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PubMed1994

Survival after failed out-of-hospital resuscitation. Are further therapeutic efforts in the emergency department futile?

BACKGROUND: Because of extremely poor outcomes, the practice of continuing cardiopulmonary resuscitation in hospital emergency departments after unsuccessful out-of-hospital cardiopulmonary resuscitation has been strongly questioned. Before revising our institutional guidelines according to previous pessimistic reports we wished to review our own experience with this practice. METHODS: The case histories of 141 consecutive victims of witnessed cardiac arrest brought to the emergency department with ongoing cardiopulmonary resuscitation were reviewed. The emergency medical system was two-tiered and was based on the emergency department of a single university hospital. The first tier, staffed with emergency medical technicians, provided only basic cardiac life support. The second, physician-staffed tier provided advanced cardiac life support and was allowed to terminate resuscitation in the field. Rates of successful resuscitation, survival to discharge and after 1 year, and the cerebral performance of resuscitated and surviving patients were determined. RESULTS: Ninety-one patients (65%) died in the emergency department; 50 (35%) were resuscitated and admitted. Thirty-two patients (23%) died in the hospital, 18 (13%; 95% confidence interval, 8% to 20%) survived to discharge. Sixteen survivors showed no or only mild neurologic impairment at discharge. Seventeen patients were alive 1 year later. Bystander resuscitation, short intervals to initiation of resuscitation, and ventricular fibrillation at emergency department entry were significantly associated with survival. CONCLUSIONS: Institutional guidelines for the decision whether to continue resuscitation after failed out-of-hospital efforts should be based on an analysis of the characteristics and results of the local emergency medical system. Continuing efforts in the hospital may not be inevitably futile.

Aged↗
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↗
PubMed1992

A randomized clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest.

OBJECTIVE: To determine the relative efficacy of high- vs standard-dose catecholamines in initial treatment of prehospital cardiac arrest. DESIGN: Randomized, prospective, double-blind clinical trial. SETTING: Prehospital emergency medical system of a major US city. PATIENTS: All adults in nontraumatic cardiac arrest, treated by paramedics, who would receive epinephrine according to American Heart Association advanced cardiac life support guidelines. INTERVENTIONS: High-dose epinephrine (HDE, 15 mg), high-dose norepinephrine bitartrate (NE, 11 mg), or standard-dose epinephrine (SDE, 1 mg) was blindly substituted for advanced cardiac life support doses of epinephrine. MAIN OUTCOME MEASURES: Restoration of spontaneous circulation in the field, admission to hospital, hospital discharge, and Cerebral Performance Category score. RESULTS: Of 2694 patients with cardiac arrests during the study period, resuscitation was attempted on 1062 patients. Of this total, 816 patients met study criteria and were enrolled. In the entire cardiac arrest population, 63% of the survivors were among the 11% of patients who were defibrillated by first responders. The three drug treatment groups were similar for all independent variables. Thirteen percent of patients receiving HDE regained a pulse in the field vs 8% of those receiving SDE (P = .01), and 18% of HDE patients were admitted to the hospital vs 10% of SDE patients who were admitted to the hospital (P = .02). Similar trends for NE were not significant. There were 18 survivors; 1.7% of HDE patients and 2.6% of NE patients were discharged from the hospital compared with 1.2% of SDE patients, but this was not significant (P = .37; beta = .38). There was a nonsignificant trend for Cerebral Performance Category scores to be worse for HDE (3.2) and NE patients (3.7) than for SDE patients (2.3) (P = .10; beta = .31). No significant complications were identified. High-dose epinephrine did not produce longer hospital or critical care unit stays. CONCLUSIONS: High-dose epinephrine significantly improves the rate of return of spontaneous circulation and hospital admission in patients who are in prehospital cardiac arrest without increasing complications. However, the increase in hospital discharge rate is not statistically significant, and no significant trend could be determined for neurological outcome. No benefit of NE compared with HDE was identified. Further study is needed to determine the optimal role of epinephrine in prehospital cardiac arrest.

Adolescent↗
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↗
PubMed2000

In-hospital resuscitation: association between ACLS training and survival to discharge.

CONTEXT: No data have been published on the relationship between advanced cardiac life support (ACLS) training of the individual who initiates resuscitation efforts and survival to discharge. OBJECTIVE: To determine whether patients whose arrests were discovered by nurses trained in ACLS had survival rates different from those discovered by nurses not trained in ACLS. DESIGN: Cohort case-comparison. SETTING: A 550-bed, tertiary care center in central Georgia. SUBJECTS: Patients whose cardiopulmonary arrest was discovered by a nurse who activated the in-hospital resuscitation mechanism. MAIN OUTCOME MEASURE: Patient survival to discharge. RESULTS: Initial rhythm was strongly related to survival to discharge and individually associated with 57% of the variability in survival. Nurse's training in advanced cardiac life support was also strongly related to survival and individually associated with 29% of the variability. Combining both the variables determined 62% of the variability in survival to discharge. Patients discovered by an ACLS-trained nurse (n=88) were about four times more likely to survive (33 survivors, 38%) than were patients, discovered by a nurse without training in ACLS (n=29, three survivors, 10%). CONCLUSION: Arrest discovery by nurses trained in ACLS is significantly and dramatically associated with higher survival-to-discharge rates.

Advanced Cardiac Life Support↗
PubMed1986

A study of out-of-hospital cardiac arrests in northeastern Minnesota.

Training in advanced cardiac life support and defibrillation and community programs in cardiopulmonary resuscitation (CPR) had limited success in resuscitating patients with cardiac arrest in the Arrowhead region of Minnesota. Factors associated with survival included advanced cardiac life support within 16 minutes, ambulance traveling less than 1 mile (less than 1.6 km), use of paramedics, CPR within four minutes, and a call for help within two minutes. The use of technicians trained in defibrillation was associated with a statistically significant increase in hospital admissions, but not in survivors. The study failed to confirm the findings of previous studies of resuscitation in some rural areas. It was consistent, however, with reports that associated poor survival in rural areas with poor response times. No victims of unwitnessed arrests survived. Of the hospital deaths, 80% were due to neurologic causes, and overall survival was low.

Adult↗
PubMedDate not supplied

Amiodarone administered for cardiac resuscitation does not alter the integrity of noncontrast cerebral computed tomography performed on neurologically symptomatic patients before therapeutic cardiac catheterization.

PURPOSE: Recent revisions of the advanced cardiac life support guidelines support the use of amiodarone in treating acute cardiac arrhythmia. Chemically, amiodarone has two atoms of iodine per molecule (39.3% wt/wt). We propose that at antiarrhythmic doses as prescribed by advanced cardiac life support guidelines, enhancement resulting from the bound amiodarone iodine is not significantly different from routine noncontrasted screening cerebral computed tomography (CT) studies. METHOD: Six patients presenting to the our emergency department with successful resuscitation after cardiac arrhythmia were identified before obtaining a screening CT scan and subsequent transfer to the cardiac catheterization laboratory for intervention. The total dose of amiodarone (bolus + drip) was calculated up to the moment of the CT scan. Subjects were age and gender matched with two control subjects. Hematocrit value and CT density measurements in the pons, putamen, centrum semiovale, and cerebral venous blood pool were recorded. Paired t test and linear regression analyses were performed. Amiodarone dose and hematocrit were used as covariates in the regression model to correct for altered density as a result of relative anemia. RESULTS: Mean density in the blood pool was increased in the amiodarone subjects in both the univariate and regression models. Although the mean density difference of 3 HU was statistically significant, it is not likely detectable by the eye. All other brain area measurements showed nonsignificant differences in mean density for both the univariate analysis and regression model. CONCLUSION: Amiodarone administered at doses recommended by the American Heart Association for treatment of cardiac arrhythmia does not interfere with interpretation of the precatheterization noncontrasted screening cerebral CT scan.

Aged↗
PubMed2005

Use of the Trendelenburg position as the resuscitation position: to T or not to T?

OBJECTIVE: To review the literature on use of the Trendelenburg position as a position for resuscitation of patients who are hypotensive. METHODS: PubMed online, cited bibliographies, critical care textbooks, and Advanced Cardiac Life Support guidelines were searched for information on the position used for resuscitation. Because of the heterogeneity of the data, only pertinent articles and chapters were summarized. RESULTS: Eight peer-reviewed publications on the position used for resuscitation were found. Pertinent information from 2 critical care textbooks and from the Advanced Cardiac Life Support guidelines was included in the review. Literature on the position was scarce, lacked strength, and seemed to be guided by "expert opinion." CONCLUSION: The general "slant" of the available data seems to indicate that the Trendelenburg position is probably not a good position for resuscitation of patients who are hypotensive. Further clinical studies are needed to determine the optimal position for resuscitation.

Adult↗
PubMed1994

The acquisition of practical skills by U.S. medical students.

Increasing interest in skills training has been prompted by concerns over risks posed by new, complex clinical environments and the need for medical students to function effectively in such settings. To gain a better idea of the type of instruction currently provided to U.S. medical students, a national survey was conducted in 1991. A survey instrument was prepared after a literature review on practical skills training. Eleven skill and knowledge areas were selected for analysis; six were considered "basic" and five "advanced." Mailings were directed to the deans of 126 U.S. medical schools. Based on a 94% response rate (118/126), the skill and knowledge areas taught most commonly included universal precautions, phlebotomy, intravenous line placement, advanced cardiac life support, and suturing lacerations. Fifty-one (43%) of 118 respondents reported that they conducted "transition courses" for practical skills training. At most such institutions, basic skills were taught more frequently than advanced skills. Where there was no transition course, formal instruction was provided in standing courses and clerkships. The survey indicates that five skills areas are formally taught in the majority of U.S. medical schools. These include universal precautions, phlebotomy, starting intravenous lines, suturing lacerations, and advanced cardiac life support. In most cases, evaluation and certification procedures are infrequent. Further studies are necessary to gain a better idea of what practical training should be undergone by all U.S. medical students.

Clinical Competence↗
PubMed2006

The usefulness of transesophageal echocardiography during intraoperative cardiac arrest in noncardiac surgery.

According to guidelines established by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists, life-threatening hemodynamic disturbances are classified as a category I indication for the intraoperative use of transesophageal echocardiography (TEE). However, the usefulness of TEE during intraoperative cardiac arrest and its impact on patient management have not been rigorously investigated. Using our departmental TEE database, we identified a population of 22 patients who underwent noncardiac surgical procedures and experienced unexpected intraoperative hemodynamic collapse requiring the initiation of Advanced Cardiac Life Support procedures between the time of induction of general anesthesia and the termination of the surgical procedure. Results of TEE examinations, patient records, detailed operative records, and outcome of patients were reviewed for the utility of TEE to diagnose the etiology of the hemodynamic collapse. Furthermore, the impact on subsequent patient management was evaluated. A primary suspected diagnosis of the underlying pathological process was established in 19 of 22 patients with TEE, including 9 with thromboembolic events, 6 with acute myocardial ischemia, 2 with hypovolemia, and 2 patients with pericardial tamponade. A definitive diagnosis could not be made in 3 patients with TEE. In 18 patients, TEE guided specific management beyond implementation of Advanced Cardiac Life Support protocols, including the addition of surgical procedures in 12 patients. Fourteen patients survived to leave the operating room, and 7 of these patients were eventually discharged from the hospital. Thus, TEE may provide additional diagnostic information in patients with intraoperative cardiac arrest and may directly guide specific, potentially life-saving therapy.

Adult↗
PubMed1983

The use of bretylium in prehospital ventricular fibrillation.

Bretylium tosylate is recommended by the American Heart Association Standards for Advanced Cardiac Life Support for refractory ventricular fibrillation after countershock, sodium bicarbonate, and epinephrine. According to this protocol, paramedics gave five to six milligrams per kilogram of intravenous bretylium by bolus in 96 patients with refractory fibrillation over a 24-month period. A positive response was defined as the presence of a palpable pulse following bretylium and countershock. Thirty-five percent of patients (34/96) responded following bretylium. Twenty-one percent (20/96) responded only temporarily with a rhythm and pulse. Fifteen percent (14/96) maintained a stable rhythm and vital signs on admission to the hospital, but only five patients, 5% of the total population, (5/96), were eventually discharged home. Clinical variables were similar in non-responders, temporary responders, and those admitted, but the times from the onset of Advanced Cardiac Life Support to receiving bretylium were 23.5 min, 20.3 min, and 14.3 min respectively. We conclude that about one-third of patients in refractory ventricular fibrillation respond following bretylium and countershock and that earlier bretylium use may give better results.

Bretylium Compounds↗
PubMed2004

Achieving house staff competence in emergency airway management: results of a teaching program using a computerized patient simulator.

OBJECTIVES: Patient simulation is emerging as a training technique in the field of medicine. It has particular application in training responses to high-risk, low-frequency clinical events, of which a typical example is in-hospital cardiac arrest. A critical element of response by the cardiac arrest team is initial airway management. In teaching hospitals, medical interns are first responders to in-hospital cardiac arrests. Our objective was to design and test a program using a computer-controlled patient simulator to train medical interns and demonstrate their competence in initial airway management. DESIGN: Prospective, randomized, controlled, unblinded trial. SETTING: Internal medicine residency training program in an urban teaching hospital. PARTICIPANTS: All 50 starting internal medicine interns in July 2002, all Advanced Cardiac Life Support certified in June 2002. INTERVENTIONS: All interns were tested in initial airway management skills and then were randomly assigned to receive either immediate or delayed individualized training using a computer-controlled patient simulator. The computer-simulated training process consisted of a scenario of respiratory arrest. The interns were challenged with the scenario twice following testing. The interns were debriefed extensively and given hands-on training by the attending using the simulator until they achieved perfect performance. MEASUREMENTS AND MAIN RESULTS: Initial airway management was divided into specific scorable steps. Individual step scores and total scores were recorded for each intern on initial and repeat testing. For 10 months following simulator training, intern airway management skills were scored in actual patient airway events. Despite recent Advanced Cardiac Life Support training and certification, all starting medical interns demonstrated poor airway management skills. The immediate training group showed significant improvement in initial airway management when tested before and 4 wks after training. In contrast, the delayed training group showed no significant improvement. Direct observation of interns in actual initial airway events revealed excellent clinical performance. CONCLUSIONS: Individualized training of medical interns using a computer-controlled patient simulator is an effective means of achieving and measuring competence in initial airway management skills. The improvement appears to be transferable to the bedside of real patients.

Adult↗
PubMedDate not supplied

Distinct criteria for termination of resuscitation in the out-of-hospital setting.

OBJECTIVE: To identify distinct criteria for appropriate on-scene termination of resuscitation efforts for out-of-hospital cardiac arrest when on-scene interventions fail to restore spontaneous circulation. DESIGN: For 18 months, all out-of-hospital cardiac arrests were evaluated prospectively for survival to hospital discharge and for all established survival predictors including age, gender, presenting cardiac rhythm, whether it was a witnessed event, performance of basic cardiopulmonary resuscitation by bystanders, and interval to paramedic arrival and return of spontaneous circulation (ROSC). SETTING: A large municipality with a single, centralized emergency medical services program. PATIENTS: All normothermic adults treated for out-of-hospital, unmonitored, primary cardiac arrest. INTERVENTIONS: Standard advanced cardiac life support provided at the scene by paramedics. MAIN OUTCOME MEASURES: The number and circumstances of patients achieving survival to hospital discharge following failure to achieve on-scene ROSC. RESULTS: Of 1461 consecutive primary cardiac arrests, 139 were monitored (paramedic witnessed), including 59 that occurred en route to the hospital. Of the 1322 unmonitored patients, 370 achieved ROSC at the scene. Only six (0.6%) of the 952 who did not achieve ROSC at the scene survived, and all six were readily identifiable as having persistent ventricular fibrillation. Excluding those patients with persistent ventricular fibrillation, all survivors achieved ROSC within 25 minutes after paramedic arrival. CONCLUSIONS: Excluding patients with persistent ventricular fibrillation, resuscitative efforts can be terminated at the scene when normothermic adults with unmonitored, out-of-hospital, primary cardiac arrest do not regain spontaneous circulation within 25 minutes following standard advanced cardiac life support. These criteria should now be validated in several large centers with high survival rates.

Aged↗
PubMed1993

Prehospital cardiac arrest treated by urban first-responders: profile of patient response and prediction of outcome by ventricular fibrillation waveform.

STUDY OBJECTIVES: To determine the speed and characteristics of patient response to urban first-responder defibrillation and to determine whether amplitude of ventricular fibrillation (VF) can predict outcome in these patients. TYPE OF PARTICIPANTS: All adult patients in prehospital VF treated by fire department first-responders (265). DESIGN AND INTERVENTIONS: A prospective observational study occurring between February 1, 1989, and January 1, 1991. Patients were defibrillated according to advanced cardiac life support and first-responder protocols. ECG and time data were recorded digitally. MAIN RESULTS: Sixty-five percent of patients converted from VF to a more stable rhythm at least once during first-responder monitoring. Fifty-four percent of converted patients refibrillated at least once, and 42% of all stable conversions occurred after at least one episode of refibrillation. Seventy percent of all refibrillations occurred less than six minutes after the defibrillator was turned on, and 23% occurred after more than ten minutes. The proportion of stable conversions decreased from 30% on first conversion to 2% on fourth conversion. With each successive conversion the interval to refibrillation grew shorter, and development of a pulse or blood pressure became less likely. Presence of blood pressure or pulse after conversion had a sensitivity for hospital discharge of 54% and a specificity of 98%. Maximum VF amplitude before countershock was highly predictive of postshock rhythm, stable conversion in the field, time interval before refibrillation, inpatient admission, and hospital discharge. VF amplitude was unrelated to response interval or interval to defibrillation but was positively related to bystander CPR. Logistic regression identified VF amplitude as the most important predictor of hospital discharge; traditional variables such as response interval and bystander CPR were not predictive once amplitude had been accounted for. Changes in VF amplitude during the course of resuscitation efforts were frequent and also predictive of outcome. CONCLUSION: Patients in VF who were treated by early countershock refibrillated much more frequently than previously reported. Refibrillations occur both early and late. Initial VF maximum amplitude is strongly predictive of outcome. Future reports of VF cardiac arrest should control for this previously neglected variable. Increased amplitude of VF during repeated refibrillation episodes is associated with increased hospital discharge, so future studies of advanced cardiac life support interventions should explore changes in VF amplitude as an outcome variable.

Aged↗