Advanced Cardiac Life Support Research Articles

Promoting Nurses' Self-Efficacy in Advanced Cardiac Life Support Through High-Fidelity Simulation

Background Self-efficacy in resuscitation is influenced by various educational models, including high-fidelity simulation (HFS). Method Sixty-two nurses who were enrolled in an Advanced Cardiac Life Support (ACLS) course using HFS were recruited for this pretest-posttest, quasi-experimental study. Self-efficacy was assessed three times-twice via the participants' self-report and once via the instructor's assessment-using the Resuscitation Self-Efficacy Scale (RSES). Results The four dimensions of self-efficacy-recognition, debriefing and recording, responding and rescuing, and reporting-improved after the HFS education (t = 4.89, SE = 1.84, p < .001, confidence interval [-12.7, -5.33]). The instructor's scoring was higher than the participants' scoring in two of the four dimensions. The score on the ACLS written examination was positively correlated with the posttest RSES score (r = 0.303, p = .017). Despite minimal variations between demographic subgroups, nurses who had never been involved in resuscitation exhibited a significant improvement in self-efficacy after the HFS ACLS education (t = 4.72, SE = 2.54, p < .001, confidence interval [-17.3, -6.7]). Conclusion Self-efficacy can be a core measurable outcome that gauges nurses' clinical competency concerning HFS education for ACLS. [J Contin Educ Nurs. 2022;53(4):185-192.].

Barriers Facing Primary Health Care Physicians in Jazan when Dealing with Emergency Cases

Background: Primary healthcare centres (PHCCs) provide curative and preventative healthcare services. Little is known about perceived competence in handling potential emergencies by family physicians at PHCCs. Aim of Study: To identify primary healthcare (PHC) physicians’ emergency management competence and the barriers they experience when dealing with emergency cases. Method: A descriptive questionnaire-based cross-sectional study of family physicians in Jazan Governorate, in south west of Saudi Arabia. We used Poisson regression modelling to evaluate the effect of background factors on perceived competence in handling emergency cases among family physicians. Results: The study included 450 PHC physicians; 342 (77.8%) were males, and 364 (82.7%) were Saudi. When compared to Arab Board of Family Medicine (ABFM) certification, physicians did better if they had Family Medicine (FM) Diploma (OR = 1.1486, p = 0.03704) or MBBS (OR = 1.1529, p = 0.00371). Compared to physicians who attended Basic Life Support (BLS) courses within the last 12 months, competence in clinical emergencies was far worse for those who did not do BLS (OR = 0.6710, p &lt;0.001), or did it over two years ago (OR = 0.8796, p&lt;0.001). Notably, there was no difference between those who did BLS last year or within two years’ time frame. Attending the Advanced Trauma Life Support (ATLS) course was associated with better emergency knowledge and competence if completed withinone year than within two years (OR = 0.9071, p = 0.002), over two years (OR = 0.8694, p&lt;0.001), or not done at all (OR = 0.9527, p = 0.01452). Advanced Cardiovascular Life Support (ACLS) course attendance was not associated with significant gains in terms of competence. Experience in Emergency Departments (ED) was associated with worse self-rating of competence in emergency cases (OR = 0.9527, p = 0.01452). Conclusions: BLS and ATLS courses improve perceived competence among PHC physicians. There is a potential gap in defibrillation training among PHC-based family physicians in the southwestern area of Saudi Arabia. Therefore, BLS training should be an integral part of family physician core competence in handling emergency cases. More educational training should be devoted to defibrillation skills in clinical practice. Key words: Primary Healthcare, Family physician, Emergency care, competence, barriers, Saudi Arabia.

Patterns and Predictors of Emergency Medical Services Utilisation by Patients Attending the Emergency Medicine Department of a Tertiary Care Hospital in India.

Introduction:Establishment of strong emergency medical services (EMS) systems plays a pivotal role in reducing morbidity and mortality, especially in low and middle-income countries. We aimed to study the EMS utilization and resources available in the ambulances to deliver prehospital care among patients presenting to the Emergency Medicine Department in a tertiary care hospital in south India.Methods:Data regarding prehospital transport practices such as mode of arrival, utilization of EMS, resources available in the ambulance, presenting complaints, triage category, and demographic details were collected and analyzed. Subgroup analysis for time-sensitive complaints was done. Variables were subjected to univariate and multivariate analysis to find the predictors of ambulance usage.Results:The study included 3935 patients. The most common time-sensitive complaints were trauma (17%) and chest pain (11.5%). The most preferred mode of transport was the personal vehicle (45.6%). 29.8% of patients arrived in the ambulance. 97.7% of ambulances were not Advanced Cardiac Life Support equipped and 87.1% did not have an accompanying health care provider. 64.5% inter-hospital patient transfers were through ambulance, 83.8% transfers were unaccompanied. Among patients with time-sensitive complaints, EMS utilization was inadequate (46.8% in acute coronary syndrome, 34% in trauma, and 56.5% in early acute ischemic stroke).Conclusion:There was underutilization of the EMS services. Majority of the ambulances were not adequately equipped/staffed to deliver prehospital interventions. Policies at national level are required to encourage EMS utilization by the public and urgent measures are needed to improve services provided by them.

Impact of staffing levels and resources of intensive care units on compliance to standard mechanical ventilator guidelines: A city-wide study in times of COVID-19 pandemic.

IntroductionThe COVID‐19 pandemic has affected millions and resulted in a considerable strain on healthcare systems around the world. Intensive care units (ICUs) are reported to be affected the most because significant percentage of ICU patients requires respiratory support through mechanical ventilation (MV). This study examines the staffing levels and compliance with a ventilator care bundle in a single city in Pakistan.MethodsA cross‐sectional survey of 14 ICUs including medical and surgical ICUs was conducted through a self‐structured questionnaire including a standardized ventilator care bundle. We assessed the compliance of ICU staff to ventilator care bundle and calculated the correlation between staffing patterns with compliance to this bundle.ResultsThe unit response rate was 64% (7/11 hospitals). Across these seven hospitals, there were 14 functional ICUs (7 surgical and 7 medical). The Mean (SD) numbers of beds and ventilators were 8.14 (3.39) and 5.78 (3.68) while the average patient‐to‐nurse and patient‐to‐doctor ratio was 3: 1 and 5:1 respectively. The median ventilator care bundle compliance score was 26 (IQR = 21–28) out of 30, while in medical and surgical ICUs, median scores were 24 (IQR = 19–26) and 28 (IQR = 23–30) respectively. The perceived least compliant component was head elevation in ventilated patients. Correlation analysis revealed that 24 h a day, 7 days a week onsite cover of Advanced Cardiovascular Life Support certified staff was positively correlated with the ventilator care bundle score (r s = 0.654, p value = .011). Similarly, 24‐h cover of senior ICU nurses was significantly correlated with the application of chlorhexidine oral care (r s = 0.676, p value = .008) while routine subglottic aspiration was correlated with the number of doctors (r s = 0.636, p value = .014).ConclusionOur study suggests that ICUs in Peshawar are not well staffed in comparison with international standards and the compliance of ICUs with the ventilator care bundle is suboptimal. We found only a few aspects of ventilator care bundle compliance were related to nursing and medical staffing levels.Relevance to clinical practiceCritical care staffs at most of the medical ICUs in Peshawar are not compliant with the standard guidelines for patients on mechanical ventilation. Moreover, the staffing levels at these ICUs are not in accordance with international standards. However, this study suggests that staffing levels may not be the only cause of non‐compliance with standard mechanical ventilator guidelines. There is an urgent need to design and implement a program that can enhance and monitor the quality of nursing care provided to mechanically ventilated patients. Lastly, nurse staffing of ICUs in Pakistan must be increased to enable high quality care and more doctors should be trained in critical care.

745 Evaluating Nurses' Perceptions of Code Cart Competency

IntroductionThis study was conducted to evaluate critical care nurses' perceptions of competency when using the code cart during Advance Cardiac Life Support (ACLS) resuscitation. During post-resuscitation debrief, it was noted that nurses reported lack of familiarity with using the code cart and could not quickly locate items when needed.MethodsUsing an email distribution list sent to nurses employed in the Burn Center, a pre-survey was conducted to evaluate baseline competency levels and provide the opportunity to self report level of familiarity with the code cart and the roles needed to conduct effective ACLS resuscitation. Following the pre-survey, various educational opportunities were offered to the nursing staff including written and hands-on activities in a low-stress setting. These activities were offered to day and night shift nurses on several occasions, and there was no limit to how many times a nurse could participate. Following 3 months of targeted educational intervention, a post-survey was conducted to re-evaluate the nurses' perceived comfort level with using the code cart during ACLS resuscitation.ResultsThe average years of nursing experience among participants was 3-4, with only two participants reporting 5 or more years of critical care experience. The nurses reported an increase in self-reported confidence level with using the code cart. The most common educational intervention that nurses felt would increase their comfort levels with using the crash cart were more frequent simulation scenarios (ie: mock codes), and hands-on training with open crash carts during in a low stress setting.ConclusionsBecause ACLS resuscitation is a stressful, chaotic event, it is not feasible for nurses to learn "in the moment." Critical care nurses in the Burn Center are trained on resuscitation and are required to maintain ACLS certification, but this is not enough training for them to feel comfortable with their responsibilities during a code. After identifying that nurses were not confident in being able to work the crash cart and could not find necessary items when asked to do so during an emergency, a plan for additional hands-on education in a low-stress setting was developed. Using a pre/post survey, the multi-faceted educational opportunities were evaluated to see if they would impact the nurses' self-reported perceptions of code cart competency. Results indicated that not only were the educational interventions successful, but the nurses would like further opportunities for ongoing participation to maintain their level of comfort with the crash cart.

Etiologies of In-hospital cardiac arrest: A systematic review and meta-analysis

BackgroundEtiologies of in-hospital cardiac arrest (IHCA) in general wards may differ from etiologies of out-of-hospital cardiac arrest (OHCA) given the different clinical characteristics of these patient populations. An appreciation for the causes of IHCA may allow the clinician to appropriately target root causes of arrest. MethodsMEDLINE/PubMed, EMBASE, and Google Scholar were queried from inception until May 31, 2021. Studies reporting etiologies of IHCA were included. A random effects meta-analysis of extracted data was performed using Review Manager 5.4. ResultsOf 12,451 citations retrieved from the initial literature search, 9 were included in the meta-analysis. The most frequent etiologies of cardiac arrest were hypoxia (26.46%, 95% confidence interval [CI] 14.19–38.74%), acute coronary syndrome (ACS) (18.23%, 95% CI 13.91–22.55%), arrhythmias (14.95%, 95% CI 0–34.93%), hypovolemia (14.81%, 95% CI 6.98–22.65%), infection (14.36%, 95% CI 9.46–19.25%), and heart failure (12.64%, 95% CI 6.47–18.80%). Cardiac tamponade, electrolyte disturbances, pulmonary embolism, neurological causes, toxins, and pneumothorax were less frequent causes of IHCA. Initial rhythm was unshockable (pulseless electrical activity or asystole) in 69.83% of cases and shockable (ventricular tachycardia or ventricular fibrillation) in 21.75%. ConclusionThe most prevalent causes of IHCA among the general wards population are hypoxia, ACS, hypovolemia, arrythmias, infection, heart failure, three of which (arrhythmia, infection, heart failure) are not part of the traditional “H’s and T’s” of cardiac arrest. Other causes noted in the “H’s and T’s” of advanced cardiac life support do not appear to be important causes of IHCA.

Effect of the Use of High-Fidelity Manikin Simulation for Learning Emergency Cardiovascular Care Skills: A Critically Appraised Topic

Clinical Scenario: Athletic trainers must be confident when performing life-saving skills, such as a cardiovascular assessment and cardiopulmonary resuscitation. Learning and performing skills on high-fidelity simulation manikins may improve athletic training students’ self-confidence and self-efficacy. Clinical Question: What are the effects of high-fidelity manikin simulation on athletic training students’ self-confidence and self-efficacy in performing emergency cardiovascular care? Summary of Key Findings: Three good-quality cohort studies were included. Two studies assessed the effect of high-fidelity cardiopulmonary resuscitation simulation, and one study assessed the effect of high-fidelity cardiovascular assessment. Two studies evaluated self-confidence, while the other study evaluated self-efficacy. All three studies found that high-fidelity simulation improved athletic training students’ self-confidence and self-efficacy. Clinical Bottom Line: There is currently consistent, good-quality evidence that supports the use of high-fidelity manikin simulation to improve athletic training students’ self-confidence and self-efficacy in performing cardiovascular skills and assessment. Future research should examine the effects of high-fidelity manikin simulation on the same academic levels of athletic training students to ensure generalizability of results. Strength of Recommendation: The grade of B is recommended by the Strength of Recommendation Taxonomy for consistent, good-quality evidence.

Updated AHA Basic and Advanced Cardiac Life Support guidance with COVID-19 considerations.

Updated AHA Basic and Advanced Cardiac Life Support guidance with COVID-19 considerations.

Correction to: 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group.

Correction to: 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group.

Nurses' Acceptance of and Satisfaction With the Advanced Cardiac Life Support Electronic Information System in Emergency Departments and Critical Care Units.

Emergency and critical care nurses perform an important role in documenting the resuscitation process. However, paper-based recording is labor intensive and complex and may result in incorrect recording of important parameters, which suggests the need for an appropriate electronic information system for emergency care. This cross-sectional descriptive study explores emergency and critical care nurses' acceptance of, and satisfaction with, the newly developed advanced cardiac life support electronic information system and examines whether paper-based recording and electronic recording approaches differ in the completeness of resuscitation records. Data were collected through a self-designed structured questionnaire and a retrospective review of medical records. Data were analyzed by descriptive statistics, independent sample t test, and one-way analysis of variance. The results indicated that novice nurses were more satisfied with the electronic information system than others. Emergency care nurses were significantly more satisfied than medical and surgical ICU nurses. The electronic information system improved the completeness of resuscitation recording by 23.5%, compared with the paper-based recording approach. Emergency and critical care nurses have a moderate to high degree of acceptance of, and satisfaction with, electronic information systems.

Updated AHA Basic and Advanced Cardiac Life Support guidance with COVID-19 considerations.

:The American Heart Association released an updated Basic and Advanced Cardiac Life Support guidance that incorporates the latest knowledge regarding COVID-19 and its transmissibility. This article details the new guidance, including strategies for reducing provider risk and exposure and for special patient-care situations.

Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest

<h3>Importance</h3> Out-of-hospital cardiac arrest (OHCA) has poor outcome. Whether intra-arrest transport, extracorporeal cardiopulmonary resuscitation (ECPR), and immediate invasive assessment and treatment (invasive strategy) is beneficial in this setting remains uncertain. <h3>Objective</h3> To determine whether an early invasive approach in adults with refractory OHCA improves neurologically favorable survival. <h3>Design, Setting, and Participants</h3> Single-center, randomized clinical trial in Prague, Czech Republic, of adults with a witnessed OHCA of presumed cardiac origin without return of spontaneous circulation. A total of 256 participants, of a planned sample size of 285, were enrolled between March 2013 and October 2020. Patients were observed until death or day 180 (last patient follow-up ended on March 30, 2021). <h3>Interventions</h3> In the invasive strategy group (n = 124), mechanical compression was initiated, followed by intra-arrest transport to a cardiac center for ECPR and immediate invasive assessment and treatment. Regular advanced cardiac life support was continued on-site in the standard strategy group (n = 132). <h3>Main Outcomes and Measures</h3> The primary outcome was survival with a good neurologic outcome (defined as Cerebral Performance Category [CPC] 1-2) at 180 days after randomization. Secondary outcomes included neurologic recovery at 30 days (defined as CPC 1-2 at any time within the first 30 days) and cardiac recovery at 30 days (defined as no need for pharmacological or mechanical cardiac support for at least 24 hours). <h3>Results</h3> The trial was stopped at the recommendation of the data and safety monitoring board when prespecified criteria for futility were met. Among 256 patients (median age, 58 years; 44 [17%] women), 256 (100%) completed the trial. In the main analysis, 39 patients (31.5%) in the invasive strategy group and 29 (22.0%) in the standard strategy group survived to 180 days with good neurologic outcome (odds ratio [OR], 1.63 [95% CI, 0.93 to 2.85]; difference, 9.5% [95% CI, −1.3% to 20.1%];<i>P</i> = .09). At 30 days, neurologic recovery had occurred in 38 patients (30.6%) in the invasive strategy group and in 24 (18.2%) in the standard strategy group (OR, 1.99 [95% CI, 1.11 to 3.57]; difference, 12.4% [95% CI, 1.9% to 22.7%];<i>P</i> = .02), and cardiac recovery had occurred in 54 (43.5%) and 45 (34.1%) patients, respectively (OR, 1.49 [95% CI, 0.91 to 2.47]; difference, 9.4% [95% CI, −2.5% to 21%];<i>P</i> = .12). Bleeding occurred more frequently in the invasive strategy vs standard strategy group (31% vs 15%, respectively). <h3>Conclusions and Relevance</h3> Among patients with refractory out-of-hospital cardiac arrest, the bundle of early intra-arrest transport, ECPR, and invasive assessment and treatment did not significantly improve survival with neurologically favorable outcome at 180 days compared with standard resuscitation. However, the trial was possibly underpowered to detect a clinically relevant difference. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT01511666

Development of a Clinical Risk Score for Prediction of Life-Threatening Arrhythmia Events in Patients with ST Elevated Acute Coronary Syndrome after Primary Percutaneous Coronary Intervention.

ST-elevated acute coronary syndrome (STEACS) is a serious condition requiring timely treatment. Reperfusion with primary percutaneous coronary intervention (pPCI) is recommended and preferred over fibrinolysis. Despite its efficacy, lethal complications, such as life-threatening arrhythmia (LTA), are common in post-PCI patients. Although various risk assessment tools were developed, only a few focus on LTA prediction. This study aimed to develop a risk score to predict LTA events after pPCI. A risk score was developed using a retrospective cohort of consecutive patients with STEACS who underwent pPCI at Chiangrai Prachanukroh Hospital from January 2012 to December 2016. LTA is defined as the occurrence of malignant arrhythmia that requires advanced cardiovascular life support (ACLS) within 72 h after pPCI. Logistic regression was used for model derivation. Among 273 patients, 43 (15.8%) developed LTA events. Seven independent predictors were identified: female sex, hemoglobin < 12 gm/dL, pre- and intra-procedural events (i.e., respiratory failure and pulseless arrest), IABP insertion, intervention duration > 60 min, and desaturation after pPCI. The LTA score showed an AuROC of 0.93 (95%CI 0.90, 0.97). The score was categorized into three risk categories: low (<2.5), moderate (2.5–4), and high risk (>4) for LTA events. The LTA score demonstrated high predictive performance and potential clinical utility for predicting LTA events after pPCI.

Advanced Cardiovascular Life Support Performance: Study on the Effectiveness of Training among Nurses in a Tertiary Care Hospital, Karachi

Nurses are the integral part of health care delivery system and play a vital role in critical areas. Nurses are required to respond quickly and effectively in the situation of cardiac arrest and the success of cardiopulmonary resuscitation depends upon their competence. Nurses’ knowledge, preparedness and skills in regard to cardiopulmonary resuscitation have to be at advanced level. Hence, this study was conducted to determine the effectiveness of advanced cardiovascular life support training among nurses at a tertiary care hospital, Karachi, Pakistan.&#x0D; Study Design: Quasi-experimental (pre and post) study was employed.&#x0D; Place and Duration of Study: Study was accomplished at Dr. Ruth K.M Pfau Civil Hospital, Karachi for the period of ten months from December 2018 to September 2019.&#x0D; Methodology: Sample size was calculated through PASS version 11.0 with proportion formula, calculated sample size was 180 nurses. Nurses’ responses regarding advanced cardiovascular life support were assessed by validated and structured questionnaire. The collected data was analyzed by using SPSS version 21. The mean score of pre-test and post-test of advanced cardiovascular life support training were computed by using paired t-test. p-value ≤0.05 were considered as level of significance.&#x0D; Results: The pre mean of advanced cardiac life support score was 19.28±5.29. While, after training mean score of advanced cardiac life support score was 22.38±4.0. It is also statistically significant (p&lt;0.001).&#x0D; Conclusion: Successful resuscitation in patients with cardiac emergencies necessitates early credit of condition, prompt activation of responders, timely and effective basic life support and timed defibrillation when needed. Formal basic life support and advanced cardiovascular life support trainings are essential for nurses to enhance their skills that lead to improve victim survival after cardiopulmonary resuscitation.

In COVID-19 Patients Who Suffer In-Hospital Cardiac Arrest, Cardiopulmonary Resuscitation Outcomes May Be Impacted by Arrest Etiology and Local Pandemic Conditions.

OBJECTIVES:The utility and risks to providers of performing cardiopulmonary resuscitation after in-hospital cardiac arrest in COVID-19 patients have been questioned. Additionally, there are discrepancies in reported COVID-19 in-hospital cardiac arrest survival rates. We describe outcomes after cardiopulmonary resuscitation for in-hospital cardiac arrest in two COVID-19 patient cohorts.DESIGN:Retrospective cohort study.SETTING:New York-Presbyterian Hospital/Columbia University Irving Medical Center in New York, NY.PATIENTS:Those admitted with COVID-19 between March 1, 2020, and May 31, 2020, as well as between March 1, 2021, and May 31, 2021, who received resuscitation after in-hospital cardiac arrest.INTERVENTIONS:None.MEASUREMENT AND MAIN RESULTS:Among 103 patients with coronavirus disease 2019 who were resuscitated after in-hospital cardiac arrest in spring 2020, most self-identified as Hispanic/Latino or African American, 35 (34.0%) had return of spontaneous circulation for at least 20 minutes, and 15 (14.6%) survived to 30 days post-arrest. Compared with nonsurvivors, 30-day survivors experienced in-hospital cardiac arrest later (day 22 vs day 7; p = 0.008) and were more likely to have had an acute respiratory event preceding in-hospital cardiac arrest (93.3% vs 27.3%; p < 0.001). Among 30-day survivors, 11 (73.3%) survived to hospital discharge, at which point 8 (72.7%) had Cerebral Performance Category scores of 1 or 2. Among 26 COVID-19 patients resuscitated after in-hospital cardiac arrest in spring 2021, 15 (57.7%) had return of spontaneous circulation for at least 20 minutes, 3 (11.5%) survived to 30 days post in-hospital cardiac arrest, and 2 (7.7%) survived to hospital discharge, both with Cerebral Performance Category scores of 2 or less. Those who survived to 30 days post in-hospital cardiac arrest were younger (46.3 vs 67.8; p = 0.03), but otherwise there were no significant differences between groups.CONCLUSIONS:Patients with COVID-19 who received cardiopulmonary resuscitation after in-hospital cardiac arrest had low survival rates. Our findings additionally show return of spontaneous circulation rates in these patients may be impacted by hospital strain and that patients with in-hospital cardiac arrest preceded by acute respiratory events might be more likely to survive to 30 days, suggesting Advanced Cardiac Life Support efforts may be more successful in this subpopulation.

2022 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration With the American Academy of Pediatrics, American Association for Respiratory Care, the Society

2022 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration With the American Academy of Pediatrics, American Association for Respiratory Care, the Society

A Multicenter, Prospective Study Comparing Subxiphoid and Parasternal Views During Brief Echocardiography: Effect on Image Quality, Acquisition Time, and Visualized Anatomy

BackgroundRecent literature has suggested echocardiography (echo) may prolong pauses in chest compressions during cardiac arrest. ObjectvesWe sought to determine the impact of the sonographic approach (subxiphoid [SX] vs. parasternal long [PSL]) on time to image completion, image quality, and visualization of cardiac anatomy during echo, as performed during Advanced Cardiac Life Support. MethodsThis was a multicenter, randomized controlled trial conducted at 29 emergency departments (EDs) assessing the time to image acquisition and image quality between SX and PSL views for echo. Patients were enrolled in the ED and imaged in a simulated cardiac arrest scenario. Clinicians experienced in echo performed both SX and PSL views, first view in random order. Image quality and time to image acquisition were recorded. Echos were evaluated for identification of cardiac landmarks. Data are presented as percentages or medians with interquartile ranges (IQRs). ResultsWe obtained 6247 echo images, comprising 3124 SX views and 3123 PSL. Overall time to image acquisition was 9.0 s (IQR 6.7–14.1 s). Image acquisition was shorter using PSL (8.8 s, IQR 6.5–13.5 s) compared with SX (9.3 s, IQR 6.7–15.0 s). The image quality was better with the PSL view (3.86 vs. 3.54; p < 0.0001), twice as many SX images scoring in the worst quality category compared with PSL (8.6% vs. 3.7%). Imaging of the pericardium, cardiac chambers, and other anatomic landmarks was superior with PSL imaging. ConclusionsEcho was performed in < 10 s in > 50% of patients using either imaging technique. Imaging using PSL demonstrated improved image quality and improved identification of cardiac landmarks.

Scoping review of Cardiac Troponin Test in the Prehospital Management of Non-ST-Elevation Myocardial Infarction in Qatar

Background: Acute coronary syndrome (ACS) is one of the most common life-threatening diseases worldwide.1 Early diagnosis, advanced cardiac life support, and rapid transportation to a cardiac center are essential to reduce mortality and morbidity. ST-segment elevation myocardial infarctions (STEMI) are life-threatening and are diagnosed with a 12-lead electrocardiogram (ECG). However, non-STEMI (NSTEMI) is not prioritized as a STEMI in the prehospital setting. Studies have confirmed that patients who are diagnosed with an ACS in the prehospital setting are more likely to survive.2,3Method: A scoping review was conducted based on the above topic. Limited data is available on prehospital cardiac troponin tests for NSTEMI. Discussion: Paramedics from the national Ambulance Service in Qatar diagnose patients with ACS based on the findings of a 12-lead ECG, clinical presentation, abnormalities in vital signs, physical examination, and congruent history which is compatible with the American Heart Association and European Resuscitation Council recommendations. In a case of NSTEMI chest pain, the paramedic cannot rule out Acute Myocardial Infarction (AMI), yet the patient will be taken to the normal emergency department until further investigations are done.1 ACS remains a challenge to diagnose in the prehospital setting as the diverse population in Qatar makes communication often difficult which would negatively impact the patient&apos;s assessment. Although the accuracy of prehospital Troponin tests done around 2010 was relatively encouraging2, their sensitivity has now significantly improved and warrants further studies to highlight their benefit to patient care.3 The routing of patients with ACS (STEMI and NSTEMI) to the appropriate cardiac center is essential to assure they receive a rapid diagnosis and appropriate care. Conclusion: The enhanced diagnostic accuracy of ACS in the prehospital setting by using a rapid Troponin test is expected to accelerate the care of NSTEMI patients and should be explored in Qatar. This scoping review indicates that limited data is available on cardiac troponin tests for NSTEMI.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Complete Heart Block Complicating Acute Inferior Myocardial Infarction: Risk Factors, Management and Mortality

Complete heart block (CHB) is a well-recognized complication in acute inferior myocardial infarction (MI) patients. A prospective observational study was conducted in the Coronary Care Unit (CCU) under Department of Cardiology, Sher-E-Bangla Medical College Hospital, Barisal, Bangladesh, from November 2014 to May 2015, to identify the risk factors and observe clinical prognosis and outcome in patients of acute inferior myocardial infarction associated with complete heart block. Convenient sampling technique was adopted and a total of 100 patients (77 males and 23 females) were selected based on specific inclusion and exclusion criteria. All the patients participated in the study were evaluated by detailed history, clinical examination and relevant investigations to identify the risk factors. ECG was done on daily basis and continuously observed. Response to treatment, complications and recovery of CHB were observed during hospital stay. The mean age of the patients was 57.16±10.24 years. Smoking (52%), dyslipidemia (36%), hypertension (31%) and diabetes mellitus (26%) were found most common risk factors among those patients. 71% of the patients had isolated inferior MI and was quite responsive to optimum medical therapy (92.95%) and mortality was low (2.81%). However, concomitant right ventricular infarction (18%), posterior infarction (4%) and anterior or lateral infarction/ischemia (7%) had a poorer outcome, i.e. 16.66%, 25%, and 57.14% death respectively. Early presentation (within 24 hours) of CHB had only 4.17% mortality. However, mortality increased in patients as CHB developed after 24 hours (26%). Overall, 10% mortality was observed even with advanced cardiac support. Our data suggest that smoking, dyslipidemia, hypertension and diabetes mellitus are most common risk factors of MI. Complete heart block complicating by acute inferior MI is very much responsive to optimum medical treatment and hardly requires temporary pacemaker. However, concomitant right ventricular infarction, posterior, anterior or lateral infarction/ ischaemia cause poor prognosis and increased mortality.&#x0D; CBMJ 2021 January: vol. 10 no. 01 P: 24-29