Advanced Cardiac Life Support Protocols Research Articles

253 Trends in Out-of-Hospital Cardiac Arrests in Los Angeles

The aim of this study was to evaluate the characteristics and outcomes of out-of-hospital cardiac arrests (OOHCA) in order to determine the potential impact of changes in CPR and advanced cardiac life support (ACLS) protocols. This was a retrospective cohort study which included all adult (age >18), non-traumatic out-of-hospital cardiac arrest patients in the City of Los Angeles from 2003 through 2010, upon whom paramedics initiated resuscitative efforts. We determined the annual number of cardiac arrests, the incidence of primary ventricular fibrillation, the rate of return of spontaneous circulation, and the frequency where paramedics terminated resuscitative (TOR) efforts on scene through on-line medical control. All Los Angeles Fire Department EMTs and paramedics were trained in 2006 on the 2005 CPR/ACLS Guidelines, which emphasized the importance of quality CPR, avoiding hyperventilation, and remaining on scene for longer periods of time prior to hospital transport. During the study period there were 11,395 OOHCA. The incidence of primary ventricular fibrillation steadily declined from 21.2 % in 2003 to 17.7 % in 2010 (p =0.07). The rate of return of spontaneous circulation for all patients increased from 14.0% to 30.2% (p<0.0001); the rate of return of spontaneous circulation for witnessed ventricular fibrillation increased from 25.6% to 46.6% (p=0.009); and the rate of TOR increased from 17.7% to 30.2% (p<0.0001). Despite a decline in the incidence of primary ventricular fibrillation, the rate of return of spontaneous circulation increased significantly while the rate of termination of resuscitative efforts on scene also increased significantly. Attention to quality CPR, providing adequate time for out-of-hospital interventions on scene, and avoiding unnecessary transports of unsuccessful resuscitative efforts are essential in improving the outcome from OOHCA. Further study is needed to determine ultimate patient survival to hospital discharge.

Cross-Clamping During Elective Abdominal Aortic Aneurysm Surgery

Cross-Clamping During Elective Abdominal Aortic Aneurysm Surgery

Critical Care Medicine

Critical Care Medicine

The impact of prolonged continuous wakefulness on resident clinical performance in the intensive care unit: A patient simulator study*

To evaluate the impact of prolonged continuous wakefulness on resident performance under controlled experimental conditions. Experimental within-subjects comparison. High-fidelity patient simulator. Twelve residents in an Internal Medicine Program at various stages of training (range, 1-35 mos). Performance was studied during 26 hrs of continuous wakefulness at four time points (8:00-10:00 am, 2:00-4:00 pm, 2:00-4:00 am, and 8:00-10:00 am the next day) using high-fidelity patient simulation. At each session, residents managed eight simulated dysrhythmias according to advanced cardiac life support protocols (advanced cardiac life support scenarios) and then managed a simulated critically ill patient (e.g., patient with meningitis) to test more complicated clinical decision-making (complex scenario). The frequency of previously defined major medical errors (i.e., action or inaction that likely would have resulted in significant harm in a real patient) was assessed by a scorer blinded to the time of the session. For each complex scenario, a global score between 0 and 100 was also given for overall performance. The impact of wakefulness on performance was assessed by using longitudinal mixed-effects models. For the complex scenarios, the mean number of errors increased from 0.92 +/- 0.90 in the first session to 1.58 +/- 0.79 in the fourth session (p = .09), and mean global score decreased from 56.8 +/- 14.6 to 49.6 +/- 12.6 (p = .02). For the advanced cardiac life support scenarios, the mean number of major errors committed in the advanced cardiac life support scenarios decreased during the study period (p = .01). However, essentially all of the improvement occurred between the first and second time points, suggesting that a substantial learning effect accounted for the findings. During prolonged continuous wakefulness of medical residents, clinical performance in the management of a simulated critically ill patient deteriorates. The practice of scheduling residents for extended work shifts (>24 hrs) should be reconsidered.

A Practice of Anesthesia for Infants and Children, 4th Edition.

A Practice of Anesthesia for Infants and Children, 4th Edition.

Intravenous Drug Administration During Out-of-Hospital Cardiac Arrest

Intravenous access and drug administration are included in advanced cardiac life support (ACLS) guidelines despite a lack of evidence for improved outcomes. Epinephrine was an independent predictor of poor outcome in a large epidemiological study, possibly due to toxicity of the drug or cardiopulmonary resuscitation (CPR) interruptions secondary to establishing an intravenous line and drug administration. To determine whether removing intravenous drug administration from an ACLS protocol would improve survival to hospital discharge after out-of-hospital cardiac arrest. Prospective, randomized controlled trial of consecutive adult patients with out-of-hospital nontraumatic cardiac arrest treated within the emergency medical service system in Oslo, Norway, between May 1, 2003, and April 28, 2008. Advanced cardiac life support with intravenous drug administration or ACLS without access to intravenous drug administration. The primary outcome was survival to hospital discharge. The secondary outcomes were 1-year survival, survival with favorable neurological outcome, hospital admission with return of spontaneous circulation, and quality of CPR (chest compression rate, pauses, and ventilation rate). Of 1183 patients for whom resuscitation was attempted, 851 were included; 418 patients were in the ACLS with intravenous drug administration group and 433 were in the ACLS with no access to intravenous drug administration group. The rate of survival to hospital discharge was 10.5% for the intravenous drug administration group and 9.2% for the no intravenous drug administration group (P = .61), 32% vs 21%, respectively, (P<.001) for hospital admission with return of spontaneous circulation, 9.8% vs 8.1% (P = .45) for survival with favorable neurological outcome, and 10% vs 8% (P = .53) for survival at 1 year. The quality of CPR was comparable and within guideline recommendations for both groups. After adjustment for ventricular fibrillation, response interval, witnessed arrest, or arrest in a public location, there was no significant difference in survival to hospital discharge for the intravenous group vs the no intravenous group (adjusted odds ratio, 1.15; 95% confidence interval, 0.69-1.91). Compared with patients who received ACLS without intravenous drug administration following out-of-hospital cardiac arrest, patients with intravenous access and drug administration had higher rates of short-term survival with no statistically significant improvement in survival to hospital discharge, quality of CPR, or long-term survival. clinicaltrials.gov Identifier: NCT00121524.

Critical action procedures testing: a novel method for test-enhanced learning

Human error is a leading cause of adverse events in anaesthesia. Residents' knowledge of how to respond to rare, yet potentially life-threatening events has been shown to deteriorate over time and thus cost-effective educational interventions are indicated. Previous research has shown that test-enhanced learning has the potential to strengthen both clinical knowledge and performance. We hypothesised that critical action procedures (CAPs) tests, similar to those employed by high-performance aircraft pilots, would help improve resident knowledge about how to respond to rare and potentially catastrophic events encountered during the perioperative period. Knowledge assessments were administered to 29 first-year anaesthesiology residents over the course of 9 months. Five-minute closed-book tests were administered with fill-in-the-blank questions regarding the American Society of Anesthesiologists' difficult airway guideline, advanced cardiac life support protocols, an institutional airway fire protocol and drug dosing for malignant hyperthermia. Inter-group comparisons were evaluated using the Kruskal-Wallis test. The difference between the pre-test and final test scores for each subsection was determined with the Mann-Whitney U-test for independent samples. Composite subtest scores, when compared with baseline pre-test scores and subsequent scores, and when adjusted for attrition, significantly improved over the course of 9 months (20.5% versus 80%; P < or = 0.001). Likert-based survey data indicated a positive report for attainment of knowledge. In this longitudinal observational study of first-year anaesthesiology residents, CAPs testing helped improve knowledge about critical events. Although the study was limited by its small number of subjects, a significant attrition rate and the lack of a control group, it demonstrates a cost-effective educational intervention that improved resident knowledge. This intervention may enable residents to transfer learned skills from theoretical testing situations to real-life scenarios. We propose the use and further study of CAPs testing as a cost-effective modality to augment both simulated and actual experiential learning.

Intensive Care Nurses’ Interest in Clinical Personal Digital Assistants

Intensive Care Nurses’ Interest in Clinical Personal Digital Assistants

Cardiac Arrest upon Induction of General Anesthesia: Transesophageal Echocardiography-assisted Diagnosis of Impending Paradoxical Embolus

CARDIAC arrest occurring upon the induction of general anesthesia in an otherwise healthy patient is distinctly rare. It is even more unusual to discover its etiology to be an impending paradoxical embolus (IPE). We present a case in which the timely use of transesophageal echocardiography (TEE), implemented during the course of cardiopulmonary resuscitation, revealed a large transatrial thromboembolus which had been trapped in transit through a patent foramen ovale.

Maximal medical therapy and palliative care can work together: When are advanced care measures appropriate?

Resuscitation status and patient wishes in terms of advanced cardiopulmonary support must be addressed during inpatient hospital admissions. However, the lack of clarity of the patients’ wishes and the variability in physicians’ comfort addressing these issues often leads to ambiguity in an emergency setting. This may result in inappropriately aggressive management, and conversely, it may also lead to withholding potentially lifesaving therapy due to ‘‘Do Not Resuscitate’’ (DNR) designation. We report a case of hemodynamic instability due to acute supraventricular tachycardia (SVT) in a patient with a DNR designation. He was successfully treated according to the advanced cardiac life support (ACLS) protocol for SVT. We also discuss some of the ethical challenges of providing potential life-sustaining interventions in palliative medicine, as well as the dilemma of whether or not to provide such interventions to patients who have DNR status.

The Utility of Simulation in Medical Education: What Is the Evidence?

Medical schools and residencies are currently facing a shift in their teaching paradigm. The increasing amount of medical information and research makes it difficult for medical education to stay current in its curriculum. As patients become increasingly concerned that students and residents are "practicing" on them, clinical medicine is becoming focused more on patient safety and quality than on bedside teaching and education. Educators have faced these challenges by restructuring curricula, developing small-group sessions, and increasing self-directed learning and independent research. Nevertheless, a disconnect still exists between the classroom and the clinical environment. Many students feel that they are inadequately trained in history taking, physical examination, diagnosis, and management. Medical simulation has been proposed as a technique to bridge this educational gap. This article reviews the evidence for the utility of simulation in medical education. We conducted a MEDLINE search of original articles and review articles related to simulation in education with key words such as simulation, mannequin simulator, partial task simulator, graduate medical education, undergraduate medical education, and continuing medical education. Articles, related to undergraduate medical education, graduate medical education, and continuing medical education were used in the review. One hundred thirteen articles were included in this review. Simulation-based training was demonstrated to lead to clinical improvement in 2 areas of simulation research. Residents trained on laparoscopic surgery simulators showed improvement in procedural performance in the operating room. The other study showed that residents trained on simulators were more likely to adhere to the advanced cardiac life support protocol than those who received standard training for cardiac arrest patients. In other areas of medical training, simulation has been demonstrated to lead to improvements in medical knowledge, comfort in procedures, and improvements in performance during retesting in simulated scenarios. Simulation has also been shown to be a reliable tool for assessing learners and for teaching topics such as teamwork and communication. Only a few studies have shown direct improvements in clinical outcomes from the use of simulation for training. Multiple studies have demonstrated the effectiveness of simulation in the teaching of basic science and clinical knowledge, procedural skills, teamwork, and communication as well as assessment at the undergraduate and graduate medical education levels. As simulation becomes increasingly prevalent in medical school and resident education, more studies are needed to see if simulation training improves patient outcomes.

Paradoxical Embolization by Amniotic Fluid Seen on the Transesophageal Echocardiography

Paradoxical Embolization by Amniotic Fluid Seen on the Transesophageal Echocardiography

Advanced Cardiac Life Support and Defibrillation in Severe Hypothermic Cardiac Arrest

The application of Advanced Cardiac Life Support (ACLS) in severe hypothermic cardiac arrest remains controversial. While the induction of mild hypothermia has been shown to improve outcomes in patients already resuscitated from cardiac arrest, it is unknown whether ACLS protocols are effective during the resuscitation of the severely hypothermic cardiac arrest patient. We describe a case of a 47-year-old man who was successfully resuscitated from a ventricular fibrillation (VF) arrest with a core body temperature of 26.4°C. The patient had been found unresponsive in a bathtub of cold water following an apparent suicide attempt. An incorrect pronouncement of death by the fire department delayed his transport to the hospital by more than four hours. Once in the emergency department (ED), the patient sustained a VF cardiac arrest and was successfully defibrillated using ACLS protocols. He ultimately survived his hospitalization with near-complete neurologic recovery. In this case report, we discuss the application of ACLS to the resuscitation of the hypothermic cardiac arrest patient as well as the issues involved in the prehospital determination of death.

Do IV Meds Matter in Out-of-Hospital Cardiac Arrest?

Intravenous access and drug administration have long been central elements of advanced cardiac life support (ACLS) protocols despite the absence of evidence that they improve outcomes. In a randomized, controlled, nonblinded trial, 851 consecutive adult patients with out-of-hospital, nontraumatic cardiac arrest in Oslo, Norway from 2003 to 2008 were randomized to receive ACLS with IV access and drug administration (epinephrine, atropine, and amiodarone were used) or …

Pain Clinic Emergencies

The increasing recognition of the need to treat chronic pain has led to an increase in the number of interventional procedures performed on an outpatient basis, and consequently, a rise in the number of complications as well. Safe interventional pain management requires Pain specialists have a comprehensive understanding of how to perform a procedure as well as how to manage any acute complications. Though simplistic, an emphasis on prevention is the solution to avoiding a complication. This involves meticulous planning of the injection technique based on the relevant anatomy, thoughtful selection of doses and concentrations of medications, careful injection of the medications, and attentive monitoring of the patient. When prevention is not enough, preparation can be life-saving. Resuscitation equipment should be readily accessible, and physicians should be prepared to institute Advanced Cardiac Life Support protocols. Immediate recognition of the signs and symptoms associated with a vasovagal reaction, hypotension, hypertension, systemic local anesthetic toxicity, high spinal, pneumothorax, and anaphylaxis is paramount, as prompt treatment offers the best chance for a successful outcome.

Be Prepared

Be Prepared

A cadaveric study of complications associated with the subxiphoid and transthoracic approaches to emergency pericardiocentesis

The aim of this cadaveric study was to compare three commonly used approaches for emergency pericardiocentesis and to determine the safest approach. Thirteen cadavers were injected at three sites with three different coloured dyes, one for each of the three different recommended approaches. The approaches used were (1) ATIP: anterior transthoracic in the fifth left intercostal space (Advanced Cardiac Life Support protocol), (2) SXP1: immediately subxiphoid and (3) SXP2: subxiphoid approach 1.5 cm inferior to SXP1 (Advanced Trauma Life Support protocol). The needles were left in the chest cavity to confirm their course on the way into the pericardial sac. Once the chest plate was removed, the location of the needle and the presence of dye enabled the identification of structures damaged and cavities entered by the needle. The associated complications from the three approaches were then recorded and compared. The anterior transthoracic intercostal pericardiocentesis approach to pericardiocentesis (2/39) and an immediately subxiphoid approach SXP1 (1/39) produced fewer potential complications than SXP2 (4/39). The SXP1 approach appeared to be the safest, followed by anterior transthoracic intercostal pericardiocentesis. The SXP2 approach caused the highest amount of complications, resulting from the needle entering the abdominal cavity. The presence of intra-abdominal pathology and the possibility of post-mortem changes in the position of the diaphragm, however, might have been a causative factor in this finding.

Successful Use of a 20% Lipid Emulsion to Resuscitate a Patient after a Presumed Bupivacaine-related Cardiac Arrest

The patient was a 58-yr-old, 82-kg, 170-cm male who presented for arthroscopic repair of a torn rotator cuff in the right shoulder. His medical history was significant for coronary artery bypass graft surgery at age 43 yr. He gave a history of angina upon exertion and occasionally at rest. He declined further preoperative cardiac workup but was considered by his cardiologist to be stable on medical therapy. This included nitroglycerine as needed, lisinopril, atenolol isosorbide mononitrate, and clopidogrel and enteric-coated aspirin, both of which had been discontinued 1 week previously. His preoperative electrocardiogram revealed a right bundle-branch block, a left anterior hemiblock, and evidence of an old anterior wall myocardial infarction. The patient arrived at the operating room holding area, where standard monitors were applied. Blood pressure was 120/80 mmHg, room air oxygen saturation measured by pulse oximetry was 98%, and heart rate was 60 beats/min. Supplemental oxygen was delivered at 3 l/min via a nasal cannula. A 20-gauge intravenous catheter was placed in the dorsum of his left hand, through which 2 mg midazolam and 50 g fentanyl were administered. A 50-mm, 22-gauge Stimuplex insulated needle was connected to a Stimuplex-DIG nerve stimulator (both B. Braun, Inc., Bethlehem, PA), and the interscalene groove was identified at the level of C6. The brachial plexus was identified by eliciting biceps stimulation (0.1-ms duration, 2 Hz) at 0.34 mA, following which 40 ml local anesthetic solution (20 ml bupivacaine, 0.5%, and 20 ml mepivacaine, 1.5%) were injected slowly (over approximately 2.5 min) in 5-ml increments with gentle aspiration between doses. The patient was awake and conversant during the performance of the block. At no time was any blood aspirated, nor did he report pain or paresthesias. Approximately 30 s after removal of the block needle, the patient became incoherent and then developed a tonic–clonic seizure. Oxygen was delivered by a facemask attached to a self-inflating resuscitation bag while 50 mg propofol was injected intravenously. The seizure stopped, and spontaneous respirations resumed. Approximately 90 s later, the patient began to seize again; this time, 100 mg intravenous propofol was administered. The electrocardiogram showed asystole, and no pulse, by carotid or femoral palpation, or blood pressure was detectable. Advanced cardiac life support was immediately started. The trachea was intubated, and end-tidal carbon dioxide was detected with an EasyCapII (Nellcor Inc., Hayward, CA). Tube position was confirmed by auscultation, after which chest compressions were immediately resumed. During the first 20 min of advanced cardiac life support, a total of 3 mg epinephrine, given in divided doses, 2 mg atropine, 300 mg amiodarone, and 40 U arginine vasopressin were administered. In addition, monophasic defibrillation was used at escalating energy levels—200, 300, 360, and 360 J, according to the advanced cardiac life support protocol. Cardiac rhythms included ventricular tachycardia with a pulse, pulseless ventricular tachycardia that momentarily became ventricular fibrillation, and eventually asystole. The arrhythmias observed during most of the resuscitation period were pulseless ventricular tachycardia and asystole. After 20 min, at which time plans were being made to institute cardiopulmonary bypass, the administration of a lipid emulsion was suggested, and 100 ml of 20% Intralipid (for Baxter Pharmaceuticals by Fresenius Kabi, Uppsala, Sweden) was given through the peripheral intravenous catheter. Cardiac compressions continued, and a defibrillation shock at 360 J was given. Within seconds, a single sinus beat appeared on the electrocardiogram, and 1 mg atropine and 1 mg epinephrine were administered. Within 15 s, while external chest compressions were continued, the cardiac rhythm returned to sinus at a rate of 90 beats/min. The blood pressure and pulse became detectable. An infusion of lipid emulsion was started and continued at 0.5 ml · kg 1 · min 1 over the following 2 h and then discontinued. The patient remained in sinus rhythm. He was weaned from mechanical ventilation, and his trachea was extubated, approximately 2.5 h later. He was awake and responsive, and had right upper extremity weakness consistent with a brachial plexus block. No neurologic sequelae were sustained, and he was subsequently transferred to a monitored setting for overnight observation. There was no evidence of complications secondary to the administration of intralipid (i.e., pancreatitis) during the following 2 weeks. Because the patient had a cardiac arrest after which he had increased levels of cardiac enzymes, he agreed to undergo cardiac catheterization. This revealed total occlusion of the right coronary artery and a left ventricular ejection fraction of 32%. As a consequence, an automatic implantable cardiac defibrillator was inserted without any complications, and the patient was discharged home.

The Usefulness of Transesophageal Echocardiography During Intraoperative Cardiac Arrest in Noncardiac Surgery

According to guidelines established by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists, life-threatening hemodynamic disturbances are classified as a category I indication for the intraoperative use of transesophageal echocardiography (TEE). However, the usefulness of TEE during intraoperative cardiac arrest and its impact on patient management have not been rigorously investigated. Using our departmental TEE database, we identified a population of 22 patients who underwent noncardiac surgical procedures and experienced unexpected intraoperative hemodynamic collapse requiring the initiation of Advanced Cardiac Life Support procedures between the time of induction of general anesthesia and the termination of the surgical procedure. Results of TEE examinations, patient records, detailed operative records, and outcome of patients were reviewed for the utility of TEE to diagnose the etiology of the hemodynamic collapse. Furthermore, the impact on subsequent patient management was evaluated. A primary suspected diagnosis of the underlying pathological process was established in 19 of 22 patients with TEE, including 9 with thromboembolic events, 6 with acute myocardial ischemia, 2 with hypovolemia, and 2 patients with pericardial tamponade. A definitive diagnosis could not be made in 3 patients with TEE. In 18 patients, TEE guided specific management beyond implementation of Advanced Cardiac Life Support protocols, including the addition of surgical procedures in 12 patients. Fourteen patients survived to leave the operating room, and 7 of these patients were eventually discharged from the hospital. Thus, TEE may provide additional diagnostic information in patients with intraoperative cardiac arrest and may directly guide specific, potentially life-saving therapy.

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.