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PubMed2002

Nurses' behaviour regarding CPR and the theories of reasoned action and planned behaviour.

Cardiopulmonary resuscitation (CPR) has been used in hospitals for approximately 40 years. Nurses are generally the first responders to a cardiac arrest and initiate basic life support while waiting for the advanced cardiac life support team to arrive. Speed and competence of the first responder are factors contributing to the initial survival of a person following a cardiac arrest. Attitudes of individual nurses may influence the speed and level of involvement in true emergency situations. This paper uses the theories of reasoned action and planned behaviour to examine some behavioural issues with CPR involvement.

Attitude of Health Personnel↗
PubMed1995

Use of end-tidal carbon dioxide to predict outcome in prehospital cardiac arrest.

STUDY OBJECTIVE: End-tidal CO2 (ETCO2) measurement can be used to predict death in prehospital cardiac arrest patients with pulseless electrical activity (PEA). DESIGN: A prospective, observational study. SETTING: An urban and rural emergency medical services system in northwestern Washington state. PARTICIPANTS: Ninety consecutive victims of prehospital cardiac arrest with PEA. INTERVENTIONS: Patients were intubated in the field and treated using standard advanced cardiac life support protocols with online medical control. In addition, all patients were evaluated using mainstream ETCO2 monitoring. In this study, a hypothetical decision was made to cease resuscitative efforts based on an ETCO2 level of 10 mm Hg or less after 20 minutes of advanced cardiac life support. RESULTS: The study included 90 patients (61 were men) with a mean age of 67.6 +/- 13.6 years (range, 27 to 95 years). The initial ETCO2 averaged 11.7 +/- 6.6 mm Hg in nonsurvivors (range, 5 to 50 mm Hg) and 10.9 +/- 4.9 mm Hg in survivors (range, 5 to 24 mm Hg) (P > .672 [NS]). After 20 minutes of advanced cardiac life support, ETCO2 averaged 3.9 +/- 2.8 mm Hg (range, 0 to 12 mm Hg) in patients in whom the theoretical decision was made to cease field resuscitation. In contrast, survivors' ETCO2, just before restoration of circulation, averaged 31 +/- 5.3 mm Hg (range, 16 to 35 mm Hg) (P < .0001). Using an ETCO2 of 10 mm Hg or less as a theoretical threshold to predict death in the field successfully discriminated between the 16 survivors to hospital admission (those that achieved return of spontaneous circulation) and 75 prehospital deaths. Of the 16 survivors to hospital admission, 9 died in the hospital, and 7 were discharged from the hospital alive. In 13 of the 16 survivors, the first evidence of return of spontaneous circulation, before a palpable pulse or blood pressure, was a rising ETCO2. The logistic-regression parameters for the model are 4.4391 + ETCO2*-0.3624 (P < .0001). Sensitivity was 97.3%; specificity 100%; positive predictive value 100%; and negative predictive value 88.9%. CONCLUSION: This study suggests that a low ETCO2 (10 mm Hg or less) can be used to predict irreversible death in patients with pulseless electrical activity undergoing prehospital advanced cardiac life support. If future studies validate this model, use of ETCO2 may allow for triage decisions in the field.

Adult↗
PubMed2006

Assessment of the general knowledge of emergency physicians from the hospitals of the city of Salvador (Brazil) on the care of cardiac arrest patients.

OBJECTIVE: To identify the proportion of emergency physicians certified in immersion courses (ACLS--Advanced Cardiac Life Support and ATLS--Advanced Trauma Life Support) correlating the variables of age, gender, medical specialty, academic title, and type of hospital with the level of theoretical knowledge on the care of Cardiac Arrest (CA) victims. METHODS: Emergency physicians from public and private hospitals of the city of Salvador, State of Bahia--Brazil, were consecutively evaluated from November, 2003 to July, 2004. They volunteered to participate in the study, and responded to a questionnaire consisting of information on the following variables of interest: professional profile, participation or not in ACLS and ATLS immersion courses, and cognitive assessment with 22 objective questions on Cardiopulmonary Resuscitation (CPR). A score of correct answers was calculated for each participant, and then designated as score variable. This questionnaire was validated based on the result of the score obtained by ACLS course instructors in Salvador, BA. RESULTS: Of the 305 physicians who responded to the questionnaire, 83 (27.2%) had attended the ACLS course and had a mean score variable of 14.9+3.0 compared with the 215 physicians (70.5%) who had not attended the course and whose mean was 10.5+ 3.5 (p=0.0001). The mean score of the 65 cardiologists (21.5%) was 14.1+3.3 compared with the mean of 9.7+3.7(p=0.0001) of the 238 physicians (78.5%) from other specialties. No difference was observed in the mean scores between physicians who had attended the ATLS course or not (p=0.67). CONCLUSION: In the sample studied, theoretical knowledge on CPR was higher among physicians who had attended the ACLS course, as opposed to those who had attended the ATLS course. Cardiologists who had attended the ACLS demonstrated a higher theoretical knowledge on the care of CA patients when compared to physicians from other specialties taken as whole--Internal Medicine, Surgery, and Orthopedics.

Advanced Cardiac Life Support↗
PubMed2002

Recent advances in emergency life support.

With additional international input, recent changes in emergency life support are reflected in updated guidelines for Advanced Cardiac Life Support (ACLS) from the American Heart Association and new technology in the arena of vascular access and emergency airway management. These changes will expand nurses' ability to provide advanced levels of care, even in the prehospital situation, and represent a more rigorous evidence-based approach than ever before. As early morbidity and mortality in emergency situations are frequently associated with complications associated with airway management and vascular access, recent development in these areas are reviewed along with evolution in ACLS guidelines.

Adult↗
PubMed2006

The Cardiac Surgery Advanced Life Support Course (CALS): delivering significant improvements in emergency cardiothoracic care.

BACKGROUND: A 3-day cardiac surgery advanced life support course was designed with a series of protocols to manage critically ill cardiac surgical patients and patients who suffer a cardiac arrest. We sought to determine the effect of this course on the management of simulated critically ill and cardiac arrest patients. METHODS: Twenty-four candidates participated in the course. Critically ill patients were simulated using intubated mannikins, with lines and drains in situ, and a laptop with an intensive care unit monitor simulation program. Candidates were tested before and after the course with rigidly predesigned clinical situations. Candidates were split into groups of 6, and cardiac arrests were simulated in the same fashion, with all required surgical equipment immediately available. All scenarios were videotaped, and after blinding, an independent surgeon assessed the times to achieve predetermined clinical endpoints. RESULTS: The time to successful definitive treatment was significantly faster postcourse for the critically ill patient scenarios: (565 secs [SD 27 secs] precourse, compared with 303 secs [SD 24 secs] postcourse; p < 0.0005). In addition, the times taken to achieve a wide range of predetermined objectives, including airway check, assessing breathing, circulation assessment, treating with oxygen, appropriate treatment of the circulation, and requesting blood gases, chest radiographs, and electrocardiograms, were also significantly faster in the postcourse scenarios. Times to successful chest reopening and internal cardiac massage were also significantly improved in cardiac arrest patients: (451 secs [SD 39 secs] precourse and 228 secs [SD 17 secs] postcourse; p = 0.011). CONCLUSIONS: Structured training and practice in the management of critically ill cardiac surgical patients and patients suffering a cardiac arrest leads to significant improvements in the speed and quality of care for these patients.

Cardiopulmonary Resuscitation↗
PubMed1993

Electrical shock and lightning strike.

Cardiac arrest from electrical shock or lightning strike is associated with significant mortality and requires modification and extension of standard advanced life support measures to achieve successful resuscitation. Patients who experience electrical shock or lightning strike may sustain cardiac and respiratory arrest secondary to the direct effects of current. However, the majority of victims have associated multisystem involvement, including neurologic complications, cutaneous burns, and associated blunt trauma. As a result, a combination of advanced cardiac life support measures and advanced trauma life support techniques is indicated. Victims with cardiac arrest from electrical shock or lightning strike require prompt, aggressive resuscitation using standard methods for airway control, ventilation, and chest compressions, as well as usual measures for defibrillation and cardiac pharmacotherapy. Unique considerations include vigorous fluid resuscitation and spinal immobilization for victims of electrical shock and reversal of normal multiple casualty triage priorities when managing several lightning strike victims. Because the majority of victims are relatively young and seldom have significant underlying cardiac disease, the chance for successful resuscitation may be greater for patients who experience sudden death from electrical shock or lightning strike than for those with other causes of cardiac arrest, even among patients with initial rhythms traditionally unresponsive to therapy. Although numerous specialized aspects are required for the successful management of victims of electrical shock and lightning strike, the following article focuses on the unique considerations necessary for immediate care of cardiac arrest victims, with emphasis on the underlying mechanisms of sudden death and currently recommended guidelines for resuscitation.

Electric Injuries↗
PubMedDate not supplied

Knowledge and attitude of nurses on medical wards to defibrillation.

We questioned 112 qualified nurses working on general medical wards about their resuscitation experience and knowledge of ECG interpretation and defibrillation. Although all but two of them had been formally trained in basic cardiopulmonary resuscitation (CPR) only 16 had received any training in the last six months. Seventy-five per cent of nurses were involved in CPR as first responders but only 18% had used a defibrillator during a cardiac arrest. Identification of ECG rhythms and practical knowledge about defibrillation was encouraging despite the lack of formal training in this field. Almost every one of the nurses would be willing to receive training in advanced cardiac life support. The responses to this inquiry suggest that nurses on medical wards are enthusiastic about advanced cardiac life support and already have some basic practical knowledge. Appropriate training (and retraining) of nursing staff should improve the outcome of resuscitation efforts on medical wards.

Arrhythmias, Cardiac↗
PubMed1997

End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest.

BACKGROUND: Survival after cardiac arrest occurring outside the hospital averages less than 3 percent. Unfortunately, the outcome of prolonged resuscitative attempts cannot be predicted. End-tidal carbon dioxide levels reflect cardiac output during cardiopulmonary resuscitation. We prospectively determined whether death could be predicted by monitoring end-tidal carbon dioxide during resuscitation after cardiac arrest. METHODS: We performed a prospective observational study in 150 consecutive victims of cardiac arrest outside the hospital who had electrical activity but no pulse. The patients were intubated and evaluated by mainstream end-tidal carbon dioxide monitoring. Our hypothesis was that an end-tidal carbon dioxide level of 10 mm Hg or less after 20 minutes of standard advanced cardiac life support would predict death. RESULTS: There was no difference in the mean age or initial end-tidal carbon dioxide level between patients who survived to hospital admission (survivors) and those who did not (nonsurvivors). After 20 minutes of advanced cardiac life support, end-tidal carbon dioxide (+/-SD) averaged 4.4+/-2.9 mm Hg in nonsurvivors and 32.8+/-7.4 mm Hg in survivors (P< 0.001). A 20-minute end-tidal carbon dioxide value of 10 mm Hg or less successfully discriminated between the 35 patients who survived to hospital admission and the 115 nonsurvivors. When a 20-minute end-tidal carbon dioxide value of 10 mm Hg or less was used as a screening test to predict death, the sensitivity, specificity, positive predictive value, and negative predictive value were all 100 percent. CONCLUSIONS: An end-tidal carbon dioxide level of 10 mm Hg or less measured 20 minutes after the initiation of advanced cardiac life support accurately predicts death in patients with cardiac arrest associated with electrical activity but no pulse. Cardiopulmonary resuscitation may reasonably be terminated in such patients.

Adult↗
PubMed1990

Cardiac resuscitability with cardiopulmonary bypass after increasing ventricular fibrillation times in dogs.

Previous studies in dogs have shown resuscitation from prolonged cardiac arrest to conscious survival to be more effective with the use of cardiopulmonary bypass (CPB) than with standard advanced cardiac life support. This study compared cardiovascular resuscitability with CPB only after varying periods of cardiac arrest without artificial circulatory support in a canine model. Group 1 (ten) was subjected to ventricular fibrillation for 15 minutes; group 2 (ten) for 20 minutes; and group 3 (ten) for 30 minutes. All received total CPB after ventricular fibrillation without advanced cardiac life support to defibrillation at two to five minutes and partial CPB to four hours. In all three groups CPB with epinephrine generated normal coronary perfusion pressure and increased ventricular fibrillation amplitude significantly. In groups 1 and 2, CPB reperfusion allowed for successful defibrillation in less than five minutes, weaning from CPB in all dogs at four hours, and stable spontaneous circulation thereafter. In group 3, only five of ten dogs could be weaned from bypass at four hours, and all died early with myocardial necroses. It was concluded that CPB may be of value in the setting of prolonged cardiac arrest when advanced cardiac life support has not been provided or is unable to restore spontaneous heart-beat.

Animals↗
PubMed2005

Update on advanced life support and resuscitation techniques.

PURPOSE OF REVIEW: This article is a review of the most recent findings in resuscitation techniques in advanced cardiac life support. The article focuses particularly on the period after July 1, 2003, but relevant new findings before this period are also included. RECENT FINDINGS: Randomized clinical trial results suggest that the current cardiopulmonary resuscitation and advanced cardiac life support guidelines may need to be modified. Early defibrillation during the electrical phase of cardiac arrest remains the most crucial intervention, but performing cardiopulmonary resuscitation before defibrillation may be more effective, as compared with immediate defibrillation, during the circulatory phase of cardiac arrest. Biphasic waveforms are superior to monophasic damped sine waveforms in achieving defibrillation. Novel cardiopulmonary resuscitation methods that increase negative intrathoracic pressure promote an increase in blood flow return to the heart. These devices have been correlated with improved short-term survival rates during the circulatory phase of cardiac arrest. Vasopressin administration, given alone or in combination with epinephrine, should be considered during the circulatory phase of out-of-hospital cardiac arrest, particularly in patients presenting with asystole as the initial rhythm. Induction of hypothermia during the metabolic phase in cardiac arrest survivors improves 6-month survival rates and neurologic outcomes. SUMMARY: Strategies to improve the low survival outcomes of cardiac arrest victims are available. Clinical trials testing these strategies suggest benefit from certain interventions but are not definitive. These different therapeutic interventions should be performed in a phase-specific-oriented fashion according to the three-phase time-sensitive model of cardiac arrest.

Amiodarone↗
PubMed1993

A characterization of hypothalamic-pituitary-adrenal axis function during and after human cardiac arrest.

OBJECTIVE: This study characterizes hypothalamic-pituitary-adrenal axis function during cardiopulmonary arrest and after return of spontaneous circulation. DESIGN: Prospective case series. SETTING: A large urban emergency department and intensive care unit over an 8-month period. PATIENTS: Two hundred five adult patients presenting in cardiopulmonary arrest to an urban emergency department. Three patients known to be taking corticosteroids were excluded from the study. MEASUREMENTS AND MAIN RESULTS: Cortisol concentrations were measured before and after advanced cardiac life support and for five consecutive hours after return of spontaneous circulation. Adrenocorticotropic hormone (ACTH) concentrations were measured before advanced cardiac life support and when the cosyntropin stimulation tests were performed 6 and 24 hrs after the return of spontaneous circulation. The mean initial serum cortisol concentration was 32.0 +/- 33.1 micrograms/dL (882.9 +/- 913.2 nmol/L). Fifty-three percent of patients had cortisol concentrations of < 20 micrograms/dL (< 552 nmol/L) at the end of cardiac arrest. Among 44 patients who achieved return of spontaneous circulation, 98% had initial cortisol concentrations of > 10 micrograms/dL (> 276 nmol/L) and 73% of patients had initial cortisol concentrations of > 20 micrograms/dL (> 552 nmol/L). Mean serum cortisol concentrations increased significantly (p = .0001) from 1 to 6 hrs after return of spontaneous circulation and decreased significantly (p = .03) from 6 to 24 hrs. A serum cortisol concentration of < 30 micrograms/dL (< 828 nmol/L) was associated with a 96% and 100% mortality rate at 6 and 24 hrs, respectively. Mean ACTH concentrations were increased without a significant difference between the initial and 6-hr concentrations. Mean ACTH concentrations decreased between 6 and 24 hrs (p = .06). There were no significant responses to the cosyntropin stimulation at 6 and 24 hrs. CONCLUSIONS: Cortisol concentrations after out-of-hospital cardiac arrest are lower than those concentrations reported in other stress states. There is an association between cortisol concentrations and short-term survival after cardiac arrest. Survivors have a significantly greater increase in serum cortisol concentrations than nonsurvivors during the first 24 hrs. Lower than expected cortisol concentrations for the extreme stress of cardiac arrest may have pathologic significance in the hemodynamic instability seen after return of spontaneous circulation. The etiology of the low cortisol concentrations may be primary adrenal dysfunction.

Adrenocorticotropic Hormone↗
PubMed1992

High-dose epinephrine in adult cardiac arrest.

BACKGROUND: Recent studies suggest that doses of epinephrine of 0.1 mg per kilogram of body weight or higher may improve myocardial and cerebral blood flow as well as survival in cardiac arrest. Such studies have called into question the traditional dose of epinephrine (0.007 to 0.014 mg per kilogram) recommended for advanced cardiac life support. METHODS: We randomly assigned 650 patients who had had cardiac arrest either in or outside the hospital to receive up to five doses of high-dose (7 mg) or standard-dose (1 mg) epinephrine at five-minute intervals according to standard protocols for advanced cardiac life support. Patients who collapsed outside the hospital received no advanced-life-support measures other than defibrillation before reaching the hospital. RESULTS: There was no significant difference between the high-dose group (n = 317) and the standard-dose group (n = 333) in the proportions of patients who survived for one hour (18 percent vs. 23 percent, respectively) or who survived until hospital discharge (3 percent vs. 5 percent). Among the survivors, there was no significant difference in the proportions who remained in the best category of cerebral performance (90 percent vs. 94 percent) and no significant difference in the median Mini-Mental State score (36 vs. 37). The exploration of clinically important subgroups, including those with out-of-hospital arrest (n = 335) and those with in-hospital arrest (n = 315), failed to identify any patients who appeared to benefit from high-dose epinephrine and suggested that some patients may have worse outcomes after high-dose epinephrine. CONCLUSION: High-dose epinephrine was not found to improve survival or neurologic outcomes in adult victims of cardiac arrest.

Adult↗
PubMedDate not supplied

Conscious sedation experiences in graduate pediatric dentistry programs.

PURPOSE: Conscious sedation is a behavior modification adjunct taught in all postgraduate pediatric dental residency programs. It has been a decade since the last survey was done specifically related to didactic and clinical aspects of conscious sedation in postgraduate pediatric dental programs. The aim of the study was to determine the clinical and didactic experiences associated with conscious sedation in these programs and to compare some of the findings to those collected a decade ago. METHODS: A 31-item survey similar to that of a decade ago was constructed and sent to all pediatric dentistry program directors of accredited postgraduate and residency programs in the United States. The items covered several didactics including didactic topics, sedative agents, monitoring, and emergency policy among others. A follow-up mailing was done involving those who had not responded 6 weeks following the initial mailing. RESULTS: Fifty-four of 58 (93%) program directors returned the 31-item survey. The following are highlighted findings. Conscious sedation among residency programs was achieved most commonly with a combination of sedative agents used with N2O. Midazolam was more popular than chloral hydrate. The oral route was the predominant route of administration. More lecture hours were spent on conscious sedation than 10 years ago. The pre-cordial stethoscope, pulse oximeter, and blood pressure cuff were the most commonly used monitors. Sedative agent and anticipated depth of sedation were the factors most often considered in choosing monitors used during the sedation of a patient. The capnograph was being used more frequently than it was 10 years ago. Programs did not report an increase in sedation emergencies but practiced emergency drills more often and had increased numbers of individuals certified in Advanced Cardiac Life Support (ACLS) or Pediatric Advanced Life Support (PALS). The percent of the total patient population which required sedation is about 1-20%, with most directors reporting an increase in the numbers of sedations done in the past few years. CONCLUSIONS: While many factors remained unchanged or slightly modified when compared to the survey done a decade ago, the results of this study suggest that there has been significant changes in several key factors including the most frequently used sedative (i.e., midazolam) and increased preparation in the area of emergency preparedness.

Administration, Oral↗
PubMed1995

Pre-hospital cardiac arrest: room for improvement.

OBJECTIVE: To audit the outcome from pre-hospital cardiac arrest managed by ambulance personnel, and to assess their proficiency by analysing the time to initiate basic and advanced cardiac life support, the compliance with national guidelines, and the overall success of resuscitation. DESIGN: A retrospective analysis of ambulance service report forms of pre-hospital cardiac arrests, where active resuscitation was attempted by ambulance personnel between October 1992 and May 1993. SETTING: The City of Salford. SUBJECTS: 100 consecutive patients who suffered cardiac arrest out-of-hospital and who were brought to the accident and emergency department of Hope Hospital alive, or with resuscitation still in progress. RESULTS: Only 4 of 100 patients were successfully resuscitated out of hospital, of whom 2 survived to leave hospital. Detailed analysis of pre-hospital performance was performed on 89 patients only, as 11 report forms were missing (no successful pre-hospital resuscitations in this 11). Ventricular fibrillation was the first recorded rhythm in 51.7%, but 85.7% were in asystole or electromechanical dissociation on arrival at hospital. No patient who was still in cardiac arrest on arrival at hospital was successfully resuscitated. 11 patients received 'bystander CPR'. The median time to basic life support was 6 min; the median call-to-response interval was 8 min; the median call-to-advanced cardiac life support interval was 21 min; the median on-scene time was 31 min (paramedics), or 15 min (technicians). The dose of drugs given by the intravenous route did not comply with the contemporary recommendations in 43.2%, and those doses given by the endotracheal route were inadequate in 37.9% of the cases. Endotracheal intubation was attempted in all paramedic resuscitations (91.4% success); intravenous access was attempted in 60.3% (91.7% success). CONCLUSIONS: The survival from pre-hospital cardiac arrest in this community is worse than the national average. There is no single explanation for this. Better community CPR training, greater efficiency at the scene through additional personnel, and stricter compliance with national ACLS guidelines, facilitated by extended refresher training, are all required if outcome is to be improved.

Adolescent↗
PubMed1989

Outcomes in unsuccessful field resuscitation attempts.

To determine the outcomes of patients who did not regain vital signs after prehospital advanced cardiac life support, we studied adult patients who sustained nontraumatic out-of-hospital cardiac arrest. Our study consisted of a 20-month retrospective review of 244 charts beginning January 1986. Twelve patients were excluded for drug overdose, family request, or unavailable data. Of the remaining 232 patients, 51 had a rhythm and pulse on arrival at the emergency department. The record of each of the remaining 181 patients was analyzed for age, sex, location, witness, CPR initiator, advanced life support unit response time, initial field rhythm, and initial ECG rhythm. Outcome alternatives were dead in emergency department or hospital admission. All hospitalized patients were further evaluated for survival to discharge and neurologic status at discharge. Ten of the 181 patients (6%) who failed prehospital resuscitation survived to hospitalization, and one (0.6%) was discharged neurologically intact. Survival to hospital admission did not correlate with any of the variables studied except gender. The one patient who survived a failed prehospital resuscitation was not endotracheally intubated in the field. Our data support the practice of pronouncing adult nontraumatic cardiac arrest victims who fail to respond to advanced cardiac life support efforts in the field as dead at the scene.

Adolescent↗
PubMed1998

Cumulative epinephrine dose during cardiopulmonary resuscitation and neurologic outcome.

BACKGROUND: Epinephrine is the drug of choice in advanced cardiac life support, but it can have deleterious side effects after restoration of spontaneous circulation. OBJECTIVE: To investigate the association between the cumulative epinephrine dose used in advanced cardiac life support and neurologic outcome after cardiac arrest. DESIGN: Retrospective cohort study. SETTING: University hospital. PATIENTS: Adults admitted to the emergency department with witnessed, nontraumatic, normothermic ventricular fibrillation cardiac arrest and unsuccessful initial defibrillation. MEASUREMENTS: Functional neurologic outcome was regularly assessed by cerebral performance category (CPC) within 6 months after cardiac arrest. A CPC of 1 or 2 was defined as favorable recovery. RESULTS: Among 178 enrolled patients, the median cumulative epinephrine dose administered was 4 mg (range, 0 to 50 mg). In 151 patients (84%), spontaneous circulation was restored; 63 of these 151 patients (42%) had favorable neurologic recovery. Patients with an unfavorable CPC received a significantly higher cumulative dose of epinephrine than did patients with a favorable CPC (4 mg compared with 1 mg; P < 0.001). This finding persisted after stratification by duration of resuscitation. After possible cofounders were controlled for, the cumulative epinephrine dose remained an independent predictor of unfavorable neurologic outcome. CONCLUSIONS: The results indicate that an increasing cumulative dose of epinephrine administered during resuscitation is independently associated with unfavorable neurologic outcome after ventricular fibrillation cardiac arrest.

Adrenergic Agonists↗
PubMed1988

Medical simulation for disaster casualty management training.

A required, role-intensive leadership simulation in emergency and disaster medicine management for fourth-year medical students is described, and the value of an extended role-playing experience discussed. The week-long (120 hours) simulation exercise is designed to provide an opportunity for Federal medical students to experience a realistic combat or disaster environment similar to environments in which they may be required to operate medical support systems. Students function in a variety of roles and have the opportunity to place into practice all emergency medical knowledge and skills acquired throughout medical school. As a prerequisite to the exercise, students successfully complete a 3-week didactic course in Operational and Emergency Medicine which includes Advanced Cardiac Life Support (ACLS) and Advanced Trauma Life Support (ATLS) Provider Courses. By means of disaster simulation they refine medical skills, leadership style, substantially improve clinical judgment, and deal with the complexities of problems associated with their future roles as medical officers.

Disaster Planning↗
PubMed2001

Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of "limited" resuscitations.

BACKGROUND: The results of in-hospital resuscitations may depend on a variety of factors related to the patient, the environment, and the extent of resuscitation efforts. We studied these factors in a large tertiary referral hospital with a dedicated certified resuscitation team responding to all cardiac arrests. METHODS: Statistical analysis of 445 prospectively recorded resuscitation records of patients who experienced cardiac arrest and received advanced cardiac life support resuscitation. We also report the outcomes of an additional 37 patients who received limited resuscitation efforts because of advance directives prohibiting tracheal intubation, chest compressions, or both. MAIN OUTCOME MEASURES: Survival immediately after resuscitation, at 24 hours, at 48 hours, and until hospital discharge. RESULTS: Overall, 104 (23%) of 445 patients who received full advanced cardiac life support survived to hospital discharge. Survival was highest for patients with primary cardiac disease (30%), followed by those with infectious diseases (15%), with only 8% of patients with end-stage diseases surviving to hospital discharge. Neither sex nor age affected survival. Longer resuscitations, increased epinephrine and atropine administration, multiple defibrillations, and multiple arrhythmias were all associated with poor survival. Patients who experienced arrests on a nursing unit or intensive care unit had better survival rates than those in other hospital locations. Survival for witnessed arrests (25%) was significantly better than for nonwitnessed arrests (7%) (P =.005). There was a disproportionately high incidence of nonwitnessed arrests during the night (12 AM to 6 AM) in unmonitored beds, resulting in uniformly poor survival to hospital discharge (0%). None of the patients whose advance directives limited resuscitation survived. CONCLUSIONS: Very ill patients in unmonitored beds are at increased risk for a nonwitnessed cardiac arrest and poor resuscitation outcome during the night. Closer vigilance of these patients at night is warranted. The outcome of limited resuscitation efforts is very poor.

Adult↗