Advanced Life Support Interventions Research Articles

Prompt Advanced Life Support Improves Survival from Ventricular Fibrillation

AbstrastObjective. To determine whether the interval between the arrival of basic life support (BLS) providers and the arrival of advanced life support (ALS) providers is associated with patient outcome after cardiac arrest. Methods. We conducted a retrospective cohort study of all witnessed, out-of-hospital ventricular fibrillation (VF) cardiac arrests between January 1, 1991, and December 31, 2007. Eligible patients (n = 1,781) received full resuscitation efforts from both BLS and ALS providers. Results. The BLS-to-ALS arrival interval was a significant predictor of survival to hospital discharge (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.93–0.99); the likelihood of survival decreased by 4% for every minute that ALS arrival was delayed following BLS arrival. Other significant predictors of survival were whether the arrest occurred in public (OR 1.48, 95% CI 1.19–1.85), whether a bystander administered cardiopulmonary resuscitation (CPR) (OR 1.34, 95% CI 1.07–1.68), and the interval between the 9-1-1 call and BLS arrival (OR 0.78, 95% CI 0.73–0.83). Conclusions. We found that a shorter BLS-to-ALS arrival interval increased the likelihood of survival to hospital discharge after a witnessed, out-of-hospital VF cardiac arrest. We conclude that ALS interventions may provide additional benefits over BLS interventions alone when utilized in a well-established, two-tiered emergency medical services (EMS) system already optimized for rapid defibrillation. The highest priorities in any EMS system should still be early CPR and early defibrillation, but timely ALS services can supplement these crucial interventions.

Post–Cardiac Arrest Syndrome

The contributors to this statement were selected to ensure expertise in all the disciplines relevant to post–cardiac arrest care. In an attempt to make this document universally applicable and generalizable, the authorship comprised clinicians and scientists who represent many specialties in many regions of the world. Several major professional groups whose practice is relevant to post–cardiac arrest care were asked and agreed to provide representative contributors. Planning and invitations took place initially by e-mail, followed a series of telephone conferences and face-to-face meetings of the cochairs and writing group members. International writing teams were formed to generate the content of each section, which corresponded to the major subheadings of the final document. Two team leaders from different countries led each writing team. Individual contributors were assigned by the writing group cochairs to work on 1 or more writing teams, which generally reflected their areas of expertise. Relevant articles were identified with PubMed, EMBASE, and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Drafts of each section were written and agreed on by the writing team authors and then sent to the cochairs for editing and amalgamation into a single document. The first draft of the complete document was circulated among writing team leaders for initial comment and editing. A revised version of the document was circulated among all contributors, and consensus was achieved before submission of the final version for independent peer review and approval for publication. This scientific statement outlines current understanding and identifies knowledge gaps in the pathophysiology, treatment, and prognosis of patients who regain spontaneous circulation after cardiac arrest. The purpose is to provide a resource for optimization of post–cardiac arrest care and to pinpoint the need for research focused on gaps in knowledge that would potentially improve outcomes …

Current and future therapies of pediatric cardiopulmonary arrest

To review contemporary guidelines and therapies for pediatric cardiac arrest and discuss potential novel therapies. Key articles and guidelines in the field were reviewed along with recent publications in the fields of neurointensive care and neuroscience germane to cerebral resuscitation. A total of 45 articles were reviewed. The majority of arrests in the pediatric population are asphyxial in origin--which differs importantly from the adult population. The International Consensus on CPR guidelines are discussed, including good quality CPR, chest compressions without interruptions, resuscitation with 100% oxygen and subsequent titration of oxygen to normal oxygen saturations, correct dose of epinephrine, and use of hypothermia in the first 12-24 hours. Novel therapies that showed success in animal studies, such as hypertensive reperfusion, thrombolytics, hemodilution and extracorporeal CPR are also discussed. With only 30% return of spontaneous circulation, 12% survival to hospital discharge and 4% intact neurologic survival, pediatric cardiac arrest remains an area of intense research for therapies to improve its outcomes. In addition to the rapid implementation of basic and advanced life support interventions, new therapies that may have value include mild hypothermia, extracorporeal support, promotion of cerebral blood flow and other more novel therapies targeting oxidative stress, excitotoxicity, neuronal death, and rehabilitation.

Can Emergency Medical Dispatch Codes Predict Prehospital Interventions for Common 9-1-1 Call Types?

Objective. The Medical Priority Dispatch System is an emergency medical dispatch (EMD) system that is widely used to categorize 9-1-1 calls andoptimize resource allocation. This study evaluates the ability of EMD andnon-EMD codes (calls not processed by EMD) to predict prehospital use of medications andprocedures. Methods. All transported prehospital patients placed in an EMD or non-EMD category that exceeded 500 total calls from January 1, 2004, to December 31, 2006, in a suburban California county were matched with their prehospital electronic patient care record. These records (N = 69,541) were queried for the following prehospital interventions: basic life support (BLS) care only, intravenous line placement only, medication given, andprocedures. Advanced life support (ALS) interventions were defined as the administration of a medications or a procedure. The numbers of medications andprocedures that were performed on patients in each EMD code were measured. Results. Thirty-one of 141 EMD andnon-EMD codes met inclusion criteria andcomprised 73% of all calls during the study period. Non-EMD codes accounted for 48% of all calls in this study. Patients with shortness of breath, chest pain, diabetic problems, andaltered mental status received the most medications. High rates of medication administration were also seen in the following codes: 17A (fall, 27%), 17B (fall, 14%), EMDX (unable to complete EMD process, 22%), MED (medical aid requested—details to follow, 26%), andMED3 (medical aid requested by police—code 3, 18%). Procedures were performed on only 0.9% of all calls, of which 75% were related to advanced airways. Higher rates of ALS interventions in higher-acuity categories (Alpha, Bravo, etc.) were seen in a number of EMD categories, including seizure, laceration/hemorrhage, sick, andtraffic accident, but not seen in many categories, including abdominal pain, falls, andchest pain. Conclusions. This study demonstrated only a modest ability of the EMD system to predict which patients would require ALS intervention. There were limited differences noted in the ALS rates between the different codes (Alpha, Bravo, etc.) in the same complaint category, bringing into question the utility of the multiple subgroups. Non-EMD codes made up a large portion of calls (48%) andshould be included in future studies.

Is Ward Experience in Resuscitation Effort Related to the Prognosis of Unexpected Cardiac Arrest?

The aim of this study was to investigate the outcome of patients of unexpected cardiac arrest initially resuscitated by first responders with dissimilar experiences under the support of cardiac arrest team (CAT). All unexpected cardiac arrest patients receiving in-hospital resuscitation with the activation of CAT in a tertiary-care teaching hospital over a 12-month period were recorded according to the Utstein criteria. We prospectively recorded various factors at resuscitation and retrospectively evaluated the outcome. Outcome measures included return of spontaneous circulation (ROSC), survival longer than 24 hours, and survival to discharge. Altogether, 76 emergency calls were registered, and among these, 44 calls (58%) were cardiac arrests, including 8 ventricular tachycardia/fibrillation, 15 pulseless electrical activity, and 21 asystole. The rate of ROSC was 61%, the rate of survival longer than 24 hours was 37%, and the rate of survival to discharge was 18%. The response time of our CAT was 271 seconds (4 minutes and 31 seconds) on average. The patients who collapsed in the wards experienced in resuscitation effort received higher rates of appropriate basic and advanced cardiac life support interventions before CAT arrival (79% vs. 44%; p = 0.019), had an increased chance of ROSC (75% vs. 38%; p = 0.014), survival longer than 24 hours (54% vs. 13%; p = 0.007), and survival to discharge (29% vs. 0%; p = 0.036). Hospital wards with more than 5 cardiac arrests per year have a better patient survival rate than those with fewer arrests. This is despite all ward staff receiving the same level of training.

The Ability of Emergency Medical Dispatch Codes of Medical Complaints to Predict ALS Prehospital Interventions

Objective. The Medical Priority Dispatch System (MPDS) is an emergency medical dispatch (EMD) system that is commonly used to triage 9-1-1 calls andoptimize paramedic andEMT dispatch. The objective of this study was to determine the sensitivity, specificity, andpositive andnegative predictive values of selected MPDS dispatch codes to predict the need for ALS medication or procedures. Methods. Patients with selected MPDS codes between November 1, 2003, andOctober 31, 2005, from a suburban California county were matched with their electronic patient care record. The records of all transported patients were queried for prehospital interventions andmatched to their MPDS classification [Basic Life Support (BLS) versus Advanced Life Support (ALS)]. Patients who received prehospital interventions or medications were considered ALS Intervention. With true positive = ALS by MPDS + ALS Intervention, true negative = BLS by MPDS + BLS Interventions, false positive = ALS by MPDS + BLS Interventions, andfalse negative = BLS by MPDS + ALS Interventions, the screening performance of the San Mateo County EMD system was determined for selected complaint categories (abdominal pain, breathing problems chest pain, sick person, seizures, andunconscious/fainting). Results. There were a total of 64,647 medical calls, and42,651 went through the EMD process; 31,187 went through the EMD process andwere transported; 22,243of these were matched to a patient care record. The sensitivity andspecificity with 95% confidence intervals in () were as follows: all EMD calls 84 (83–85), 36 (35–36); abdominal pain, 53 (41–65), 47 (43–51); chest pain 99 (99–100), 2 (1–3); seizure 83 (77–88), 20 (17–23), sick 59 (53–64), 51 (49–54), andunconscious/fainting 99 (98–100), 2 (2–3). Conclusion. In our EMS system, MPDS coding for all medical calls had high sensitivity andlow specificity for the prediction of calls that required ALS intervention. Chest pain andunconscious/fainting calls were screened with very high sensitivity but very low specificity.

Sodium bicarbonate improves outcome in prolonged prehospital cardiac arrest

Objective This study evaluates the effect of early administration of an empirical (1 mEq/kg) sodium bicarbonate dose on survival from prehospital cardiac arrest within brief (<5 minutes), moderate (5-15 minutes), and prolonged (>15 minutes) down time. Methods Prospective randomized, double-blinded clinical intervention trial that enrolled 874 prehospital cardiopulmonary arrest patients managed by prehospital, suburban, and rural regional emergency medical services. Over a 4-year period, the randomized experimental group received an empirical dose of bicarbonate (1 mEq/kg) after standard advanced cardiac life support interventions. Outcome was measured as survival to emergency department, as this was a prehospital study. Results The overall survival rate was 13.9% (110/792) for prehospital arrest patients. There was no difference in the amount of sodium bicarbonate administered to nonsurvivors (0.859 ± 0.284 mEq/kg) and survivors (0.8683 ± 0.284 mEq/kg) ( P = .199). Overall, there was no difference in survival in those who received bicarbonate (7.4% [58/420]), compared with those who received placebo (6.7% [52/372]) ( P = .88; risk ratio, 1.0236; 0.142-0.1387). There was, however, a trend toward improved outcome with bicarbonate in prolonged (>15 minute) arrest with a 2-fold increase in survival (32.8% vs 15.4%; P = .007). Conclusion The empirical early administration of sodium bicarbonate (1 mEq/kg) has no effect on the overall outcome in prehospital cardiac arrest. However, a trend toward improvement in prolonged (>15 minutes) arrest outcome was noted.

Management and outcomes of pediatric patients transported by emergency medical services in a Canadian prehospital system

There is uncertainty around the types of interventions that are provided by emergency medical services (EMS) to children during prehospital transport. We describe the patient characteristics, events, interventions provided and outcomes of a cohort of children transported by EMS. This prospective cohort study was conducted in a city of 750 000 people with a 2-tiered EMS system. All children <16 years of age who were attended by EMS during a 6-month period were enrolled. Data were extracted from ambulance call reports and hospital charts, and analyzed using descriptive statistics. During the study period there were 1377 pediatric EMS calls. Mean age was 8.2 years (standard deviation 5.4), and the most Common diagnoses were trauma (44.9%), seizure (11.8%) and respiratory distress (8.8%). The ambulance return code was Urgent in 7%, Prompt in 57%, Deferrable in 8% and Not Transported in 28%. Fifty-six percent received either an Advanced Life Support or Basic Life Support prehospital intervention. Common procedures included cardiac monitoring (20.0%), oxygen administration (19.8%), blood glucose monitoring (16.3%), spine board (12.2%), limb immobilization (11.1%) and cervical collar (10.0%). Uncommon procedures included administering medications intravenously (IV) (1.4%), bag-valve-mask ventilation (0.3%) and endotracheal intubation (0.1%). Seventy-eight percent of attempted IV lines were successful. Only 9.0% of EMS-transported children were admitted to hospital, and 2.2% were admitted to the intensive care unit. This first study of Canadian pediatric prehospital interventions shows a high rate of non-transport, and a low rate of Urgent transports and hospital admissions for children. Very few children receive prehospital airway management, ventilation or IV medications; consequently EMS personnel have little opportunity to maintain these pediatric skills in the field.

Key advances in critical care in the out-of-hospital setting: the evolving role of laypersons and technology

During the past decade, critical care in the out-of-hospital setting has transcended the original emphasis on on-scene advanced life support interventions by doctors, paramedics, and nurses. Many of the life-saving efforts and advances in critical care situations have now begun to focus more and more on how, through evolving technology, the average person can save lives and perhaps even spare precious intensive care unit (ICU) resources. A striking example was the recent study conducted at the Chicago airports at which automated external defibrillators (AEDs) were deployed throughout the airline terminals for use by the public at large. Not only did random bystanders on the concourses save an extremely high percentage of cardiac arrest patients with the AEDs, most patients rapidly awakened, even before the arrival of professional rescuers. Thus, this technology-assisted intervention, performed by an average person, pre-empted the need for many other critical care interventions and prolonged care in the ICU. Equipped with automated prompts to improve performance, new technology also exists to help to monitor the inadequacies and too-frequent interruption of life-saving chest compressions during basic cardiopulmonary resuscitation. As a result of these technological advances, survival rates for cardiac arrest are now expected to improve significantly.

Feasibility of Basic Emergency Medical Technicians to Perform Selected Advanced Life Support Interventions

Objective. Emergency medical technician-basic (EMT-B) providers often provide the initial care to victims of out-of-hospital cardiac arrest. While automated external defibrillators enable EMT-B providers to deliver rescue shocks, patients in cardiac arrest may require additional interventions that EMT-B providers may not presently deliver. We sought to evaluate the feasibility of training EMT-B providers to provide additional cardiac resuscitation procedures using the laryngeal mask airway (LMA) andintraosseous (IO) access. Methods. In this prospective observational study, we trained 18 EMT-B providers to use the LMA andIO drill (EZ-IO) in a three-hour educational session. Working in two-person teams, the rescuers performed a simulated ventricular fibrillation resuscitation. We evaluated placement success as well as elapsed time to placement of the LMA andEZ-IO. Results. EMT-B providers successfully placed the LMA in 14 of 18 scenarios (78%; 95% confidence interval, 52% to 94%), with a mean of two attempts for placement. Subjects successfully placed the EZ-IO in 17 of 18 scenarios (94%; 95% confidence interval, 73% to 100%), all on the first attempt. The median time to LMA placement following the third shock was 109 seconds (interquartile range, 58–158) andthe median time to EZ-IO placement was 72 seconds (interquartile range, 50–93) after LMA placement. Conclusions. EMT-B providers demonstrated moderate success in performing advanced-level cardiac resuscitation interventions. These observations suggest potential for expanding the role of basic-level rescuers in cardiopulmonary resuscitation. Key words: cardiopulmonary resuscitation; emergency medical services; simulation; out-of-hospital cardiac arrest; intraosseous; laryngeal mask airway.

Part 1: Introduction

Part 1: Introduction

Endocrine Emergencies: Recognizing Signs and Symptoms

Endocrine emergencies may present to the pediatric practitioner in the office setting in a variety of forms. Four of the more common pediatric endocrine emergencies (DKA, symptomatic hypoglycemia, adrenal insufficiency, and hypocalcemia) have been discussed here. The recommended approach to a child or adolescent with an endocrine emergency involves recognizing clinical disease, stabilizing the patient with basic and advanced life support intervention, and transferring the patient to a facility which can provide appropriate definitive care.

Responses to Written Notification during Out-of-hospital Care Trials Using Waiver of Informed Consent

Resuscitation research has been allowed to proceed using waiver of consent when compliance with guidelines is assured. In these circumstances, institutional review boards (IRBs) may request notification of enrolled patients. To describe the notification process developed with IRB feedback and implemented in two out-of-hospital randomized controlled trials (RCTs) in a large urban setting. This was a descriptive review of two RCTs recruiting a total of 620 patients: the Out-of-hospital Cardiac Arrest Rectilinear Biphasic to Monophasic Damped Sine Defibrillation Waveforms with Advanced Life Support Intervention Trial (ORBIT), which compared rectilinear biphasic and monophasic damped sine waveform for out-of-hospital cardiac arrest, and the Prehospital Pacing versus Conventional Treatment Effectiveness Trial (PrePACE), which compared dopamine and transcutaneous pacing for unstable bradycardia. The ORBIT study enrolled 538 patients. In 44 (8%) patients, contact information could not be obtained. Notification was attempted for 494 (92%) patients; 48 (10%) letters were returned to sender. Researchers were contacted by telephone regarding 37 (8%) subjects: 16 (43%) requested information, 14 (38%) responded positively, and one (3%) did not return follow-up calls. Overall, two (0.4%) were withdrawn from the study. The PrePACE study enrolled 82 subjects. Contact information was unavailable for one (1%). For the remaining 81 patients, four (5%) letters were returned to sender. Researchers were contacted regarding ten (13%) subjects: seven (70%) requested information, two (20%) responded positively, and one (10%) did not return follow-up calls. No patient was withdrawn from the study. Contact information may be difficult to obtain for up to 20% of out-of-hospital critical patients. In 8% to 13% of cases, patients or designates contacted researchers; most feedback was positive. Frequently, non-study-related information was requested, consuming significant resources. Using this method, fewer than 1% of patients were withdrawn from the studies.

Flight crew skills requirements for advanced life support interventions: Reality and solutions

Introduction: In the past 15 years, several prospective trials have called into question the benefit of several advanced life support (ALS) procedures in the pre-hospital management of critically injured patients. The benefit controversy appears to be centered around the proficiency of pre-hospital personnel's technical skills based on present experience models (live, dry lab and didactic), and their appropriate clinical application. As with other emergency medical services, there is a lack of standardization of education requirements within the air medical transport community, especially with respect to an advanced skill maintenance program.

Does Advanced Life Support Provide Benefits to Patients?: A Literature Review

Emergency medical services have invested substantial resources to establish advanced life support (ALS) programs. However, it is unclear whether ALS care provides better outcomes to patients compared to basic life support (BLS) care. To evaluate the current evidence regarding the benefits of ALS. Electronic medical databases were searched to identify articles that directly compared ALS versus BLS care. A total of 455 articles were found. Articles were excluded for the following reasons: (1) the article was not written in English; (2) BLS response was not compared to an ALS response; (3) a physician or nurse was included as part of the ALS response; (4) it was an aeromedical response; or (5) defibrillation was included in the ALS, but not the BLS, scope of care. Twenty-one articles met the inclusion criteria for this literature review. Results were divided into four categories: (1) trauma; (2) cardiac arrest; (3) myocardial infarction; and (4) altered mental status. Trauma: The majority of articles showed that ALS provided no benefits over BLS in urban trauma patients. In fact, most studies showed higher mortality rates for trauma patients receiving ALS care. Further research is needed to evaluate the benefits of ALS for rural trauma patients, and whether ALS care improves outcomes in subgroups of urban trauma patents. Cardiac Arrest: Cardiac arrest studies show that early CPR plus early defibrillation provide the greatest improvement in survival. However, most cardiac arrest research includes defibrillation as an ALS skill which has now moved into the BLS scope of care. The 2004 multi-center OPALS study provided good evidence that ALS does not improve cardiac arrest survival over early defibrillation. Further research is needed to address whether any ALS interventions improve cardiac arrest outcome. Myocardial Infarction: Only one study directly compared the outcome of BLS and ALS care on myocardial infarction. The study found no difference in outcomes between BLS and ALS care in an urban setting. Advanced Life Support: Only one study directly compared the outcome of BLS and ALS care on patients with altered mental status. The study found that the same number of patients had improved to "alert" on arrival at the emergency department, but there was a decreased length of emergency department stay for patients treated by ALS for hypoglycemia. This review article does not take into account the benefits of 2005 ALS interventions, such as thrombolytics, dextrose, or nitroglycerin, since no studies directly compared these interventions to BLS care. Furthermore, only one study in this literature review was a large, multi-center trial. ALS shows little, if any, benefits for urban trauma patients. Cardiac arrest studies show that ALS does not provide additional benefits over BLS-defibrillation care, but more research is needed in this area. In two small studies, ALS care did not provide benefits over BLS care for patients with myocardial infarctions or altered mental status. Larger-scale studies are needed to evaluate which specific ALS interventions improve patient outcomes.

Out-of-hospital cardiac arrest rectilinear biphasic to monophasic damped sine defibrillation waveforms with advanced life support intervention trial (ORBIT)

Background: Although biphasic defibrillation waveforms appear to be superior to monophasic waveforms in terminating VF, their relative benefits in out-of-hospital resuscitation are incompletely understood. Prior comparisons of defibrillation waveform efficacy in out-of-hospital cardiac arrest (OHCA) are confined to patients presenting in a shockable rhythm and resuscitated by first responder (basic life support). This effectiveness study compared monophasic and biphasic defibrillation waveform for conversion of ventricular arrhythmias in all OHCA treated with advance life support (ALS). Methods and results: This prospective randomized controlled trial compared the rectilinear biphasic (RLB) waveform with the monophasic damped sine (MDS) waveform, using step-up energy levels. The study enrolled OHCA patients requiring at least one shock delivered by ALS providers, regardless of initial presenting rhythm. Shock success was defined as conversion at 5 s to organized rhythm after one to three escalating shocks. We report efficacy results for the cohort of patients treated by ALS paramedics who presented with an initially shockable rhythm who had not received a shock from a first responder (MDS: n = 83; RLB: n = 86). Shock success within the first three ascending energy shocks for RLB (120, 150, 200 J) was superior to MDS (200, 300, 360 J) for patients initially presenting in a shockable rhythm (52% versus 34%, p = 0.01). First shock conversion was 23% and12%, for RLB and MDS, respectively ( p = 0.07). There were no significant differences in return of spontaneous circulation (47% versus 47%), survival to 24 h (31% versus 27%), and survival to discharge (9% versus 7%). Mean 24 h survival rates of bystander witnessed events showed differences between waveforms in the early circulatory phase at 4–10 min post event (mean (S.D.) RLB 0.45 (0.07) versus MDS 0.31 (0.06), p = 0.0002) and demonstrated decline as time to first shock increased to 20 min. Conclusion: Shock success to an organized rhythm comparing step-up protocol for energy settings demonstrated the RLB waveform was superior to MDS in ALS treatment of OHCA. Survival rates for both waveforms are consistent with current theories on the circulatory and metabolic phases of out-of-hospital cardiac arrest.

When minutes count—the fallacy of accurate time documentation during in-hospital resuscitation

The purpose of this study is to examine the commonly held assumption that time is measured and documented accurately during resuscitation from cardiac arrest in the hospital. Methods: A two-pronged approach was used to evaluate the accuracy of time documentation and measurement. First, two existing databases—the National Registry of Cardiopulmonary Resuscitation (NRCPR) and a 240-bed hospital's repository of cardiac arrest records—were evaluated for completeness and accuracy of documentation on resuscitation records of times required for calculating the Utstein gold-standard process intervals—recognition of pulselessness to starting cardiopulmonary resuscitation (CPR), delivery of first defibrillation shock, successful intubation, and epinephrine (adrenaline) administration. Second, nurses from a 900-bed hospital were interviewed to determine timepieces used during resuscitations, and timepieces were assessed for coherence and precision. Results: From the NRCPR database that included 10,689 pulseless cardiac arrests submitted by 176 hospitals, time data for calculating the Utstein intervals were missing for 10.9% of the interventions; negative intervals were calculated for 4%. From 232 consecutive resuscitation records from the 240-bed hospital, 85 records were identified from non-monitored units with staff who provided only CPR. Defibrillation, intubation and epinephrine administration were delayed until after arrival of advanced life support (ALS) responders; unlikely intervals of 0 min from event recognition to these ALS interventions were calculated for 11.5%. Sixty-seven nurses from the 900-bed hospital were interviewed; when documenting information during resuscitations, 21 (31.3%) reported using only patient room clocks, 30 (44.8%) only their watches, and 16 (23.9%) several timepieces. In all in-patient units in the same hospital, 241 timepieces (nurses’ and physicians’ watches, clocks in patient rooms, defibrillator clocks, central station monitors, and nursing station clocks) were compared to atomic time. The mean absolute time difference from atomic clock was 2.83 min (S.D. ±5.9 min), median 1.88 min, and range 52.1 min slow to 72.85 min fast. There was no difference among timepieces ( P = 0.35). Conclusions: Missing time data, negative calculated Utstein gold-standard process intervals, unlikely intervals of 0 min from arrest recognition to ALS interventions in units with CPR providers only, use of multiple timepieces for recording time data during the same event, and wide variation in coherence and precision of timepieces bring into question the ability to use time intervals to evaluate resuscitation practice in the hospital. Practitioners, researchers and manufacturers of resuscitation equipment must come together to create a method to collect and document accurately essential resuscitation time elements. Our ability to enhance the resuscitation process and improve patient outcomes requires that this be done.

Evidence Review: Emergency Medical Services Treatment of Patients With Congestive Heart Failure/Acute Pulmonary Edema: Do Risks Outweigh Benefits?

The evaluation and treatment of congestive heart failure (CHF) and acute pulmonary edema (APE) have long been recognized as problematic for EMS providers.1,2 It is extremely difficult to differentiate cardiac causes of respiratory distress (RD) from noncardiac causes based on physical signs and symptoms alone, yet that—in addition to the patient’s history and medication list—is all that EMS providers have to work with. Despite these known difficulties, EMS providers are expected to institute advanced life support (ALS) interventions based on a presumed diagnosis for patients’ RD.

An Evaluation of Pediatric In-hospital Advanced Life Support Interventions Using the Pediatric Utstein Guidelines

Survey of Anesthesiology: October 2004 - Volume 48 - Issue 5 - p 248-249 doi: 10.1097/01.sa.0000140543.55353.f5

Can First Responders Be Sent to Selected 9-1-1 Emergency Medical Services Calls without an Ambulance?

To evaluate the feasibility and safety of initially dispatching only first responders (FRs) to selected low-risk 9-1-1 requests for emergency medical services. First responders are rapidly-responding fire crews on apparatus without transport capabilities, with firefighters trained to at least a FR level and in most cases to the basic emergency medical technician (EMT) level. Low-risk 9-1-1 requests include automatic medical alerts (ALERTs), motor vehicle incidents (MVIs) for which the caller was unable to answer any medical dispatch questions designed to prioritize the call, and 9-1-1 call disconnects (D/Cs). A before-and-after study of patient dispositions was conducted using historical controls for comparison. During the historical control phase of six months, one year prior to the study phase, basic life support ambulances (staffed with two basic EMTs) were dispatched to selected low-risk 9-1-1 incidents. During the six-month study phase, a fire FR crew equipped with automated external defibrillators (AEDs) was sent initially without an ambulance to these incidents. For ALERTs (n = 290 in historical group vs. 330 in study group), there was no statistical difference in the transport rate (7% vs 10%), but there was a statistically significant increase in the follow-up use of advanced life support (ALS) (1% vs 4%, p = 0.009). No patient in the ALERTs historical group required airway management, while one patient in the study group received endotracheal intubation. No patient required defibrillation in either group. Analysis of the MVIs showed a significant decrease (p < 0.0001) in the patient transport rate from 39% of controls to 33% of study patients, but no change in the follow-up use of ALS interventions (2% for each group). For both the ALERTs and MVIs, the FR's mean response time was faster than ambulances (p < 0.0001). Among the 9-1-1 D/Cs with FRs only (n = 1,028), 15% were transported and 43 (4%) received subsequent ALS care. Four of these patients (0.4%) received intubation and two (0.2%) required defibrillation. However, no patient was judged to have had adverse outcomes as a result of the dispatch protocol change. Fire apparatus crews trained in the use of AEDs can safely be used to initially respond alone (without ambulances) to selected, low-risk 9-1-1 calls. This tactic improves response intervals while reducing ambulance responses to these incidents.