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PubMedDate not supplied

Cardiac arrest and resuscitation epidemiology in Singapore (CARE I study).

OBJECTIVES: To describe the epidemiology of out-of-hospital cardiac arrest (OHCA) in Singapore, the emergency medical services (EMS) response, and to identify possible areas for improvement. METHODS: This prospective observational study constitutes phase I of the Cardiac Arrest and Resuscitation Epidemiology (CARE) project. Included were all patients with nontraumatic OHCA conveyed by the national emergency ambulance service. Patient characteristics, cardiac arrest circumstances, EMS response, and outcomes were recorded according to the Utstein style. RESULTS: From October 1, 2001, to April 30, 2002, 548 patients were enrolled into the study. Mean (standard deviation [SD]) age was 62.2 (17.9) years, with a male predominance (65.6%). A total of 59.8% of collapses occurred at home, 35.3% of arrests were not witnessed, and bystander cardiopulmonary resuscitation was present for 20.6%. Mean (SD) time from collapse to call received by EMS was 10.6 (13.1) minutes. Mean (SD) EMS response time was 10.2 (4.3) minutes. Mean (SD) time from call to defibrillation was 16.7 (7.2) minutes. Mean (SD) on-scene time was 9.9 (4.5) minutes. First presenting rhythm at the scene was asystole in 54.5%, pulseless electrical activity 22.9%, ventricular fibrillation 19.6%, and ventricular tachycardia 0.4%. Of all cardiac arrests, 351 had resuscitation attempted and were of cardiac origin. Among these patients, 17.9% had return of spontaneous circulation, 8.5% survived to hospital admission, and 2.0% survived to discharge. CONCLUSION: CARE I establishes the baseline for the evaluation of incremental introduction of prehospital Advanced Cardiac Life Support interventions planned for future phases. Continuing efforts should be made to strengthen all chains of survival. This represents the most comprehensive OHCA study yet conducted in Singapore.

Age Distribution↗
PubMed1994

Comparison of i.v. and intra-tracheal administration of adrenaline.

Adrenaline is the single most important therapeutic agent used in advanced cardiac life support (ACLS). Ideally it should be given into a large central vein but the European Resuscitation Council, the American Heart Association and the Resuscitation Council (U.K.) advise that adrenaline may be given into the trachea if i.v. access is not available. We have studied the effects of intra-tracheal and i.v. adrenaline in 16 patients undergoing mechanical ventilation. Log dose-response curves were constructed for systolic arterial pressure and heart rate responses. Intra-tracheal doses of adrenaline up to 10 micrograms kg-1, approximately one-third of that recommended for resuscitation, had no effect on arterial pressure or heart rate, whereas adrenaline 0.1 microgram kg-1 i.v. produced a mean increase in systolic pressure of 24 mm Hg. The intra-tracheal doses recommended for resuscitation (2-3 mg) are likely to be ineffective and consideration should be given to abandoning the tracheal route for adrenaline in ACLS.

Administration, Inhalation↗
PubMed2002

Vasopressin: new uses in critical care.

The science of medicine has evolved dramatically over recent years, with better understanding of the mechanisms of disease leading to innovative new treatments. However, the critical care patient still suffers from a high mortality rate with few advances from the traditional modalities of therapy. Arginine vasopressin has been explored as a vasoconstrictor in the treatment of the hypotension associated with septic shock. This drug has also recently been added to the advanced cardiac life support protocol for the resuscitation of pulseless ventricular tachycardia and ventricular fibrillation. Studies of arginine vasopressin in these situations have been promising but still have yet to prove a survival benefit over traditional therapies. Newer and larger trials are necessary to determine whether any mortality benefit can be sustained from the use of arginine vasopressin in critical care patients with septic shock and cardiac arrest secondary to pulseless ventricular tachycardia and ventricular fibrillation.

Arginine Vasopressin↗
PubMed2001

Cardiac resuscitation after incremental overdosage with lidocaine, bupivacaine, levobupivacaine, and ropivacaine in anesthetized dogs.

UNLABELLED: There is no information comparing the ability to reverse the cardiotoxic effects associated with incremental overdosage of bupivacaine (BUP) to levobupivacaine (LBUP), ropivacaine (ROP), or lidocaine (LIDO). Open-chest dogs were randomized to receive incremental escalating infusions of BUP, LBUP, ROP, and LIDO to the point of cardiovascular collapse (mean arterial pressure [MAP] < or = 45 mm Hg). Hypotension and arrhythmias were treated with epinephrine, open-chest massage, and advanced cardiac life support protocols, respectively. Outcomes were defined as the following: successful (stable rhythm and MAP > or = 55 mm Hg for 20 min), successful with continued therapy (stable rhythm and MAP <55 mm Hg after 20 min), or death. Continued therapy was required in 86% of LIDO dogs compared with only 10%-30% of the other dogs (P < 0.002). Mortality from BUP, LBUP, ROP, and LIDO was 50%, 30%, 10%, and 0%, respectively. Myocardial depression was primarily responsible for the profound hypotension, as the occurrence of lethal arrhythmias preceding resuscitation was not different among local anesthetics. Epinephrine-induced ventricular fibrillation occurred more frequently in BUP-intoxicated dogs than in dogs given LIDO or ROP (P < 0.05). The unbound plasma concentrations at collapse were larger for ROP, 19.8 microg/mL (10-39 microg/mL), compared with BUP, 5.7 microg/mL (3-11 microg/mL); whereas the concentrations of LBUP, 9.4 microg/mL (5-18 microg/mL) and BUP were not significantly different from each other. IMPLICATIONS: There were consistent differences among the local anesthetics, the sum of which suggests that larger doses and blood concentrations of ropivacaine (ROP) and lidocaine will be tolerated as compared with bupivacaine (BUP) and levobupivacaine (LBUP). Lidocaine intoxication results in myocardial depression from which resuscitation is consistently successful but will require continuing drug support. After BUP, LBUP, or ROP, resuscitation is not always successful, and the administration of epinephrine may lead to severe arrhythmias. The unbound plasma concentrations at collapse were larger for ROP compared with BUP, whereas the concentrations of LBUP and BUP were not significantly different from each other. Furthermore, larger plasma concentrations of ROP than BUP are present after resuscitation, suggesting a wider margin of safety when large volumes and large concentrations are used to establish upper or lower extremity nerve blocks for surgical anesthesia and during long-term infusions for pain management.

Amides↗
PubMed2002

Hypertonic-hyperoncotic solutions reduce the release of cardiac troponin I and s-100 after successful cardiopulmonary resuscitation in pigs.

UNLABELLED: In some patients, cardiopulmonary resuscitation (CPR) can revive spontaneous circulation (ROSC). However, neurological outcome often remains poor. Hypertonic-hyperoncotic solutions (HHS) have been shown to improve microvascular conductivity after regional and global ischemia. We investigated the effect of infusion of HHS in a porcine CPR model. Cardiac arrest was induced by ventricular fibrillation. Advanced cardiac life support was begun after 4 min of nonintervention and 1 min of basic life support. Upon ROSC, the animals randomly received 125 mL of either normal saline (placebo, n = 8) or 7.2% NaCl and 10% hydroxyethyl starch 200,000/0.5 (HHS, n = 7). Myocardial and cerebral damage were assessed by serum concentrations of cardiac troponin I and astroglial protein S-100, respectively, up to 240 min after ROSC. In all animals, the levels of cardiac troponin I and S-100 increased after ROSC (P < 0.01). This increase was significantly blunted in animals that received HHS instead of placebo. The use of HHS in the setting of CPR may provide a new option in reducing cell damage in postischemic myocardial and cerebral tissues. IMPLICATIONS: Infusion of hypertonic-hyperoncotic solutions (HHS) after successful cardiopulmonary resuscitation in pigs significantly reduced the release of cardiac troponin I and cerebral protein S-100, which are sensitive and specific markers of cell damage. Treatment with HHS may provide a new option to improve the outcome of cardiopulmonary resuscitation.

Animals↗
PubMed1992

Anesthesiologists' management of simulated critical incidents.

Human error is believed to contribute to the majority of negative anesthesia outcomes. Because retrospective analysis of critical incidents has several shortcomings and prospective studies are limited by the low frequency of critical incidents, an anesthesia simulator was used to evaluate the management of simulated emergency situations by ten anesthesia residents, ten faculty anesthesiologists, and ten anesthesiologists in private practice in order to identify specific patterns of errors in diagnosis and treatment. The simulator is a computer program that presents the patient, monitors, and management choices in a graphical display on an IBM or compatible personal computer. Many errors were observed in the management of these emergency situations, and even anesthesiologists with years of experience made serious errors. Although all experienced anesthesiologists correctly diagnosed simulated esophageal intubation, two residents misinterpreted the lack of end-tidal carbon dioxide. Only 40% of subjects correctly diagnosed simulated anaphylactic reaction; 27% adequately treated simulated myocardial ischemia; and 30% managed a simulated cardiac arrest according to Advanced Cardiac Life Support (ACLS) guidelines. Problems with continuous infusions of vasoactive agents were common. Fixation errors or failure to revise a plan in the presence of inconsistent cues were made by 63% of subjects. The subjects that gathered more information during simulated anaphylaxis made the correct diagnosis more often and made fewer treatment errors. The time since the last ACLS training was found to be an important predictor of correct management of simulated cardiac arrest.(ABSTRACT TRUNCATED AT 250 WORDS)

Anaphylaxis↗
PubMed1979

A multidisciplinary clerkship in emergency medicine.

An obligatory, multidisciplinary, fourth-year emergency medicine clerkship is described and the particular problems of multidisciplinary courses discussed. The course is designed to produce medical students who adequately demonstrate: knowledge of emergency care and facility in specified skills, familiarity with the appropriate use of an emergency room, and conversance with treatment of nonemergency cases. Students are required to complete successfully an advanced cardiac life support providers course, serve on ambulance duty, rotate through a community hospital emergency room, and participate in the more traditional clinical experiences. The course offers the fourth-year student an opportunity to synthesize prior knowledge within the context of a multidisciplinary patient care experience.

Clinical Competence↗
PubMed1997

Defining the cost of educating undergraduate medical students at the University of Virginia.

PURPOSE: To develop a model for calculating the cost of a four-year undergraduate medical education at the University of Virginia School of Medicine (UVA) in 1994-95. METHOD: All data were based on faculty contact hours (FCHs), the primary driver of cost. (An FCH was an hour during which a faculty member was actively teaching.) First- and second-year data were derived from a published curriculum schedule. Third-year data were derived from hours spent in each clerkship and a series of calculations to assess direct teaching time in each clerkship accurately. Fourth-year data were modeled on an artificial but typical program consisting of the required clerkship in neurology, a two-day course in advanced cardiac life support, and seven elective blocks; electives were chosen based on relative overall popularity. The number of full-time-equivalent (FTE) faculty required was calculated. The salary costs of UVA full-time faculty were calculated. Other total direct costs, including the costs of support and administrative services as well as the costs of the educational contributions of housestaff and contract faculty, were calculated. The overall cost, including direct and indirect costs, was calculated. An average of 139 students per year was assumed. RESULTS: The total number of FCHs was just under 100,000. The number of FTE faculty required was 223. UVA faculty salary and fringe benefits totaled $29,400,000. The costs of support and administrative services totaled $4,100,000; the costs of housestaff and contract faculty totaled $2,300,000. The overall educational costs totaled $49,600,000. CONCLUSION: The overall cost of a four-year medical education at UVA was $357,000 per student. Although the process of calculating this cost was complex and, at times, based on assumptions open to debate, the model developed can be applied to any medical education setting.

Clinical Clerkship↗
PubMed1983

Measurement of ventilation during cardiopulmonary resuscitation.

Determining adequacy of mechanical ventilation is as important during CPR as in a more stable situation (such as, a patient on a ventilator in an ICU). Yet, such assessment during CPR usually only means listening for breath sounds, checking chest excursion, and blood gases. Exhaled tidal volume (VT) was measured on 45 intubated adult patients during resuscitation using a Wright's spirometer attached to a T-valve above the endotracheal tube. Ten patients had aspiration prior to intubation; 15 received advanced cardiac life support in the field, including esophageal airway insertion. CPR was performed in all cases with a mechanical compression device (Thumper). The pressure ventilator on this device was calibrated (peak inspiratory pressure, VT vs compliance) using a Dixie Test Lung, allowing indirect assessment of pulmonary compliance during CPR. Our findings suggest that lung compliance is markedly reduced within a short time after cardiac arrest. Fifty-five % of patients in this series could not be adequately oxygenated (PaO2 less than 50 torr) despite an FIO2 of 0.8 and adequate ventilation. Due to the reduced cardiac output during CPR causing venoarterial shunting, it is speculated that pulmonary edema is the most plausible explanation for this observation.

Aged↗
PubMed1988

Effect of injection site on circulation times during cardiac arrest.

Cardiopulmonary resuscitation requires effective, prompt drug administration. In order to analyze Advanced Cardiac Life Support (ACLS) recommendations for site of drug administration, we studied dye circulation times after central, femoral, and peripheral venous injection during both closed and open chest CPR using a canine arrest model. Measurements of circulation times were made after injection of indocyanine green dye at femoral, central, and peripheral venous sites. Circulation times during closed chest CPR were 62.7 +/- 19.6 sec after central injection, 86.6 +/- 23.5 sec after femoral injection, and 93.6 +/- 17.9 sec after peripheral injection (p less than .001). During closed chest CPR, peak dye concentration after central injection was significantly higher than that after peripheral injection (4.0 +/- 1.3 vs. 3.1 +/- 0.8 mg/L, p less than .01). Circulation times were significantly shorter during open chest CPR with times again shortest after central injection. This animal model suggests that prompt drug delivery during CPR is enhanced by central venous injection of medication. There appears to be no advantage in femoral over peripheral injection.

Animals↗
PubMed1991

Aortic-carotid artery pressure differences and cephalic perfusion pressure during cardiopulmonary resuscitation in humans.

OBJECTIVE: Animal studies have shown an aortic-carotid artery pressure difference during cardiopulmonary resuscitation (CPR), which compromises cerebral perfusion. This pressure difference is most marked with prolonged CPR and can be abolished with administration of high doses of epinephrine. To better understand the mechanism of cerebral blood flow during CPR in humans, we determined the aortic-carotid artery pressure difference, the cephalic perfusion pressure (the carotid artery-jugular vein pressure difference), and thoracic inlet venous "valving" (the central venous-jugular vein pressure difference), while administering standard doses of epinephrine. DESIGN: Prospective study with randomization as to which side the carotid artery was catheterized. SETTING: The resuscitation room of a large urban hospital's emergency department. PATIENTS: Fifteen adults in normothermic, nontraumatic prehospital cardiac arrest treated according to Advanced Cardiac Life Support guidelines, including administration of 1 mg epinephrine iv every 5 mins. INTERVENTIONS: The descending aorta, cervical common carotid artery, internal jugular vein, and central venous system were catheterized. Pressures were recorded during standard CPR for 5 mins after administration of 1 mg epinephrine iv. MEASUREMENTS AND MAIN RESULTS: Most patients received CPR for greater than 20 mins before the first epinephrine dose and for greater than 45 mins before pressure recording as described above. There was no significant difference between aortic and carotid artery compression and relaxation phase pressures. The mean +/- SD compression central venous-jugular vein pressure difference was 22.1 +/- 15.0 mm Hg, and the mean cephalic perfusion pressure was 20.8 +/- 19.5 mm Hg. CONCLUSIONS: There is no clinically important aortic-carotid artery pressure difference during human CPR using the standard dose of epinephrine, even with prolonged CPR. Despite carotid artery patency and thoracic inlet venous valving, the cephalic perfusion pressure is low during CPR in humans.

Aged↗
PubMed1993

Simultaneous radial, femoral, and aortic arterial pressures during human cardiopulmonary resuscitation.

OBJECTIVE: To examine the validity of interchanging arterial sites and their responses to graded doses of epinephrine during human cardiopulmonary resuscitation (CPR). DESIGN: Consecutive case series. SETTING: Large, urban Emergency Department. PATIENTS: Adult, normothermic, nonhemorrhagic cardiac arrest patients. INTERVENTIONS: While receiving advanced cardiac life support, patients received right atrial (n = 40), aortic (n = 40), radial (n = 40), and femoral (n = 17) artery catheters. Pressures were measured simultaneously at baseline, after 0.01 mg/kg and 0.2 mg/kg of epinephrine. MEASUREMENTS AND MAIN RESULTS: The mean aortic compression-phase pressure was 9.3 +/- 10 (SD), 8.1 +/- 11, and 4.4 +/- 9.5 mm Hg higher than radial artery pressure at baseline, after 0.01 mg/kg, and 0.2 mg/kg of epinephrine, respectively (all statistically significant). When compared with the femoral artery at the same time points, the mean aortic compression-phase pressure was also 3.0 +/- 6.8, 1.9 +/- 8, and 0.6 +/- 7.7 mm Hg higher, respectively (none statistically significant). The aortic relaxation-phase pressure was 1.3 +/- 3.6, 1.1 +/- 3.8, and 1.6 +/- 2.5 mm Hg lower than the radial artery at baseline, after 0.01 mg/kg and 0.2 mg/kg of epinephrine, respectively (all statistically significant). When compared with the femoral artery at the same time points, the aortic relaxation-phase pressure was 0.6 +/- 2.0, 0.3 +/- 3.3, and 0.3 +/- 2.4 mm Hg lower, respectively (none statistically significant). CONCLUSIONS: Radial artery relaxation-phase pressure, although statistically higher, correlated with aortic relaxation-phase pressure. Femoral artery relaxation-phase pressure was not statistically different from aortic relaxation-phase pressure. Aortic pressure was statistically higher and had a lower correlation with radial artery pressures during compression phase. The aortic to radial artery and aortic to femoral artery compression-phase gradients abated with increasing doses of epinephrine therapy. Caution must be used when substituting compression-phase pressure obtained at radial or femoral artery sites for aortic pressure during human CPR. Coronary artery perfusion pressures obtained with radial and femoral arteries correlate with aortic pressure when measuring the response to vasopressor therapy during CPR when an interpretable waveform exists.

Aged↗
PubMed1993

Cardiac arrest presenting with rhythms other than ventricular fibrillation: contribution of resuscitative efforts toward total survivorship.

OBJECTIVE: The medical literature portrays a bleak prognosis for out-of-hospital cardiac arrest cases presenting with asystole, idioventricular rhythms with pulselessness, or primary electromechanical dissociation. In view of evolving philosophies to waive resuscitation attempts in such cases, we sought to delineate the actual contribution toward overall survivorship that is provided by resuscitation efforts for patients who have these electrocardiographic presentations. DESIGN: A prospective outcome study which analyzed all out-of-hospital cardiac arrest cases in a large city for a 2-yr period in terms of presenting electrocardiogram, age, sex, presence and status of witnesses, performance of bystander cardiopulmonary resuscitation, and survival to successful hospital discharge. SETTING: A large urban municipality (population, two million) served by a single, centralized emergency medical services program. PATIENTS: Excluding cases associated with trauma, drugs, airway obstruction, submersion or primary respiratory illness, 2,404 consecutive adult out-of-hospital cardiac arrest patients were studied. INTERVENTIONS: Standard advanced cardiac life support. MEASUREMENTS AND MAIN RESULTS: Although survival "rates" of patients with asystole, idioventricular rhythms with pulselessness, and electromechanical dissociation were low (1.6%, 4.7% and 6.9%, respectively), 22.2% of the 193 total survivors (confidence interval: +5.9%) initially presented with one of these electrocardiographic rhythms (14 asystole, 18 idioventricular rhythms with pulselessness, 10 electromechanical dissociation, plus one other). CONCLUSIONS: Despite poor survival "rates," resuscitative efforts for patients presenting with asystole, electromechanical dissociation, and idioventricular rhythms with pulselessness all contribute significantly toward a community's total survivorship from out-of-hospital cardiac arrest. Initial, aggressive attempts at resuscitation still should be emphasized in such patients.

Accelerated Idioventricular Rhythm↗
PubMed1994

High atrial natriuretic peptide concentrations blunt the pressor response during cardiopulmonary resuscitation in humans.

OBJECTIVE: To determine the relationship of circulating atrial natriuretic peptide concentrations to the pressor response to high-dose epinephrine in patients undergoing cardiopulmonary resuscitation (CPR) for cardiac arrest. DESIGN: Prospective study. PATIENTS: Fourteen normothermic, adult, prehospital and emergency department patients suffering unexpected cardiac arrest. INTERVENTION: Patients received high-dose epinephrine (0.2 mg/kg) i.v. when standard advanced cardiac life support (including multiple 1-mg dosages of epinephrine) failed to result in return of spontaneous circulation. MEASUREMENTS AND MAIN RESULTS: Cardiac arrest patients were separated into those patients with and without detectable serum atrial natriuretic peptide concentrations, and were termed the "low atrial natriuretic peptide" and "high atrial natriuretic peptide" groups, respectively. Their aortic pressure response to high-dose (0.02 mg/kg) epinephrine was compared. The proportion with positive assays was compared with a group of healthy control subjects. Fourteen patients were studied. Eight patients had low serum atrial natriuretic peptide concentrations and six patients had high circulating atrial natriuretic peptide concentrations. The mean concentration in the high atrial natriuretic peptide group was 151 +/- 82 pg/mL. The proportion with positive assays (six of 14 patients) was greater than in the group in spontaneous circulation (three of 29 patients) (p = .002). The maximal increase in the aortic relaxation-phase pressures after high-dose epinephrine was 9 +/- 7 torr (1.2 +/- 0.9 kPa) in the low atrial natriuretic peptide group and 0 +/- 5 torr (0 +/- 0.7 kPa) in the high atrial natriuretic peptide group (p = .03). The maximal increase in the aortic compression pressures after high-dose epinephrine was 17 +/- 13 torr (2.3 +/- 1.7 kPa) in the low atrial natriuretic peptide group and 2 +/- 10 torr (0.3 +/- 1.3 kPa) in the high atrial natriuretic peptide group (p = .03). Thus, pressor responses after high-dose epinephrine administration were observed in patients in the low atrial natriuretic peptide group, but this response was absent in patients in the high atrial natriuretic peptide group. CONCLUSIONS: Cardiac arrest patients receiving CPR have higher circulating atrial natriuretic peptide concentrations than healthy subjects. High serum atrial natriuretic peptide concentrations may antagonize the vasopressor response to epinephrine. Blocking this effect of atrial natriuretic peptide may improve outcomes in patients suffering cardiac arrest.

Adult↗
PubMed1994

High-dose epinephrine results in greater early mortality after resuscitation from prolonged cardiac arrest in pigs: a prospective, randomized study.

OBJECTIVE: To determine whether high-dose epinephrine (0.2 mg/kg) during cardiopulmonary resuscitation (CPR) results in improved outcome, compared with standard-dose epinephrine (0.02 mg/kg). DESIGN: A prospective, randomized, blinded study. SETTING: Research laboratory of a university medical center. SUBJECTS AND INTERVENTIONS: Thirty domestic swine were randomized to receive standard- or high-dose epinephrine during CPR after 15 mins of fibrillatory cardiac arrest. Three minutes of CPR were provided, followed by advanced cardiac life support per American Heart Association guidelines. Animals that were successfully resuscitated were supported for 2 hrs in an intensive care unit (ICU) setting, and then observed for 24 hrs. MEASUREMENTS AND MAIN RESULTS: Electrocardiogram, aortic blood pressure, right atrial blood pressure, and end-tidal CO2 were monitored continuously until the intensive care period ended. Survival and neurologic outcome were determined. Return of spontaneous circulation was attained in 14 of 15 animals in each group. Four of 14 high-dose epinephrine pigs died during the ICU period after return of spontaneous circulation vs. zero of the 14 standard-dose pigs (p < .05). Six standard-dose pigs survived 24 hrs vs. four high-dose pigs. Twenty-four-hour survival rate and neurologic outcome were not significantly different. Within 10 mins of defibrillation, severe hypertension (diastolic pressure > 120 mmHg) occurred in 12 of 14 high-dose pigs vs. two of 14 standard-dose pigs (p < .01). Severe tachycardia (heart rate > 250 beats/min) occurred in seven of 14 high-dose pigs vs. zero of 14 standard-dose pigs (p < .01). All four high-dose epinephrine pigs that died during the ICU period experienced both severe hypertension and tachycardia immediately postresuscitation. CONCLUSIONS: High-dose epinephrine did not improve 24-hr survival rate or neurologic outcome. Immediately after return of spontaneous circulation, most animals in the high-dose epinephrine group exhibited a hyperadrenergic state that included severe hypertension and tachycardia. High-dose epinephrine resulted in a greater early mortality rate.

Animals↗
PubMed1995

A technique revisited: hemodynamic comparison of closed- and open-chest cardiac massage during human cardiopulmonary resuscitation.

OBJECTIVE: To compare the hemodynamics of closed-chest cardiac massage vs. open-chest cardiac massage in patients resuscitated from cardiac arrest that occurred outside of the hospital. DESIGN: Prospective, non-outcome, case series. SETTING: Large urban emergency department. PATIENTS: Ten adult, normothermic, nontraumatic, out-of-hospital, cardiac arrest patients who failed advanced cardiac life support (ACLS) therapy. INTERVENTIONS: Patients presenting to the hospital in cardiac arrest were managed according to the ACLS protocol at the clinician's discretion. Proximal aortic and central venous pressure catheters were placed to measure arteriovenous compression- and relaxation-phase pressure gradients. After 5 mins of baseline measurements during closed-chest cardiac massage, patients underwent a left lateral thoracotomy, and open-chest cardiac massage was performed for 5 mins. MEASUREMENTS AND MAIN RESULTS: The mean coronary perfusion pressure and compression-phase pressure gradients were 7.3 +/- 5.7 and 6.2 +/- 5.4 mm Hg, respectively, during closed-chest cardiac massage, while increasing to 32.6 +/- 17.8 and 32.6 +/- 29.9 mm Hg, respectively, during open-chest cardiac massage. The differences between both measurements were statistically significant (p < .05). CONCLUSIONS: Open-chest cardiac massage is superior to closed-chest cardiac massage in providing relaxation-phase and compression-phase pressure gradients during cardiac arrest in patients failing current ACLS protocols. During open-chest cardiac massage, all patients exceeded the minimum coronary perfusion pressure of 15 mm Hg, which is recommended to obtain a return of spontaneous circulation. Further outcome studies are needed to determine the timeliness and appropriate indications for open-chest cardiac massage.

Aged↗
PubMed1997

Echocardiographic observations during in hospital cardiopulmonary resuscitation.

OBJECTIVE: To assess echocardiographic observations during in hospital cardiopulmonary resuscitation (CPR) and the utility of this information in the management of cardiac arrest. DESIGN: Echocardiographic system brought to the hospital site of cardiac arrest and applied to patients in conjunction with conventional CPR. SETTING: Large community-hospital with portable echocardiographic system and an alerted cardiology team skilled in this technique. MEASUREMENTS AND MAIN RESULTS: Mechanical asystole was initially observed in 18 (90%) of 20 cardiac arrest patients during CPR, including four patients with severe bradyarrhythmia as the arrest rhythm. The return of ventricular contractions in four of these 18 patients a short time after starting CPR prompted positive inotropic therapy. Ventricular wall motion was noted in two patients with severe bradyarrhythmia (pseudo-electromechanical dissociation) and the causes of cardiac arrest identified as massive pulmonary embolism and hypovolemia, respectively. A gel-like, coalescent echo contrast within the cardiac chambers was observed 20 to 30 mins after CPR in ten patients with unrelenting cardiac arrest and uniformly associated with an adverse outcome. Six patients survived resuscitation but only two patients survived to hospital discharge. CONCLUSIONS: An echocardiographic examination is feasible during CPR and may offer useful information in the management of the individual patients with cardiac arrest. It may depict the proximate cause of cardiac arrest, e.g., pulmonary embolism, cardiac tamponade, or hypovolemia, and signal the return of ventricular contractions in patients with initially absent mechanical activity. The appearance of intracardiac coalescent echo contrast in our patients with unrelenting cardiac arrest was associated with a failed outcome. The role of echocardiographic imaging in the setting of advanced cardiac life support requires further study.

Aged↗