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PubMed2002

Sex-related differences in the presentation and outcome of out-of-hospital cardiopulmonary arrest: a multiyear, prospective, population-based study.

OBJECTIVE: To examine whether previously observed sex-related differences in coronary artery disease syndromes also apply to patients with out-of-hospital sudden cardiac arrest, a probable subset of patients with coronary artery disease who are easy to recognize and are treated in a standardized fashion. DESIGN: Prospective, population-based study conducted over a 6-yr period. SETTING: A large urban municipality (population, 1.1 million) served by a single emergency medical services system with centralized medical direction and standardized protocols. PATIENTS: All patients with out-of-hospital, nontraumatic, primary cardiac arrest. INTERVENTIONS: Standardized advanced cardiac life support protocols. MEASUREMENTS AND MAIN RESULTS: During the 6 yrs of the study, 4147 consecutive patients were studied, 42% of whom were women (p <.001). Although women were significantly older than men (mean age, 68.7 +/- 18 vs. 61.7 +/- 17 yrs; p =.001), there were no significant differences for the percentages of witnessed and unwitnessed arrests, response intervals, and the length and type of treatment provided. Although men were more likely to have ventricular fibrillation/ventricular tachycardia on presentation (41% vs. 30%), women had more asystole (8.8% vs. 7%) and (organized) pulseless electrical activity than men (24% vs. 18%; p <.001). Nevertheless, more women were resuscitated (13.5% vs. 10.7%; p =.005), particularly women with non-ventricular fibrillation/ventricular tachycardia presentation (12.6% vs. 9.6%; p <.02). These differences were more pronounced when controlling for age (95% confidence interval, 1.44 [1.25-1.74]). CONCLUSIONS: In cases of out-of-hospital sudden cardiac arrest, women have significantly better resuscitation rates than men, especially when controlling for age, particularly among women with non-ventricular fibrillation/ventricular tachycardia presentations. Additional studies are required to validate these observations, not only for long-term survival and external validity, but also for other potential genetic factors and potential discrepancies with other studies.

Age Factors↗
PubMedDate not supplied

Preparation techniques for ACLS exam.

This author presents specific techniques for the critical care nurse to use in preparing for the Advanced Cardiac Life Support (ACLS) certification examination. Techniques that help the inservice instructor or manager to assist the nurse in preparation for this certification exam are also included.

Educational Measurement↗
PubMedDate not supplied

The sodium bicarbonate controversy.

Sodium bicarbonate has been deleted from the advanced cardiac life support protocol. Sodium bicarbonate is no longer endorsed as the method of choice for the management of metabolic acidosis in the early rounds of cardiopulmonary resuscitation. This paper discusses mechanisms of acidosis occurring during cardiopulmonary arrest, past and present protocols for sodium bicarbonate administration and rationale for the deletion of sodium bicarbonate from resuscitation protocols.

Acidosis, Lactic↗
PubMed1991

ECG interpretation for obstetric nurses.

Obstetric nurses are not routinely called on to perform continuous cardiac monitoring or ECGs. However, obstetric nurses will be caring for most pregnant women with cardiac complications. Basic and advanced ECG courses and Advanced Cardiac Life Support (ACLS) courses are offered at most hospitals. Obstetric nurses are encouraged to take advantage of these courses, as even nurses in Level I institutions are caring for patients on continuous ECG monitors. A basic understanding of the ECG is expected of all nurses. Obstetric nurses are encouraged to participate in an ACLS program. Full reviews of the anatomy, physiology, and electrical pathways are available in numerous texts.

Electrocardiography↗
PubMed1996

Initial end-tidal CO2 is markedly elevated during cardiopulmonary resuscitation after asphyxial cardiac arrest.

OBJECTIVES: To compare the initial end-tidal CO2 (PetCO2) during cardiopulmonary resuscitation in asphyxial versus ventricular fibrillatory cardiac arrest. DESIGN: A cohort study. SETTING: University research laboratory. SUBJECTS: Forty domestic piglets. INTERVENTIONS: Asphyxial cardiac arrest was produced by clamping the endotracheal tube in 20 piglets and was continued for 10 minutes after loss of aortic pulsations occurred. Ventricular fibrillation (VF) was induced by applying 60 Hz of alternating current via a pacing wire to the myocardium of the other 20 piglets, and continued for a 15-minute downtime. Cardiopulmonary resuscitation (CPR) was then provided to each group for two minutes, followed by standard advanced cardiac life support protocols. MEASUREMENTS AND MAIN RESULTS: All piglets were instrumented for continuous monitoring of PetCO2, electrocardiogram, central venous pressure, and aortic pressure. PetCO2 of the first breath of CPR was 91 +/- 20 mmHg in the asphyxial group versus 34 +/- 14 mmHg in the VF group (P < 0.001). The asphyxial group continued to exhibit significantly greater PetCO2 for the first five breaths of resuscitation, after which there were no differences. The coronary perfusion pressures during the first breaths of CPR did not differ between the two groups. High initial PetCO2 did not correlate with return of spontaneous circulation. CONCLUSIONS: End-tidal CO2 during the first five breaths of CPR is much higher after an asphyxial cardiac arrest than VF. In each case, the initial PetCO2 appears to reflect alveolar CO2 prior to CPR. After one minute of CPR, PetCO2 is useful in monitoring the effectiveness of CPR.

Animals↗
PubMed1980

Modular approach to CPR training.

Basic and advanced cardiopulmonary resuscitation training is worthwhile yet time consuming. Anesthesiologists should be among the most qualified leaders in CPR teaching programs. Using a modular self-teaching presentation for basic and advanced cardiac life support courses, minimal instructor time is required to accomplish proficiency in both didactic and mannequin performance for participants. This method can be adapted to various educational levels and time constraints without compromising quality of teaching.

Anesthesiology↗
PubMedDate not supplied

A regional comparison of cardiac rehabilitation personnel. Adherence to the 1995 American Association of Cardiovascular and Pulmonary Rehabilitation Guidelines by Staff Position.

PURPOSE: The American Association of Cardiopulmonary Rehabilitation (AACVPR) established guidelines for cardiac rehabilitation (CR) personnel regarding educational degree attainment, licensure, and certification. New England hospital-based CR personnel were surveyed by staff position to determine their adherence to these guidelines. METHODS: The New England Hospital-Based CR Program Questionnaire was designed to obtain information regarding program characteristics and personnel credentialing. Initially, 117 program directors agreed to participate, and 108 returned completed questionnaires for a response rate of 92.3%. RESULTS: Of the CR programs surveyed, 41% were within hospitals containing 101 to 250 beds, whereas most of those providing inpatient (66.6%) and outpatient (82.4%) CR enrolled less than 200 patients annually. Overall, 40.7% of personnel (n = 450) by staff position reported that they met the minimum recommendations, whereas 7.0% (n = 470) met the preferred AACVPR recommendations. Registered nurses (n = 67) and physical therapists (n = 58) were most compliant with the minimum guidelines: 89.6% and 84.5%, respectively. In contrast, 10.9% of the program directors/coordinators (PD/C; n = 128) met the minimum qualifications, and 5.5% met the preferred AACVPR qualifications. Most PD/C had Advanced Cardiac Life Support Certification (84.4%), but few (18%) attained American College of Sports Medicine (ACSM) certification. CONCLUSIONS: Overall, compliance of New England hospital-based CR personnel with the AACVPR minimum/preferred guidelines for educational degree and certification was lacking, as was acquisition of ACSM certification. The effect of these findings on the future status of recommended and required CR personnel qualifications for hire merits attention.

Cardiac Rehabilitation↗
PubMed1999

Out-of-hospital cardiopulmonary resuscitation: a population-based Norwegian study of incidence and survival.

The Trondheim region's (315 km2, population 154,000) emergency medical service (EMS) provides advanced cardiac life support (ACLS) with combined paramedic and physician response. This EMS system is commonly employed in Norway, yet no population based study of outcome in cardiac arrest has been published to date. This retrospective study reports incidence and outcome from every attempted out-of-hospital cardiopulmonary resuscitation (CPR) during 1990 through 1994 according to the Utstein template. Information on the patient's pre-morbid conditions and final outcome was obtained from hospital records. The incidence of cardiac arrest and CPR from all causes was 68 per 100,000 per year, with 83% primary cardiac aetiology. The median alarm to patient arrival interval for ambulance and emergency physician was 8 minutes and 11 minutes, respectively. The presenting rhythm was ventricular fibrillation or tachycardia in 51%, asystole in 34%, pulseless electrical activity in 8% and undetermined in 8%. Definite return of spontaneous circulation occurred in 211 patients (40%, 27 per 100,000 per year) and 57 patients (11%, 7.4 per 100,000 per year) survived to discharge. Most patients made a favourable cerebral outcome, although nine were severely disabled. This is the first population-based Norwegian study of outcome from out-of-hospital cardiac arrest in this combined paramedic/physician staffed EMS. Incidence, survival and neurological outcome are comparable with results obtained in other EMS systems.

Aged↗
PubMed2001

Out-of-hospital thrombolytic therapy during cardiopulmonary resuscitation in refractory cardiac arrest due to acute myocardial infarction.

Out-of-hospital thrombolytic therapy was administrated to a 53-year-old woman with confirmed acute myocardial infarction and refractory cardiac arrest. Standard advanced cardiac life support measures were performed by an out-of-hospital critical care team but they were unsuccessful. Thrombolytic therapy was given as a rescue therapy after prolonged cardiopulmonary resuscitation. The patient recovered a sinus rhythm and circulation 20 minutes after a bolus infusion of tissue plasminogen activator and was fit to be transported to the hospital. Reversal of arterial occlusion was confirmed at the hospital. There was no sequelae related to thrombolytic therapy and the patient was finally discharged 21 days later. This is the first published report of out-of-hospital thrombolytic therapy during cardiopulmonary resuscitation for a patient with refractory cardiac arrest due to acute myocardial infarction.

Ambulatory Care↗
PubMed2002

Alternative cardiopulmonary resuscitation devices.

Cardiac arrest survival rates remain low despite increased access to advanced cardiac life support. Survival from cardiac arrest is, at least in part, related to the perfusion pressures and blood flow achieved during cardiopulmonary resuscitation (CPR). A number of alternative CPR devices have been developed that aim to improve the perfusion pressures and/or blood flow achieved during CPR. Active compression-decompression CPR devices are by far the most studied alternative CPR devices, but the results have been inconsistent and conflicting. A number of other devices, including the inspiratory impedance threshold valve, minimally invasive direct cardiac massage, phased chest and abdominal compression-decompression CPR, and vest CPR, are all capable of improving perfusion pressures and/or blood flow compared with standard external chest compressions. However, no convincing human outcome data has been produced yet for any of these devices. Although an interesting area of research, none of the alternative CPR devices convincingly improve long-term patient outcomes.

Animals↗
PubMed2006

Therapeutic hypothermia utilization among physicians after resuscitation from cardiac arrest.

OBJECTIVE: We sought to evaluate current physician use of therapeutic hypothermia after cardiac arrest, to ascertain reasons for nonadoption of this treatment, and to determine current cooling techniques employed. DESIGN: Web-based survey. SETTING: International physician cohort in the United States, UK, and Finland. SUBJECTS: Physicians (MD or DO) caring for resuscitated cardiac arrest patients. INTERVENTIONS: An anonymous Web-based survey was distributed to physicians identified through United States-based critical care, cardiology, and emergency medicine directories and critical care networks in the UK and Finland. Recipients were queried regarding use of postresuscitation therapeutic hypothermia. MEASUREMENTS AND MAIN RESULTS: Of the final 13,272 surveys actually distributed to physicians, 2,248 (17%) were completed. Most respondents were attending physicians (82%) at teaching hospitals (76%) who practiced critical care (35%), cardiology (20%), or emergency medicine (22%). Of all replies, 74% of United States respondents and 64% of non-United States respondents had never used therapeutic hypothermia. United States emergency medicine physician adoption of cooling was significantly less than that of United States intensivists (16% vs. 34%, p < .05). The most often cited reasons for nonuse by respondents were "not enough data," "not part of Advanced Cardiac Life Support guidelines," and "too technically difficult to use." Factors associated with increased use included non-United States residence, critical care specialty, and larger hospital size. CONCLUSIONS: Physician utilization of cooling after cardiac arrest remains low. For improved adoption of therapeutic hypothermia, our data suggest that development of better cooling methodology and recent incorporation into resuscitation guidelines may improve use.

Attitude of Health Personnel↗
PubMed2005

What is the optimal chest compression-ventilation ratio?

PURPOSE OF REVIEW: Despite a more widespread knowledge of basic cardiopulmonary resuscitation maneuvers in the community, the survival rate for patients with cardiac arrest has remained essentially unchanged in the past 30 years. Over the past few decades, many different compression-ventilation ratios have been studied in terms of best coronary and cerebral oxygen delivery, restoration of spontaneous circulation, and neurologic outcome. This article summarizes the recent evidence presented at the International Consensus on Resuscitation Science in January 2005. RECENT FINDINGS: Recent data from animal and mathematical models suggest a move to a higher compression-ventilation ratio to maximize coronary and cerebral oxygen delivery during cardiac arrest and long-term neurologic outcome. Prospective randomized human data on alternative compression-ventilation ratios are missing and new evidence seems to indicate the inadequacy of both lay and professional rescuers in providing chest compression and ventilating the victim in cardiac arrest. Finally, observational and animal studies highlight the hidden danger of inadvertent hyperventilation during advanced cardiac life support as a reduction of both coronary and perfusion pressure secondary to increased intrathoracic pressure and decreased venous return. SUMMARY: The optimal compression-ventilation ratio is still unknown and the best tradeoff between oxygenation and organ perfusion during cardiopulmonary resuscitation is probably different for each patient and scenario. A discrepancy between what is recommended by the current guidelines and the 'real world' of cardiopulmonary resuscitation has resulted in a near flat survival rate from cardiac arrest in the past few years.

Cardiopulmonary Resuscitation↗
PubMed2006

Death caused by myocarditis in Wayne County, Michigan: a 9-year retrospective study.

This paper reviews 72 cases of death caused by myocarditis between the years 1996 and 2004, autopsied at the Office of the Wayne County Medical Examiner in Michigan. Myocarditis as a cause of sudden and unexpected death represented 1.3% of all natural deaths in Wayne County during said period. The year 1999 contained the highest number of deaths of this cause (18), where the average number of myocarditis deaths was 8 per year for this 9-year span. In this study, each case was reviewed based on information gathered from investigative, autopsy, and toxicology reports. Significantly, 58% of these cases were male, and 63.4% were African American. Myocarditis caused death in every age group between 7 months and 67 years, but adults between the ages of 19 and 67 were most significantly affected (75%). Flu and/or cold were the most common symptoms experienced in the days directly proceeding death (28%), followed by shortness of breath (17%) and sudden collapse (15%). Sixty-nine percent of these 72 cases were pronounced dead after ACLS (advanced cardiac life support) protocol by emergency medical services or hospital attendants. Cardiomegaly was observed in 24 cases of adults aged 19 or older (54%), and flabby/soft myocardial tissue was observed grossly in 16% of all 72 cases.

Adolescent↗
PubMed2004

Tenecteplase and return of spontaneous circulation after refractory cardiopulmonary arrest.

Even with the benefit of cardiopulmonary resuscitation, the prognosis of cardiac arrest remains poor. Multiple case series describe survival with the use of thrombolytic therapy for refractory cardiac arrest. Presumably thrombolysis treats that subset of cardiac arrest cases resulting from fulminant pulmonary embolism, or perhaps massive myocardial infarctions. Published reports to date have dealt exclusively with streptokinase, urokinase, reteplase, or recombinant tissue plasminogen activator. The authors report the first case of return of spontaneous circulation with the administration of tenecteplase. Tenecteplase is a recently developed reengineered isomer of tissue plasminogen activator that possesses many properties of the ideal cardiac arrest thrombolytic agent. It is bolus dosed, stable at room temperature before reconstitution, and is compatible with most other advanced cardiac life support medications. Because of clinical equivalency and its logistical advantages, tenecteplase should be evaluated as an alternative to other thrombolytics in future trials involving cardiac arrest.

Aged↗
PubMed2004

Adrenaline administration during cardiopulmonary resuscitation: poor adherence to clinical guidelines.

BACKGROUND: Adrenaline does not appear to improve the outcome after cardiac arrest in clinical trials in spite of beneficial effects in experimental studies. The objective of this study was to determine whether adrenaline was administered in accordance with advanced cardiac life support (ACLS) guidelines during adult cardiopulmonary resuscitation (CPR). METHODS: From 15 January to 31 December 2000, all patients at Uppsala University Hospital in whom CPR was attempted were registered prospectively. The duration of CPR was documented in the register and the total dose of adrenaline was retrieved retrospectively from patient records. From these data the average interval between adrenaline doses was calculated. RESULTS: Data for evaluation of the between-dose interval of adrenaline was available in 53 of 107 registered cardiac arrests. In 68% (36/53) the average between-dose interval was longer than the 3-5 min recommended in the guidelines, and 8% (4/53) received no adrenaline. The median interval between adrenaline doses during CPR was 6.5 min (25th-75th percentile: 5.1-10.4). Adherence to guidelines was lower in out-of-hospital cardiac arrest than in in-hospital cardiac arrest (P = 0.01). CONCLUSIONS: In the majority of cases adrenaline did not appear to be administered according to current ACLS guidelines.

Adult↗
PubMed2005

Acute cardiodepressant effects induced by bolus intravenous administration of amiodarone in rabbits.

Amiodarone is a potent anti-arrhythmic with a large pharmacological spectrum that shares the mechanisms of action of all classes of anti-arrhythmic drugs. Originally used in the treatment of supraventricular arrhythmias, it has also been used to treat ventricular tachyarrhythmias. The recent inclusion of amiodarone in the Advanced Cardiac Life Support protocols warrants the characterization of the hemodynamic profile resulting from the rapid venous administration of the drug. Thus, the main purpose of the present study was to investigate the acute hemodynamic profile resulting from the bolus i.v. injection of amiodarone, compared with bolus i.v. administration of lidocaine. We investigated the acute hemodynamic effects of amiodarone and lidocaine, in an experimental model of open-chest pentobarbital-anesthetized rabbits (n = 24). Amiodarone (5 mg/kg) induced immediate reductions in mean arterial pressure (MAP) of 32 +/- 5% (P < 0.001), accompanied by reductions in cardiac contractility and relaxation, as assessed by left ventricular (LV) +dP/dt(max) and -dP/dt(max) (40 +/- 4 and 36 +/- 4% respectively) (P < 0.001), heart rate (HR) 10 +/- 1% (P < 0.05), cardiac output (CO) 24 +/- 5% (P < 0.001) and systemic vascular resistance (SVR) 19 +/- 3.5% (P < 0.05). Lidocaine (3 mg/kg) induced reductions in: MAP of 18 +/- 7% (P < 0.001), LV +dP/dt(max) and -dP/dt(max) (40 +/- 5 and 22 +/- 7% respectively) (P < 0.001), HR 7 +/- 1% (P < 0.01) and CO of 23 +/- 6% (P < 0.001). SVR increased by 9 +/- 1.5% (P > 0.05). It is concluded that rapid i.v. administration of both amiodarone and lidocaine induces significant cardiovascular depression mainly characterized by immediate reductions in cardiac contractility.

Amiodarone↗
PubMed1997

Vasopressin can increase coronary perfusion pressure during human cardiopulmonary resuscitation.

OBJECTIVES: To determine the hemodynamic effect of vasopressin on coronary perfusion pressure (CPP) in prolonged human cardiac arrest. METHODS: A prospective, open-label clinical trial of vasopressin during cardiac resuscitation was performed. Ten patients presenting in cardiac arrest initially received resuscitative measures by emergency physicians according to Advanced Cardiac Life Support (ACLS) guidelines. A central venous catheter for fluid and drug administration and a femoral artery catheter for measurement of CPP (aortic minus right atrial relaxation phase pressures) were placed. When each patient was deemed nonsalvageable, 1.0 mg epinephrine was given and CPP was measured for 5 minutes, followed by a dose of vasopressin (1.0 U/kg). CPP measurements were continued for another 5 minutes. RESULTS: The mean duration of cardiac arrest (out-of-hospital interval plus duration of ED ACLS) was 39.6 +/- 16.5 min. There was no improvement in CPP after 1.0 mg of epinephrine. Vasopressin administration resulted in a significant increase of CPP in 4 of the 10 patients. Patients responding to vasopressin had a mean increase in CPP of 28.2 +/- 16.4 mm Hg (range: 10-51.5), with these peak increases occurring at 15 seconds to 4 minutes after administration. The increases in the vasopressin levels after administration did not differ between the responders and nonresponders. CONCLUSIONS: In this human model of prolonged cardiac arrest, 40% of the patients receiving vasopressin had a significant increase in CPP. This pilot study suggests that investigation of earlier use of vasopressin as a therapeutic alternative in the treatment of cardiac arrest is warranted.

Adult↗
PubMed1999

Prevalence, therapeutic response, and outcome of ventricular tachycardia in the out-of-hospital setting: a comparison of monomorphic ventricular tachycardia, polymorphic ventricular tachycardia, and torsades de pointes.

OBJECTIVE: To investigate out-of-hospital ventricular tachycardia (VT) cardiac arrest patients, comparing the prevalences and outcomes of the following VT subtypes among this population: monomorphic VT (MVT), polymorphic VT (PVT), and torsades de pointes (TdP, PVT with a prolonged QT interval). METHODS: This was a retrospective review from a fire department-based paramedic system of nontraumatic VT cardiac arrest patients (January 1991 to December 1994) with a supraventricular perfusing rhythm (SVPR) at some time during out-of-hospital care, with a measurable QT interval. QT interval was measured from an SVPR, and corrected QT interval (QTc) was calculated and considered prolonged if > 0.45 sec. VT was classified as polymorphic or monomorphic. TdP was defined as PVT with a prolonged QT interval. RESULTS: 196 patients were identified; six were excluded due to incomplete medical records, leaving 190 who met inclusion criteria and were used for data analysis. 117 (62%) patients had MVT, while 73 (38%) patients had PVT; of the 73 patients with PVT, 37 (51%) had normal QTc (non-TdP PVT) and 36 (49%) had prolonged QTc (TdP PVT). 97 (51%) patients had prolonged QTc (PQTc). Regardless of VT type (i.e., MVT vs PVT), 97 (51%) patients had prolonged QTc, with a mean QTc of 0.476+/-0.15 seconds prearrest and 0.464+/-12 seconds postarrest. Patients with PQTc were not more likely to have PVT (70 [37%] vs 76 [40%]; p = 0.705). No significant difference with respect to paramedic-witnessed arrests in each VT morphology group and each QT group was found. The overall hospital discharge rate was 28.4%. Regardless of VT type, patients had similar rates of out-of-hospital return of spontaneous circulation (ROSC) and hospital discharge; patients with PQTc were less likely to be discharged from the hospital (19.6% vs 37.6%; p = 0.01). 27.8% of TdP and 26.8% of non-TdP patients were discharged (p = 0.912). CONCLUSIONS: In this population of out-of-hospital VT arrest patients, MVT is the most common form of VT encountered; PVT and the subtype TdP are also seen in this population with approximately equal frequencies. All three rhythm types demonstrate similar responses to standard Advanced Cardiac Life Support therapy with equal rates of out-of-hospital ROSC and hospital discharge. PQTc may be a marker of poor clinical outcome in patients with out-of-hospital VT arrest.

Aged↗