Achieving optimal antiarrhythmic therapy in advanced cardiac life support.
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Advanced Cardiac Life Support↗
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The development and evaluation of new versions of the written examination for the American Heart Association Advanced Cardiac Life Support provider course.
STUDY OBJECTIVE: To create new versions of the written, multiple-choice examination used in the American Heart Association (AHA) Advanced Cardiac Life Support course, evaluate their reliability and difficulty, and then design revised versions with improved reliability and of standardized difficulty. DESIGN: Psychometric evaluation of new versions of the AHA Advanced Cardiac Life Support test and revisions. SETTING: AHA Advanced Cardiac Life Support courses. PARTICIPANTS: Candidates for completion of AHA Advanced Cardiac Life Support provider courses in five states. INTERVENTION: The course content was divided into 11 content areas that were weighted for importance and appropriateness for testing in a multiple-choice format. The weights were used to construct a blueprint for a 50-question, multiple-choice examination. Five versions of the examination were then constructed based on the content blueprint, drawing from new questions and expert revision of previously written questions. Reliability and difficulty were assessed using 915 administrations at five different sites nationwide. The initial test versions differed in their degree of difficulty, which was not explained by demographic factors. The results were used to revise three of the versions to improve reliability and equalize difficulty of the versions. MEASUREMENTS AND MAIN RESULTS: The final five versions have estimated reliability ranging from Cronbach's alpha of .62 to .86. Mean scores ranged from 87.4% to 89.1%. CONCLUSION: After field testing and revision, five examinations with acceptable reliability and roughly equal difficulty were constructed. The new examinations test the participants' knowledge of important aspects of resuscitation science and practice based on a blueprint of the course content.
American Heart Association↗
A longitudinal study of internal medicine residents' retention of advanced cardiac life support skills.
BACKGROUND: Internal medicine residents must be competent in Advanced Cardiac Life Support (ACLS) for board certification. Traditional ACLS courses have limited ability to enable residents to achieve and maintain skills. Educational programs featuring reliable measurements and improved retention of skills would be useful for residency education. METHOD: We developed a training program using a medical simulator, small-group teaching and deliberate practice. Residents received traditional ACLS education and subsequently participated in four two-hour educational sessions using the simulator. Resident performance in six simulated ACLS scenarios was assessed using a standardized checklist. RESULTS: After the program, resident ACLS skill improved significantly. The cohort was followed prospectively for 14 months and the skills did not decay. CONCLUSIONS: Use of a simulation-based educational program enabled us to achieve and maintain high levels of resident performance in simulated ACLS events. Given the limitations of traditional methods to train, assess and maintain competence, simulation technology can be a useful adjunct in high-quality ACLS education.
Advanced Cardiac Life Support↗
An experimental algorithm versus standard advanced cardiac life support in a swine model of out-of-hospital cardiac arrest.
STUDY OBJECTIVE: To compare an experimental algorithm with standard advanced cardiac life support in a swine model of out-of-hospital cardiac arrest. DESIGN: Randomized, controlled experimental trial. SETTING/TYPE OF PARTICIPANT: Animal laboratory using swine. INTERVENTIONS: Eighteen swine (17.8 to 23.7 kg) were sedated, intubated, anesthetized, and instrumented for monitoring of arterial and central venous pressures and ECG. Ventricular fibrillation was induced using a bipolar pacing catheter. Animals were randomized to treatment with the experimental algorithm or standard advanced cardiac life support therapy after eight minutes of untreated ventricular fibrillation. The experimental algorithm consisted of starting CPR; giving high-dose epinephrine (0.20 mg/kg), lidocaine (1.0 mg/kg), bretylium (5.0 mg/kg), and propranolol (0.5 to 1.0 mg) by peripheral IV; hyperventilating (20 to 25 breaths per minute); and delaying countershock (5 J/kg) 60 seconds after completion of drug delivery. Data were analyzed with the Student's t-test and Fisher's exact test. MEASUREMENTS AND MAIN RESULTS: Outcome variables were arterial and central venous pressures, return of spontaneous circulation, and one-hour survival. Hemodynamics were not different between groups during CPR. Return of spontaneous circulation occurred in seven of nine swine (77%) in the experimental algorithm group versus two of nine swine (22%) in the advanced cardiac life support group (P = .057). Four of nine swine (44%) in the experimental algorithm group survived to one hour versus none of the animals in the advanced cardiac life support group (P = .041). CONCLUSION: In this swine model of out-of-hospital cardiac arrest, animals treated with an experimental algorithm had a significant improvement in one-hour survival compared with those treated with advanced cardiac life support.
Algorithms↗
The ventilation/compression ratio influences the effectiveness of two rescuer advanced cardiac life support on a manikin.
Time is of crucial importance during advanced cardiac life support (ACLS). Several parallel tasks have to be performed more or less simultaneously. The guidelines recommend a ventilation/ compression ratio of 1:5 in two-rescuer ACLS. This was compared with respect to time and CPR quality to an alternative method of a 2:15 ratio performed by one of the two rescuers freeing one rescuer to concentrate on other tasks than ventilation and chest compression. Seventeen paramedic students were trained in pairs in ACLS according to the European Resuscitation Council guidelines using an Ambu Mega Code trainer manikin. From a starting point of asystole paramedics were required to perform ECG analysis, intubation, i.v. access, adrenalin and atropine injection, flushing of the drug bolus before conversion to ventricular fibrillation followed by defibrillation in addition to ventilation and chest compression. Unpaired two-tailed Student t-test and the Fisher's exact test were used for statistical analysis, with a P-value less than 0.05 regarded as significant. It took significantly less time to perform successful CPR with the 2:15 ratio compared to the 1:5 ratio. The quality of the ventilations and compressions performed were not significantly different between 2:15 and 1:5 ratio. When two rescuers are performing ACLS, the 2:15 ratio method appears to be time saving vs. the 1:5. This could potentially improve the outcome after cardiac arrest.
Allied Health Personnel↗
An integrated logistics support system for training crew medical officers in advanced cardiac life support management.
The purpose of this paper is to present an approach for the development of an integrated logistics support system for training space flight crew medical officers in advanced cardiac life support (ACLS). The most practical approach to deal with this problem has been determined to be the training of one or more of the crew members on the mission as crew medical officers (CMO's). If this approach is taken, there are a number of problems that must be addressed. The basic approach presented in this paper is to develop a performance quality index for ACLS tasks and use this index to monitor and control the performance of crew members throughout their tenure as CMO's. The control tool of the system is based on an integrated learning and forgetting model used to forecast CMO performance level at a given point during flight training. The model represents an aid for trainers in determining a training regime and maintaining the performance standards. A performance evaluator and trainer is also developed to help in the establishment of trainee performance level during training or retraining. All of these tools were evaluated using either expert opinion questionnaires or experimental results. In conclusion, the results presented provide the tools required for an integrated logistics support system for training ACLS personnel.
Aerospace Medicine↗
Cardioversion in the new advanced cardiac life support guidelines.
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Advanced Cardiac Life Support↗
Inventory control for advanced cardiac life support medications.
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Advanced Cardiac Life Support↗
Advanced cardiac life support becomes basic.
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Advanced Cardiac Life Support↗
Association of drug therapy with survival in cardiac arrest: limited role of advanced cardiac life support drugs.
OBJECTIVE: To generate hypotheses regarding the association of standard Advanced Cardiac Life Support (ACLS) drugs with human cardiac arrest survival. METHODS: This observational cohort study was conducted over a two-year period in the wards, intensive care units, and EDs of two tertiary care hospitals. Included werc adult patients who suffered cardiac arrest either inside or outside the hospital and who required epinephrine according to standard ACLS guidelines. Six standard ACLS drugs (given while CPR was in progress) were assessed for association with survival from resuscitation to one hour and to hospital discharge by univariate and multivariate logistic regression analyses. RESULTS: In the 529 patients studied, initial cardiac rhythm had no impact on the association between drug administration and survival. The time of drug administration (quartile of ACLS period) was associated with resuscitation for atropine (p < 0.05) and lidocaine (p < 0.01). The odds ratios (95% CIs) for successful resuscitation, after multivariate adjustment for potential confounders, were: a respiratory initiating cause, 3.7 (2.1 -6.4); each 5-minute increase in CPR-ACLS interval, 0.5 (0.4-0.7); each 5-minute duration of ACLS. 0.9 (()1.8- 1.0; atropine, 1.2 (1.0-1.3); bretylium. (0.4 (0.1-1.1); calcium 0.8 (0.2-2.4); lidocaine, 0.9 (0.7-1.1); procainamide. 21.0 (5.2-84.0) d sodium bicarbonate 1.2 (1.0-1.6). All other potential confounding variables entered into the model were not significantly associated with resuscitation. CONCLUSION: Initiating cause of arrest, time to ACLS, and duration of ACLS were important correlates of survival. Other than procainaimide, standard ACLS drugs had relatively little association with survival, but timing of administration may be an important factor. Further research using definitive large randomized controlled trials is warranted to assess the role of drug therapy in improving cardiac arrest survival.
Adult↗
Maintaining competency in advanced cardiac life support skills.
One hundred thirty-two physicians who successfully completed advanced cardiac life support (ACLS) training were randomly placed in a control group or one of two groups receiving interventions designed to provide reinforcement of previously mastered knowledge and skills. These interventions included mailed periodic reprints (group 1) or quarterly patient management problems (group 2). All physicians were retested for knowledge and skills related to ACLS one year later. Fifty-two (39.4%) could successfully ventilate the mannequin, and 62 (47.0%) could perform cardiac compression adequately. No differences were noted among groups. Significant differences in knowledge were found. The control group initiated appropriate therapy in a mock-arrest situation 52% of the time, while group 1 averaged 75% and group 2 averaged 82%. These results indicate that reinforcement after continuing medical education may enhance knowledge retention, but does not maintain motor skills. Yearly recertification in ACLS skills should be considered, and frequent practice sessions should be encouraged for those physicians who are not active participants in ACLS activities.
Clinical Competence↗
Cardiopulmonary resuscitation and advanced cardiac life support: common errors and current techniques.
Competence in the techniques of Advanced Cardiac Life Support is essential for physicians who are in frequent contact with patients at high risk for cardiac arrest. The methods utilized are complex and rapidly changing. However, a consistent pattern of errors in fundamental concepts or methods emerges. These can be characterized as (1) errors in the general management of patients, (2) erros in basic cardiopulmonary resuscitation (CPR) techniques, (3) mistakes in the use or omission of appropriate drugs, (4) errors in the associated necessary techniques which require some technical skills, and (5) errors in management of the patient subsequent to the cardiac arrest. Attention to these details may increase success in management of patients with cardiac arrest.
Heart Arrest↗
Simulation-based training of internal medicine residents in advanced cardiac life support protocols: a randomized trial.
BACKGROUND: Internal medicine residents must be competent in Advanced Cardiac Life Support (ACLS) for board certification. PURPOSE: The purpose was to use a medical simulator to assess baseline proficiency in ACLS and determine the impact of an intervention on skill development. METHOD: This was a randomized trial with wait-list controls. After baseline evaluation in all residents, the intervention group received 4 education sessions using a medical simulator. All residents were then retested. After crossover, the wait-list group received the intervention, and residents were tested again. Performance was assessed by comparison to American Heart Association guidelines for treatment of ACLS conditions with interrater and internal consistency reliability estimates. RESULTS: Performance improved significantly after simulator training. No improvement was detected as a function of clinical experience alone. The educational program was rated highly.
Academic Medical Centers↗
The ABCs of teaching advanced cardiac life support.
This article describes the evolution in methods used at The Christ Hospital in Cincinnati, Ohio, to teach advanced cardiac life support over the past 10 years. The interactive nature of the teaching methods has improved participants' enjoyment of this course. With smaller teaching groups, instructors find this course challenging and fun to teach. This article provides outlines of teaching stations at The Christ Hospital and examples in which to implement the current advanced cardiac life support content according to the American Heart Association's teaching recommendations.
Heart Arrest↗
The association between age of hospitalized patients and the delivery of advanced cardiac life support.
OBJECTIVE: To determine the extent of variability in the administration of advanced cardiac life support (ACLS) and to determine if age is associated with variability. DESIGN: Retrospective cohort. SETTING: Urban teaching hospital. PATIENTS: One hundred twenty-two adult inpatients without a "do-not resuscitate" order who suffered cardiopulmonary arrest during 1993. MEASUREMENTS AND MAIN RESULTS: Of the total, 35 (29%) survived the arrest and 87 (71%) died. Among the nonsurvivors, two patients received no ACLS and six were not intubated, despite the inclusion of intubation in all ACLS protocols. Of the 87 nonsurvivors, 31 had a single electrocardiographic rhythm during their arrest and should have had similar ACLS trials. However, the 9 nonsurvivors with ventricular fibrillation received a range of 0 to 17 interventions, the 11 with electromechanical dissociation received 1 to 22, and the 11 with asystole received 0 to 14. Based on a protocol-derived definition of a minimal trial of ACLS (a "short ACLS trial") for all 87 nonsurvivors, age greater than 75 was associated with receiving a short trial. Dependent functional status and being on a medical service were also associated with a short ACLS trial. In a logistic regression model including these variables as covariates, age remained significantly associated with a short ACLS trial; odds ratio, 9.71 (95% confidence interval 1.68, 56.1). CONCLUSIONS: Wide variability exists in the administration of ACLS at the studied site. The finding that some patients receive no ACLS suggests that physicians at this site may be making bedside determinations of the likelihood of its benefit based on individual patient characteristics. The association between older age and short ACLS trials among all nonsurvivors suggests that age is most important of these characteristics.
Adult↗
The retention of advanced cardiac life support knowledge among registered nurses.
In an investigation into the retention of advanced cardiac life support (ACLS) knowledge over time, the authors found that ACLS scores significantly decreased for a subgroup of a sample of 40 RNs employed in critical care areas in the first year after certification. Several variables that influenced scores were identified. Recommendations for inservice educators include reconstructing the ways in which ACLS courses are taught, conducting mock mega code scenarios every 6 months, constructing mega code scenarios that reflect the reality of practice, and routinely conducting refresher courses based on problems identified in a particular group.
Adult↗
Advanced cardiac life support for the new millennium.
The American Heart Association has been the recognized source for Advanced Cardiac Life Support (ACLS) education for the past three decades. Since the first ACLS course, numerous revisions have been made to the management algorithms based on evolving scientific evidence. The last revisions made in August 2000 were the first international guidelines published. These guidelines reflect the intense review and analysis of scientific work and emphasize the importance of evidence-based therapies. This article outlines the major changes to ACLS guidelines for dysrhythmias, acute coronary syndromes, and acute stroke management.
Acute Disease↗
Advanced cardiac life support.
It is important for all physicians to be familiar with the equipment and medications needed for advanced cardiac life support. The most important aspect in advanced life support is the establishment and maintenance of an airway and ventilation of the patient. Office personnel should be trained in Basic Cardiac Life Support, so that the physician can intubate the patient, start an intravenous line, and administer intravenous medications to support the patient. Appropriate drug dosage tables and defibrillation tables are included in this article.
Adult↗