Advanced Cardiac Life Support Algorithm Research Articles

CURRENT LEVEL OF KNOWLEDGE AND AWARENESS OF HEALTHCARE PERSONNEL IN BASIC AND ADVANCED LIFE SUPPORT IN ARREST CASES WITH AND WITHOUT COVID-19 INFECTION

Objective: The knowledge of healthcare professionals about life support is crucial for saving lives. It was aimed to evaluate the knowledge and awareness level of healthcare professionals about advanced life support. Materials and methods: Our study was conducted between 15.02.2021 and 15.03.2021 with healthcare personnel working in our hospital. Data were collected by the questionnaire method. The researcher prepared the survey questions according to the European Resuscitation Council COVID-19 guidelines and American Heart Association Advanced Cardiac Life Support algorithms updated in 2020. 265 healthcare personnel (physicians, physician assistants, family physicians, nurses, health officers, and anesthesia technicians) participated in the study. Demographic characteristics of the participants (gender, age, duration of service, duties, duty stations), training and practice status, and level of knowledge were evaluated. Results: 67.2% of the participants were female, and 32.8% were male. The majority of the participants were nurses working in the inpatient clinics. 49.9% had a tenure of 1-5 years. 52.0% had received advanced cardiac life support training, and 19.6% had obtained and used automatic external defibrillators. 63.8% had performed advanced cardiac life support on a patient. In our study, the general level of advanced cardiac life support knowledge of the participants was found to be low. There was no significant difference in advanced cardiac life support scores in terms of gender, age, occupation, workplace, and tenure (p=0.604; p=0.986; p=0.927; p=0.982; p=0.295, respectively). Conclusion: Providing in-service resuscitation training to healthcare workers in line with current guidelines and supporting them with practical applications can provide quality knowledge and skills and increase their awareness of their responsibilities.

Feasibility of a 4 French resuscitative endovascular balloon occlusion of the aorta (REBOA) device for nontraumatic cardiac arrest in a randomized controlled study using a large porcine model

AimThe objectives of this study were to assess the return of spontaneous circulation rates and hemodynamic response of large swine (>65Kg) during cardiopulmonary resuscitation after nontraumatic cardiac arrest using the COBRA-OS® aortic occlusion balloon and to address limitations of large swine closed-chest cardiopulmonary resuscitation by comparing closed-chest vs. open-chest cardiopulmonary resuscitation. MethodsYorkshire pigs (n = 10) weighing >65 kg were anesthetized and ventilated. After 7 min of untreated ventricular fibrillation (VF), animals were randomized to receive mechanical closed-chest cardiopulmonary resuscitation or open-chest cardiac massage. Following a 5-minute low-flow state, advanced cardiac life support algorithms were started and the COBRA-OS® was inflated in the thoracic aorta. Animals that achieved return of spontaneous circulation were re-started on mechanical ventilation and medications, CPR, defibrillation, and aortic occlusion were discontinued. The primary outcome was return of spontaneous circulation and secondary outcomes were mean arterial pressures generated in the low flow and aortic occlusion states before return of spontaneous circulation. Groups were compared with a t-test or Mann-Whitney U test for normal and non-parametric data, respectively, while categorical data was compared with the chi square test. ResultsReturn of spontaneous circulation was obtained in 4 animals (80%) in the open cardiac massage group and none in the mechanical closed-chest CPR group (p < 0.05). The COBRA-OS® successfully occluded all aortas and animals experienced higher mean arterial pressures in both groups with aortic occlusion (median 15 mm Hg, IQR 13–23 mm Hg), but with a higher MAP difference in the open cardiac massage group (−12.2 mm Hg, [−2.581, −21.819]). ConclusionsConsideration should be given to intra-thoracic cardiac massage to increase cardiopulmonary resuscitation effectiveness and therefore return of spontaneous circulation rates in large (>65 kg) swine models of nontraumatic cardiac arrest. The COBRA-OS® demonstrated feasibility for use in this model.The Keenan Research Center, Li Ka Shing Knowledge Institute of St. Michael’s Hospital Animal Care Committee: ACC Protocol #726.

Extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: Lessons learned from recent clinical trials.

Cardiac arrest is a leading contributor to morbidity and mortality in the United States. Survival has been historically dependent on high-quality cardiopulmonary resuscitation (CPR) and rapid defibrillation. However, a large percentage of patients remain in refractory cardiac arrest despite adherence to structured advanced cardiac life support algorithms in which these factors are emphasized. Veno-arterial extracorporeal membrane oxygenation is becoming an increasingly used rescue therapy for patients in refractory cardiac arrest to restore oxygen delivery by extracorporeal CPR (ECPR). Recently published clinical trials have provided new insights into ECPR for patients who sustain an outside hospital cardiac arrest (OHCA). In this narrative review, we summarize the rationale for, results of, and remaining questions from these recently published clinical trials. The existing observational data combined with the latest clinical trials suggest ECPR improves mortality in patients in refractory arrest. However, a mixed methodstrial is essential to understand the complexity, context, and effectiveness of implementing an ECPR program.

A Randomized Trial Assessing the Effectiveness of High-fidelity Simulation Training in Managing Maternal Cardiac Arrest among Emergency Medical Professionals in India.

Maternal cardiac arrest is a rare but critical event that poses significant risks to both the mother and the fetus. As majority of population in India lives in the rural areas, Emergency Medical Professionals assist in childbirth in transit in ambulances. This timely assistance ensures the safe transportation of both mother and new born baby to the hospital. The aim of this study was to assess the effectiveness of high-fidelity simulation training in the management of maternal cardiac arrest among emergency medical professionals. The randomized simulation study aimed to assess the effectiveness of high-fidelity simulation in managing maternal cardiac arrest. Two hundred and fifty emergency medical professionals were randomly assigned to 50 groups. Participants underwent a prebriefing session before engaging in simulation scenarios. After the initial scenarios, participants received a debriefing session emphasizing the standardized algorithm for maternal cardiac arrest management. A week later, participants engaged in a second simulation scenario, and their adherence to the algorithm was assessed. The data were analyzed using statistical tests, and the entire simulation session was video recorded for reliability. The results showed that participants demonstrated an improvement in managing both maternal and obstetric interventions in the posttraining scenario compared to the pretraining scenario. The successful implementation of the advanced cardiac life support algorithm and the debriefing session were key factors in improving participants' performance. However, continuous exposure and practice are necessary to maintain and enhance these skills. Health-care professionals should actively seek opportunities for ongoing training and education to stay updated with the latest guidelines and advancements in managing maternal cardiac arrest.

Epinephrine in Cardiac Arrest: Identifying a Potential Limit for Resuscitation.

Epinephrine continues to be a fundamental part of the Advanced Cardiac Life Support algorithm despite a lack of evidence that it improves neurologically intact survival. Our aim was both to identify a potential upper limit of epinephrine use in resuscitations and to demonstrate real-world epinephrine use in different patient subgroups. This was a single-center, retrospective cohort study, conducted between August 1, 2016-July 1, 2021, of patients with medical cardiac arrest who were administered a known number of epinephrine doses. The primary outcome was neurologically intact discharge defined by a modified Rankin scale ≤3, with secondary outcomes of comparing epinephrine doses by age, rhythm, and emergency medical services vs emergency department administration of epinephrine. The study included 1,330 patients, with 184 patients (13.8%) surviving to neurologically intact discharge. The primary outcome of neurologically intact discharge was found in 89 (65.4%) patients in the zero epinephrine dose group, 75 (20.0%) in the 1-3 dose group, 15 (4.3%) in the 4-6 dose group, and one (0.002%) in the ≥7 dose group (P < 0.001). Patients received similar amounts of epinephrine when stratified by age, while patients with shockable rhythms received more epinephrine than patients with non-shockable rhythms. There was a significant decrease in neurologically intact discharge with increasing number of epinephrine doses, and our data suggests that seven or more doses of epinephrine is almost always futile. While further prospective studies are needed, clinicians should consider epinephrine doses when weighing the futility or benefit of continued resuscitation efforts.

A National Survey Assessing the Variability in the Management of Traumatic Cardiac Arrest.

Resuscitation of traumatic cardiac arrest (TCA) is variable, with approaches that overlap Advanced Trauma Life Support (ATLS) and Advanced Cardiac Life Support (ACLS) algorithms. There is no standard algorithm for TCA, with some withholding ACLS protocols given abysmal outcomes. This study aims to assess surgeon practices and attitudes toward resuscitation practices in TCA. A 16-question web-based survey was distributed to the membership of a national trauma association. Respondent demographics and management of TCA were analyzed. Chi-squared tests determined statistical significance. Open-ended responses were coded and analyzed inductively. Two hundred and three surveys were completed. 73.4% of respondents reported utilizing ACLS, while 26.6% reported they never utilized ACLS. A statistically significant difference in the performance of ACLS was found based on number of years in practice (P = .025) and the state of practice (P = .006). There was no significant difference in self-reported survival rates or legal, ethical, or interpersonal conflicts. Qualitative data highlighted themes of interpersonal conflict and futility. This study shows that one-quarter of respondents never utilize ACLS in TCA. Of those that utilize ACLS, there was variability in the technique, indication, and duration of resuscitation. Despite significant variability in technique, there appears to be similar survival rates and incidence of conflict. The association between years in practice and ACLS use suggests this may represent an emerging change in practice. The low response rate limits generalizability; however, there is significant variability in practice, highlighting a need for evidence-based guidelines.

A simulation-enhanced, spaced learning, interprofessional “code blue” curriculum improves ACLS algorithm adherence and trainee resuscitation skill confidence

ABSTRACT In-hospital cardiac arrest resuscitation training often happens in silos, with minimal interprofessional training. The aim of this study was to implement and evaluate a simulation-enhanced, interprofessional cardiac arrest curriculum in a university hospital. The curriculum ran monthly for 12 months, training interprofessional teams of internal medicine residents, nurses, respiratory therapists, and pharmacy residents. Teams participated in a 90-min high-fidelity simulation including “code blue” (30 min) followed by a 30-min debriefing and a repeat identical simulated “code blue” scenario. Teams were tested in an unannounced mock Code Blue the following month. Advanced Cardiac Life Support (ACLS) algorithm adherence was assessed using a standardized checklist. In-hospital cardiac arrest (IHCA) incidence and survival was tracked for 2 years prior, during, and 1 year after curriculum implementation. Team ACLS-algorithm adherence at baseline varied from 47% to 90% (mean of 71 ± 11%) and improved immediately following training (mean 88 ± 4%, range 80–93%, p = .011). This improvement persisted but decreased in magnitude over 1 month (mean 81 ± 7%, p = .013). Medical resident self-reported comfort levels with resuscitation skills varied widely at baseline, but improved for all skills post-curriculum. This simulation-enhanced, spaced practice, interprofessional curriculum resulted in a sustained improvement in team ACLS algorithm adherence.

A case series of oleander poisoning: challenges faced by emergency physicians in developing countries

Objective: Through the reporting of this case series, we aim to establish whether a conservative approach, through managing arrhythmias and vital signs, can be reliably used as a treatment modality for oleander poisoning in developing countries.&#x0D; &#x0D; Methods: This study is a case series of 11 patients who presented with oleander poisoning and were conservatively managed in the absence of standard antidote.&#x0D; &#x0D; Results: All 11 patients treated with conservative approach survived. Conservative approach included use of atropine for management of symptomatic bradycardia followed by Dopamine infusion, correction of serum potassium and magnesium levels, standby defibrillation, and transvenous pacing.&#x0D; &#x0D; Conclusion: The absence of reliable dosage of poison ingested, the lack of facilities for serum digoxin estimation, and the unavailability of digoxin fab antibodies pose challenges for the management of patients with oleander poisoning. Patients can, however, be managed conservatively following the Advanced Cardiac Life Support (ACLS) algorithm in a setting that lacks the standard treatment of this poison.

Abstract 10435: A Plea for Inclusion of Surface Echocardiography for Acute Coronary Syndrome in the Advanced Cardiac Life Support Algorithm

Background: The AHA/ACC guidelines algorithm for Acute Coronary Syndrome (ACS) does not include echocardiographic evaluation in the assessment of chest pain. Such patients may be subjected to interventions based on ECG leading invasive procedures which may prove unnecessary. This study was performed to determine if a bedside echocardiography would help identify the conditions that do not need intervention and might possibly change the treatment pathway at the right time. Methods: In a prospective observational study design, adult patients presenting to acute emergency care with chest pain were included in the study. Patients exhibiting a significant ST change on a 12-lead ECG were subjected to bedside echocardiography, i.e. 2D transthoracic echocardiography (2D-TTE) The findings of echocardiography were correlated with ECG and coronary angiography for possible percutaneous coronary intervention. Results: Among the 385 patients in the study, 312 suffered acute coronary syndrome. In 18.7% patients presented to acute emergency care with chest pain, ST-T changes and were found to have causes other than ACS; and bedside echocardiography (2D-TTE) was able to identify 90.4% of those cases. From this study we conclude that bedside echocardiography had high specificity (90.4%) and sensitivity (97.43%) in identifying regional wall motion abnormality (RWMA) due to ACS and exclude non-ischemic causes of chest pain. Conclusion: Bedside echocardiography is recommended in patients with chest pain and ST-segment abnormality to avoid unnecessary delay in diagnosis and invasive interventions in non-acute coronary syndrome (ACS). Hence it is reasonable to include bedside echocardiography in either box 3 or 4 in the ACS algorithm.

A Virtual Platform for Teaching ACLS Pharmacology to Undergraduate Medical Students

Introduction: During the initial surge of the COVID-19 pandemic, in accordance with AAMC recommendations, all undergraduate medical student learning at the Herbert Wertheim College of Medicine was transitioned to online platforms. We developed a voice-over interactive presentation for the teaching of pharmacologic treatments used in the American Heart Association (AHA) Advanced Cardiac Life Support (ACLS) algorithms. Methods All fourth-year students in the Class of 2020 (n=120) viewed the mandatory online presentation and completed the associated 28 item MCQ assessment. The 16-minute voice-over presentation was prepared using Microsoft PowerPoint. Content addressed all major AHA ACLS algorithms including approximately six minutes of content specifically addressing pharmacologic interventions. Both the presentation and the assessment were delivered to students though the CanvasMed learning management system. Student satisfaction and feedback were obtained via anonymous post-session survey administered through the Qualtrics survey tool. Results: All students (n=120) completed the post-session assessment. Of the 28 items, seven assessed pharmacologic interventions. Overall mean performance on the post-session assessment was 89.6% (SD 7.5%) and 74.4% (SD 17.4%) on pharmacology-directed items. 80 out of 120 students (response rate= 66.7%) completed the post-session survey. On a 5-point Likert scale (0-“Not at all” through 4-“Very”), mean post-session response to the statement “How satisfied were you with the online lesson?” was found to be 3.27 (SD 0.85), with 47.5% (n=38) selecting “Very” and 37.5% (n=30), selecting “Mostly.” Conclusion: An interactive online platform may be used effectively to teach pharmacologic ACLS interventions to fourth year medical students. This online module may also be used to facilitate more active learning pedagogies when students safely return to the classroom.

Intravenous versus intraosseous adrenaline administration in out-of-hospital cardiac arrest: A retrospective cohort study

BackgroundAdrenaline is an important component in the resuscitation of individuals experiencing out-of-hospital cardiac arrest (OHCA). The 2018 Advanced Cardiac Life Support (ACLS) algorithm gives the option of either intravenous (IV) or intraosseous (IO) routes for adrenaline administration during cardiac arrest. However, the optimal route during prehospital resuscitation remains controversial. This study aims to investigate whether IV and IO routes lead to different outcomes in OHCA patients who received prehospital adrenaline. MethodsThis retrospective analysis included adult patients with OHCA of presumed cardiac origin who had Emergency Medical Services (EMS) CPR, received adrenaline, and were enrolled in the Resuscitation Outcomes Consortium (ROC) Cardiac Epistry version 3 database between 2011 and 2015. We divided the study population into IV and IO groups based on the administration route. Logistic regression analysis was performed to evaluate the association between adrenaline delivery routes and prehospital return of spontaneous circulation (ROSC), survival to hospital discharge, and favorable neurological outcome. ResultsOf the 35,733 patients included, 27,758 (77.7%) had adrenaline administered via IV access and 7975 (22.3%) via IO access. With the IO group as a reference in the logistic regression model, the adjusted odds ratios of the IV group for prehospital ROSC, survival and favorable neurological outcome were 1.367 (95%CI, 1.276–1.464), 1.468 (95%CI, 1.264–1.705) and 1.849 (95%CI, 1.526–2.240), respectively. Similar results were found in the propensity score matched population and subgroup analysis. ConclusionCompared with the IO approach, the IV approach appears to be the optimal route for adrenaline administration in advanced life support for OHCA during prehospital resuscitation.

Initiation and Assessment of Timekeeping Roles During In-Hospital Cardiac Arrests to Track Rhythm Checks and Epinephrine Dosing.

Objectives:Compliance to advanced cardiac life support algorithm is low and associated with worse outcomes from in-hospital cardiac arrests. This study aims to improve algorithm compliance by delegation of two separate code team members for timing rhythm check and epinephrine administration in accordance to the advanced cardiac life support algorithm.Design:Prospective intervention with historical controls.Setting:Single academic medical center.Patients:Patients who suffered in-hospital cardiac arrest during study period were considered for inclusion. Patients in which the advanced cardiac life support algorithm or new timekeeper roles were not used were excluded.Interventions:Two existing code team members were delegated to time epinephrine and rhythm checks.Measurements and Main Results:Primary endpoint was deviations from the 2-minute rhythm check or 3- to 5-minute epinephrine administration. Each deviation outside allotted time intervals was counted as one deviation. However, instances in which multiple intervals passed were counted as multiple deviations. Algorithm adherence was analyzed before and after intervention. Secondary endpoints included return of spontaneous circulation rate, time until first dose of epinephrine, and anonymous survey data. Thirteen pre intervention in-hospital cardiac arrests were compared with 13 in-hospital cardiac arrests post. Prior to intervention, the median deviation per in-hospital cardiac arrest was 5 (interquartile range, 3–7) versus 1 post (interquartile range 0–1; p = 0.0003). The median time until first dose of epinephrine was administered pre intervention was 5 minutes (interquartile range, 0–4) versus post intervention median of 0 (interquartile range, 0–0; p = 0.02). Pre-intervention return of spontaneous circulation rate was 46.1% versus 69.2% post. Surveys demonstrated advanced cardiac life support providers felt time keeping roles made it easier to track epinephrine administration and rhythm checks and improved team communication.Conclusions:Two separate timekeeper roles during in-hospital cardiac arrests improved algorithm compliance, code team function, and was favored by code team members. Timekeeper roles may be associated with improved rates of return of spontaneous circulation and less time until the first dose of epinephrine was administered. This study is limited by small sample size and single-center design.

Pulseless Electrical Activity Cardiac Arrest.

This simulation-based scenario is appropriate for senior level emergency medicine residents. Pulseless electrical activity (PEA) accounts for up to 25% of sudden cardiac arrest;1 therefore the ability to recognize and care for this condition is an essential skill of emergency medicine physicians. Management of PEA arrest in the emergency department centers on Advanced Cardiac Life Support (ACLS) algorithms and the identification and treatment of potentially reversible causes. Massive pulmonary embolism (PE) is one of several causes of PEA cardiac arrest.2 However, diagnosis by CT-angiographic or nuclear imaging may not be obtainable in the hemodynamically unstable patient, requiring physicians to have a high index of suspicion. Systemic thrombolytic therapy is indicated in cardiac arrest due to known or presumed massive pulmonary embolism.3,4,5. After competing this simulation-based session, the learner will be able to:Identify PEA arrestReview the ACLS commonly recognized PEA arrest etiologies via the H &T mnemonicReview and discuss the risks and benefits of tissue plasminogen activator (tPA) for massive PE. This is a high-fidelity simulation that allows learners to evaluate and treat a PEA arrest secondary to massive PE in a safe environment. The learners will demonstrate their ability to recognize a PEA arrest, sort through possible etiologies, and demonstrate treatment of a massive PE with tPA. Debriefing will focus on diagnosis and management of the PEA arrest. This case was piloted with 12 PGY-2 and PGY-3 residents. Group and individual debriefing occurred post-case. Post-simulation feedback from the faculty suggested two potential issues. First was fidelity, which we increased by using our ultrasound simulator. Second, the elevated presenting glucose with lactic acidosis could be a poor cue, leading some towards diabetic ketoacidosis (DKA). Learners felt more confident about running a PEA arrest. The simulation improved resident awareness of the value of point of care ultrasound (POCUS) in cardiac arrest. It also clarified the dosing of tPA in massive PE. Faculty felt simulating the actual US without breaking simulation would be more challenging without our US simulator. Although there was concern about results pointing towards possible DKA, this did not occur in any of the pilot simulations. The presenting glucose was reduced to make this less likely in future simulations. Pulseless electrical activity (PEA), syncope, cardiac arrest, Hs and Ts from ACLS PEA instruction, tPA for massive PE, critical care medicine, simulation.

Guiding Cardiopulmonary Resuscitation with Focused Echocardiography: A Report of Five Cases

Background: Focused transthoracic echocardiography has been used to determine etiologies of cardiac arrest and evaluate utility of continuing resuscitation after cardiac arrest. Few guidelines exist advising ultrasound timing within the advanced cardiac life support algorithm. Natural timing of echocardiography occurs during the pulse check, when views are unencumbered by stabilization equipment or vigorous movements. However, recent studies suggest that ultrasound performance during pulse checks prolongs the pause duration of cardiopulmonary resuscitation. Transesophageal echocardiography studies have demonstrated benefits in this regard, but there have been no transthoracic echocardiography studies assessing the physical performance of compressions during cardiopulmonary resuscitation. Objective: The purpose of this study was to describe cases where echocardiography performed at the beginning of the cardiac arrest algorithm offers actionable information to cardiopulmonary resuscitation itself without delaying provision of compressions. Conclusion: Providers using focused echocardiography to evaluate cardiac arrest patients should consider initiating scans at the start of compressions to identify the optimal location for compression delivery and to detect inadequate compressions. Subsequent visualization of full left ventricular compression may be seen after a location change, and combined with end tidal carbon dioxide values, gives indication for improved forward circulatory flow. Although it is not possible in all patients, doing so hastens provision of quality compressions that affect hemodynamic parameters without causing prolongations to the pulse check pause. Further research is needed to determine patient outcomes from both out-of-hospital and in-hospital cardiac arrest when cardiopulmonary resuscitation is visually guided by focused echocardiography.

MP24: The University of Ottawa's Department of Emergency Medicine pre-internship boot camp: a descriptive review

Innovation Concept: Emergency Medicine (EM) residency programs in Canada have transitioned to competency based medical education and the first stage of the curriculum focuses on standardizing learner competency. Pre-internship boot camps provide a focused opportunity to assist with this standardization prior to residency training. The objective of this descriptive review was to describe our institution's EM pre-internship boot camp in the context of current literature and to summarize the state of EM boot camp curricula across all reported EM residency programs. Methods: The description of our two-day boot camp included its curriculum design, required preparation and resources, and a detailed timeline of each day's events. To compare our boot camp to current literature, a comprehensive search of both primary and gray literature was performed. Curriculum, Tool or Material: Our institution's boot camp is two days of teaching focused on clinical knowledge and procedural competency, with a large component centered on simulation. Day one consisted of an introduction to the boot camp, a review of crisis resource management principles and advanced cardiac life support (ACLS) algorithms, ACLS simulation sessions, and small group skill sessions on common emergency department procedures. Day two contained a point of care ultra sound lecture, an ultrasound guided central venous catheterization session, pigtail and chest tube insertion sessions, and high-fidelity simulation cases. In comparison to the other pre-internship boot camps that were identified in the literature, our boot camp offers a unique focus and format. Conclusion: This review is the first to report on an EM-specific boot camp at a non-American institution, and it provides a framework for the development and refinement of pre-internship EM boot camps at other universities.

Acute Management of VentricularArrhythmia inPatients WithSuspectedInherited HeartRhythmDisorders.

After the most common causes of sudden cardiac death including ischemic and structural heart disease have been ruled out, clinicians on the front lines of emergent medical care can be faced with unexplained and recurrent life-threatening arrhythmia episodes in children and adults. In these cases, an inherited arrhythmia syndrome should be suspected, and a departure from conventional advanced cardiac life support algorithms may be required. This review focuses on the electrocardiographic clues of an inherited arrhythmia syndrome that can be uncovered through a careful analysis of the baseline electrocardiogram (ECG) and classification of the presenting ventricular arrhythmia and its mode of onset. After presenting an informed working diagnosis and an explanation of the implied electrophysiologic mechanisms, discussion provides a protocol approach to acute and subacute management decisions. Careful attention to a patient's response to treatment and its ECG surrogates have the potential to facilitate tailored therapy based on the underlying arrhythmogenic substrate and pathophysiology.

Cardiac Arrest in the Operating Room: Part 2-Special Situations in the Perioperative Period.

As noted in part 1 of this series, periprocedural cardiac arrest (PPCA) can differ greatly in etiology and treatment from what is described by the American Heart Association advanced cardiac life support algorithms, which were largely developed for use in out-of-hospital cardiac arrest and in-hospital cardiac arrest outside of the perioperative space. Specifically, there are several life-threatening causes of PPCA of which the management should be within the skill set of all anesthesiologists. However, previous research has demonstrated that continued review and training in the management of these scenarios is greatly needed and is also associated with improved delivery of care and outcomes during PPCA. There is a growing body of literature describing the incidence, causes, treatment, and outcomes of common causes of PPCA (eg, malignant hyperthermia, massive trauma, and local anesthetic systemic toxicity) and the need for a better awareness of these topics within the anesthesiology community at large. As noted in part 1 of this series, these events are always witnessed by a member of the perioperative team, frequently anticipated, and involve rescuer-providers with knowledge of the patient and the procedure they are undergoing or have had. Formulation of an appropriate differential diagnosis and rapid application of targeted interventions are critical for good patient outcome. Resuscitation algorithms that include the evaluation and management of common causes leading to cardiac in the perioperative setting are presented. Practicing anesthesiologists need a working knowledge of these algorithms to maximize good outcomes.

Reversible Causes in Cardiovascular Collapse at the Emergency Department Using Ultrasonography (REVIVE-US)

Ultrasonographic evaluation of patients in cardiac arrest is currently not protocolised in the advanced cardiac life support (ACLS) algorithm. Potentially reversible causes may be identified using bedside ultrasonography that is ubiquitous in most emergency departments (EDs). This study aimed to evaluate the incidence of sonographically detectable reversible causes of cardiac arrest by incorporating an ultrasonography protocol into the ACLS algorithm. Secondary objectives include rates of survival to hospital admission, hospital discharge, and 30-day mortality. We conducted a prospective study using bedside ultrasonography to evaluate for potentially reversible causes in patients with cardiac arrest at the ED of National University Hospital, Singapore, regardless of the initial electrocardiogram rhythm. A standardised ultrasonography protocol was performed during the 10-second pulse check window. Between June 2015 and April 2016, 104 patients were recruited, corresponding to 65% of all out-of-hospital cardiac arrest patients conveyed to the ED. Median age was 71 years (interquartile range, 55 to 80) and 71 (68.3%) patients were male. The most common rhythm on arrival was asystole (45.2%). Four (3.8%) patients had ultrasonographic findings suggestive of massive pulmonary embolism while 1 received intravenous thrombolysis and survived until discharge. Pericardial effusion without tamponade was detected in 4 (3.8%) patients and 6 (5.8%) patients had intra-abdominal free fluid. Twenty (19.2%) patients survived until admission, 2 of whom (1.9%) survived to discharge and beyond 30 days. Bedside ultrasonography can be safely incorporated into the ACLS protocol. Detection of any reversible causes may alter management and improve survival in selected patients.

Effect of an interactive cardiopulmonary resuscitation assist device with an automated external defibrillator synchronised with a ventilator on the CPR performance of emergency medical service staff: a randomised simulation study

BackgroundThe present study evaluates whether the quality of advanced cardiac life support (ALS) is improved with an interactive prototype assist device. This device consists of an automated external defibrillator linked to a ventilator and provides synchronised visual and acoustic instructions for guidance through the ALS algorithm and assistance for face-mask ventilations.MethodsWe compared the cardiopulmonary resuscitation (CPR) quality of emergency medical system (EMS) staff members using the study device or standard equipment in a mannequin simulation study with a prospective, controlled, randomised cross-over study design. Main outcome was the effect of the study device compared to the standard equipment and the effect of the number of prior ALS trainings of the EMS staff on the CPR quality. Data were analysed using analyses of covariance (ANCOVA) and binary logistic regression, accounting for the study design.ResultsIn 106 simulations of 56 two-person rescuer teams, the mean hands-off time was 24.5% with study equipment and 23.5% with standard equipment (Difference 1.0% (95% CI: −0.4 to 2.5%); p = 0.156). With both types of equipment, the hands-off time decreased with an increasing cumulative number of previous CPR trainings (p = 0.042). The study equipment reduced the mean time until administration of adrenaline (epinephrine) by 23 s (p = 0.003) and that of amiodarone by 17 s (p = 0.016). It also increased the mean number of changes in the person doing chest compressions (0.6 per simulation; p < 0.001) and decreased the mean number of chest compressions (2.8 per minute; p = 0.022) and the mean number of ventilations (1.8 per minute; p < 0.001). The chance of administering amiodarone at the appropriate time was higher, with an odds ratio of 4.15, with the use of the study equipment CPR.com compared to the standard equipment (p = 0.004). With an increasing number of prior CPR trainings, the time intervals in the ALS algorithm until the defibrillations decreased with standard equipment but increased with the study device.ConclusionsEMS staff with limited training in CPR profit from guidance through the ALS algorithm by the study device. However, the study device somehow reduced the ALS quality of well-trained rescuers and thus can only be recommended for ALS provider with limited experience.

LO045: Sonography in Hypotension and Cardiac Arrest (SHoC) - Cardiac Arrest: A consensus on the integration of point of care ultrasound into advanced cardiac life support during cardiac arrest

Introduction: Point of care ultrasound (PoCUS) provides invaluable information during resuscitation efforts in cardiac arrest by determining presence/absence of cardiac activity and identifying reversible causes such as pericardial tamponade. There is no agreed guideline on how to safely and effectively incorporate PoCUS into the advanced cardiac life support (ACLS) algorithm. We consider that a consensus-based priority checklist using a “4 F’s” approach (Fluid; Form; Function; Filling), would provide a better algorithm during ACLS. Methods: The ultrasound subcommittee of the Australasian College for Emergency Medicine (ACEM) drafted a checklist incorporating PoCUS into the ACLS algorithm. This was further developed using the input of 24 international experts associated with five professional organizations led by the International Federation of Emergency Medicine. A modified Delphi tool was developed to reach an international consensus on how to integrate ultrasound into cardiac arrest algorithms for emergency department patients. Results: Consensus was reached following 3 rounds. The agreed protocol focuses on the timing of PoCUS as well as the specific clinical questions. Core cardiac windows performed during the rhythm check pause in chest compressions are the sub-xiphoid and parasternal cardiac views. Either view should be used to detect pericardial fluid, as well as examining ventricular form (e.g. right heart strain) and function, (e.g. asystole versus organized cardiac activity). Supplementary views include lung views (for absent lung sliding in pneumothorax and for pleural fluid), and IVC views for filling. Additional ultrasound applications are for endotracheal tube confirmation, proximal leg veins for DVT, or for sources of blood loss (AAA, peritoneal/pelvic fluid). Conclusion: The authors hope that this process will lead to a consensus-based SHoC-cardiac arrest guideline on incorporating PoCUS into the ACLS algorithm.