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Extracorporeal circulation as an alternative to

open-chest cardiac compression for cardiac

R J Gazmuri, M H Weil, K Terwilliger, D M Shah, C Duggal and W Tang

Chest 1992;102;1846-1852
DOI 10.1378/chest.102.6.1846
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Extracorporeal Circulation as an Alternative to Open
ChestCardiacCompressionfor CardiacResuscitation*
Raiilj Gazrnuri, M. D.; Max Harry Weil, M. D. , F.C. C. F;
Karl Terwilliger, BA.; Dinesh M. Shah, M.D.; Chandresh Duggal, M.D.;
and Wanchun Tang, M.D.

Ope n-chest direct cardiac compression represents a more intervals. Systemic blood flows averaged 198 ml@kg'@mmn'
potent but highly invasive option for cardiac resuscitation with extracorporeal circulation. This contrasted with direct
when conventional techniques of closed-chest cardiac re cardiac compression, in which flows averaged only 40
suscitation fail after prolonged cardiac arrest. We postu mlkg―min'. Coronary perfusion pressure, the major
lated that venoarterial extracorporeal circulation might be determinant ofresuscitabiity on the basis ofearlier studies,
a more effective intervention with less trauma. In the was correspondingly lower (94 vs 29 mm Hg). Extracorpo
setting of human cardiac resuscitation, however, controlled real circulation, in conjunction with transthoracic DC
studies would be limited by strategic constraints. Accord countershock and epinephrine, successfully reestablished
ingly, the effectiveness of open-chest cardiac compression spontaneous circulation in each of eight animals after 15
was compared with that of extracorporeal circulation after mm of untreated ventricular fibrillation. This contrasted
.4 . ‘- a 15-mm interval of untreated ventricular fibrillation in a with the outcome after open-chest cardiac compression, in
@ porcine model ofcardiac arrest. Sixteen domestic pigs were which spontaneous circulation was reestablished in only
. randomized to resuscitation by either peripheral venoar four of eight animals (p .038). We conclude that extracor
terial extracorporeal circulation or open-chest direct car poreal circulation is a more effective alternative to direct
diac compression. During resuscitation, epinephrine was cardiac compression for cardiac resuscitation after pro
continuously infused into the right atrium, and defibrillation tracted cardiac arrest. (Chest 1992; 102:1846-52)
was attempted by transthoracic countershock at 2-mm

E lectrical countershock is the immediate treatment Open-chest direct cardiac compression is a well
for ventricular fibrillation. When applied within established option by which substantially greater car
less than 60 s, it typically restores spontaneous circu diac output and coronary perfusion pressures may be
lation without additional interventions. ‘@
When the achieved.'2'4 The success of resuscitation under ex
duration of cardiac arrest is more prolonged, the perimental conditions is consequently increased two
success of resuscitation is contingent on the capability to threefold, contingent on the duration of cardiac
of achieving threshold levels of coronary perfusion arrest prior to open-chest cardiac massage.4'5'6 It is
pressure and therefore myocardial blood flow. The for these reasons that open-chest techniques have
coronary perfusion pressure itself is highly predictive been investigated as an option when conventional
of the success of resuscitation.47 methods of closed-chest resuscitation fail to restore
@ Current methods of closed-chest cardiac resuscita spontaneous Yet the practical issues of
tion lose effectiveness for maintaining critical coronary surgical skill and postthoracotomy patient care, to
perfusion pressures when the duration ofeardiac arrest gether with insecure proofofultimate clinical benefit,
prior to attempted cardiac resuscitation increases to have restrained the routine use of open-chest tech
more than 8 mm.89 Accordingly, the success of closed niques.
chest compression methods after more protracted More recent studies in animal models of cardiac
intervals exceeding 8 mm is remote.'°― arrest and reports on human victims of cardiac arrest
have provided evidence that extracorporeal circulation
@ the Department of Medicine, Divisions of Cardiology and (utilizing peripheral vascular access) may be a highly
Critical Care Medicine, University of Health SciencesfFhe Chi
cago Medical School, North Chicago, Illinois.
effective option for cardiac resuscitation.9―@ In our
Supported in part by National Heart, Lung and BIcod Institute studies, extracorporeal circulation successfully re
grants l-RO1-11L39148 and 1-RO1-11L42590;Institute of Critical stored spontaneous circulation in 19 of 21 pigs after a
Care Medicine, Palm Springs, Calif; and a grant-in-aid from the
American heart Association supported by Winthrop Pharmaceu 15-mm interval ofcardiac arrest. This contrasted with
Reprint 7x'que.sts:I)r @@/(‘il,
Institute ()fCrltical Care Medicine, 3333 closed-chest resuscitation, in which none of five ani
Green Bay Road, North Chicago, IL 60064 mals was resuscitated.9

1846 Alternativeto Open-Chest Cardiac Compression for Resuscitation (Gazmun et a!)

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© 1992 American College of Chest Physicians
In the present studies, we compared the effective PEBS-1600, Cook mc, Bloomington, Ind) was advanced through
ness of extracorporeal circulation and direct cardiac the left external jugular vein into the superior vena cava. Under
fluoroscopic visualization, the tip was positioned at the junction of
compression following 15 mm of untreated cardiac
the right atrium with the inferior vena cava. For arterial return (in
arrest with the anticipation that extracorporeal circu pigs the femoral artery is ofmuch smaller dimension than in humans
lation would be more effective for restoring sponta or dogs), two 14F cannulas (William Harvey model 1858 USCI CR.
neous circulation. Bart mc, Billerica, Mass) were advanced from each of the femoral
arteries into the external iliac arteries.
METHODS In preparation for internal cardiac massage, the skin, subeuta
The studies were approved by our University Animal Care neous tissue, and muscles of the left fifth intercostal space were
Committee, and the procedures were performed in accord with incised between the midclavicular line and the midaxillarv line,
National Institutes of Health guidelines.@' and hemostasis was obtained with electrocautery. The parietal
pleura was exposed and the rib cage was retracted for exposure of
Animal &eparation the heart. The parietal pericardium was incised in preparation for
Our previously described porcine model of cardiac arrest'@ and manual cardiac compression. The thoracic opening was then closed
the methods developed in o@r laboratory for resuscitation by with the aid of clamps and reopened only immediately prior to
extracorporeal circulation' were utilized. In preliminary trials, the cardiac compression. Aseptic techniques were used throughout the
porcine model was also adapted for investigations of open-chest experiments.
cardiac compression. A total of 16 randomized experiments were
planned to investigate whether extracorporeal circulation was a
more effective alternative to open-chest direct cardiac compression Cardiac output was measured during spontaneous circulation and
in eight animals each. during open-chest cardiac compression by thermoclilution tech
In brief, domestic pigs weighing between 22 and 31 kg were nique with the aid ofa cardiac output computer (model 9250, Baxter
fasted for 12 h. Anesthesia was induced by intramuscular injection Edwards Laboratories) after bolus injection of 5 ml of 5 percent
of ketamine (30 mg per kilogram of body weight), followed by glucose at a temperature between 0°Cand 4°Cin the right attium.@
intravenous injection of sodium pentobarbital (30 mg/kg). The Extracorporeal flow was measured with an ultrasonic flow meter in
trachea was intubated, and the lungs were ventilated with a volume the efferent tubing ofthe oxygenator (model TiOl , Transonic System
controlled ventilator at a frequency of 12 breaths per minute, tidal Inc. Ithaca, NY). Intravascular pressures were measured with fluid
volume of 12 mI/kg, and F1o2 of 0.5. The respiratory rate was filledcatheters utilizingStatham P50 or P23db transducers (Spec
adjusted to maintain arterial Pco2 at 35 to 45 mm Hg. Anesthesia tramed, Oxnard, Calif).
was maintained with intravenous doses of pentobarbital (8 mg/kg) Coronary perfusion pressure was calculated as the arithmetic
at 30-mm intervals. Neuromusuclar blockade was induced by difference between the end-diastolic aortic pressure and the time
intravenous injection of pancuronium (0.09 mg/kg) and was main coincident right atrial pressures during spontaneous circulation and
tamed with supplemental doses (0.05 mg/kg) at intervals offiO mm. during cardiac compression. In the absence of pulsatile aortic
For aortic pressure measurements and blood sampling, an 8F pressure during extracorporeal circulation, the difference between
angiographic catheter was advanced from the left carotid artery mean aortic and mean right atrial pressures served as estimate of
into the ascending thoracic aorta. The left carotid artery was used coronary perfusion pressure. A scalar lead 2 ECG was recorded
because the femoral arteries were reserved for extracorporeal continuously.
circulation. For measurements ofcardiac output, core temperature, Aortic and great cardiac vein blood gas values and pH were
and right atrial pressures, a balloon-tipped pentalumen thermodi measured with a blood gas analyzer (model 1L813, Instrumentation
lution catheter was flow-directed from the right femoral vein into Labs, Lexington, Mass). Total hemoglobin and oxyhemoglobmnwere
the pulmonary artery. The proximal port was used for continuous measured with a CO-oximeter (model 11282, Instrumentation Labs)
infusion of epmnephrine into the right atrium during cardiac resus with corrections for porcine blood. Oxygen content was calculated
citation. For coronary venous blood measurements, a 7F angio from the measured total hemoglobin, oxygen saturation, and PO@,
graphic catheter was advanced from the left cephalic vein into the utilizing an oxygen hemoglobin binding coefficient of 1.39 ml/g.
great cardiac vein with fluoroscopic guidance. For induction of Myocardial oxygen extraction was computed as the difference
ventricular fibrillation, a 4F pacing electrode was advanced from between arterial and coronary vein oxygen content divided by the
the right cephalic vein into the right ventricle such that its tip arterial oxygen content.
impinged on the right ventricular endocardium.
Experimental Procedure
Prior to induction ofcardiac arrest, the animals were randomized.
Either vascular cannulization was performed in preparation for Prior to induction of cardiac arrest, the intravascular volume was
extracorporeal circulation, or thoracotomy was performed in prep expanded by administration of6 percent hetastarch so as to increase
aration for open-chest cardiac compression. pulmonary wedge pressure to 8 mm Hg. Core (pulmonary artery)
For extracorporeal circulation, a centrifugal pump (model 7850 temperature prior to cardiac arrest was maintained between 36.1°C
Sarns Inc. 3M, Ann Arbor, Mich) and a capillary membrane and 37. 1°C.
oxygenator (model BOS-CM4O, American Bentley, Irvine, Calil) Ventricular fibrillation was induced by a 10-mA AC current
were connected in series utilizing Bentley Bypass TM7O tubing delivered to the right ventricular endocardium and was confirmed
(American Bentley). Either the blood interface ofthe extracorporeal by ECG morphology and coincident decrease in both mean aortic
circuit was coated with heparin (four animals), or systemic anticoag pressure and end-tidal Pco2. The inspired oxygen concentration
ulation was produced with bovine heparin in doses of 100 lU/kg was then increased to 100 percent. After 14 mm 45 s of untreated
injected into the venous circuit ofthe oxygenator immediately prior ventricular fibrillation, a maximum of two 300-J transthoracic
to induction ofventricular fibrillation (four animals). The dead space countershocks were delivered, which failed to reestablish sponta
of the pump, oxygenator, and cannulas was filled with 6 percent neous circulation in each instance. Either extracorporeal circulation
hetastarch in 0.9 percent NaCl (Hespan, DuPont Merck, Wilming or direct cardiac compression was then begun.
ton, Del). Extracorporeal nonpulsatile flow was maintained with a Extracorporeal flow was established at 200 mlkg ‘min ‘ and
centrifugal pump (model 7800 Sarns Inc. 3M, Ann Arbor, Mich). adjusted over the range of 161 to 265 mlkg@ ‘min ‘ contingent on
For venous access, a 17F multiple-hole, thin-walled cannula (C- venous return. The oxygen flow through the oxygenator was adjusted

CHEST I 102 I 6 I DECEMBER, 1992 1847

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© 1992 American College of Chest Physicians
Table 1—Outcomeofinitial Defibrillation Attempts after continuousdatabetweenextracorporealcirculationandopen-chest
15 mM ofUntreate4 Ventricular Fibrillation* cardiaccompression.A p value less than 0.05 was regarded as
8)EMD75Asystole11Ventricular ECC (n =8)OCCC (n =

fibrillation02 Defibrillation failed to convert ventricular fibrilla

tion in only two instances at the end of 15 mm of
*ECC = extracorporeal circulation; OCCC open chest cardiac
compression; EMD electromechanical dissociation. untreated ventricular fibrillation. Most animals devel
oped either electromechanical dissociation or asystole
to maintain an oxygen-blood flow ratio of 2: 1 to secure physiologic (Table 1). Within 2 mm after the start of extracorporeal
gas exchange. During cardiac compression, the heart was com
circulation or direct cardiac compression, electrome
pressed against the sternum with the supinated palm with fingers
extended. The rate was maintained between 60 and 80 per minute chanical dissociation and asystole reverted to ventric
with equal compression and relaxation intervals. The operator was ular fibrillation in each instance.
relieved at 5-mm intervals. In preliminary trials in four animals, we With extracorporeal circulation, a supraventricular
confirmed that this method yielded greater cardiac output and rhythm was restored in each instance within 5 mm.
mean aortic pressure with lesser trauma than compression between
Spontaneous circulation returned within an average of
thumb and fingers.'@
Concurrently with the initiation of either extracorporeal circula 7.3 mm (range, 3 to 25 mm). With direct cardiac
tion or direct cardiac compression, epinephrine hydrochloride compression, spontaneous circulation was restablished
(International Medication Systems Ltd. South El Monte, Calif) was in only four of the eight animals within an average
infused into the right atrium in amounts of 3 @igkg min ‘.In interval of 6.9 min (range, 3 to 11 mm). In the
earlier studies with extracorporeal circulation, this favored restora
remaining four animals, defibrillation resulted in either
tion of spontaneous circulation within as little as 3 mm.' Defibril
lation was attempted at 2-mm intervals with up to two 300-J
electromechanical dissociation or asystole, which per
transthoracic countershocks. Successful resuscitation with return of sisted for 30 mm. Thus, extracorporeal circulation in
spontaneous circulation was defined as a supraventricular rhythm conjunction with epmnephrine and DC countershock
and a spontaneous mean aortic pressure of6O mm Hg. Failing such, successfully restored spontaneous circulation in each
resuscitation attempts were abandoned at 30 mm after the start of
of eight animals, compared with only four of eight
the resuscitation procedures. The infusion of epinephrine was
reduced by 25 percent decrements when spontaneously generated
animals that underwent open-chest cardiac compres
mean aortic pressure exceeded 65 mm Hg and was discontinued sion (p = 0.038).
within an interval of42 to 291 mm (mean, 117 mm).
Hemodynamic Effects
Statistical Analysis
The systemic blood flow generated by the extracor
Data are presented as mean ±SD unless otherwise stated. The poreal system averaged 198 ±11 mlkg ‘-min‘ and
one-sided Fisher exact test was utilized to confirm or reject the
hypothesis that extracorporeal circulation was more effective for
corresponded to 113 percent of prearrest cardiac
cardiac resuscitation than open-chest precordial compression?@A output. With direct cardiac compression, cardiac out
@ two-sided unpaired t test was utilized to compare differences for put averaged 40 ±4 mlkg ‘min (p 0.0001); this
I 20 r !@ V
4@j mmHg
0 ECC (8/8)

@ 1001 . occc (4/8)

@ .@..-

20j mmHg
FIGURE 1. Greater mean aortic pressures (MAP) and
coronary perfusion pressures (CPP) were produced by
extracorporeal circulation (ECC) than by open-chest 20 PErCO2
cardiac compression (OCCC). Significantly greater in torr
creases in end-tidal Pco, (Ps@rCOÃwere observed with
direct cardiac compression. Values are shown as mean
0 m i I U __T_.....1@*.T___;r@
(circles) and standard error of the mean. VF = ventric
ular fibrillation; DF ‘defibrillation by DC counter -10-5 04 12 +1 +3+30 +60 +120 +180
shock; # = pO.Ol and * pO.OOi for ECC vs OCCC Minutes UHS/CMS RJG,MHW 2/92
by unpaired t test. Domestèc
Pigs22 . 31 Kg

1848 Alternath,eto open@chest Cardi@ Compmssion for Resuscitation (Gazmurietal)

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© 1992 American College of Chest Physicians
corresponded to 27 percent ofthe prearrest level. The Gas Exchange and Metabolic Effects
mean aortic and coronary perfusion pressures were During ventricular fibrillation, profound acidemia
correspondingly greater during extracorporeal circu with threefold increases in PCO2was demonstrated in
lation (Fig 1). The coronary perfusion pressure had great cardiac vein blood (Table 2). In arterial blood,
increased to 76 ±39 mm Hg within 1 min and had however, concurrent alkalemia with decreases in
reached 94±25 mm Hg by the third minute. With PaCO2 to one third ofnormal was documented. These
direct cardiac compression, the coronary perfusion changes were comparable to those previously reported
pressure increased from 20 ±7 to 29 ±6 mm Hg by us in the porcine model.6 Two minutes after the
(p=0.0001) during the initial 3-min interval. The start of extracorporeal
circulationor direct cardiac
amounts ofepinephrine that were administered during compression, aortic PCO2 increased to approximately
direct cardiac compression exceeded those employed 50 mm Hg and pH decreased to approximately 7.20
@ during extracorporeal circulation (4.8 ±1.5 vs 2.6±1.1 (H 63nmollL).
p@gkg'mmn@, p=O.005). carbia were rapidly reversed by extracorporeal circu
During direct cardiac compression, end-tidal PCO2 lation; this coincided with threefold increases in great
correlated with the cardiac output, as previously cardiac vein oxygen content. With direct cardiac
reported.2@ After restoration of spontaneous circula compression, however, the great cardiac vein acide
tion, PE'rCO2 in four animals returned to prearrest mia, hypercarbia, and oxygenation remained un
levels (Fig 1). However, there was no significant changed. Accordingly, the venoarterial gradients for
@ correlation between PEi'C02 and cardiac output dur H and PCO2 and the myocardial oxygen extraction
ing extracorporeal circulation. This was consistent were reduced only by extracorporeal circulation (Fig
with prior observations, which indicated a linear 2).
relationship between pulmonary blood flow and The hemodynamic and gas exchange measurements
PEi'C02 during closed and open-chest cardiac com in animals that were successfully resuscitated by direct
pression. Accordingly, there was insignificant pulmo cardiac compression were then compared with those
nary blood flow during extracorporeal circulation and in animals that were not successfully resuscitated after
prior to the return of spontaneous circulation.m direct cardiac compression. We observed greater car

Table 2—Aortic and Coronary Vein Values before, during, and after Attempted Resuscitation by
Extracorporeal Circulation and by Open-Chest Cardiac Compression5

mmPot, —5mmVF + 12 mmResuscitation +2 mmPostresuscitation +60 mm+ 180

mm Hg
ECCCV231±36 20±2259±99 40±11(3)113±56 54±10403±34 50±16393±40

OCCC CV 23 ±3t 35±8(4) 34 ±13@ 54 ±11 37±10

02, volume %
ECCAo 10.2±1.8 10.1±2.7 9.3±2.5 11.6±1.9 10.7±2.0
ECCCV210±31 1.9±0.7240±100 2.2±1.5(3)66±26 6.6±1.7314±112 6.4±2.9356±84

OCCCCV 2.3±0.5 2.7±1.0(4) 2.4±1.5@ 9.4±2.8 5.1±2.1

Pco2,mm Hg
ECCAo 40±4 14±7 49±6 46±4 39±5
ECCCV10.1±1.3 50±59.7±2.3 155±36(3)10.3±3.0 67±3215.0±3.9 54±714.6±3.9t

OCCCCV 49±7 150±93(4) 158±54f 56±8 54±2

ECC Ao 7.47+0.05 7.87±0.18 7.20±0.06 7.24±0.66 7.39±0.08
ECC CV41±5 7.39±0.0416±8 6.56±0.19(3)56±10 7.06±0.2050±9 7.20±0.0443±5

OCCC CV7.48±0.05 7.40±0.037.82±0.12 6.77±0.39(4)7.25±0.05 6.76±0.17@7.21±0.07 7.18±0.077.32±0.05 7.25±0.03

@VF@= ventricular fibrillation; ECC extracorporeal circulation; Ao aortic; CV coronary vein; OCCC open-chest cardiac compression.
Values are expressed as mean ±standard deviation. Values were Obtained in eight animals except for postresuscitation OCCC (n 4). Values
in parentheses are number ofsamples obtained during VF.
tOCCC vs ECC, p<0.05.
@OCCCvs ECC, p<O.Ol.
§OCCCvs ECC, p<O.OOl.

CHEST I 102 I 6 I DECEMBER,1992 1849

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© 1992 American College of Chest Physicians
Table 3—Hemodynamic and Gas Exchange Measurements after 2 mm of
Extracorporeal Circulation and Open-Chest Cardiac Compression5

(4)p@Bood (8)Resuscitated (4)Non-Resuscitated

flow index, ml@kg'@mmnt198±

Pco,, mm Hg5
20.008Coronary ±624 ±212 ±
perfusion pressure, mm Hg87±2529±529±

5ECC = extracorporeal circulation; OCCC = open-chest cardiac compression.

tRefers to either extracorporeal flow index (ECC subset) or cardiac index (OCCC subset).
@Betweenresuscitated and nonresuscitated animals.

diac index and PEi'CO2 and a lower myocardial oxygen than 3 min.'2'3@ This is consistent with previous
extraction ratio (Table 3). However, differences in observations on the hemodynamic effects of closed
resuscitability were not explained by differences in and open-chest cardiac compression with increasing
coronary perfusion pressures in the setting of open duration of cardiac arrest.ssm In a canine model,
chest cardiac massage. Sanders et al@reported a decrease in the coronary
perfusion pressure generated by direct cardiac com
pression from 59 to 39 mm Hg when the preceding
These studies confirm previous investigations in interval ofcardiac arrest, which included closed-chest
both animals and human patients on the efficacy of compression, was increased from 15 to 25 mm. Ac
extracorporeal circulation for cardiac resuscitation cordingly, the low flows and pressures observed in the
after prolonged arrest.9'@°@Extracorporeal circulation current model are best explained by the prolonged
sustained quantitatively normal systemic blood flows downtime prior to intervention.
and served to “jumpstart―the heart within as little Increasing downtime may also compromise resus
as 3 mm.9 citability by increasing the minimal coronary perfusion
With direct cardiac compression, however, cardiac pressure threshold required for successful resuscita
output was only one fifth and coronary perfusion tion.9 When the duration of untreated ventricular
pressure only one third of that generated by extracor fibrillation was increased from 9 to 15 mm in our
poreal circulation, notwithstanding optimal compres rodent model of cardiac arrest, resuscitability was
sion technique and larger doses ofepmnephrine.@ This correspondingly decreased even though coronary per
is in contrast to the near.normal cardiac outputs and fusion pressure was maintained at comparable levels.@°
coronary perfusion pressures that are generated when This may explain why only 50 percent ofanimals were
open-chest cardiac compression is initiated within less successfully resuscitated by direct cardiac compres

0.6- M@W@@4

(4/8) b,.-



300 GCV-Ao [H+] b...,
nmol/I . ..
@ 0.@ I, ____________
)V.::@G@@r p S C
@ 4- GCV-Ao lact .@@. FIGURE 2. Extracorporeal circulation (ECC) decreased
myocardial oxygen extraction ratio (MOE) and the
0@ coronary venoarterial gradient (GCF-Ao) values for
@ Pco2 and H when compared with open-chest cardiac
compression (OCCC) without significant effect on lac
tate gradients. Values are shown as mean ±standard
-10 -5 0 4 12 +2 +30 +60 +120 +180 error of the mean. VF=ventricular fibrillation;
Minutes UHS/CMSRJG,MHW 2/92 DF = defibrillation by DC countershock; # pO.Ol
DomesticPigs 22. 31 Kg and * pO.OOl for ECC vs OCCM by unpaired t test.

1850 Alternativeto Open-Chest Cardiac Compressionfor ReSuScitatiOn(Gazmuri et a!)

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© 1992 American College of Chest Physicians
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@ October 24

1852 Alternativeto Open-Chest Cardiac Compression for Resuscitation (Gazmuri et a!)

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© 1992 American College of Chest Physicians
Extracorporeal circulation as an alternative to open-chest cardiac
compression for cardiac resuscitation.
R J Gazmuri, M H Weil, K Terwilliger, D M Shah, C Duggal and W Tang
Chest 1992;102; 1846-1852
DOI 10.1378/chest.102.6.1846
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