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PubMed1984

Management of ventricular dysrhythmias in the prehospital and emergency department setting.

Each year approximately 1,500,000 people experience acute myocardial infarction. About 40% of them die, half before they reach the hospital. Ventricular fibrillation (VF) is a major cause of cardiac arrest, and delay in administering antiarrhythmic agents contributes to the incidence of out-of-hospital deaths. The 3 antiarrhythmic drugs currently used by paramedics for cardiac arrest are bretylium, lidocaine, and procainamide. The early use of bretylium tosylate is stressed in Advanced Cardiac Life Support protocols because of the agent's antifibrillatory properties, that is, its ability to increase the VF threshold and to block reentry. Evidence indicates that early, aggressive use of bretylium tosylate as a first-line agent improves the likelihood of successful resuscitation. Preliminary data are presented from an ongoing comparative study of prehospital use of bretylium tosylate and lidocaine for VF. One hundred seventeen cardiac arrests have occurred, 55 of which were associated with VF and are included in the study. Resuscitation was not attempted in 3 of the 55 patients at the request of the family and physician. Of the remaining 52 patients, 17 received bretylium tosylate plus lidocaine, 12 lidocaine alone, and 7 only bretylium tosylate. There were 16 patients who did not receive medications. According to the study protocol, the choice of antiarrhythmic agents was determined by the paramedic shift during which arrest occurred. Of the 52 patients treated, 16 (30%) survived. It is too soon to draw any conclusions.

Arrhythmias, Cardiac↗
PubMed1990

Educational aspects of cardiopulmonary resuscitation (CPR) training.

The knowledge and skills surrounding the practice of cardiopulmonary resuscitation (CPR) have become essential to intensive care nurses and to nurses in general. With formalized training and refresher courses becoming more common in this country, it is evident that after relatively short periods of time the knowledge and skills acquired at such courses may be lost. While much consideration has been given to the content of both Basic and Advanced Cardiac Life Support (BCLS and ACLS) courses, relatively little attention has been paid to the educational issues surrounding CPR training. This paper explores some of these issues from the perspective of adult learning (andragogy). Research is cited from a wide range of sources to illustrate that CPR skill and knowledge deterioration is not unique to nursing, and that educational techniques exist which may improve current educational practices.

Critical Care↗
PubMed1995

Improved outcome for patients with a cardiac arrest by supervision of the emergency medical services system.

BACKGROUND: The outcome for patients with an out-of-hospital cardiac arrest can only be improved through optimal pre-hospital therapy by the emergency medical services (EMS) system. So far it is not clear if physician supervision of the EMS system is necessary for an optimal result. METHODS: In a retrospective and prospective case series we describe the changes in outcome for patients with an out-of-hospital cardiac arrest after the implementation of limited physician supervision of the EMS system. We also analysed the factors that were responsible for these changes. RESULTS: We studied 479 consecutive patients with an out-of-hospital cardiac arrest. In the pre-intervention period, the survival rate for patients with an out-of-hospital cardiac arrest was 13%. This increased to 21.6% when physician supervision was implemented (p = 0.013). This increase in survival coincided with an improvement in pre-hospital advanced cardiac life support with an increase in the number of patients who arrived with a stable cardiac rhythm in the emergency department (p < 0.001). CONCLUSIONS: Limited physician supervision of an EMS system in a non-metropolitan area may improve the outcome for patients with an out-of-hospital cardiac arrest.

Adult↗
PubMed1986

The comparative pathology of open chest vs. mechanical closed chest cardiopulmonary resuscitation in dogs.

We compared the pathologic changes following open-chest cardiopulmonary resuscitation (OCCPR) vs. closed chest cardiopulmonary resuscitation (CCCPR) in 28 healthy mongrel dogs subjected to experimentally induced ventricular fibrillation (VF). VF was induced in 29 dogs. No treatment was given for 3 min, then mechanical CCCPR was given for the next 12 min. External defibrillation (80 joules) was then attempted twice. One dog was resuscitated. The remaining 28 dogs were divided into 2 groups of 14 each. Group A received continued CCCPR and group B received OCCPR. All dogs received advanced cardiac life support and were followed until resuscitated or dead. All dogs were autopsied and gross pathology scores and histopathology scores were determined for each animal, and for each of 19 separate tissues within each animal. The mean gross pathology scores for the following tissues were significantly greater for dogs that received OCCPR vs. those that received CCCPR: skin (3.4 vs. 1.2; P less than 0.001), subcutaneous tissue (3.7 vs. 0.6; P less than 0.001), chest wall muscle (3.7 vs. 0.5; P less than 0.001), and pleura (1.9 vs. 0.1; P less than 0.001). The mean total gross pathology score was also greater in dogs that received OCCPR vs. those that received CCCPR (17.2 vs. 7.7; P less than 0.001). The mean histopathology scores for the following tissues were significantly greater for dogs that received OCCPR vs. those that received CCCPR: skin (2.5 vs. 0.0; P less than 0.001), subcutaneous tissue (2.2 vs. 0.1; P less than 0.001), muscle (2.3 vs. 0.1; P less than 0.001), pleura (1.6 vs. 0.0; P less than 0.001), pericardium (1.4 vs. 0.2; P less than 0.01), epicardium (2.5 vs. 0.2; P less than 0.001), myocardium (2.5 vs. 0.3; P less than 0.001), and endocardium (1.9 vs. 0.5; P less than 0.01). The mean total histopathology score was also greater in dogs that received OCCPR vs. those that received CCCPR (20.1 vs. 7.4; P less than 0.001). The histopathology score for brain tissue was greater for the CCCPR group than for the OCCPR group (1.9 vs. 0.4; P less than 0.05). This study showed that OCCPR in dogs following VF caused more severe pathologic changes than CCCPR. These changes were attributed to thoracotomy-induced chest wall injury and to internal defibrillation induced myocardial injury. However, OCCPR caused less severe microscopic brain lesions than CCCPR.

Animals↗
PubMed1991

The problem of poor retention of cardiopulmonary resuscitation skills may lie with the instructor, not the learner or the curriculum.

Many studies (several even before American Heart Association recommended in 1973 that lay public be trained in cardiopulmonary resuscitation (CPR] have documented that retention of CPR skills is poor, unaffected by modifications in curriculum or whether the students are lay or professional. We chose to investigate what actually occurs during a CPR course, and gained the following insights: despite clearly defined curricula, we found that instructors did not teach in a standardized way. Practice time was limited and errors in performance were not corrected. Instructors consistently rated the students' overall performance as acceptable; at the same time, using the same checklist, we consistently rated performance as unacceptable. The checklist is an inaccurate tool for evaluating CPR performance. Despite the poor performance that we documented, students and instructors were satisfied with the courses and believed that the level of performance was high. As a result of these studies, we discovered that the problem of poor retention of CPR skills may lie not with the learner or the curriculum, but with the instructor. But, since lives are being saved with bystander CPR, does this documented poor retention matter? Perhaps the solution is not only to improve instructor training to make certain that students receive adequate practice time and accurate skill evaluation, but also to modify the criteria for correct performance when testing for retention. These criteria should be based on the minimum CPR skills that are required to sustain life for the critical 4-8 min before defibrillation and other advanced cardiac life support are delivered.

American Heart Association↗
PubMed1993

Initial countershock in the treatment of asystole.

BACKGROUND: Routine provision of defibrillatory countershock (CS) in the initial management of asystolic cardiac arrest has been advocated because certain cases of ventricular fibrillation (VF) may present as asystole (AS). OBJECTIVE: To determine the value of initial CS versus endotracheal intubation and pharmacologic therapy alone in the treatment of asystolic cardiac arrest. DESIGN/PARTICIPANTS: A retrospective analysis of data collected prospectively during a multicenter study of out-of-hospital cardiac arrest. The study subjects were all patients whose initial cardiac arrest rhythm was AS and were treated with standard advanced cardiac life support (ACLS). SETTING: Six urban emergency medical services (EMS) systems. INTERVENTION: Patients in AS were treated initially with CS followed by ACLS therapy (CS Group), and were compared to those patients receiving endotracheal intubation and pharmacologic therapy alone (No CS Group). OUTCOME MEASURES: Those receiving initial CS were compared to those not receiving CS using both Chi-square and logistic regression analysis. Outcome parameters included: rates of return of spontaneous circulation (ROSC), emergency department admission, hospital admission and hospital discharge. RESULTS: Of the 194 patients presenting with AS, 77 received CS as their initial therapy. Of these, 13 (16.9%) had ROSC compared to 27 of the 117 (23.1%) from the No CS Group (P = 0.30). Emergency department and hospital admission rates were not significantly different; 13.0% versus 18.0% (P = 0.36), and 13.0% versus 11.1% (P = 0.69) for CS versus No CS, respectively. None of the patients in the CS Group were discharged alive versus two (1.7%) from No CS (P = 0.52). Of 42 patients with bystander-witnessed cardiac arrests, 13.3% in the CS Group had ROSC compared to 40.7% in the No CS Group (P = 0.07). Emergency department admission rates were 6.7% for the CS Group and 33.3% for the No CS Group (P = 0.07); while hospital admission rates were 6.7% and 22.2%, respectively (P = 0.39). When these comparisons were adjusted for bystander-initiated CPR, CPR interval, and paramedic response interval, the P-values became 0.10, 0.05 and 0.17, respectively. CONCLUSIONS: Although, statistically, the results for both groups were not distinguishable, outcomes for asystolic patients had a tendency to be better when the initial therapy did not involve CS. Larger study populations are recommended to confirm these preliminary observations.

Aged↗
PubMed1994

Outcome of cardiopulmonary resuscitation and predictors of resuscitation status in an urban community teaching hospital.

Medical records of all expired patients as well as all patients designated on billing logs as having received cardiopulmonary resuscitation (CPR) during a 6-month period were reviewed. Patients were considered to have been 'coded' if they were found unresponsive and if the advanced cardiac life support (ACLS) protocol of the American Heart Association (AHA) was subsequently initiated. Of 105 patients who received CPR, 98 died during their hospital stay. Of the seven remaining patients, four had undergone coronary by-pass graft surgery, one was discharged in a persistent vegetative state, one died during an admission 2 months later, and one patient was transferred to another institution where he died. Various factors were studied in an effort to determine how patients on whom resuscitation was attempted differed from those who died without ever having received CPR. Patients who underwent CPR at least once during their hospitalization were more likely to have had cardiac diagnoses on admission (P < 0.001), to have been postoperative (P = 0.02), to have been admitted to a monitored bed on admission (P < 0.001) to have received more days of intensive care (P < 0.001) and to have received more specialist consultations (P = 0.004). Patients not receiving CPR were more likely to have had a primary diagnosis of neoplastic disease (P < 0.001), stroke or intracranial hemorrhage (P = 0.02) or dementia (P < 0.001). Age, race, or gender did not differ significantly between the two groups.

Aged↗
PubMed1988

Evaluation of clinical competence in cardiovascular disease.

The American Board of Internal Medicine has called on directors of cardiology training programs to establish systems to evaluate, document and substantiate those components of overall clinical competence considered essential for certification in the subspecialty. Many of these can be assessed only by repeated direct observations. In particular, proficiency is now required in advanced cardiac life support including cardioversion, electrocardiography (including ambulatory electrocardiographic monitoring) and exercise testing, echocardiography, insertion of arterial lines and right heart catheterization (including insertion of temporary pacemakers). The goal of this expanded evaluation program is to ensure that the public and the profession can identify, through certification, physicians with demonstrated excellence in cardiovascular disease.

Cardiology↗
PubMed1984

Survivors of out-of-hospital cardiac arrest: morbidity and long-term survival.

Sudden cardiac death accounts for two thirds of death due to coronary artery disease. Advanced cardiac life support can now be brought directly to patients with out-of-hospital cardiac arrest, and in this country, as many as 30% of such patients can be discharged from the hospital annually. Certain clinical and resuscitation-related factors are predictive of mortality and morbidity. The best clinical predictors of long-term survival are absence of previous history of myocardial infarction, lack of congestive heart failure during hospitalization, and age less than 60 years. Resuscitation-related predictors of long-term survival are a short time collapse to cardiopulmonary resuscitation (CPR), and a short time from collapse to CPR combined with a short time to provision of definitive care. The majority of cardiac arrest survivors are able to resume previous levels of function.

Emergencies↗
PubMed1986

Performance of aeromedical crewmembers: training or experience?

In a clinical trial testing delivery of cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC) in a medical helicopter, 40-45% of physicians, nurses, and paramedics certified in advanced cardiac life support (ACLS) performed below standard as compared with full-time flight nurses and paramedics. Personnel regularly engaged in aeromedical activities perform far better than those similarly qualified but less familiar with the aviation environment. Because regular ACLS techniques apply during air transport, training, comfort, experience, and confidence are critical factors in crew performance and may affect outcome. The ideal crew should include regular partners who train and work together. The temptation to assign personnel to aeromedical duties without adequate preparation, testing, and commitment must be resisted. Those responsible for the medical direction of hospital-based helicopter services should insist on full-time crew members and provide them with liberal training opportunities and opportunities for skill maintenance.

Aircraft↗
PubMed1988

Initial treatment of ventricular fibrillation: defibrillation or drug therapy.

The belief that defibrillation of unwitnessed ventricular fibrillation frequently results in asystole, combined with perceived low survival rates, led to deviation from "standard" advanced cardiac life support (ACLS) by physicians directing paramedics in the field. In nonstandard ACLS, intubation or drug therapy preceded defibrillation. This study retrospectively compared standard and nonstandard ACLS for ventricular fibrillation. The long-term survival rates were 12.3% (7/57) and 3.6% (6/168) for the two forms of ACLS, respectively (p = 0.03). The incidence of postcountershock asystole was 35% and 28% (p = 0.45). The survival rates for patients with a postcountershock rhythm and a pulse were 83% and 17% after standard and nonstandard ACLS (p less than 0.0001). Other factors reported to have a significant effect on survival were compared, and no significant differences (p greater than 0.05) were noted for mean age, sex, cardiopulmonary resuscitation (CPR) initiated by a bystander, ACLS response time, time to CPR, lay-witnessed arrest, or time to definitive care. The significant difference in the time to defibrillation (14 and 26 minutes) was expected. This is the first clinical study to clearly confirm the ACLS recommendation of early defibrillation before drug therapy in ventricular fibrillation.

Aged↗
PubMed1988

Sudden cardiac arrest in Israel: factors associated with successful resuscitation.

Out-of-hospital cardiac arrests were studied in Israel from 1984 to 1985. More than 3,500 patients in cardiac arrest received paramedic care. Eighty-three percent of cases were caused by underlying heart disease. Overall, 17% of patients with arrest caused by heart disease were admitted and 7% were discharged from the hospital. There was a wide variation in the percent discharged among the 15 paramedic service areas, ranging from 0% to 13%. Factors associated with successful resuscitation included witnessed collapse, rhythm of ventricular fibrillation, short interval from collapse to cardiopulmonary resuscitation (CPR) and delivery of advanced cardiac life support, collapse at public location, and bystander initiation of CPR. Improvements in survival are likely to result if CPR is more frequently and promptly initiated and the time to arrival of definitive paramedic care can be improved.

Aged↗
PubMed1990

The effect of bolus injection on circulation times during cardiac arrest.

Previous investigations have shown that peripheral injection of medication during cardiac arrest leads to prolonged circulation times and low peak drug levels. Current Advanced Cardiac Life Support guidelines suggest that administering a bolus of flush solution after injection of medication may hasten drug delivery, but there is little evidence to support this. The purpose of this study is to investigate the effect of peripheral bolus injection on circulation times during cardiac arrest. Measurements of circulation times were made following injection of indocyanine green dye both with and without a bolus of 20 mL saline flush into a peripheral vein of mongrel dogs. There was no difference in systolic, diastolic, or coronary perfusion pressures during the injections with or without bolus injection. Similarly, there was no difference in end-tidal CO2 or in arterial-venous PO2, PCO2, or pH gradient. The circulation time without bolus injection was 77.7 +/- 42.7 seconds while circulation time with the saline flush was 48.3 +/- 20.9 seconds (P less than .001). Peak dye concentration without saline flush was 3.0 +/- 1.0 mg/L, and peak dye concentration with saline flush was 3.8 +/- 0.9 mg/L (P less than .001). We conclude that a bolus injection of 20 mL of saline enhances dye circulation times and peak levels during cardiac arrest in this animal model. The clinical application of this technique warrants further investigation.

Animals↗
PubMed1993

Effect of extreme temperatures on drugs for prehospital ACLS.

Advanced cardiac life support drugs undergo a wide range of temperature exposures in the prehospital setting. Although manufacturers place temperature restrictions for drug stability on their products, it has been shown that these limits are often exceeded in the prehospital environment. We exposed four different drugs to temperatures of -20 degrees C (-6 degrees F) and 70 degrees C (150 degrees F) and subsequently performed assays to determine their respective chemical stability compared with that of control samples. We determined that no significant difference in chemical structure occurred between the standard sample and the four drugs exposed to extreme temperatures (P > .05). This information has obvious implications in making further recommendations for drug storage. More work to determine bioactivity of temperature-exposed drugs may show results with implications for success in prehospital cardiac resuscitation.

Analysis of Variance↗
PubMed1993

Out-of-hospital resuscitation preferences of emergency health care workers.

The objective of this study was to assess the personal preferences of emergency physicians, nurses, and medical technicians regarding their own potential out-of-hospital resuscitation. An anonymous multiitem survey instrument was used at a statewide emergency medicine educational conference. Emergency personnel who regularly treat out-of-hospital cardiac arrest patients were enlisted to participate. Subjects picked the last intervention that they would wish for themselves in an optimally managed advanced cardiac life support (ACLS)-based resuscitation for ventricular fibrillation. One hundred millimeter visual analog scales were used to measure individual preferences for severe neurological disability or death. Hypothesis testing was by analysis of variance with Newman-Keuls, multiple regression with stepwise variable selection, and the chi 2 and binomial distributions. Of 185 survey instruments, 105 were returned completed by eligible subjects. There was little difference among the three occupational groups (P > .5), although older respondents favored shorter resuscitations (r = -.38; P = .002). Ten subjects did not want cardiopulmonary resuscitation started, and 65% wanted resuscitation stopped before the second dose of epinephrine. Only three subjects chose to undergo the entire ACLS sequence. Eighty-two percent of respondents preferred death to severe neurological disability. Emergency health care professionals have a unique personal awareness of issues surrounding out-of-hospital resuscitation. That a large majority would prefer death to severe disability and few would willingly undergo full resuscitation as currently practiced suggests that prevailing guidelines should be reevaluated.

Adult↗
PubMed1994

Out-of-hospital cardiac arrest in an Oriental metropolitan city.

To investigate the epidemiology of out-of-hospital cardiac arrest in Taipei City, Taiwan, a prospective chart review and follow-up study was conducted by collecting the prehospital cardiac arrest record from 10 designated responsible emergency departments (EDs) from August 1, 1992 through May 31, 1993. Cases with the restoration of spontaneous circulation (ROSC) were followed up until discharged from hospital. The information gathered included age, sex, bystander cardiopulmonary resuscitation, response time (time elapsed from receiving the call to arrival on the scene), advanced cardiac life support (ACLS) time (time elapsed from receiving the call to arrival at the ED), initial cardiac rhythm in the ED, ROSC, survival to discharge from the hospital, underlying disease, past history, personal history, and neurological outcome at discharge. Of 638 out-of-hospital cardiac arrests, 554 (86.7%) were nontraumatic. Response time, ACLS time, ROSC rates, and survival rates were 7.4 minutes, 21.6 minutes, 15.8%, and 1.4%, respectively. In comparing the trauma and nontrauma group, there were significant differences in age, sex, response time, and ACLS time. Between cases of patients who had ROSC and those who died, the data were statistically significant, P = .0143, showing that ACLS time was shorter in the ROSC group (19.5 v 21.9 minutes). In analysis of underlying disease, definite and probable cardiac-origin sudden deaths were found in only 120 patients, which may extend the annual sudden cardiac death rates to be 0.0053%. In conclusion, the low resuscitation and survival rates in this country were because of delayed initiation of both basic life support and ACLS.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMedDate not supplied

Hyperkalemia during human cardiopulmonary resuscitation: incidence and ramifications.

Although hypokalemia has been reported after cardiac arrest and successful resuscitation, experimental data indicate that potassium is released from cells during ischemia. The purpose of this investigation was to study serum potassium concentration ([K+]) during closed chest cardiopulmonary resuscitation (CC-CPR) in humans. Twenty-two patients presenting to the emergency department (ED) in cardiopulmonary arrest had simultaneous measurement of central venous and arterial [K+] and blood gases during CC-CPR utilizing current advanced cardiac life support protocols and a pneumatic chest compressor and ventilator. Mean arterial and central venous [K+] were 5.0 +/- 1.3 and 5.6 +/- 2.9 mEq/L, respectively, (p greater than .05) with 7 patients having [K+] of greater than 6 mEq/L. Significant hyperkalemia does occur in some patients during cardiac arrest and CC-CPR. Because poor tissue perfusion during CC-CPR impairs exchange between the interstitial and intravascular compartments, increases in interstitial [K+] would be expected to be even greater. Interstitial hyperkalemia may play a role in the genesis of wide complex electromechanical dissociation (EMD) seen after prolonged cardiac arrest. Since calcium has long been known to be beneficial in the treatment of hyperkalemia-induced dysrhythmias, the success of calcium chloride in treating wide complex EMD may be on the basis of this phenomenon.

Aged↗
PubMedDate not supplied

Epinephrine in cardiopulmonary resuscitation.

This review assesses the role of epinephrine in cardiopulmonary resuscitation from the perspective of mechanisms of action, cardiac and cerebral effects, and use in human beings. We reviewed the literature from 1966 onward, using a Medline Search of the National Library of Medicine with the key words: "heart arrest," "resuscitation," and "epinephrine." Pertinent articles that represented original research were critically appraised by at least two authors. We concluded that the Advanced Cardiac Life Support recommended dose of epinephrine (1 mg or 0.007 to 0.014 mg/kg) has little scientific basis. Evidence from animal studies demonstrates that doses of 0.1 to 0.2 mg/kg are required to significantly improve myocardial and cerebral blood flow and resuscitation rates. Limited human data confirm the dose-dependent vasopressor response to epinephrine and the potential for improved immediate survival with higher doses. We suggest that randomized controlled human trials are needed to document the usefulness of higher doses of epinephrine in cardiopulmonary resuscitation.

Animals↗