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PubMed1999

Hypertonic saline resuscitation for head injured patients.

OBJECTIVE: To discuss the reasons why 250 ml 7.5% hypertonic saline was chosen as a pre-hospital resuscitation fluid for head injured patients in a multicentred, prospective, randomised controlled trial investigating its long term effects on central nervous system outcome. DATA SOURCES: Recent published peer-review articles on the incidence and mechanisms of traumatic head injury and clinical use of hypertonic saline in pre-hospital resuscitation of trauma. SUMMARY OF REVIEW: Head injury is commonly associated with major trauma and if hypotension also exists the morbidity and mortality due to cerebral injury are high. Hypertonic saline has been used in clinical practice to treat cerebral oedema and resuscitate burns patients following experimental evidence that it reduces tissue oedema, improves blood flow to damaged organs and may reduce the incidence of multiple organ dysfunction, when compared with resuscitation using isotonic solutions. In pre-hospital trauma patients, initial resuscitation using hypertonic saline rather than conventional isotonic solutions has the potential advantage of requiring a small volume of fluid that is easily stored and administered, and may improve cerebral circulation and reduce the long term neurological effects that are determined by pre-hospital hypovolaemia and hypotension. To answer the question whether hypertonic saline will improve the outcome in trauma patients with hypotension and head injury, a multicentred, randomised controlled trial comparing 250 ml of 7.5% hypertonic saline (320 mmol) with 250 ml of Hartmann's solution (32 mmol) in pre-hospital resuscitation of trauma patients with a Glasgow coma score < 9 and systolic blood pressure < 100 mmHg, began in 1998 and is anticipated to be completed by 2001. CONCLUSIONS: Pre-hospital resuscitation of head injured and hypotensive trauma patients using hypertonic saline, has the potential to reduce long term cerebral injury and reduce social and financial costs to the community.

Journal Article↗
PubMed1988

Head injury and hemorrhagic shock: studies of the blood brain barrier and intracranial pressure after resuscitation with normal saline solution, 3% saline solution, and dextran-40.

The effect of fluid resuscitation from hemorrhagic shock on cerebral edema, intracranial pressure (ICP), and blood brain barrier function was investigated in the presence of a simulated head injury. Beagle dogs were anesthetized and ICP was measured via a right subarachnoid bolt while a contralateral epidural balloon was inflated in the left hemicranium to mimic a closed head injury. Forty percent of the dogs' blood was shed and the shock state was maintained for 1 hour. Resuscitation was initiated with shed blood and a volume of either normal saline solution (NS, n = 5), 10% dextran-40 (D-40, n = 6), or hypertonic (3%) saline solution (HS, n = 6) equal to the amount of shed blood. Evans blue solution was infused intravenously, and intravascular volume was then maintained with normal saline solution. Control (n = 5) dogs did not undergo shock, but received equivalent volumes of normal saline solution and Evans blue solution. The dogs were killed after 2 hours of resuscitation, and the brains were removed, weighed, and fixed in formalin. The average intracranial pressure value after epidural balloon inflation was 18.6 +/- 0.80 mm Hg and decreased equally in all groups during the shock period, averaging 10.8 +/- 1.24 mm Hg at the end of the shock period. Fluid resuscitation markedly elevated ICP in the NS and D-40 groups, reaching maximal values of 46.6 +/- 12.11 mm Hg and 45.3 +/- 28.95 mm Hg, respectively. Maximal ICP values in control and HS groups measured 21.8 +/- 1.36 mm Hg and 15.8 +/- 2.04 mm Hg, respectively (p less than 0.25 for HS versus NS control). Wet brain weights were significantly less in the HS group compared with either NS or D-40 groups (p less than 0.05). Coronal sections of fixed HS brains showed deep cortical Evans blue staining on the side of balloon injury. Therefore, in the presence of an intracranial mass lesion, resuscitation with hypertonic (3%) saline solution is accompanied by lower ICP values and less cerebral edema than is isotonic saline or colloid resuscitation. Blood brain barrier function is not restored by hypertonic saline solution resuscitation.

Animals↗
PubMed1993

Hypertonic saline resuscitation detrimentally affects renal function and survival in dehydrated rats.

The purpose of our studies was to determine whether hypertonic (7.5%) saline (HTS) resuscitation is effective in the setting of dehydration. We compared the effects of HTS (5 cc/kg) to those of Ringer's lactate (RL; 45 cc/kg) on renal function, following resuscitation from hypovolemia in hydrated (free access to food/water) vs. dehydrated (food/water restricted) rats (300-350 g). Renal failure was produced by hemorrhage (15 cc/kg) plus renal artery occlusion (25 min) followed by fluid resuscitation. Dehydration was confirmed by hemoconcentration and weight loss (8-10%). Renal function was assessed at 24 hr using 14C-inulin clearance (Cin) measurements. In hydrated animals, the Cin of RL-treated rats (625 +/- 54 microliters/min/100 g; n = 12) was no different from the Cin in HTS-treated rats (517 +/- 48 microliters/min/100 g; n = 13). Among dehydrated rats, Cin in HTS-treated rats (n = 6) was significantly lower (P < or = 0.05) than in RL-treated rats (n = 5) (117 +/- 33 microliters/min/100 g vs. 542 +/- 84 microliters/min/100 g, respectively). Cin in dehydrated RL-treated rats was not significantly different from that in hydrated RL-treated rats. Furthermore, in dehydrated animals, nine of nine resuscitated with RL survived, compared to six of 13 resuscitated with HTS. All hydrated animals survived. In summary, renal failure was ameliorated by RL and worsened by HTS resuscitation in dehydrated rats. Furthermore, mortality was increased in dehydrated animals resuscitated with HTS compared to RL.

Animals↗
PubMed1992

Cardiopulmonary resuscitation: how useful? Attitudes and knowledge of an elderly population.

Two hundred forty-eight elderly outpatients completed a survey designed to assess knowledge about the procedural aspects and efficacy of in-hospital cardiopulmonary resuscitation. We found that older people overestimate the percentage survival to actual hospital discharge following in-hospital cardiopulmonary resuscitation by nearly 300%. Most older people also have definite opinions about the appropriate application of cardiopulmonary resuscitation for different clinical circumstances. Most believe that patients with advanced Alzheimer's disease or widespread cancer should not be resuscitated, while patients with depression or early Alzheimer's disease should. Inaccurate beliefs about cardiopulmonary resuscitation efficacy can adversely impact on decision making about resuscitation by older patients. Educational efforts for the elderly may lead to more informed decision making and thereby more appropriate use of this technology.

Aged↗
PubMed2001

Characteristics of cardiac arrest in cancer patients as a predictor of survival after cardiopulmonary resuscitation.

BACKGROUND: Despite advances in cardiopulmonary resuscitation and the education of its providers, survival remains dismal for cancer patients suffering in-hospital cardiac arrest. In an effort to determine if characteristics of cardiac arrest would represent a useful parameter for prognostication and recommendations regarding the suitability of ongoing resuscitation for various groups, this review was undertaken for patients who experienced in-hospital cardiac arrest. METHODS: A retrospective study of data gathered between January 1993 and December 1997 was undertaken in a 518-bed comprehensive cancer center. The records of 243 inpatients who experienced cardiac arrest and received cardiopulmonary resuscitation were reviewed, and their course observed until hospital discharge or death. RESULTS: Sixteen of 73 patients (22%) who had sudden, unanticipated cardiac arrests survived to be discharged from the hospital; however, none (0 of 171) of the patients who experienced an anticipated cardiac arrest survived (P < 0.001). Logistic regression analysis revealed that anticipated cardiac arrest associated with metabolic derangement was an independent predictor of hospital mortality. CONCLUSIONS: Patients experiencing an anticipated cardiac arrest, the course of which could not be interrupted through aggressive management in an intensive care unit, have an extremely poor prognosis. Ongoing resuscitative measures in these patients need not be routinely provided. The authors suggest an algorithm for resuscitation that evaluates the characteristics of the arrest as a prognostic factor. This algorithm should be implemented once progressive deterioration spirals toward cardiac arrest that cannot be prevented. Such an approach should avoid painful and costly interventions that are futile with the present techniques of cardiopulmonary resuscitation.

Algorithms↗
PubMed2002

One-year survival and neurological outcome after pediatric cardiopulmonary resuscitation.

OBJECTIVE: Reported survival after cardiopulmonary resuscitation (CPR) in children varies considerably. We aimed to identify predictors of 1-year survival and to assess long-term neurological status after in- or outpatient CPR. DESIGN: Retrospective review of the medical records and prospective follow-up of CPR survivors. SETTING: Tertiary care pediatric university hospital. PATIENTS AND METHODS: During a 30-month period, 89 in- and outpatients received advanced CPR. Survivors of CPR were prospectively followed-up for 1 year. Neurological outcome was assessed by the Pediatric Cerebral Performance Category scale (PCPC). Variables predicting 1-year survival were identified by multivariable logistic regression analysis. INTERVENTIONS: None. RESULTS: Seventy-one of the 89 patients were successfully resuscitated. During subsequent hospitalization do-not-resuscitate orders were issued in 25 patients. At 1 year, 48 (54%) were alive, including two of the 25 patients with out-of-hospital CPR. All patients died, who required CPR after trauma or near drowning, when CPR began >10 min after arrest or with CPR duration >60 min. Prolonged CPR (21-60 min) was compatible with survival (five of 19). At 1 year, 77% of the survivors had the same PCPC score as prior to CPR. Predictors of survival were location of resuscitation, CPR during peri- or postoperative care, and duration of resuscitation. A clinical score (0-15 points) based on these three items yielded an area under the ROC of 0.93. CONCLUSIONS: Independent determinants of long-term survival of pediatric resuscitation are location of arrest, underlying cause, and duration of CPR. Long-term survivors have little or no change in neurological status.

Adolescent↗
PubMed1991

Resuscitation attitudes among medical personnel: how much do we really want to be done?

Cardiopulmonary resuscitation (CPR) is attempted every day. Whereas medical professionals and personnel perform these resuscitation attempts, no previous studies have reported the attitudes of medical personnel towards resuscitation for themselves. We have attempted to assess the prevalent attitudes among various physicians at various levels in training and nurses. An eleven item questionnaire was sent to medical students, house officers, attending physicians and registered nurses at university medical centers. Each questionnaire consisted of respondent's sociodemographic information, their attitudes about CPR for themselves and their beliefs about outcome after CPR with particular disease states. The results were analyzed using chi-square analysis. Four hundred questionnaires were mailed and 240 were returned (60% response rate). All groups favored resuscitation in a university hospital over other sites (P less than 0.05). More nurses requested to be 'no code' compared with other professionals (P less than 0.005). Attending physicians requested that CPR attempts be terminated after less time than any other group (P less than 0.005). Medical students requested resuscitation significantly more than any other group in the presence of terminal conditions such as metastatic cancer, acquired immunodeficiency syndrome and severe chronic obstructive pulmonary disease (P less than 0.005). Medical personnel's beliefs about CPR may be influenced by their experiences with particular patients and events. As trainees acquire more experience they appear less inclined to desire resuscitation efforts for themselves.

Attitude of Health Personnel↗
PubMed2005

International Resuscitation Network Registry: design, rationale and preliminary results.

There is a lack of high-quality information about the effectiveness of resuscitation interventions and international differences in structure, process and outcome after out-of-hospital cardiac arrest and cardiopulmonary resuscitation because data are not collected uniformly. An internet-based international registry could make such evaluations possible, and enable the conduct of large randomized controlled trials of resuscitation therapies. A prospective international cohort study was performed that included 571 infants, children and adults (a) who experienced cardiac arrest requiring chest compressions or external defibrillation, (b) outside the hospital in the study communities and (c) upon whom resuscitation was attempted by EMS personnel. Cardiac arrest was defined as lack of responsiveness, breathing or movement in individuals for whom the EMS system is activated for whom an arrest record is completed. All data were collated via a secure and confidential web-based method by using automated forms processing software with appropriate variable range checks, logic checks and skip rules. Median number of missing responses for each variable was 0 (interquartile range 0, 0). Twenty-seven percent of the patients had a first recorded rhythm of ventricular fibrillation or ventricular tachycardia, 60% had a witnessed arrest, and 34% received bystander CPR. Mean time from call to arrival on scene was 7.1+/-5.1 min. Six percent of the patients survived to hospital discharge. The resuscitation process was highly variable across centers, and survival and neurological outcome were also significantly and independently different across centers. This study shows that it is possible to collect data prospectively describing the structure, process and outcome associated with cardiac arrest in multiple international sites via the internet. Therefore, it is feasible to conduct adequately powered randomized trials of resuscitation therapies in international settings.

Adolescent↗
PubMed1996

Spectral analysis of ventricular fibrillation and closed-chest cardiopulmonary resuscitation.

This study was designed to assess the interference by closed-chest cardiopulmonary resuscitation (CPR) on the ventricular fibrillation (VF) ECG signal in a porcine model of cardiac arrest and to elucidate which variable of VF spectral analysis reflects best myocardial blood flow and resuscitation success during CPR. Fourteen domestic pigs were allocated to receive either 0.4 U/kg vasopressin (n = 7) or 10 ml saline (n = 7) after 4 min of VF and 3 min of CPR. Using radiolabeled microspheres, myocardial blood flow was determined during CPR before, and 90 s and 5 min after, drug administration. Using spectral analysis of VF, the median frequency, dominant frequency, edge frequency and amplitude of VF were determined simultaneously and before the first defibrillation attempt. Using filters in order to specify frequency ranges, stepwise elimination of mechanical artifacts resulting from CPR revealed that at a frequency bandpass of 4.3-35 Hz, median fibrillation frequency has a sensitivity, specificity, positive and negative predictive value of 100% to differentiate between resuscitated and non-resuscitated animals. The best correlation between myocardial blood flow and fibrillation frequency was found at a median frequency range of 4.3-35 Hz. We conclude that spectral analysis of VF can provide reliable information relating to successful resuscitation. In this model after elimination of oscillations due to mechanical CPR, median fibrillation frequency best reflects the probability of resuscitation success.

Analysis of Variance↗
PubMed2002

In-hospital cardiopulmonary resuscitation: organization, management and training in hospitals of different levels of care.

BACKGROUND: : During recent years in-hospital cardiopulmonary resuscitation (CPR) management has received much attention. This can be attributed to the Utstein model for in-hospital CPR developed in 1997. The present status of in-hospital resuscitation management in Finnish hospitals is not known. Therefore, a study was designed to describe the organization of training and clinical management of CPR in Finnish hospitals of different levels of care. METHODS: : In the summer of 2000, we performed a cross-sectional mail survey throughout Finland, including all district, central and university hospitals. The questionnaire outlined in detail in-hospital resuscitation management and training. For analysis the hospitals were divided into primary, secondary and tertiary groups, depending on levels of care. RESULTS: : Most hospitals (72%) reported having a physician or a nurse in charge of resuscitation management and training. Training in advanced life support was more common among nurses (80%) than among physicians (53%). Surprisingly, a majority of respondents (75%) reported that they felt training in CPR was insufficient. On the general wards and on wards treating cardiac patients, defibrillation was in most cases performed by a physician (91% and 51%, respectively), and less often by a nurse (16% and 31%, respectively). In the secondary and tertiary hospitals cardiac arrest was managed by a cardiac arrest team (53% and 62%, respectively) and in the primary hospitals by the ward physician (56%), anesthesiologist or emergency physician on call (44%). Most hospitals used do-not-resuscitate orders (83%) but only 33% of the hospitals had a unified style of notation. Systematic data collection was practised in 55% of hospitals, predominantly by using a model of their own. Only a few hospitals (11%) used the in-hospital Utstein model. CONCLUSION: : Our study showed that more attention needs to be paid to CPR management in Finnish hospitals. At present, 25% of hospitals do not have an appointed physician or nurse in charge of organizing CPR management. The study also revealed a lack of regular organized training in resuscitation for physicians. Fifty-five per cent of hospitals practise systematic data collection, but only 11% according to the Utstein template; and without which further quality assurance is difficult.

Cardiopulmonary Resuscitation↗
PubMed2003

Hospitalisation, care plans and not for resuscitation orders in older people in the last year of life.

BACKGROUND: over 60% of older people have at least one admission to hospital in their last year of life, with the majority of people having multiple admissions. In Bankstown, New South Wales, Australia, we have a diverse ethnic and cultural population. We were interested in bed utilisation, documentation, and follow through of "care plans" as well as "not for resuscitation" orders in the last year of life of the older people in our area. METHODS: we reviewed and collected data from the medical records of patients over 65 years of age who died in our hospital. Reviewers included a medical registrar, a research officer and two geriatricians. We collected a wide range of information pertaining to the 12 months before death. This included demographics, chronic illnesses, geriatric syndromes, number of admissions, bed days, care plans, and not for resuscitation orders as well as other relevant data. RESULTS: 110 patients' records were reviewed. The mean age was 80 years and 31% were from a non English-speaking background. The average number of admissions was 2.4 and the average number of bed days in the last year of life was 25. Sixty-one of the patients had a care plan and a not for resuscitation order, 91% of which were written shortly before death. Using bi-variate analysis of old age (over 80), number of chronic illnesses, or geriatric syndromes present, the number of bed days was positively correlated to care plan and not for resuscitation orders. Logistic multivariate analysis of chronic illnesses revealed that stroke (P=0.024) as well as stroke and fracture (P=0.008) were strongly correlated with care plan and not for resuscitation orders. Only 8 patients had an advanced care plan documented prior to last admission. When advanced care plans were documented, they were generally clearly written and followed through appropriately (7 out of 8). CONCLUSION: this study showed that in our diverse population there were multiple admissions and utilisation of hospital beds for older people in their last year of life. Care plans and not for resuscitation orders were rarely documented prior to last admission. However, when advanced care plans were done, they were usually well documented and followed through appropriately.

Aged↗
PubMed1999

Unilateral do-not-attempt-resuscitation orders and ethics consultation: a case series.

OBJECTIVE: To describe the role of an ethics consultation service in unilaterally withholding cardiopulmonary resuscitation. DESIGN: Retrospective case series of 31 ethics consultations regarding unilateral do-not-attempt-resuscitation orders between 1992 and 1996. SETTING: A large, urban, academic medical center. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, physicians' rationale for withholding cardiopulmonary resuscitation, ethics consultants' recommendations, and patient outcomes were measured. The consultation service agreed with the medical team's intent to withhold cardiopulmonary resuscitation in 25 cases, but a unilateral do-not-attempt-resuscitation order was written in only seven of these. In 17 cases, the disagreement between the physician and the patient or surrogate over code status was resolved in a conference organized by the ethics service. CONCLUSIONS: The process of ethics consultation is useful in resolving disagreements over withholding cardiopulmonary resuscitation and other treatment and can frequently result in a consensus. Hospital policies that permit unilateral treatment limitation should be based on a model that is process-based and that encourages interdisciplinary participation in decision-making, such as that recently proposed by the Houston Task Force.

Academic Medical Centers↗
PubMed2003

Do-not-resuscitate order after 25 years.

BACKGROUND: In 1976, the first hospital policies on orders not to resuscitate were published in the medical literature. Since that time, the concept has continued to evolve and evoke much debate. Indeed, few initials in medicine today evoke as much symbolism or controversy as the Do-Not-Resuscitate (DNR) order. OBJECTIVE: To review the development, implementation, and present standing of the DNR order. DESIGN: Review article. MAIN RESULTS: The DNR order concept brought an open decision-making framework to the resuscitation decision and did much to put appropriate restraint on the universal application of cardiopulmonary resuscitation for the dying patient. Yet, even today, many of the early concerns remain. CONCLUSIONS: After 25 yrs of DNR orders, it remains reasonable to presume consent and attempt resuscitation for people who suffer an unexpected cardiopulmonary arrest or for whom resuscitation may have physiologic effect and for whom no information is available at the time as to their wishes (or those of their surrogate). However, it is not reasonable to continue to rely on such a presumption without promptly and actively seeking to clarify the patient's (or surrogate's) wishes. The DNR order, then, remains an inducement to seek the informed patient's directive.

Advance Directives↗
PubMed1997

Decisions not to resuscitate in a Swedish university hospital.

BACKGROUND: Cardiopulmonary resuscitation (CPR) has the potential to save many lives. Used indiscriminately though, it may be harmful and not in the best interest of the patient. An advance directive to refrain from resuscitation in selected patients is probably not uncommon in Sweden, but guidelines ruling this are still generally lacking. This study was performed to evaluate the use and documentation of do-not-resuscitate orders in a Swedish university hospital. METHODS: Adult inpatients at 7 medical, 3 surgical and 2 neurological wards, a total of 220, were investigated on one specific day by interviewing the physicians and nurses responsible for their care. RESULTS: We found a discrepancy in doctors' and nurses' perception concerning the appropriateness of CPR in selected patients. CPR was judged by doctors to be inappropriate for 45 patients (20%). Out of these 45 patients, only 24 had a written do-not-resuscitate order in their medical record, in most cases noted as a code word or sign only. Rarely were the patient or his/her relatives involved in the decision-making process. CONCLUSION: We conclude that a decision to refrain from resuscitation is often not made, even when considered medically and ethically justifiable. Also, the use of coded information as a sole indicator for a patient not to be resuscitated is still common practice. The patient or his/her relatives are rarely involved in this decision.

Adult↗
PubMed2000

Physician understanding of patient resuscitation preferences: insights and clinical implications.

OBJECTIVE: To describe physician understanding of patient preferences concerning cardiopulmonary resuscitation (CPR) and to assess the relationship of physician understanding of patient preferences with do not resuscitate (DNR) orders and in-hospital CPR. DESIGN: We evaluated physician understanding of patient CPR preference and the association of patient characteristics and physician-patient communication with physician understanding of patient CPR preferences. Among patients preferring to forego CPR, we compared attempted resuscitations and time to receive a DNR order between patients whose preference was understood or misunderstood by their physician. PATIENTS/SETTING: Seriously ill hospitalized adult patients were enrolled in the Study to Understand Prognoses and Preferences for the Outcomes of Treatments. GENERAL RESULTS: Physicians understood 86% of patient preferences for CPR, but only 46% of patient preferences to forego CPR. Younger patient age, higher physician-estimated quality of life, and higher physician prediction of 6-month survival were independently associated with both physician understanding when a patient preferred to receive CPR and physician misunderstanding when a patient preferred to forego CPR. Physicians who spoke with patients about resuscitation and had longer physician-patient relationships understood patients' preferences to forego CPR more often. Patients whose physicians understood their preference to forego CPR more often received DNR orders, received them earlier, and were significantly less likely to undergo resuscitation. CONCLUSIONS: Physicians often misunderstand seriously ill, hospitalized patients' resuscitation preferences, especially preferences to forego CPR. Factors associated with misunderstanding suggest that physicians infer patients' preferences without asking the patient. Patients who prefer to forego CPR but whose wishes are not understood by their physician may receive unwanted treatment.

Activities of Daily Living↗
PubMed2002

[Obstacles to the routine discussion with hospital patients of possible cardiopulmonary resuscitation].

Nowadays, cardiopulmonary resuscitation is not routinely discussed with all hospital patients, even though it should be for a number of reasons. First of all, every patient may suffer cardiac arrest, and the overall outcome of a subsequent attempt at resuscitation is difficult to predict. Besides, patients who do not wish to be resuscitated often do not tell that to the physician of their own accord. Patients should therefore be more actively informed and encouraged to express their own preferences. The routine discussion of possible resuscitation gives physicians the opportunity to discuss, determine and delimit the extent of the intended medical procedure. In the literature, communication problems in three different areas can be identified as a cause of the present situation. These are--for both physician and patient--inability, lack of insight and unwillingness to discuss resuscitation. Physicians should be aware of the identified communication problems and deal with them in a professional manner. An understanding of these problems forms the basis for a broader implementation of resuscitation discussions in hospitals.

Advance Care Planning↗
PubMed2003

Knowledge of cardiopulmonary resuscitation among the public in Hong Kong: telephone questionnaire survey.

OBJECTIVES: To evaluate the knowledge of basic life-support and training experience in cardiopulmonary resuscitation among the public in Hong Kong and to identify areas for improvement in public education. DESIGN: Telephone interview using a structured multiple-choice questionnaire. SETTING: Random cross-section of the Hong Kong public, from mid-March to May 2002. PARTICIPANTS: Men and women aged 16 years and older selected using random telephone dialling. MAIN OUTCOME MEASURE: Overall score in the cardiopulmonary resuscitation knowledge questionnaire. RESULTS: Of the 357 participants, approximately 12% had received cardiopulmonary resuscitation training. Cardiopulmonary resuscitation knowledge in Hong Kong was poor, even among the previously trained and especially with regard to circulatory maintenance. The most common reason for not taking cardiopulmonary resuscitation training was lack of time. CONCLUSION: The degree of citizen preparedness in initiating cardiopulmonary resuscitation is very poor in Hong Kong. Intensified educational efforts and exploration of new approaches to improve this first stage in the chain of survival are warranted.

Adolescent↗
PubMed2000

Teaching resuscitation to pediatric residents: the effects of an intervention.

OBJECTIVE: To evaluate the effectiveness of an educational intervention on pediatric residents' resuscitation fund of knowledge, technical skills, confidence, and overall performance. DESIGN: Prospective, nonconcurrent, controlled interventional trial. SETTING: Urban pediatric tertiary care hospital. PARTICIPANTS: An intervention group (IG) of 28 pediatric residents graduating in 1997, and a control group (CG) of 30 pediatric residents graduating in 1996. INTERVENTIONS: Resuscitation course with didactic lectures and skills practice stations, as well as a minimum of 3 practice mock resuscitations with immediate feedback throughout postgraduate year 3. MAIN OUTCOME MEASURES: Fund of knowledge, using the Pediatric Advanced Life Support test and short answer test; technical skills, using the Airway and Vascular Access Skills Assessment; experience and confidence, using an anonymous survey; and overall performance, evaluated using a videotaped mock resuscitation test. RESULTS: The IG scored better on the short answer test (P<.001). A larger number of IG residents were successful in the completion of ancillary airway maneuvers and femoral vascular access (P =.02), as well as endotracheal intubation (P =.004) and intraosseous access (P =.002). The IG was more confident in their leadership role (P =.0001) and technical skills (P =.05). Trends toward improved overall performance were noted for the IG mock resuscitations. Residents in the IG were more likely to assess the airway in fewer than 2 minutes (P =.02), recognize the threat to life in fewer than 5 minutes (P =.02), and complete the primary survey in a timely fashion (P =.05). They required fewer prompts (P =.04) and made fewer mistakes (P =.07). CONCLUSIONS: A structured, formal curriculum can improve the necessary fund of knowledge, skills, confidence, and leadership required for resuscitation.

Clinical Competence↗