Advanced Cardiac Life Support Protocols Research Articles

An innovative approach to teaching resuscitation skills

We report the impact of a monthly educational exercise for residents that emphasized practical skills and equipment usage rather than knowledge of advanced cardiac life support (ACLS) protocols. Residents were divided into groups of approximately four that rotated through three stations. Each station included several objectives, most of which related to specific types of equipment. The exercise was held six times from July 2003 to June of 2004. Sixty-seven residents participated and completed a questionnaire prior to and following the exercise. The questionnaire elicited comfort level with basic tasks including using an automated external defibrillator (AED), attaching leads and paddles to read a cardiac rhythm, delivering unsynchronized shocks with monophasic and biphasic defibrillators and implementing the pacing function on a defibrillator. There were significant differences in the pre- and post-answers to each question. The largest difference was found in the question asking how comfortable participants were delivering unsynchronized shocks with a defibrillator. Importantly, responses for the question ‘How comfortable are you being a code leader?’ showed significant improvement. Simple skills such as attaching tubing to the oxygen tank, turning on the defibrillator and entering appropriate charge, or positioning paddles and monitor leads properly often caused significant difficulty. Cardiopulmonary arrests tend to generate anxiety among house staff, despite certification in ACLS and adequate knowledge of protocols. Exercises, such as the one presented here, will reduce anxiety by specifically addressing this skill. We conclude that residents benefit from additional teaching and practice in actual performance of basic skills used during cardiac arrests. Furthermore, our data demonstrate that comfort levels among house officers increase when they are given the opportunity to practice these skills.

Using simulation for training and to change protocol during the outbreak of severe acute respiratory syndrome

IntroductionDuring the 2003 severe acute respiratory syndrome (SARS) crisis, we proposed and tested a new protocol for cardiac arrest in a patient with SARS. The protocol was rapidly and effectively instituted by teamwork training using high-fidelity simulation.MethodsPhase 1 was a curriculum design of a SARS-specific cardiac arrest protocol in three steps: planning the new protocol, repeated simulations of this protocol in a classroom, and a subsequent simulation of a cardiac arrest on a hospital ward. Phase 2 was the training of 275 healthcare workers (HCWs) using the new protocol. Training involved a seminar, practice in wearing the mandatory personal protection system (PPS), and cardiac arrest simulations with subsequent debriefing.ResultsSimulation provided insights that had not been considered in earlier phases of development. For example, a single person can don a PPS worn for the SARS patient in 1 1/2 minutes. However, when multiple members of a cardiac arrest team were dressing simultaneously, the time to don the PPS increased to between 3 1/2 and 5 1/2 minutes. Errors in infection control as well as in medical management of advanced cardiac life support (ACLS) were corrected.ConclusionDuring the SARS crisis, real-time use of a high-fidelity simulator allowed the training of 275 HCWs in 2 weeks, with debriefing and error management. HCWs were required to manage the SARS cardiac arrest wearing unfamiliar equipment and following a modified ACLS protocol. The insight gained from this experience will be valuable for future infectious disease challenges in critical care.

Simulation-Based Training of Internal Medicine Residents in Advanced Cardiac Life Support Protocols: A Randomized Trial

Background: Internal medicine residents must be competent in Advanced Cardiac Life Support (ACLS) for board certification.Purpose: The purpose was to use a medical simulator to assess baseline proficiency in ACLS and determine the impact of an intervention on skill development.Method: This was a randomized trial with wait-list controls. After baseline evaluation in all residents, the intervention group received 4 education sessions using a medical simulator. All residents were then retested. After crossover, the wait-list group received the intervention, and residents were tested again. Performance was assessed by comparison to American Heart Association guidelines for treatment of ACLS conditions with interrater and internal consistency reliability estimates.Results: Performance improved significantly after simulator training. No improvement was detected as a function of clinical experience alone. The educational program was rated highly.

Prioritization and Treatment of Patients with Thoracolumbar Trauma and Multiple Injuries

Individuals with thoracolumbar trauma commonly sustain other injuries. Proper prioritization of these injuries is critical for obtaining optimal patient outcomes. Initial treatment should focus on life-threatening injuries utilizing advanced trauma life support (ATLS) and advanced cardiac life support (ACLS) protocols; when stabilized, the patient's skeletal injuries should be addressed. A thoracolumbar injury can be considered an additional long bone fracture when prioritizing treatment. Neurological status dictates which injuries are addressed initially. Worsening neurologic status, specifically cauda equina syndrome, dictates urgent (<48 hours) decompression and stabilization if necessary. Long bones (especially the femur) should be addressed definitively within 24 hours whenever possible, but complex fractures may require temporary stabilization (i.e., external fixation). Spinal surgery performed within 72 hours of injury is also recommended and can be performed concomitantly with limb injuries if the...

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

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

Amiodarone attenuates fluoride-induced hyperkalemia in vitro.

Poisoning by hydrofluoric acid or fluoride salts results in hypocalcemia, hypomagnesemia, and hyperkalemia with subsequent cardiac dysrhythmias. In previous studies, quinidine attenuated fluoride-induced hyperkalemia in vitro, and enhanced survival in animals. Like quinidine, amiodarone is a potassium channel blocker, although amiodarone is more familiar to clinicians due to its recent inclusion in advanced cardiac life support (ACLS) protocols. This in-vitro study of human erythrocytes was designed to determine whether amiodarone could attenuate fluoride-induced hyperkalemia. Six healthy volunteers each donated 60 mL of blood on three occasions. Each specimen was divided into 12 tubes, incubated at 37 degrees C, and oxygenated with room air. An aqueous sodium fluoride (F(-)) solution was added to tubes 1-9. Incremental amounts of quinidine were added to tubes 1-4 (Q(1)-Q(4)) to attain calculated concentrations of 0.73 microg/mL, 1.45 microg/mL, 2.9 microg/mL, and 5.8 microg/mL, respectively. Incremental amounts of amiodarone were added to tubes 5-8 (A(1)-A(4)) to attain calculated concentrations of 0.38 microg/mL, 0.75 microg/mL, 1.5 microg/mL, and 3.0 microg/mL, respectively. Tubes 9-12 were controls for each of F(-), amiodarone, quinidine alone, and no additive, respectively. Extracellular potassium concentration ([K(+)]) was followed, and an objective endpoint was defined as the rise in potassium concentration at 6 hours. Fluoride produced a significant change in [K(+)] by 6 hours in all samples. Quinidine produced a J-shaped curve in its ability to attenuate the rise in [K(+)], with only one concentration, Q(3), demonstrating significance versus tube 9 (control). Amiodarone also demonstrated a J-shaped dose-response effect, with statistical significance at A(1), A(2), and A(3) versus tube 9 (control). There was no significant difference among the effective concentrations (Q(3), A(1), A(2), and A(3)) of both drugs. In this in-vitro model using human blood, amiodarone and quinidine both attenuated F(-)-induced hyperkalemia. Further study is indicated to determine whether amiodarone enhances survival in F(-)-poisoned animals.

Amiodarone Attenuates Fluoride‐induced Hyperkalemia in Vitro

AbstractPoisoning by hydrofluoric acid or fluoride salts results in hypocalcemia, hypomagnesemia, and hyperkalemia with subsequent cardiac dysrhythmias. In previous studies, quinidine attenuated fluoride‐induced hyperkalemia in vitro, and enhanced survival in animals. Like quinidine, amiodarone is a potassium channel blocker, although amiodarone is more familiar to clinicians due to its recent inclusion in advanced cardiac life support (ACLS) protocols. Objectives: This in‐vitro study of human erythrocytes was designed to determine whether amiodarone could attenuate fluoride‐induced hyperkalemia. Methods: Six healthy volunteers each donated 60 mL of blood on three occasions. Each specimen was divided into 12 tubes, incubated at 37°C, and oxygenated with room air. An aqueous sodium fluoride (F−) solution was added to tubes 1–9. Incremental amounts of quinidine were added to tubes 1–4 (Q1–Q4) to attain calculated concentrations of 0.73 μg/mL, 1.45 μg/mL, 2.9 μg/mL, and 5.8 μg/mL, respectively. Incremental amounts of amiodarone were added to tubes 5–8 (A1–A4) to attain calculated concentrations of 0.38 μg/mL, 0.75 μg/mL, 1.5 μg/mL, and 3.0 μg/mL, respectively. Tubes 9–12 were controls for each of F−, amiodarone, quinidine alone, and no additive, respectively. Extracellular potassium concentration ([K+]) was followed, and an objective endpoint was defined as the rise in potassium concentration at 6 hours. Results: Fluoride produced a significant change in [K+] by 6 hours in all samples. Quinidine produced a J‐shaped curve in its ability to attenuate the rise in [K+], with only one concentration, Q3, demonstrating significance versus tube 9 (control). Amiodarone also demonstrated a J‐shaped dose–response effect, with statistical significance at A1, A2, and A3 versus tube 9 (control). There was no significant difference among the effective concentrations (Q3, A1, A2, and A3) of both drugs. Conclusions: In this in‐vitro model using human blood, amiodarone and quinidine both attenuated F−‐induced hyperkalemia. Further study is indicated to determine whether amiodarone enhances survival in F−‐poisoned animals.

Training Residents in ACLS/Code Response Using a Computerized Medical Simulator: Improving Resident Comfort and Preparedness

Internal Medicine residents are responsible for leading thecode response team at most teaching hospitals, yet manygraduating interns (PGY1s) may feel unprepared to runcodes. Currently, the only formal training for house staffis the two-day American Heart Association’s AdvancedCardiac Life Support (ACLS) course, generally required atthe beginning of internship, with recertification necessaryevery two years. This course does not address leadershipskills or a resident’s self-reported sense of comfort withleading a code team within a teaching hospital. Priorinvestigations have highlighted the deterioration inknowledge of important ACLS protocols, with knowledgelevels at or near ACLS training levels within 6 months.1,2Schwid and Sivarajan showed that the use of computerizedACLS simulator on CD-ROM improves retention of theguidelines better than textbook review alone.3 Others haveshown that refresher courses can enhance performance ina mock resuscitation setting, with improvementsmaintained, in part, over several months.4 The use of morelife-like simulation training has recently come into favor,through a variety of commercially available medicalsimulators. We designed an ACLS training program withsuch a medical simulator for interns preparing for theirPGY2 year, namely those residents about to assumeresponsibility for leadership of the code team. Prior to thesimulation training sessions, we collected baseline dataregarding interns’ experiences in code situations andcomfort with the anticipated transition to leading the codeteam, as they advance to the PGY2 year of training.

Vasopressin: New Uses in Critical Care

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

On Call Cardiology

HomeCirculationVol. 105, No. 12On Call Cardiology Free AccessBook ReviewPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessBook ReviewPDF/EPUBOn Call Cardiology Lane R. Miller, MD Lane R. MillerLane R. Miller Texas Heart Institute, Houston, Texas Search for more papers by this author Originally published26 Mar 2002https://doi.org/10.1161/01.CIR.0000012627.97761.FECirculation. 2002;105:e77M. Gabriel Khan 486 pp. Philadelphia: Saunders; 2001. $28.00. ISBN 0-7216-9222-2Another title for this book could be “The Survivor’s Guide to CCU Call.” Directed at medical students and residents, this book is intended for use as a quick guide to common, cardiology-related problems that may arise while on call.The premise is that young physicians in training are faced with difficult and intimidating clinical scenarios at night with limited back-up resources. This book is a quick “how to” on clinical cardiology in the acute inpatient arena.This is the second edition of this book. New features include expansion of new diagnostic and therapeutic strategies, study sections to allow the reader to review key concepts, a new chapter on evaluating and treating patients with murmurs, and a Global Drug Table comparing the names of cardiac drugs among different countries.The general outline of the book is easy to read and follows a simplistic style (often cookbook-like). The book is divided into 3 sections. The first section covers introductory material on the following: (1) approach to the diagnosis and management of on-call problems, (2) documentation, (3) extrathoracic physical examination, (4) cardiac physical examination, and (5) guide to ecg diagnosis.The second section is called “Patient-Related Problems: The Common Calls.” This places the reader in a first-person scenario in the setting of common cardiac situations. Acute myocardial infarction, unstable angina, pericarditis, cardiac tamponade, hypotension/shock, dyspnea, edema, cough, pulmonary embolism, congestive heart failure, palpitations, arrhythmias, fever, hypertension, syncope, cardiac arrest, deep vein thrombosis, and murmurs are covered. The book walks you through every aspect of critical thinking, including what questions to ask the nurse on the phone, what you should be thinking about on the elevator, and what to do at the bedside.The third section is an appendix that includes advanced cardiac life support protocols, infusion pump charts, and drug tables outlining indications, interactions, dosages, and adverse effects.This book is well organized, and the content covers the salient points of caring for hospitalized cardiac patients. The ECG section is excellent. This section is complete with vector pathophysiology and a nice assortment of abnormal ECGs that the reader will need to recognize while on call.I thought that the common calls section was well thought-out and complete. This is not a board review textbook; thus, the pathophysiology is minimal. However, this section does a nice job of walking the house officer through many cardiac challenges. There are a few landmark trial references that are nice for the reader to use for further study.A section on central lines would have been appropriate for this book. Indications, anatomy, technique, and pitfalls of central line placement deserve some mention in a textbook of this context. Some attention to basic pacemaker interrogation would also have been of value.In summary, this book is well written and serves as a nice guide for medical students and residents in managing acute cardiac problems in the hospital. The content is a bit shallow for a fellow’s daily use; however, it may come in handy when getting swamped in the cardiac care unit (CCU). Previous Back to top Next FiguresReferencesRelatedDetails March 26, 2002Vol 105, Issue 12Article InformationMetrics https://doi.org/10.1161/01.CIR.0000012627.97761.FE Originally publishedMarch 26, 2002 PDF download Advertisement

Comments on the Laryngeal Mask Insertion Technique Presented in the New Advanced Cardiac Life Support Protocol

To the Editor: The new 2000 guidelines for cardiopulmonary resuscitation and emergency cardiovascular care were published in August 2000.1 The laryngeal mask airway (LMA) was presented as an alternative airway. We would like to comment on the illustration to insert the LMA. The picture depicts several classic mistakes made during the insertion of the LMA. These may lead to LMA malpositioning and inability to achieve an airway and ventilation.2 In the 2000 guidelines, the LMA is depicted with a semi-inflated cuff, held by the shaft with the left hand and introduced straight into the mouth. The correct LMA technique3 is based on a close imitation of the swallowing mechanism. Before attempting insertion, the LMA cuff should be completely deflated and lubricated. The LMA is held with the dominant hand. The hand holds the LMA like a pen, with the index finger placed at the junction of the cuff and the shaft, with the LMA opening oriented over the tongue. The LMA is passed behind …

Vasopressin or epinephrine: which initial vasopressor for cardiac arrests?

The use of vasopressors in the management of cardiac arrests seems at face value to be beyond question. Together with defibrillation, the maintenance of an adequate perfusion pressure to the heart and brain has long been deemed a priority of Advanced Cardiac Life Support protocols. To this end, the quest for the optimum vasopressor(s), drug and dose, has generated many laboratory studies and clinical trials. Indeed, the recent meta-analysis of studies of high-dose epinephrine for out-of-hospital resuscitation included over 6000 patients.

Cultivating Conscience: Learning to Make End-of-Life Decisions in the Emergency Department

Cultivating Conscience: Learning to Make End-of-Life Decisions in the Emergency Department

Effects of Adding Links to “The Chain of Survival” for Prehospital Cardiac Arrest: A Contrast in Outcomes in 1975 and 1995 at a Single Institution

Study objective: The concept of a “chain of survival” to improve outcome from prehospital cardiac arrest has been defined and promulgated over the last two decades. The purpose of this study was to compare outcomes of prehospital cardiac arrest in 1975 and 1995 at a single institution. Methods: This longitudinal, before-after study compares published data collected at our municipal, tertiary care in 1974–1975 with data collected prospectively in 1995. The 1975 study group served as control subjects (n=120). We enrolled an equal number of consecutive patients who met inclusion criteria in the 1995 cohort (consecutive patients who experienced prehospital arrest and who received prehospital Advanced Cardiac Life Support (ACLS) measures during the two study periods). Patients younger than 18 years or with posttraumatic arrest were excluded. Between 1975 and 1995 the following “links” in the “chain of survival” were added to the prehospital care system: (1) 911 access and dispatch, (2) paramedic endotracheal intubation, (3) EMT automated defibrillation, (4) standing out-of-hospital orders before hospital radiotelemetry contact, and (5) introduction of American Heart Association ACLS algorithms. Results: The following significant differences (χ 2) were observed between the study periods: prevalence of ventricular fibrillation or tachycardia (42% in 1975 versus 28% in 1995, P=.021), prevalence of asystole or pulseless electrical activity as the first documented rhythm (58% versus 72%, P=.021), survival to hospital discharge (22% versus 9%, P=.007), and percent of survivors of ventricular fibrillation or tachycardia (30% versus 0%, P=.004). Eighty-six percent of the 1995 cohort had advanced chronic disease and 29% experienced cardiopulmonary arrest in a nursing home. Conclusion: Survival decreased dramatically during the 20-year study period. This may be because of the high incidence of chronic disease, the greater frequency of asystole and pulseless electrical activity, and the inclusion of patients with “end-of-life” arrests in which ACLS protocol was initiated in the 1995 cohort. The patient population in which ACLS is initiated is the weakest link in the “chain of survival.” [Stratton S, Niemann JT: Effects of adding links to “the chain of survival” for prehospital cardiac arrest: A contrast in outcomes in 1975 and 1995 at a single institution. Ann Emerg Med April 1998;31:471-477.]

Advanced cardiac life support events in a community hospital and their outcome: evaluation of actual arrests

To evaluate resuscitation efforts for patients with cardiac and/or pulmonary arrest in our hospital a retrospective study was conducted and compared with available data from other community teaching hospitals. Records of 131 consecutive patients of ages 16–98 who received resuscitation according to Advanced Cardiac Life Support protocols were reviewed. Short-term survival (return of spontaneous circulation) and discharge-from-the-hospital survival were measured. Nineteen patients (15%) were excluded from the study because the information recorded on the code record sheet was insufficient. Overall short-term survival rate was 34.8%. Resuscitations in the Emergency Room were evaluated separately, because most of them were initiated outside of the hospital. Their short-term survival was 14%, but none of them survived to be discharged. Out of 69 inpatient resuscitative efforts, 33 were successful (47.8%). Of these 33, nine (13.0%) left the hospital. The rest expired during the same hospitalization. Short-term survival for patients after coronary artery bypass graft surgery was 60% (6 of 10) and 30% (3 of 10) were discharged home. Forty percent of official code records were incomplete. We concluded that better education and more emphasis on record-keeping are mandatory, with the main burden falling upon the nurse in charge to have received more precise instruction. Contrary to published data, women did not have a better survival than men ( P>0.05). There was no difference in outcomes between resident physician directed codes compared to attending physician directed codes ( P>0.05). The mean age of inpatient short-term survivors was 69.0 (±13.2) years and that of non-survivors 69.8 (±15.7) years ( P>0.05). Post-bypass surgery patients had a better survival than non-surgical patients, but the difference was not significant ( P>0.05). Survival in our hospital was comparable to one hospital and worse than another (34.8% vs. 39.6% or 63.0%). Despite success, prognosis after arrest remains poor.

Case of the Month

A 20-YEAR-OLD MAN who was a college baseball player in excellent health complained of back pain and malaise. His symptoms became progressively worse despite being prescribed several medications. Nausea, bloody diarrhea, submandibular lymphadenopathy, hemoptysis, blurred vision, and dizziness developed. On presentation to an emergency department, the results of laboratory studies showed marked leukocytosis and disseminated intravascular coagulation. The patient was transferred to a university hospital, where the possibility of an unusual viral illness was considered. He appeared stable on admission to the hospital but suddenly became unresponsive and apneic 4 hours later. A cardiac monitor indicated electromechanical dissociation, and the advanced cardiac life support protocol was unsuccessful. An autopsy was requested by the physician primarily to identify the etiologic agent of the presumed fatal viral illness. <h3>AUTOPSY FINDINGS</h3> Major autopsy findings included severe hypersensitivity myocarditis, acute respiratory disease syndrome, interstitial nephritis, and centrilobular hepatic necrosis. All the organs examined showed

Effect of Advanced Cardiac Life Support Training on Resuscitation Efforts and Survival in a Rural Hospital

Study objective: To determine the impact of an Advanced Cardiac Life Support (ACLS) training program on resuscitation and survival in a rural hospital. Methods: Retrospective review of arrests in a 119-bed rural community hospital before, during, and after organization of an ACLS teaching program. ICU logs, death logs, and code review sheets were used to determine resuscitation efforts and outcomes; these were cross-checked with medical and administrative records. From 1980 through 1984, resuscitation attempts were conducted only in the ICU. By 1985, after the training program was instituted, resuscitation efforts were conducted throughout the hospital. Data are presented on resuscitations in the ICU only and on total hospital resuscitations. To assess effort, resuscitation attempts and successes were compared with total death events (ie, total number of hospital deaths plus total number surviving a resuscitation effort). Results: From 1980 through 1984, before ACLS training was instituted, 42 patients were resuscitated and 15 (36%) survived to discharge. From 1985 through 1987, 113 ICU patients were resuscitated and 29 (26%) survived. From 1988 through 1990, after ACLS protocol and code review procedures were established, 81 ICU patients were resuscitated and 23 (28%) survived. The number of attempted resuscitations throughout the hospital increased from 42 in the early period to 179 in the final period, with 15 (36%) and 52 (29%) survivors, respectively. Rates of ICU or hospitalwide resuscitation success were not significantly different over time ( P>.3). There were 893 total death events in the early period and 485 in the final period. The percentage of death events with an intervention rose from 5% to 37% ( P<.001), and the percentage reversed by intervention increased from 2% to 11% ( P<.001). Conclusion: After widespread ACLS training and code team organization, there was a significant increase in resuscitation efforts and reversal of death events despite a slight decline in the percentage of patients surviving resuscitation attempts. An ACLS training program in a rural hospital can contribute to increased overall survival. [Camp BN, Parish DC, Andrews RH: Effect of Advanced Cardiac Life Support training on resuscitation efforts and survival in a rural hospital. Ann Emerg Med April 1997; 29:529-533.]

Real-Time Ultrasound–Guided Femoral Vein Catheterization During Cardiopulmonary Resuscitation

Study objective: To compare the use of real-time–ultrasound guidance with the standard landmark-oriented approach for obtaining femoral vein catheterization in patients requiring intravenous access during CPR. Methods: Prospective, randomized, paired subject-controlled clinical trial in the setting of an urban teaching county hospital emergency department. The study comprised a convenience sample of 20 patients presenting with apnea and pulselessness in the ED. Each patient received bilateral femoral lines, one by ultrasound guidance and one by the landmark approach (control). Randomization determined which technique and which side would be attempted first. The following parameters were recorded: time to initial flash of blood, time to completion of catheterization, number of needle passes, and rate of arterial catheterization. CPR and Advanced Cardiac Life Support protocols were continued during both procedures. Results: Real-time ultrasound-guided catheterization had a higher success rate (90% versus 65%, P=.058), a lower number of needle passes (2.3±3 versus 5.0±5, P=.0057), and a lower rate of arterial catheterization (0% versus 20%, P=.025) than the standard landmark-oriented approach. Ultrasound was also slightly faster in time to blood flash and in time to catheterization. An incidental finding of interest was that real-time ultrasound demonstrated the presence of femoral vein pulsations during CPR. Conclusion: Real-time ultrasound-guided femoral vein catheterization was faster and produced a lower rate of inadvertent arterial catheterization and a higher rate of success during CPR than the standard landmark-oriented approach. Also, ultrasound demonstrated that palpable femoral pulsation during CPR is venous rather than arterial. [Hilty WM, Hudson PA, Levitt MA, Hall JB: Real-time ultrasound–guided femoral vein catheterization during cardiopulmonary resuscitation. Ann Emerg Med March 1997;29:331-337.]

The association between age of hospitalized patients and the delivery of advanced cardiac life support.

To determine the extent of variability in the administration of advanced cardiac life support (ACLS) and to determine if age is associated with variability. Retrospective cohort. Urban teaching hospital. One hundred twenty-two adult inpatients without a "do-not resuscitate" order who suffered cardiopulmonary arrest during 1993. Of the total, 35 (29%) survived the arrest and 87 (71%) died. Among the nonsurvivors, two patients received no ACLS and six were not intubated, despite the inclusion of intubation in all ACLS protocols. Of the 87 nonsurvivors, 31 had a single electrocardiographic rhythm during their arrest and should have had similar ACLS trials. However, the 9 nonsurvivors with ventricular fibrillation received a range of 0 to 17 interventions, the 11 with electromechanical dissociation received 1 to 22, and the 11 with asystole received 0 to 14. Based on a protocol-derived definition of a minimal trial of ACLS (a "short ACLS trial") for all 87 nonsurvivors, age greater than 75 was associated with receiving a short trial. Dependent functional status and being on a medical service were also associated with a short ACLS trial. In a logistic regression model including these variables as covariates, age remained significantly associated with a short ACLS trial; odds ratio, 9.71 (95% confidence interval 1.68, 56.1). Wide variability exists in the administration of ACLS at the studied site. The finding that some patients receive no ACLS suggests that physicians at this site may be making bedside determinations of the likelihood of its benefit based on individual patient characteristics. The association between older age and short ACLS trials among all nonsurvivors suggests that age is most important of these characteristics.

A technique revisited: Hemodynamic comparison of closed- and open-chest cardiac massage during human cardiopulmonary resuscitation: Crit Care Med 1995; 23/3 (498–503)

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