Advanced Cardiac Life Support Guidelines Research Articles

Hospital Variation in Epinephrine Administration Before Defibrillation for Cardiac Arrest Due to Shockable Rhythm.

Contrary to advanced cardiac life support guidelines that recommend immediate defibrillation for shockable in-hospital cardiac arrest (IHCA), epinephrine administration before first defibrillation is common and associated with lower survival at a "patient-level." Whether this practice varies across hospitals and its association with "hospital-level" IHCA survival remains unknown. The purpose of this study was to determine hospital variation in rates of epinephrine administration before defibrillation for shockable IHCA and its association with IHCA survival. Observational cohort study. Five hundred thirteen hospitals participating in the Get With The Guidelines Resuscitation Registry. A total of 37,668 adult patients with IHCA due to an initial shockable rhythm from 2000 to 2019. Epinephrine before first defibrillation. Using multivariable hierarchical regression, we examined hospital variation in epinephrine administration before first defibrillation and its association with hospital-level rates of risk-adjusted survival. The median hospital rate of epinephrine administration before defibrillation was 18.8%, with large variation across sites (range, 0-68.8%; median odds ratio: 1.54; 95% CI, 1.47-1.61). Major teaching status and annual IHCA volume were associated with hospital rate of epinephrine administration before defibrillation. Compared with hospitals with the lowest rate of epinephrine administration before defibrillation (Q1), there was a stepwise decline in risk-adjusted survival at hospitals with higher rates of epinephrine administration before defibrillation (Q1: 44.3%, Q2: 43.4%; Q3: 41.9%; Q4: 40.3%; p for trend < 0.001). Administration of epinephrine before defibrillation in shockable IHCA is common and varies markedly across U.S. hospitals. Hospital rates of epinephrine administration before defibrillation were associated with a significant stepwise decrease in hospital rates of risk-adjusted survival. Efforts to prioritize immediate defibrillation for patients with shockable IHCA and avoid early epinephrine administration are urgently needed.

The critical role of anaesthesia in multifaceted care for severe thoracic trauma: A case study

Blunt trauma to the thorax can be viciously dangerous and carries high mortality which warrants aggressive resuscitation and life-saving measures failing which cardiac arrest can occur. We present a case of a polytrauma male patient in the emergency department with diaphragmatic rupture, and bilateral pelvic and clavicular fractures in hypovolemic shock which progressed to cardiac arrest. The patient was immediately resuscitated with Cardiopulmonary and cerebral resuscitation (CPCR) according to Advanced cardiac life support (ACLS) guidelines and stabilized with intravenous fluids and further optimized with blood products. He was operated on for diaphragmatic rupture and shifted to intensive care where he was paralysed and kept on mechanical ventilation for 48 hours treated for severe metabolic acidosis and hemodynamic instability following which he was weaned off successfully. During his stay, he was evaluated for pelvic and clavicular fractures and treated for ICU-related delirium and Methicillin Resistant Staphylococcus infection(MRSA). Our case suggests that diaphragmatic injuries are uncommon but deadly in cases of abdominal forceful trauma because they can result in hemothorax and the movement of intestinal contents into the thoracic cavity. Such cases must be managed with clinical knowledge employing expedient surgical care and the best critical care. This case demonstrates the indispensable and undeniable contributions by anaesthesiologists who assume multiple roles within a hospital setup.

Analysis of cardiopulmonary resuscitation outcomes among critically ill patients at a university hospital, Kafr-El-Sheikh Governorate

Background Cardiopulmonary resuscitation (CPR) is a vital intervention in managing critically ill patients experiencing cardiac arrest (CA). Understanding the factors influencing CPR outcomes is crucial for optimizing resuscitation strategies and improving patients’ survival rates. Aim To analyze the outcome of CPR among critically ill patients. Research questions To fulfill the aim of this study, four research questions were formulated. Design A descriptive exploratory research design was used. Setting Three ICUs affiliated to a university hospital in Kafr-El-Sheikh, Egypt. Sample A purposive sample that included 69 CA patients for 7 months, and a convenience sample of 97 members of the emergency response team working at the above-mentioned setting. Tools Three tools were formulated. Results The highest age category (31.9%) of CA patients was of 61–70 years. Over 7 months, the frequency of CA among critically ill patients was 7.61%. Regarding ICUs’ preparedness, institutional factors affecting emergency readiness had an unsatisfactory practice level (mean±SD=17.04±2.10), and crash cart preparedness was at mean±SD=30.42±4.32. The study showed unsatisfactory practice levels related to International Liaison Committee on Resuscitation 2020 guidelines for total advanced cardiac life support (ACLS) performance with a mean score and SD of 87.81±18.19. Patient outcomes showed a 10.1% overall survival rate at ICU discharge, 82.6% experiencing return of spontaneous circulation, and 89.9% experiencing brain death. Clinical high-risk scores against National Early Warning Score 2 were 98.2 and 88.2% on the first and last days, respectively. Poor cerebral performance category outcome scores were found at 96.5 and 88% on the first and last days, respectively. However, there were insignificant statistical correlations (P&gt;0.05) between different patients’ outcomes and total adult ACLS role during CA based on International Liaison Committee on Resuscitation guidelines 2020. Conclusion CA among critically ill patients creates a significant burden for healthcare facilities and continues to be associated with a high mortality rate. The institutional factors affecting CPR outcomes among CA patients concerning preparedness level have a significant influence on survival. Conversely, the majority of resuscitated patients experienced return of spontaneous circulation, indicating successful initial efforts with severe neurological disability. Recommendations Hospital preparedness for CA situations has to be severely considered through implementing and regularly reviewing institutional policies and ensuring the availability and functionality of necessary resources. Update regular continuous educational programs toward enhancing the performance of emergency response team focusing on ACLS guidelines. Replication of this study on a larger probability sample from different geographical locations in Egypt is recommended.

Relationship between cardiac ultrasound findings during cardiopulmonary resuscitation with the outcome of patients

Objective: Cardiopulmonary arrest is a devastating outcome of some clinical situations and requires strict implementation of cardiopulmonary resuscitation (CPR) protocols. Since ultrasound is one of the recommended tools to determine the presence of cardiac movements and may be a predictor of the outcome, this study examined the relationship between echocardiographic findings during CPR with patients’ outcomes. Methods: This cross-sectional prospective observational study was conducted on patients with cardio-respiratory arrest in the emergency department of Shariaty hospital during 2019. sampling method was random. Echocardiography was done at the patient’s bedside during the CPR process in accordance with the last advanced cardiac life support (ACLS) guidelines, on two points, after the end of the second and 10th minutes from the start of CPR. The echocardiography findings (cardiac movement vs standstill) were recorded, and patient outcomes were followed. Thirty-two patients enrolled in this study with a mean age of 56.9±15.3 years. Chi-square and Mann-Whitney U tests were used to calculate the association between heart contractions during resuscitation and the outcomes via SPSS V.22. Fisher’s exact test and Kruskal-Wallis test were used to evaluate the relationship between heart rhythm in the second and tenth minutes with the outcomes of CPR. Results: The presence of cardiac movement in the 10th minute of CPR, in contrast to the findings of the second minute, had a significant correlation with the success rate of CPR and outcomes (P&lt;0.05). Moreover, patients with ventricular tachycardia (VT)/ventricular fibrillation (VF) cardiac rhythm had a better resuscitation rate, 24-hour survival rate, and better outcome than patients with other cardiac rhythms and asystole (P&lt;0.05). Conclusion: Echocardiographic findings in the 10th minute of the CPR process can be used as a prognostic factor for cardiac arrest.

A Clinical Audit to Assess the Adherence of the Code Blue Team to Advanced Cardiac Life Support Protocol and its Effect on the Patient Outcome in a Tertiary Care Hospital in Kochi, Kerala

Introduction: Cardiopulmonary resuscitation is a sequence of techniques that combines chest compression with artificial ventilation to manually maintain the circulation to preserve intact brain function. The aim is to maintain circulation and breathing in a person who is in cardiac arrest until emergency aid arrives. Effective teamwork by Code Blue team raises chances of a successful outcome. The advanced cardiac life support (ACLS) guidelines were developed by the American Heart Association using the comprehensive review of resuscitation literature performed by the International Liaison Committee on Resuscitation. Aim: To assess adherence of Code Blue team to ACLS protocol, to assess outcome of resuscitation, and to compare outcome between those where ACLS guidelines were followed and those not followed. Patients and Methods: A clinical audit was done between 2014 and 2015 at Lourdes Hospital, Kochi, on inpatients aged between 30 and 80 years, with witnessed cardiac arrests/respiratory arrest. Pregnant and unwilling patients were excluded. Results: The common arrest rhythm was pulseless electrical activity, followed by asystole. ACLS protocol was followed in 58.7%. The most common deviation was usage of inappropriate drugs. Return of spontaneous circulation (ROSC) was attained in 53.3%, of which 28.5% were discharged (P

Comparative Effectiveness of Amiodarone and Lidocaine for the Treatment of In-Hospital Cardiac Arrest

American Heart Association Advanced Cardiac Life Support (ACLS) guidelines support the use of either amiodarone or lidocaine for cardiac arrest caused by ventricular tachycardia or ventricular fibrillation (VT/VF) based on studies of out-of-hospital cardiac arrest. Studies comparing amiodarone and lidocaine in adult populations with in-hospital VT/VF arrest are lacking. Does treatment with amiodarone vslidocaine therapy have differential associations with outcomes among adult patients with in-hospital cardiac arrest from VT/VF? This retrospective cohort study of adult patients receiving amiodarone or lidocaine for VT/VF in-hospital cardiac arrest refractory to CPR and defibrillation between January 1, 2000, and December 31, 2014, was conducted within American Heart Association Get With the Guidelines-Resuscitation participating hospitals. The primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes were 24h survival, survival to hospital discharge, and favorable neurologic outcome. Among 14,630 patients with in-hospital VT/VF arrest, 68.7%(n= 10,058) were treated with amiodarone and 31.3%(n= 4,572) with lidocaine. When all covariates were statistically controlled, compared with amiodarone, lidocaine was associated with statistically significantly higher odds of the following: (1) ROSC (adjusted OR [aOR], 1.15, P= .01; average marginal effect [AME], 2.3; 95%CI, .5-4.2); (2) 24h survival (aOR, 1.16; P= .004; AME, 3.0; 95%CI, 0.9-5.1); (3) survival to discharge (aOR, 1.19; P< .001; AME, 3.3; 95%CI, 1.5-5.2); and (4) favorable neurologic outcome at hospital discharge (aOR, 1.18; P< .001; AME, 3.1; 95%CI, 1.3-4.9). Results using propensity score methods were similar to those from multivariable logistic regression analyses. Compared with amiodarone, lidocaine therapy among adult patients with in-hospital cardiac arrest from VT/VF was associated with statistically significantly higher rates of ROSC, 24h survival, survival to hospital discharge, and favorable neurologic outcome.

A Rent in the Left Ventricle: A Sea-Saw Between Life and Death

Penetrating injuries to the precordium are life-threatening and require early detection and immediate intervention. We present a case of penetrating cardiac injury who presented with a definitive airway and hemodynamically unstable. During the primary survey, the patient had a cardiac arrest with pulseless ventricular tachycardia. The patient was resuscitated as per advanced cardiac life support (ACLS) and advanced trauma life support (ATLS) guidelines with manual digital compression at the penetrating site leading to a return of spontaneous circulation (ROSC). After ROSC, he was shifted for emergency explorative median sternotomy. During the sternotomy, we found a clotted rent in the anterior wall of the left ventricle, which was repaired. Aggressive resuscitation and appropriate management strategy in the emergency department (ED) resulted in a successful outcome, and he was discharged after 10 days of hospital stay. Our case highlights the importance of early diagnosing and managing penetrating cardiac trauma.

Temporal Changes in Epinephrine Dosing in Out-of-Hospital Cardiac Arrest: A Review of EMS Protocols across the United States.

Administration of epinephrine has been associated with worse neurological outcomes for survivors of out-of-hospital cardiac arrest. The publication of the 2018 PARAMEDIC-2 trial, a randomized and double-blind study of epinephrine in out-of-hospital cardiac arrest, provides the strongest evidence to date that epinephrine increases return of spontaneous circulation (ROSC) but not neurologically intact survival. This study aims to determine if Emergency Medical Services (EMS) cardiac arrest protocols have changed since the publication of PARAMEDIC-2. States in the US utilizing mandatory or model state-wide EMS protocols, including Washington DC, were included in this study. The nontraumatic cardiac arrest protocol as of January 1, 2018 was compared to the protocol in effect on January 1, 2021 to determine if there was a change in the administration of epinephrine. Protocols were downloaded from the relevant state EMS website. If a protocol could not be obtained, the state medical director was contacted. A 2021 state-wide protocol was found for 32/51 (62.7%) states. Data from 2018 were available for 21/51 (41.2%) states. Of the 11 states without data from 2018, all follow Advanced Cardiac Life Support (ACLS) guidelines in the 2021 protocol. Five (15.6%) of the states with a state-wide protocol made a change in the cardiac arrest protocols. Maximum cumulative epinephrine dose was limited to 4mg in Maryland and 3mg in Vermont. Rhode Island changed epinephrine in shockable rhythms to be administered after three cycles of cardiopulmonary resuscitation (CPR) and an anti-arrhythmic. Rhode Island also added an epinephrine infusion as an option. No states removed epinephrine administration from their cardiac arrest protocol. Simple statistical analysis was performed with Microsoft Excel. Several states have adjusted cardiac arrest protocols since 2018. The most frequent change was limiting the maximum cumulative dosage of epinephrine. One state changed timing of epinephrine dosing depending on the rhythm and also provided an option of an epinephrine infusion in place of bolus dosing. While the sample size is small, these changes may reflect the future direction of prehospital cardiac arrest protocols. Significant limitations apply, including the exclusion of local and regional protocols which are more capable of quickly adjusting to new research. Additionally, this study is only focused on EMS in the United States.

Comparison of femoral and carotid arteries in terms of pulse check in cardiopulmonary resuscitation: A prospective observational study

Detecting the presence of a pulse is pivotal to initiating and guiding cardiopulmonary resuscitation (CPR). Palpating the carotid or femoral artery pulse are historically the most common areas providers assess during a resuscitation. Unfortunately manual palpation of a pulse is operator dependent and varies based on patient anatomical differences and vital signs. The Advanced Cardiac Life Support (ACLS) guidelines defined by the American Heart Association (AHA) states that pulse checks should be accomplished quickly to minimize time between chest compressions in CPR.

Comparison of femoral and carotid arteries in terms of pulse check in cardiopulmonary resuscitation: A prospective observational study

Detecting the presence of a pulse is pivotal to initiating and guiding cardiopulmonary resuscitation (CPR). Palpating the carotid or femoral artery pulse are historically the most common areas providers assess during a resuscitation. Unfortunately manual palpation of a pulse is operator dependent and varies based on patient anatomical differences and vital signs. The Advanced Cardiac Life Support (ACLS) guidelines defined by the American Heart Association (AHA) states that pulse checks should be accomplished quickly to minimize time between chest compressions in CPR. Manual pulse checks are the most common, but there is no consensus on the most accurate and efficient location to perform a manual pulse check.

Mitochondrial dysfunction in fatal ventricular arrhythmias.

Ventricular fibrillation (VF) and sudden cardiac arrest (SCA) remain some of the most important public health concerns worldwide. For the past 50years, the recommendation in the Advanced Cardiac Life Support (ACLS) guidelines has been that defibrillation is the only option for shockable cardiac arrest. There is growing evidence to demonstrate that mitochondria play a vital role in the outcome of postresuscitation cardiac function. Although targeting mitochondria to improve resuscitation outcome following cardiac arrest has been proposed for many years, understanding concerning the changes in mitochondria during cardiac arrest, especially in the case of VF, is still limited. In addition, despite new research initiatives and improved medical technology, the overall survival rates of patients with SCA still remain the same. Understanding cardiac mitochondrial alterations during fatal arrhythmias may help to enable the formulation of strategies to improve the outcomes of resuscitation. The attenuation of cardiac mitochondrial dysfunction during VF through pharmacological intervention as well as ischaemic postconditioning could also be a promising target for intervention and inform a new paradigm of treatments. In this review, the existing evidence available from in vitro, ex vivo and in vivo studies regarding the roles of mitochondrial dysfunction during VF is comprehensively summarized and discussed. In addition, the effects of interventions targeting cardiac mitochondria during fatal ventricular arrhythmias are presented. Since there are no clinical reports from studies targeting mitochondria to improve resuscitation outcome available, this review will provide important information to encourage further investigations in a clinical setting.

Out with the Old and in With the New: Deimplementation in Emergency Medicine.

Much of emergency medicine care and quality standards are rooted in evidence-based guidelines. The Society for Academic Emergency Medicine (SAEM) and the journal Academic Emergency Medicine through publications, conferences, and various initiatives have encouraged the emergency medicine community to create and disseminate evidence-based guidelines. New and updated guidelines must also be implemented into practice. Increasing numbers of publications in this journal and elsewhere are shining light on how the theories and frameworks of implementation science can increase the uptake, reach, and sustainability of evidence-based guidelines in emergency medicine.

Impact of CPR Quality and Adherence to Advanced Cardiac Life Support Guidelines on Patient Outcomes in In-Hospital Cardiac Arrest.

Sudden cardiac arrest is a major cause of death worldwide. Performance of prompt, high-quality cardiopulmonary resuscitation improves patient outcomes. To evaluate the association between patient survival of in-hospital cardiac arrest and 2 independent variables: adherence to resuscitation guidelines and patient severity of illness, as indicated by the number of organ supportive therapies in use before cardiac arrest. An observational study was conducted using prospectively collected data from a convenience sample. Cardiopulmonary arrest forms and medical records were evaluated at an academic medical center. Adherence to resuscitation guidelines was measured with the ZOLL R Series monitor/defibrillator using RescueNet Code Review software. The primary outcome was patient survival. Of 200 cases, 37% of compressions were in the recommended range for rate (100-120/min) and 63.9% were in range for depth. The average rate was above target 55.7% of the time. The average depth was above and below target 1.4% and 34.7% of the time, respectively. Of the 200 patients, 125 (62.5%) attained return of spontaneous circulation. Of those, 94 (47%) were alive 24 hours after resuscitation. Fifty patients (25%) were discharged from the intensive care unit alive and 47 (23.5%) were discharged from the hospital alive. These exploratory data reveal overall survival rates similar to those found in previous studies. The number of pauses greater than 10 seconds during resuscitation was the one consistent factor that impacted survival. Despite availability of an audiovisual feedback system, rescuers continue to perform compressions that are not at optimal rate and depth.

Effectiveness of Sodium Bicarbonate Administration on Mortality in Cardiac Arrest Patients: A Systematic Review and Meta-analysis.

The 2010 Advanced Cardiac Life Support guidelines stated that routine sodium bicarbonate (SB) use for cardiac arrest patients was not recommended. However, SB administration during resuscitation is still common. To evaluate the effect of SB on return of spontaneous circulation (ROSC) and survival-to-discharge rates in adult cardiac arrest patients. We searched Medline, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to December 2019. We included trials on nontraumatic adult patients after cardiac resuscitation and SB treatment vs. controls. A meta-analysis was performed with six observational studies, including 18,406 adult cardiac arrest patients. There were no significant differences in the ROSC rate (odds ratio [OR] 1.185; 95% confidence interval [CI] 0.680-2.065) and survival-to-discharge rate (OR 0.296; 95% CI 0.066-1.323) between the SB and no-SB groups. In the subgroup analysis based on the year factor, there were no significant differences in the mortality rate in the After-2010 group. In the subgroup analysis based on the continent, the ROSC rate (OR 0.521; 95% CI 0.432-0.628) and survival-to-discharge rate (OR 0.102; 95% CI 0.066-0.156) were significantly lower in the North American group. SB use was not associated with improvement in ROSC or survival-to-discharge rates in cardiac resuscitation. In addition, mortality was significantly increased in the North American group with SB administration.

Ability of Critical Care Medics to Confirm Endotracheal Tube Placement by Ultrasound.

The Advanced Cardiac Life Support (ACLS) guidelines were recently updated to include ultrasound confirmation of endotracheal tube (ETT) location as an adjunctive tool to verify placement. While this method is employed in the emergency department under the guidance of the most recent American College of Emergency Physicians (ACEP; Irving, Texas USA) guidelines, it has yet to gain wide acceptance in the prehospital setting where it has the potential for greater impact. The objective of this study to is determine if training critical care medics using simulation was a feasible and reliable method to learn this skill. Twenty critical care paramedics with no previous experience with point-of-care ultrasound volunteered for advanced training in prehospital ultrasound. Four ultrasound fellowship trained emergency physicians proctored two three-hour training sessions. Each session included a brief introduction to ultrasound "knobology," normal sonographic neck and lung anatomy, and how to identify ETT placement within the trachea or esophagus. Immediately following this, the paramedics were tested with five simulated case scenarios using pre-obtained images that demonstrated a correctly placed ETT, an esophageal intubation, a bronchial intubation, and an improperly functioning ETT. Their accuracy, length of time to respond, and comfort with using ultrasound were all assessed. All 20 critical care medics completed the training and testing session. During the five scenarios, 37/40 (92.5%) identified the correct endotracheal placements, 18/20 (90.0%) identified the esophageal intubations, 18/20 (90.0%) identified the bronchial intubation, and 20/20 (100.0%) identified the ETT malfunctions correctly. The average time to diagnosis was 10.6 seconds for proper placement, 15.5 seconds for esophageal, 15.6 seconds for bronchial intubation, and 11.8 seconds for ETT malfunction. The use of ultrasound to confirm ETT placement can be effectively taught to critical care medics using a short, simulation-based training session. Further studies on implementation into patient care scenarios are needed.

Mobile App to Improve House Officers' Adherence to Advanced Cardiac Life Support Guidelines: Quality Improvement Study.

BackgroundEffective and timely delivery of cardiac arrest interventions during in-hospital cardiac arrest resuscitation is associated with greater survival. Whether a mobile app that provides timely reminders of critical interventions improves adherence to Advanced Cardiovascular Life Support (ACLS) guidelines among house officers, who may lack experience in leading resuscitations, remains unknown.ObjectiveThe aim of this study was to assess the impact of a commercially available, dynamic mobile app on house officers’ adherence to ACLS guidelines.MethodsAs part of a quality improvement initiative, internal medicine house officers were invited to participate and randomized to lead 2 consecutive cardiac arrest simulations, one with a novel mobile app and one without a novel mobile app. All simulations included 4 cycles of cardiopulmonary resuscitation with different cardiac arrest rhythms and were video recorded. The coprimary end points were chest compression fraction and number of correct interventions in each simulation. The secondary end point was incorrect interventions, defined as interventions not indicated by the 2015 ACLS guidelines. Paired t tests compared performance with and without the mobile app.ResultsAmong 53 house officers, 26 house officers were randomized to lead the first simulation with the mobile app, and 27 house officers were randomized to do so without the app. Use of the mobile app was associated with a higher number of correct ACLS interventions (out of 7; mean 6.2 vs 5.1; absolute difference 1.1 [95% CI 0.6 to 1.6]; P<.001) as well as fewer incorrect ACLS interventions (mean 0.3 vs 1.0; absolute difference –0.7 [95% CI –0.3 to –1.0]; P<.001). Simulations with the mobile app also had a marginally higher chest compression fraction (mean 90.9% vs 89.0%; absolute difference 1.9% [95% CI 0.6% to 3.4%]; P=.007).ConclusionsThis proof-of-concept study suggests that this novel mobile app may improve adherence to ACLS protocols, but its effectiveness on survival in real-world resuscitations remains unknown.

Triple-sequential defibrillation for refractory ventricular fibrillation in a 24-year-old male out of hospital cardiac arrest.

SUMMARYRefractory ventricular fibrillation encountered during cardiac arrest has a mortality rate of 97%.1 As per the advanced cardiac life support (ACLS) guidelines, the management algorithm of ventricular fibrillation consists of chest compressions, epinephrine, defibrillation, and anti-arrhythmics.2 There have been reports describing the use of the fast-acting selective β-blocker, esmolol, and dual-sequential defibrillation in the management of ventricular fibrillation that is refractory to standard ACLS. We present a case of a 24-year-old male who had an out-of-hospital cardiac arrest, with refractory ventricular fibrillation despite high-quality cardiopulmonary resuscitation (CPR) and ACLS management. Along with standard ACLS, triple-sequential defibrillation was used to achieve return of spontaneous circulation (ROSC) after 82 minutes of downtime. An electrocardiogram (ECG) after ROSC showed an ST-elevation myocardial infarction (MI), and the patient underwent angiography showing a 100% occlusion of his left anterior descending artery. Following management of his coronary artery disease, he was discharged from the hospital 16 days later and was neurologically intact.

ADHERENCE TO GUIDELINE-RECOMMENDED VENTILATION RATE DURING CARDIAC ARREST: A QUALITY IMPROVEMENT STUDY

SESSION TITLE: Monday Electronic Posters 2 SESSION TYPE: Original Inv Poster Discussion PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM PURPOSE: The delivery of cardiopulmonary resuscitation (CPR) with correct chest compression quality and ventilation rate is critical for patient survival. The American Heart Association adult advanced cardiac life support guidelines recommend a respiratory rate of 8-10 breaths per minute after advanced airway placement during CPR. However, multiple small observational studies have demonstrated ventilation rates during CPR are in excess of recommendations. Physiologically, hyperventilation raises positive intrathoracic pressure, decreases preload, reduces cardiac output, and may therefore worsen clinical outcomes. We sought out to evaluate real-world guideline adherence to ventilation rate during CPR during in-hospital cardiac arrest. METHODS: This was a retrospective analysis of a multicenter prospective observational study that evaluates outcomes in cardiac arrest involving 15 sites in the US and the UK. RESULTS: Of the 393 patients with end-tidal CO2 (EtCO2) monitoring, 100 had tracings to evaluate median respiratory rate. The average patient was 69 years old (SD 16), 33% were female, average CPR duration was 33.4 minutes (SD 32.3), median end-tidal CO2 was 21.6 (SD 11), and median respiratory rate was 15 breaths/min (SD 7). Of the cohort, 56% had return of spontaneous circulation (ROSC) with 32% of the cohort achieving sustained ROSC for >20 minutes. Eight percent were ventilated at a rate of 0-6 breaths/min, 28% at 7-12 breaths/min, 46% at 13-19 breaths/min, 18% at ≥20 breaths/min. Among this group of patients, there was no association with ventilation rate and ROSC. CONCLUSIONS: Nearly two thirds of patients in our database were receiving hyperventilation during CPR. Approximately a fifth of patients were being ventilated over double the recommended rate. CLINICAL IMPLICATIONS: There may be a role for ventilation rate feedback devices, or timers during in-hospital cardiac arrest. DISCLOSURES: no disclosure on file for James Horowitz; No relevant relationships by Oscar Mitchell, source=Web Response No relevant relationships by Sam Parnia, source=Web Response No relevant relationships by Emma Roellke, source=Web Response No relevant relationships by Rachel Sibley, source=Web Response No relevant relationships by Eugene Yuriditsky, source=Web Response

69 Treatment Variation of Stable Ventricular Tachycardia in the Emergency Department

Advanced cardiac life support (ACLS) guidelines allow various treatments for stable monomorphic ventricular tachycardia (VT). Research on this topic has been limited by the transient nature of this rhythm, hence most studies have small sample sizes and are difficult to reproduce. The purpose of this study is to compare the relative effectiveness and safety of initial therapies used to treat stable VT across 21 community emergency departments (EDs). This retrospective cohort study used structured chart review of all treated adults with ED presentations for prolonged (>2 min) monomorphic VT in 21 community EDs from 01/2010 through 12/2017. We defined monomorphic VT as a regular wide complex tachycardia (WCT) with QRS >120 ms and rate >120 beats/min. Supraventricular tachycardia with aberrancy was excluded based on Brugada criteria for VT and confirmed by the cardiology consult obtained during the patient encounter. We excluded unstable patients defined as those with an abnormal level of consciousness, dyspnea at rest, severe anginal symptoms, or physician documentation of instability. We used descriptive statistics and reported results at the patient encounter level. We described the incidence of initial treatments, successful termination (defined as VT termination within 20 minutes lasting >30 min), ED cardiac arrest following the initial intervention, and death. We compare outcomes using a two-tailed chi-square test. We analyzed 359 eligible ED presentations from 339 patients. Mean age was 70.0 years and 22.3% of cases were female: 125 (34.8%) had an automated implantable cardioverter-defibrillator (AICD), 185 (51.5%) had congestive heart failure, and 122 (34.0%) were taking chronic antiarrhythmic medications. WCT was evaluated with adenosine in 40 cases (11.1%). Initial VT treatments were intravenous amiodarone (n=196, 54.6%), external direct-current cardioversion [DCC] (n=88, 24.5%), lidocaine (n=30, 8.4%), AICD shock (n=14, 3.9%), procainamide (n=3, 0.8%), and other treatments (n=28, 7.8%). We report initial treatment success in the Table. DCC was significantly more effective than amiodarone (81.8% vs 37.2%; p<0.0001). Overall, 160 presentations (45.1%) required multiple treatments prior to ED disposition. Cardiac arrest was uncommon in this study (2.7%) and could not be associated with specific interventions due to small sample size. Five patients (1.5%) suffered cardiac arrest after the initial ED intervention, four others (1.2%) suffered cardiac arrest in the ED after subsequent interventions, one of whom died in the ED prior to disposition. Emergency physicians use a variety of treatments for stable monomorphic VT with differing rates of success. Amiodarone is the most common initial treatment, but it may be less effective than DCC. Because initial treatments are often ineffective, patients frequently require multiple interventions. Opportunities exist for improvements in care.

Trends Over Time in Drug Administration During Adult In-Hospital Cardiac Arrest.

Clinical providers have access to a number of pharmacologic agents during in-hospital cardiac arrest. Few studies have explored medication administration patterns during in-hospital cardiac arrest. Herein, we examine trends in use of pharmacologic interventions during in-hospital cardiac arrest both over time and with respect to the American Heart Association Advanced Cardiac Life Support guideline updates. Observational cohort study. Hospitals contributing data to the American Heart Association Get With The Guidelines-Resuscitation database between 2001 and 2016. Adult in-hospital cardiac arrest patients. The percentage of patients receiving epinephrine, vasopressin, amiodarone, lidocaine, atropine, bicarbonate, calcium, magnesium, and dextrose each year were calculated in patients with shockable and nonshockable initial rhythms. Hierarchical multivariable logistic regression was used to determine the annual adjusted odds of medication administration. An interrupted time series analysis was performed to assess change in atropine use after the 2010 American Heart Association guideline update. A total of 268,031 index in-hospital cardiac arrests were included. As compared to 2001, the adjusted odds ratio of receiving each medication in 2016 were epinephrine (adjusted odds ratio, 1.5; 95% CI, 1.3-1.8), vasopressin (adjusted odds ratio, 1.5; 95% CI, 1.1-2.1), amiodarone (adjusted odds ratio, 3.4; 95% CI, 2.9-4.0), lidocaine (adjusted odds ratio, 0.2; 95% CI, 0.2-0.2), atropine (adjusted odds ratio, 0.07; 95% CI, 0.06-0.08), bicarbonate (adjusted odds ratio, 2.0; 95% CI, 1.8-2.3), calcium (adjusted odds ratio, 2.0; 95% CI, 1.7-2.3), magnesium (adjusted odds ratio, 2.2; 95% CI, 1.9-2.7; p < 0.0001), and dextrose (adjusted odds ratio, 2.8; 95% CI, 2.3-3.4). Following the 2010 American Heart Association guideline update, there was a downward step change in the intercept and slope change in atropine use (p < 0.0001). Prescribing patterns during in-hospital cardiac arrest have changed significantly over time. Changes to American Heart Association Advanced Cardiac Life Support guidelines have had a rapid and substantial effect on the use of a number of commonly used in-hospital cardiac arrest medications.