Association Advanced Cardiac Life Support Research Articles

CURRENT LEVEL OF KNOWLEDGE AND AWARENESS OF HEALTHCARE PERSONNEL IN BASIC AND ADVANCED LIFE SUPPORT IN ARREST CASES WITH AND WITHOUT COVID-19 INFECTION

Objective: The knowledge of healthcare professionals about life support is crucial for saving lives. It was aimed to evaluate the knowledge and awareness level of healthcare professionals about advanced life support. Materials and methods: Our study was conducted between 15.02.2021 and 15.03.2021 with healthcare personnel working in our hospital. Data were collected by the questionnaire method. The researcher prepared the survey questions according to the European Resuscitation Council COVID-19 guidelines and American Heart Association Advanced Cardiac Life Support algorithms updated in 2020. 265 healthcare personnel (physicians, physician assistants, family physicians, nurses, health officers, and anesthesia technicians) participated in the study. Demographic characteristics of the participants (gender, age, duration of service, duties, duty stations), training and practice status, and level of knowledge were evaluated. Results: 67.2% of the participants were female, and 32.8% were male. The majority of the participants were nurses working in the inpatient clinics. 49.9% had a tenure of 1-5 years. 52.0% had received advanced cardiac life support training, and 19.6% had obtained and used automatic external defibrillators. 63.8% had performed advanced cardiac life support on a patient. In our study, the general level of advanced cardiac life support knowledge of the participants was found to be low. There was no significant difference in advanced cardiac life support scores in terms of gender, age, occupation, workplace, and tenure (p=0.604; p=0.986; p=0.927; p=0.982; p=0.295, respectively). Conclusion: Providing in-service resuscitation training to healthcare workers in line with current guidelines and supporting them with practical applications can provide quality knowledge and skills and increase their awareness of their responsibilities.

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

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

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

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

Cardiac Arrest in the Operating Room: Part 2-Special Situations in the Perioperative Period.

As noted in part 1 of this series, periprocedural cardiac arrest (PPCA) can differ greatly in etiology and treatment from what is described by the American Heart Association advanced cardiac life support algorithms, which were largely developed for use in out-of-hospital cardiac arrest and in-hospital cardiac arrest outside of the perioperative space. Specifically, there are several life-threatening causes of PPCA of which the management should be within the skill set of all anesthesiologists. However, previous research has demonstrated that continued review and training in the management of these scenarios is greatly needed and is also associated with improved delivery of care and outcomes during PPCA. There is a growing body of literature describing the incidence, causes, treatment, and outcomes of common causes of PPCA (eg, malignant hyperthermia, massive trauma, and local anesthetic systemic toxicity) and the need for a better awareness of these topics within the anesthesiology community at large. As noted in part 1 of this series, these events are always witnessed by a member of the perioperative team, frequently anticipated, and involve rescuer-providers with knowledge of the patient and the procedure they are undergoing or have had. Formulation of an appropriate differential diagnosis and rapid application of targeted interventions are critical for good patient outcome. Resuscitation algorithms that include the evaluation and management of common causes leading to cardiac in the perioperative setting are presented. Practicing anesthesiologists need a working knowledge of these algorithms to maximize good outcomes.

A Turbine-Driven Ventilator Improves Adherence to Advanced Cardiac Life Support Guidelines During a Cardiopulmonary Resuscitation Simulation.

Research has shown that increased breathing frequency during cardiopulmonary resuscitation is inversely correlated with systolic blood pressure. Rescuers often hyperventilate during cardiopulmonary resuscitation (CPR). Current American Heart Association advanced cardiac life support recommends a ventilation rate of 8-10 breaths/min. We hypothesized that a small, turbine-driven ventilator would allow rescuers to adhere more closely to advanced cardiac life support (ACLS) guidelines. Twenty-four ACLS-certified health-care professionals were paired into groups of 2. Each team performed 4 randomized rounds of 2-min cycles of CPR on an intubated mannikin, with individuals altering between compressions and breaths. Two rounds of CPR were performed with a self-inflating bag, and 2 rounds were with the ventilator. The ventilator was set to deliver 8 breaths/min, pressure limit 22 cm H2O. Frequency, tidal volume (VT), peak inspiratory pressure, and compression interruptions (hands-off time) were recorded. Data were analyzed with a linear mixed model and Welch 2-sample t test. The median (interquartile range [IQR]) frequency with the ventilator was 7.98 (7.98-7.99) breaths/min. Median (IQR) frequency with the self-inflating bag was 9.5 (8.2-10.7) breaths/min. Median (IQR) ventilator VT was 0.5 (0.5-0.5) L. Median (IQR) self-inflating bag VT was 0.6 (0.5-0.7) L. Median (IQR) ventilator peak inspiratory pressure was 22 (22-22) cm H2O. Median (IQR) self-inflating bag peak inspiratory pressure was 30 (27-35) cm H2O. Mean ± SD hands-off times for ventilator and self-inflating bag were 5.25 ± 2.11 and 6.41 ± 1.45 s, respectively. When compared with a ventilator, volunteers ventilated with a self-inflating bag within ACLS guidelines. However, volunteers ventilated with increased variation, at higher VT levels, and at higher peak pressures with the self-inflating bag. Hands-off time was also significantly lower with the ventilator. (ClinicalTrials.gov registration NCT02743299.).

Prolonged QT Syndrome in a 27-Year-Old Female Presenting as a Cardiac Arrest after Elective Surgery.

Cardiac arrest is a true medical emergency and clinicians should base the management on American Heart Association advanced cardiac life support algorithm. The potential triggers of cardiac arrest should be sought. We present a case of a 27-year-old female who developed cardiac arrest and was later found to have congenital long QT syndrome. The patient's outcome was favorable. Discussion of the key management options will be discussed in the text.

Lipid resuscitation: development in basic research and application to clinical practice

It has been nearly 15 years since the effectiveness of intravenous lipid emulsion in resuscitation from bupivacaine-induced cardiac arrest was reported by Weinberg et al. [1]. Despite the outstanding novelty and originality of this finding, it was not until a 2006 case report of a patient resuscitated with lipid emulsion after bupivacaine-induced refractory dysrhythmia and cardiac arrest that its clinical effectiveness was acknowledged [2]. This event was followed by a large number of case reports that showed the effectiveness of lipid emulsion for treating the central nervous system as well as cardiac toxicity induced by various kinds of local anesthetics [3–8]. Treatment with intravenous lipid emulsion has been incorporated into practice advisories of the Association of Anesthesiologists of Great Britain and Ireland, the American Society of Regional Anesthesia and Pain Medicine [9], and endorsed by the American Heart Association Advanced Cardiac Life Support (ACLS) guidelines [10] (Table 1). In response to widespread interest, numerous studies have been undertaken using various animal models [8]. Notably, most of the animal experiments have been focused on examining the effect of lipid on local anesthetic-induced cardiac toxicity, not central nervous system toxicity, probably because of the primary concern of resuscitation and the entirely different animal models required for studying these two types of toxicity. Animals under mechanical ventilation with oxygen are needed to examine the effect of lipid emulsion on cardiac toxicity of local anesthetics while eliminating the influence of hypoxia induced by sedation and convulsions preceding circulatory collapse [11–14]. In contrast, awake, spontaneously breathing animals are needed to observe its effect on the central nervous system toxicity [15]. Randomized clinical trials are no longer ethically defensible for studying local anesthetic toxicity. Moreover, clinical data from healthy volunteers given nontoxic doses of bupivacaine would not precisely reflect the condition at the onset of the toxic effects [16].

Lipid Resuscitation

Lipid Resuscitation

Advanced Cardiac Life Support: A Review Before Residency

OPEN ACCESSDecember 21, 2011Advanced Cardiac Life Support: A Review Before Residency Frank Messina, MD Frank Messina, MD Indiana University School of Medicine Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.8175 SectionsAbout ToolsDownload Citations ShareFacebookTwitterEmail AbstractThis revised resource reviews the 2010 American Heart Association (AHA) Advanced Cardiac Life Support (ACLS) guidelines and is to be used for a faculty-led, 2-hour, case-based interactive discussion aimed at graduating fourth-year medical students. This resource was created to fill a specific curricular need: a brief yet comprehensive and priority-based review of advanced cardiac life support principles which can be accomplished with minimal equipment and set-up. The module consists of four documents; the cases, rhythm strips, an instructor guide, and a structured outline for faculty. Faculty facilitators use eight structured cases which simulate realistic situations a first-year resident in various specialties is likely to encounter. Facilitators are given a detailed outline with suggestions on how to lead each of the cases. The resource can be used for small-group sessions or in a larger group guided discussion format. It is part of a fourth-year medical student clinical-review elective that has been taught for over 10 years. Student participants have consistently rated the ACLS section of that course, built upon this resource, as one of the top 3 of 20 or more sections in usefulness and applicability. Use of the resource will not lead to AHA ACLS provider certification however. Educational Objectives By the end of the module, the learner will be able to: Recite the American Heart Association Advanced Cardiac Life Support (ACLS) Pulseless Arrest algorithm including medication doses.Recognize the following dysrhythmias: ventricular tachycardia; ventricular fibrillation; supraventricular tachycardia, sinus tachycardia; sinus bradycardia; atrioventricular block: 1°, 2° (Types I and II), 3°; asystole, agonal; atrial fibrillation.Understand the ACLS emphasis on high quality CPR, early defibrillation, a team approach, and addressing primary causes (generating a differential diagnosis).Apply appropriately the ACLS algorithms for: bradycardia, tachycardia, acute coronary syndromes, and acute stroke. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Instructor's Guide.docx ACLS Cases.docx ACLS Cases Faculty Notes.docx Rhythm Strips.docx To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. CitationMessina F. Advanced Cardiac Life Support: A Review Before Residency. MedEdPORTAL. 2011;7:8175. https://doi.org/10.15766/mep_2374-8265.8175 Copyright & Permissions© 2011 Messina. This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial-Share Alike license.KeywordsAdvanced Cardiac Life SupportCardioversionAtrioventricular BlockSupraventricular TachycardiaAtrial FibrillationSinus BradycardiaDysrythmiaVentricular FibrillationCPRPulseless Arrest Disclosures None to report. Funding/Support None to report. Loading ...

Coagulopathy during cardiac arrest and resuscitation in a swine model of electrically induced ventricular fibrillation

AimsCoagulopathy is often present after resuscitation from cardiac arrest but plays an undefined role in the post cardiac arrest syndrome. The aim of this study was to characterize coagulation changes during cardiac arrest and post-resuscitation care in order to direct further focused study. MethodsVentricular fibrillation (VF) was induced electrically in immature male swine, followed by normothermic American Heart Association Advanced Cardiac Life Support and a uniform post-resuscitation goal-directed resuscitation protocol. PT, aPTT, fibrinogen, Thrombelastography (TEG), platelet contractile force (PCF), clot elastic modulus (CEM), and collagen-induced platelet aggregation were compared at baseline, at 8min of VF, during the 3rd round of chest compressions (CPR), and at 15, 90, 180, and 360min after return of circulation using repeated measures ANOVA. Results8/18 (44%) animals were resuscitated after 10.9±0.9min of VF and 7.6±3.4min of CPR. TEG revealed a significant impairment in clot strength (MA) and clot formation kinetics (K, alpha angle) arising during CPR, followed by a brief prolongation of clot onset times (R) after return of circulation. Both PCF and CEM fell significantly during CPR (PCF by 50%, CEM by 47% of baseline) and platelet aggregation was significantly decreased during CPR. Coagulation changes were partially recovered by 3h of post-resuscitation care. ConclusionWhole blood coagulation was rapidly impaired during CPR after electrically induced VF in this swine model by impaired platelet aggregation/contractile function and clotting kinetics. Further platelet-specific study is indicated.

Optimal vasopressor drug therapy during resuscitation

Optimal vasopressor support during resuscitation should theoretically enhance aortic diastolic and coronary perfusion pressure as well as coronary and cerebral blood flow/oxygen delivery without increasing cellular oxygen demand. Intravenous vasopressor support, using 1 mg doses of epinephrine every 5 minutes in adults or vasopressin 40 IU, is recommended by American Heart Association Advanced Cardiac Life Support Guidelines to maximize oxygen delivery to the heart and brain and increase cellular high energy phosphate levels. Vasopressin offers theoretical advantages over epinephrine in that it does not increase myocardial oxygen demand significantly and its receptors are relatively unaffected by acidosis. However, unlike epinephrine, it is not a myocardial stimulant. Despite these differences in physiologic actions, two large randomized clinical trials yielded virtually identical overall survival to hospital discharge when these agents were compared during inhospital or out-of-hospital resuscitation in Canada and Europe, respectively. More recent clinical and experimental evidence suggests that a combination of vasopressin and epinephrine used during resuscitation can improve hemodynamics and perhaps survival. The verdict on a combination vasopressor strategy may soon come from a large (>2,000 patients) prospective clinical trial that is underway in France to clarify the role of combination vasopressin/epinephrine therapy in out-of-hospital resuscitation.

Lipid Infusion Resuscitation for Local Anesthetic Toxicity

Lipid Infusion Resuscitation for Local Anesthetic Toxicity

The use of amiodarone for in-hospital cardiac arrest at two tertiary care centres

Although amiodarone significantly increases survival to hospital admission when used in resuscitation of out-of-hospital pulseless ventricular tachycardia and fibrillation, there are limited data on its utility for in-hospital arrests. To determine whether the use of amiodarone, as recommended by the year 2000 American Heart Association Advanced Cardiac Life Support guidelines, improved survival following its introduction to the resuscitation algorithm at two tertiary care institutions. Charts of 374 cardiac resuscitations were retrospectively studied at the two institutions. Basic survival outcomes and demographic data were recorded for cardiac arrests with ventricular tachyarrhythmias qualifying for administration of antiarrhythmic agents. Qualifying rhythms were present in 95 patients. Clinical uptake of amiodarone was limited. In the 36 patients who received amiodarone, survival of resuscitation was 67% versus 83% (P=0.07) in the 59 patients receiving only other antiarrhythmic agents (chiefly lidocaine [94%]), while survival to discharge was 36.1% and 55.9% (P=0.06) in these two groups, respectively. Following two years' experience with the introduction of intravenous amiodarone for resuscitation in the institutions, use was less than 50% and no clinically observable survival benefit could be documented. Possible explanations for the difference between this experience and that found in out-of-hospital resuscitation trials include differing patient populations and operator bias during resuscitation. These results should provoke other institutions to question whether amiodarone has improved survival of cardiac arrest under the conditions prevailing in their hospitals. A patient registry or prospective, randomized trial will be required to assess what parameters affect the success of intravenous amiodarone for resuscitation in-hospital.

Evaluation of advanced cardiac life support written examinations

OBJECTIVE: To examine the quality of 2 advanced cardiac life support written examinations and the relationship between demographic variables and test performance.DESIGN: Descriptive.SETTING: Advanced cardiac life support courses held at 4 midwestern hospitals, one outpatient surgery center, and one community college.SUBJECTS: Nonprobability sample of 367 participants.OUTCOME MEASURE: Two versions of the American Heart Association advanced cardiac life support written examinations.RESULTS: Reliability coefficients of test A and test B were 0.45 and 0.54, respectively. Discrimination and difficulty indices calculated on both tests revealed that test B questions were more difficult, with better discriminators. Prior experience, sex of participant, and profession were identified as factors influencing test performance.CONCLUSION: Although test B surpassed the performance of test A, both examinations were problematic. Additional investigation and refinement of the advanced cardiac life support tests are warranted.

Evaluation of advanced cardiac life support written examinations

To examine the quality of 2 advanced cardiac life support written examinations and the relationship between demographic variables and test performance. Descriptive. Advanced cardiac life support courses held at 4 midwestern hospitals, one outpatient surgery center, and one community college. Nonprobability sample of 367 participants. Two versions of the American Heart Association advanced cardiac life support written examinations. Reliability coefficients of test A and test B were 0.45 and 0.54, respectively. Discrimination and difficulty indices calculated on both tests revealed that test B questions were more difficult, with better discriminators. Prior experience, sex of participant, and profession were identified as factors influencing test performance. Although test B surpassed the performance of test A, both examinations were problematic. Additional investigation and refinement of the advanced cardiac life support tests are warranted.

Advanced cardiac life support training: Comparison of Brazilian versus North American student responses

A nationally coordinated effort has recently begun to teach Advanced Cardiac Life Support (ACLS) to health care professionals throughout Brazil. Under the direction of FUNCOR of the Brazilian Heart Foudation Society of Cardiology these courses have carefully followed the American Heart Association's ACLS guidelines. ACLS materials (english) were available prior to the course for each student. Data on student preparation and end of course evaluations have been prospectively gathered and comparisons made between the first 122 Brazilian students and a similar 1997 student cohort from the University of Arizona (n = 31). Students evaluated the different course aspects as non-satisfactory, satisfactory, or superior. No differences in ratings concerning course schedule, course dynamics, or content were detected with both groups giving each of these categories approximately a 45% "superior" rating. Significantly more Brazilian students rated "superior" course organization (62 vs 42%; p < .02) and duration (10 vs 27%; p < .05) than did the Arizona students.

The Development and Evaluation of New Versions of the Written Examination for the American Heart Association Advanced Cardiac Life Support Provider Course

Study objective: To create new versions of the written, multiple-choice examination used in the American Heart Association (AHA) Advanced Cardiac Life Support course, evaluate their reliability and difficulty, and then design revised versions with improved reliability and of standardized difficulty. Design: Psychometric evaluation of new versions of the AHA Advanced Cardiac Life Support test and revisions. Setting: AHA Advanced Cardiac Life Support courses. Participants: Candidates for completion of AHA Advanced Cardiac Life Support provider courses in five states. Intervention: The course content was divided into 11 content areas that were weighted for importance and appropriateness for testing in a multiple-choice format. The weights were used to construct a blueprint for a 50-question, multiple-choice examination. Five versions of the examination were then constructed based on the content blueprint, drawing from new questions and expert revision of previously written questions. Reliability and difficulty were assessed using 915 administrations at five different sites nationwide. The initial test versions differed in their degree of difficulty, which was not explained by demographic factors. The results were used to revise three of the versions to improve reliability and equalize difficulty of the versions. Measurements and main results: The final five versions have estimated reliability ranging from Cronbach's α of .62 to .86. Mean scores ranged from 87.4% to 89.1%. Conclusion: After field testing and revision, five examinations with acceptable reliability and roughly equal difficulty were constructed. The new examinations test the participants' knowledge of important aspects of resuscitation science and practice based on a blueprint of the course content. [Billi JE, Gruppen LD, Boxer GJ, Oh M, Donnelly MB, Schroeder P, Littrell KA, Grauer K, Cavallaro DL, Thies W, Membrino GE: The development and evaluation of new versions of the written examination for the American Heart Association Advanced Cardiac Life Support provider course. Ann Emerg Med July 1994;24:26-31.]

A Randomized Clinical Trial of High-Dose Epinephrine and Norepinephrine vs Standard-Dose Epinephrine in Prehospital Cardiac Arrest

To determine the relative efficacy of high- vs standard-dose catecholamines in initial treatment of prehospital cardiac arrest. Randomized, prospective, double-blind clinical trial. Prehospital emergency medical system of a major US city. All adults in nontraumatic cardiac arrest, treated by paramedics, who would receive epinephrine according to American Heart Association advanced cardiac life support guidelines. High-dose epinephrine (HDE, 15 mg), high-dose norepinephrine bitartrate (NE, 11 mg), or standard-dose epinephrine (SDE, 1 mg) was blindly substituted for advanced cardiac life support doses of epinephrine. Restoration of spontaneous circulation in the field, admission to hospital, hospital discharge, and Cerebral Performance Category score. Of 2694 patients with cardiac arrests during the study period, resuscitation was attempted on 1062 patients. Of this total, 816 patients met study criteria and were enrolled. In the entire cardiac arrest population, 63% of the survivors were among the 11% of patients who were defibrillated by first responders. The three drug treatment groups were similar for all independent variables. Thirteen percent of patients receiving HDE regained a pulse in the field vs 8% of those receiving SDE (P = .01), and 18% of HDE patients were admitted to the hospital vs 10% of SDE patients who were admitted to the hospital (P = .02). Similar trends for NE were not significant. There were 18 survivors; 1.7% of HDE patients and 2.6% of NE patients were discharged from the hospital compared with 1.2% of SDE patients, but this was not significant (P = .37; beta = .38). There was a nonsignificant trend for Cerebral Performance Category scores to be worse for HDE (3.2) and NE patients (3.7) than for SDE patients (2.3) (P = .10; beta = .31). No significant complications were identified. High-dose epinephrine did not produce longer hospital or critical care unit stays. High-dose epinephrine significantly improves the rate of return of spontaneous circulation and hospital admission in patients who are in prehospital cardiac arrest without increasing complications. However, the increase in hospital discharge rate is not statistically significant, and no significant trend could be determined for neurological outcome. No benefit of NE compared with HDE was identified. Further study is needed to determine the optimal role of epinephrine in prehospital cardiac arrest.

Medical student retention of intubation skills

Medical students are trained in airway management by endotracheal intubation in most medical schools. Unfortunately, little data exist examining retention, and no data exist that actually break down the steps of intubation to determine where students encounter problems. We studied 64 medical students trained to intubate as part of an American Heart Association advanced cardiac life support course and their performance two to three months after training. The rate of successful intubation (confirmed by visualization) was 70 +/- 12%. The most frequent errors during intubation were failure to check the light before intubation, use of the teeth as a fulcrum, and failure to check the cuff on the endotracheal tube. Knowledge of the most common errors will allow instructors to place greater emphasis on those areas during the initial instruction period with a focus on decreasing their occurrence in the future.