rate for those individuals who presented with ventricular fibrillation and who were treated with an AED. A 19% survival rate was reported.for individuals waiting for a paramedic team. The response time was approximately three times shorter for the automated external defibrillation response. Defibrillation was provided an average 5 minutes sooner with an AED.

Of interest, upon review of the presenting arrhythmia, the AED only showed improvement with a treatment of ventricular fibrillation. Individuals with an initial rhythm of asystole or electromechanical dissociation had negligible survival rates. For individuals initially presenting with an initial rhythm of ventricular tachycardia, paramedics had a much greater survival rate than did the fire fighters with the AEDS.

In response to the multiple requests, as well as in recognition of the importance of defibrillation, the AHA Emergency Care Committee has developed a provider course and instructor-training materials for automated external defibrillation. The materials are presently under final review and should be available in the summer of 1990.

With the advent of advanced technology, the AED can be placed in homes or in other remote areas. The simplicity of operation opens up tremendous opportunities to shorten the response time for defibrillation.

The final link in the chain of survival is early advanced care. For those individuals who did not respond to initial CPR or did not have a rapid response to early defibrillation, there may be some benefits to providing advanced cardiac life support (ACLS).

The Seattle data in relation to survival rate and promptness of response of CPR and ACLS demonstrate the highest survival from a cardiac arrest - when CPR is initiated within 4 minutes and an ACLS unit arrives within 8 minutes. Any further delays dramatically decrease one's chance for a successful outcome.³

Lastly, the half chain at the end suggests that early intervention will be the next link in the chain of survival. The next decade will be full of controversy concerning the appropriate utilization of thrombolytic agents, laser therapy, and other advances.

There are a number of controversial issues that the field of resuscitation faces as it moves into the next decade.

Risk of infection During CPR Training and Rescue

It is impossible to discuss controversies in CPR without addressing the issue of infectious diseases and, most importantly, human immunodeficiency virus (HIV) infections.

The current epidemic of acquired immunodeficiency syndrome (AIDS) certainly has raised significant moral, ethical, and legal issues concerning the performance of CPR, as well as the role of future CPR training. While there are many myths concerning the actual infectivity of the HIV infection, study after study continues to confirm the fact that there is a much higher infectivity with the hepatitis B virus (HBV) than with the HIV. The blood of a person infected with hepatitis B contains a million more times the viral particles per millimeter than the blood of an HIV infected person.¹² In spite of these facts, the Emergency Cardiac Care Committee of the AHA found it necessary to incorporate recent advisories from the Center for Disease Control as well as other information into the guidelines that it issued after its 1985 national conference. This update was published in a recent issue of the Journal of the Anierican Medical Association.¹³ The guidelines address the following issues.

Guidelines for Rescuers with Known or Suspected Infections: There has been documentation of transmission of the HBV between health care workers and patients with a documented infection. Instruments in the patient's open wounds have been contaminated when health care workers with high concentrations of HBV in their blood sustain a puncture while performing invasive procedures. Transmission of HIV from patients to health care workers have been documented in cases of blood exchange or penetration of the skin by blood-borne contaminated instruments.

Direct mouth-to-mouth resuscitation certainly will result in exchange of saliva between victim and rescuer. Hepatitis B positive saliva as well as saliva from individuals infected with HIV have not to date been shown to be infectious. There is the remote possibility that in the performance of mouth-to-mouth resuscitation, there could be blood exchange between the victim and rescuer if either or both have breaks in the skin around the lips or soft tissues. Thus, there is a theoretical risk of HBV and HIV transmission during mouth-to-mouth resuscitation. In light of this information the following guideline has been issued: "rescuers that have an infection that may be transmitted by blood or saliva, or who believe they have been exposed to such an infection, should not perform mouth-to-mouth resuscitation if circumstances allow other immediate or effective methods of ventilation".¹³

For rescuers with a duty to provide CPR, it is again reiterated that the probability of infection is minimal. Universal blood and body fluid precautions have been recommended repeatedly. It is strongly recommended that mechanical barriers be provided in the work place; masks with one-way valves, bag-valve masks, or plastic mouth and nose barriers. It is well documented that handkerchiefs and masks without one-way valves offer little if no protection and should not be considered for routine use. Early intubation eliminates the need for mouth-to-mouth resuscitation and is strongly encouraged.

Guidelines for the lay person acknowledge that the performance of CPR is an individual decision. It is based on moral and ethical values, as well as the knowledge of the risks involved in performing CPR. Lay persons should be reminded that over 70% of cardiac arrests occur at home. The probability is very high that one would perform CPR on a family member or loved one. Acknowledging these particular situations, lay persons may perceive a very high risk for disease transmission. It was recommended that the lay rescuer should at a minimum assess the victim's responsiveness, call for help, position the victim, open the airway, and in the absence of a pulse perform chest compressions. This is in acknowledgment of the fact that at least during the first minute of CPR, blood gas analyses remain reasonable even in the absence of ventilation. An accompanying editorial to the supplemental guidelines acknowledges that this statement offers a crack through which "the polluted stream of hysteria about acquired immunodeficiency syndrome may seep."¹⁴ With some success with telephone-CPR and other modifications of the techniques of CPR, this modification may not be as radical or peceived as negatively as might be anticipated. To date, except for some hysteria in the local news, there has been little reaction in the AHA training network concerning this recommendation for lay persons.

Addressing the issue of CPR training for infected individuals, the guidelines reiterated the position that one should postpone training if an individual has an acute respiratory infection, recent exposure to an infectious agent, or open skin lesions in the hands or in the oral or circumoral areas.

Regarding the issue of CPR training for those individuals with a chronic illness, and especially those infected with HBV or HIV, the overriding principle is to protect the other participants in a class. Requesting a separate manikin to be used throughout the class by the infected individual is essential. Strictly adhering to established procedures for decontamination of manikins after the course should protect subsequent users of the manikins from infections.

These guidelines will certainly not put to rest the concerns regarding HIV infection. It must be repeated that as of mid-1989, only 25 documented cases of HIV conversion have occurred in health care workers exposed to the blood of HIV positive patients. There were three conversions among 963 health care workers exposed to blood after a needle exposure. The Center for Disease Control Cooperative Needlestick Surveillance Group has abandoned follow-up on health care workers exposed to saliva and other nonblood fluids from patients with HIV because none of the 106 workers were followed for more than one year seroconverted.¹⁵ HBV certainly remains the greatest infectious risk to CPR providers.

A second issue of controversy is the actual appropriate mechanism for ventilation during CPR. Melker^l6 presented work suggesting that the previously performed stair-step ventilation during CPR created excessive peak inspiratory pressures. These pressures were greater than the gastroesophageal sphincter pressure and produced gastric insufflation. Gastric insufflation has been associated with gastric regurgitation and aspiration. Certainly in infants and children, as well as in a number of adults, excessive distention and pulmonary complications have frequently been noted from the ventilatory effect during CPR. The current recommendations for adult CPR of two slow respirations, delivered at 1 to 11/2 seconds per inspiration, theoretically decrease the pulmonary inspiratory pressure. Appropriate changes have been made to the two-person sequence as well as the infant sequence. To date this information has not been verified nor challenged by any additional research activity.

The mechanism of blood flow during CPR has received a great deal of attention. Historically, it was felt that the blood flowed by what has been called a "cardiac pump" mechanism, that is, blood flow during CPR resulted from direct squeezing of the heart between the sternum and the spine. There has been a recent challenge to this theory by what has been labeled the "thoracic pump mechanism. This theory emphasizes that blood flow is generated by changes in the intrathoracic pressure. The heart merely acts as a passive conduit through which blood passes. There is evidence for both theories. A study with small animals^l7 demonstrated that direct cardiac compression occurred. Direct cardiac compression was noted in very high compression CPR.¹⁸ Others have demonstrated changes in ventricular shape taking place during CPR.¹⁹ Researchers at Duke University in North Carolina have found that external chest compression produced equivalent increases in arterial and intrathoracic pressure.¹⁹

The cardiac pump theory began to be questioned for individuals who had performed CPR and had a flail chest; it was essential that external binding take place in order to generate a measurable medical blood pressure.²⁰ The most compelling arguments questioning cardiac pump theory resulted from the work done on cough-CPR.²¹

By coughing while fibrillating during a cardiac catheterization, it has been demonstrated that it is increased thoracic pressure, rather than the actual pumping of the heart, that was able to maintain systolic blood pressure. Additional researchers have further suggested that the thoracic pump mechanism is indeed the appropriate model. Two-dimensional echocardiographs during CPR demonstrated that the aortic and mitral valves are open and that there was no change in the ventricular dimensions.²² Additional geographic evidence has demonstrated that blood injected into the pulmonary vein and left atrium passes directly to the aorta during a single compression in CPR.²³ This controversy is clouded with conflicting inforina tion, probably explained by different animal models with different chest compliances as well as varying experimental models.

Of importance is the implication of the actual theories on how blood is moved anterograde during CPR and what impact that has on how one performs CPR. For the cadiac pump theory, stroke volume is determined by the force of compression. By increasing the compression rate, it will increase the cardiac output. For the thoracic pump theory, flow is enhanced by increasing both the force and the duration of compression. During the 1985 conference, it was resolved that it would be beneficial to increase the compression rate from 60 to 100 per minute. The increased rate permits an equal compression relaxation cycle and supports the beneficial effect in CPR regardless of the actual mechanism blood flow during CPR.

Ornato²⁴ reported his results in utilizing a chest compression device (thumper) on 12 humans. The results show that there was a direct linear correlation between the arterial systolic pressure and the compression force. End-tidal PCO₂ was also linearly related to the chest compression force (Figures 4 and 5). This research generated a concern that the current recommendations for chest compression, 1.5 to 2 inch chest depression per compression in adult or 60 to 80 pounds of force, may be inadequate to maximize the performance of CPR. The author recommends that the chest should be depressed to "3" in the performance of CPR. While the argument is compelling, additional information and confirmation of these findings are warranted.

Lastly, one must mention that there are many alternate techniques for performing CPR. Proposals have included continuous abdominal binding, simultaneous chest compression and ventilation, simultaneous chest and abdominal compression, interposed abdominal compression, the use of military anti-shock trousers, high-impulse CPR, and pneumatic chest compression and simultaneous ventilation. All of these procedures require extensive instrumentation and adjuncts in the performance of CPR. As such, they are limited in usefulness to the hospital setting. There are no studies that clearly demonstrate the efficacy of adapting any one of these methods as a standard for the performance of CPR.

Regarding medications, there have been a number of changes as a result of the AHA conference held in 1985.

Calcium Chloride: The first of these changes was in the recommendations for calcium chloride. Prior to this conference calcium chloride was recommended for electromechanical dissociation and asystole. The physiologic basis for this recommendation includes the fact that calcium increases myocardial contractility, prolongs asystole, and enhances ventricular automaticity. There were a number of concerns raised regarding the use of calcium in a cardiac arrest. Serum levels recorded during a cardiac arrest were at extremely high levels.²⁵ In addition, there was increased cellular damage noted with high calcium in a biochemical model. Research has demonstrated that increased anoxic cerebral insult is a direct result of the calcium ion²⁶ and, as such, further increases in calcium could further increase anoxic injury. Lastly, with the introduction of calcium antagonists, it has been demonstrated that they protect the cerebellum and myocardium from reperfusion injury and in the process restore adenosine triphosphate stores.²⁷ Retrospective studies were conducted regarding the usefulness of calcium in ACLS in both Milwaukee and Tampa.^28,29 There was no improvement with the utilization of calcium for asystole or ventricular fibrillation and only a minor improvement in those individuals who presented with electromechanical dissociation. A prospective doubleblind study was conducted showing essentially no survivors for individuals who presented with asystole.³⁰ There was only one survivor who presented with electromechanical dissociation.

In light of this information, it was recommended that calcium not be utilized for asystole, and it was concluded it had questionable effectiveness for electromechanical dissociation. Only in the presence of acute hyperkalemia, hypercalcemia, or calcium channel-block toxicity should calcium be routinely recommended.

Sodium Bicarbonate: The use of sodium bicarbonate in resuscitation is supported by more traditional rather than experimental evidence. Acidosis occurs during a cardiopulmonary arrest due to the generation of lactic acid, as well as due to a respiratory acidosis from carbon dioxide retention. Effective ventilation and circulation during CPR can prevent and eliminate the acidemic state associated with a cardiac arrest.

The major problem with sodium bicarbonate is its high carbon dioxide content (260 to 280 mm Hg for each 50 mEq).³¹ Liberation of carbon dioxide and rapid intracellular diffusion after sodium bicarbonate administration worsen intracellular acidosis. This can compromise myocardial function, decrease systemic vascular resistance, decrease the threshold for ventricular fibrillation, and cause dysfunction in the central nervous system.³²

Guerci³³ found that bicarbonate did not have any more beneficial effect in defibrillating dogs than saline. Additional information has suggested bicarbonate may, in fact, be detrimental.³⁴ As such, a primary role for sodium bicarbonate is not suggested. Emphasis must be switched from bicarbonate to prompt defibrillation, vigorous chest compression, and the administration of epinephrine or other vasoconstrictors.

Glucose: Another controversy that has recently been raised is in the area of the utilization of glucose during a cardiac arrest. Hyperglycemia has been noted to be associated with a higher mortality rate and a worse neurologic outcome.³⁵ Of interest is the fact that there is really minimal glucose given during a cardiac arrest except when it is given in bolus form. It is unclear what the etiology of the hypoglycemia during a cardiac arrest is. It is presumed to be reactive rather than primary. There is warning that judicious use of glucose must be reinforced in all of our ACLS education. Some investigations have recommended that glucose be eliminated from ACLS. At this time the evidence is not convincing enough to warrant a routine use of lactated ringers.

End-Tidal PCO₂ Monitoring: Lastly, in the area of new technology, a number of investigators have found PCO₂ monitoring to be an excellent monitor and indicator of resuscitation success. Observations of the relationship between end-tidal PC0₂ and cardiac output confirmed a high linear correlations In addition, a strong correlation between end-tidal PCO₂ measures and survival from cardiac arrest evaluates the effectiveness of the CPR effort.³⁷ The ease of utilization of this tool strongly indicates that if these findings are consistently replicated, this technology may become a standard for monitoring all ACLS efforts.

In this report, the chain of survival and a number of issues concerning background information for some of the changes recommended by the AHA in 1985 have been highlighted.

There are several challenges that we face during this decade. Certainly the first issue that must be addressed is the protection of the rescuer. The AIDS epidemic will not disappear in the foreseeable future. The resistance in terms of lay individuals and others to CPR training and the propagation of a number of protective devices (one-way masks, shields, etc.) will continually challenge the CPR effort. It is incumbent upon all of us to keep well informed and implement strong recommendations that will protect the rescuer and the rescuee from any disease transmission.

A second challenge we face, in terms of decreasing the morbidity and mortality from cardiovascular disease, will be in the area of prevention. A pediatric approach to this problem is essential. In the United States, a number of successes have been generated in a campaign against smoking. There are still, however, large numbers of adolescents who smoke today compared to 20 years ago. The issues around cholesterol screening and the controversies concerning the effectiveness of monitoring and intervention will remain an area of great concern during the next decade. Certainly, if we can change individuals' life-styles and recognize a significant cardiac arrest in the earliest stage, we will be much more successful in our fight to control heart disease.

To this end, the AHA has recently convened a task force looking at the future of CPR activities in the association. The task force was charged with reviewing the following:

4. Select the best way to teach those skills identified as essential to the performance of CPR.

It is expected this task force will issue its report and focus on the AHA's emergency cardiac care activities for the next decade.

Likewise, the Canadian Heart and Stroke Foundation had an Emergency Cardiac Care Consensus Conference in 1988. Regarding the issues of insuring standardized care, insuring individual focus, and insuring local participation, a large number of ideas has been identified and a blue print for a community-wide plan has been developed. Under insuring standardized care, there is a commitment to have universal access, national acute standards, and universal quality. In the arena of insuring individual focus is promotion of a healthy life-style. In the areas of insuring local participation, the focus is the development of acute care standards for initial response, as well as the development of local and national acute care standards for the emergency response team. This comprehensive approach to the issues certainly focuses the resuscitative efforts.

It is incumbent upon all of us worldwide to look at the issues of education and evaluation. The CPR educational literature is very weak in lending help to those of us who are in positions to develop and implement programs. Guidelines as to how these programs should be developed and what is truly effective from an educational focus are in its infancy. Certainly, some of the problems lie with large organizations that have not been very clear with its goals. While for a long time CPR training has really been a nice entry in terms of educating people around the issues of coronary heart disease, the exciting part of taking a CPR course has really been to train in the areas of psychomotor skills. If there is a general acknowledgment that the major benefits to society are in the area of prevention, then the AHA and others must change the focus of our program from precision on manikins or precise ACLS performance to an educational approach that addresses the issues of prevention. Creative and stimulating educational alternatives, traditional CPR, and ACLS courses must be generated during the next decade.

Finally, as an ongoing concern, the issue of sound basic and clinical research must be addressed. When one critically looks at how standards and guidelines are developed, the decisions are often based on consensus and political considerations rather than a solid scientific body of knowledge. It is essential that the large organizations take a very strong advocacy position with the granting agencies to fund significant research. Population studies as to who should be resuscitated, why, and under what circumstances are sorely lacking. Recently, there have been a number of editorial and studies suggesting that the elderly population, particularly those at high risk, should not be resuscitated. Some of these studies have very significant merit and need to be expanded to larger populations.

It is critical that for all of our CPR and ACLS studies that a universal data collection tool be developed. One of the difficulties in evaluating the significance of the varying research studies is the fact that the same data collection criteria are not used. The United Kingdom has recently developed such a universal tool and is presently collecting data under this system. It is expected that some of this information from their first few years of collecting data with a universal database will be reported at the end of this year. To date, in the United States, there have only been scattered telephone conversations concerning this issue.

It is also essential that this rigorous approach be applied to the evaluation of new technology both in instrumentation and drug therapy. For an issue that has worldwide impact, it is unfortunate that we have to make decisions on the basis of studies with 12 individuals, 12 animals, or 100 clinical events. While I believe the best and the most rational decisions that could have been made have been made in evaluating and making recommendations for the treatment of emergency cardiac victims, the emergency cardiac care program has been hampered by a lack of significant funding. It is essential that the funding of CPR research be given priority. Without significant funding, the emergency cardiac care community will not be moving forward into the next century, not just this decade, and will still be asking questions about many of the issues that have been discussed in this report. Our fight to prevent unnecessary deaths from coronary artery disease will only be as successful as the weakest link in our chain of survival. All of the links can and will be strengthened with a nationwide focus on the emergency cardiac care problem and significant funding of emergency cardiac care research.