Current Advanced Cardiac Life Support Research Articles

Improving Transition to Practice: Integration of Advanced Cardiac Life Support Into a Baccalaureate Nursing Program.

Nursing students often lack the skills and confidence to intervene in the care of a deteriorating patient as they transition into clinical practice. Exposure to these situations is limited during their academic career. Our team sought to address this by embedding American Heart Association (AHA) advanced cardiac life support (ACLS) content into the curriculum and offering certification to senior-level students. The senior skills course was redesigned to include education on current AHA ACLS guidelines and skills. ACLS algorithms were introduced and reinforced by mock code labs utilizing rapid cycle deliberate practice and interprofessional simulation. After completion of the semester, students were given the option to be ACLS certified. Students and stakeholders reported positively on the ability to certify in ACLS at our institution prior to graduation and reported increased confidence in their ability to manage patients with cardiopulmonary arrest. Providing simulated experiences for these clinical situations can reportedly increase confidence and improve preparedness in senior-level BSN students. [J Nurs Educ. 2019;58(3):182-184.].

Ultrasound Use During Cardiopulmonary Resuscitation is Associated with Delays in Chest Compressions: Huis in’t Veld MA, Allison MG, Bostick DS, et al. Resuscitation. 2017; 119: 95-98

The goal of cardiopulmonary resuscitation (CPR) is to maintain coronary perfusion pressure (CPP) in patients in cardiopulmonary arrest. Advanced cardiac life support (ACLS) teaches us that high-quality chest compressions – depth of 5cm, rate of 100/min, with limited interruptions – are the key to maintaining CPP. With this in mind, it is unclear what role, if any, frequently performed adjuncts such as point of care ultrasound (POCUS) should have during the delivery of CPR. The goal of this study was to investigate the impact of POCUS on pulse check duration during CPR performed on adults in cardiac arrest treated in the emergency department (ED). This prospective cohort study was conducted in an urban emergency department (ED) between August 2015 and September 2016. Eligible patients included all patients over the age of 18 who presented to the ED in cardiac arrest or in whom cardiac arrest occurred while they were in the ED in one of three resuscitation rooms equipped with video monitoring equipment. Researchers then reviewed the recorded resuscitations and documented the duration of pulse checks and whether POCUS was employed during pulse check. A linear mixed-effects model was used to assess the effect of POCUS on the duration of pulse checks. Twenty-three patients were enrolled in the study with a total of 123 pulse checks. The mean duration of pulse checks without POCUS was 13 seconds (95% confidence interval (CI) 12-15). This increased to 21 seconds (95% CI 18-24) when POCUS was performed. Therefore, the use of POCUS increased the duration of pulse checks by 8.4 seconds (95% CI 6.7-10). The authors of this study concluded that the use of POCUS during CPR was associated with a significant increase in the duration of pulse checks, nearly doubling the 10-second duration recommended in current ACLS guidelines. They further iterate that should providers perform POCUS during resuscitation, it is incumbent upon them to pay close attention to time spent between administrations of quality compressions. Comment: Although physiologically it is clear that prolonged intervals between quality chest compressions will result in decreased coronary perfusion pressures and therefore poorer outcomes; this study was too small to show any effect on patient outcomes. For now, more research is required to determine whether the potential benefits of POCUS during cardiac arrest resuscitations outweigh its delay in high quality compressions. In the meantime, as ED providers, we must remain diligent in minimizing interruptions to chest compressions by developing strategies for performing adjuncts such as POCUS within the confines of the standard 10-second pulse check.

A Collaborative Maternal Arrest Safety Initiative

Poster Presentation Purpose for the Program The American Heart Association's (AHA) 2010 guidelines address cardiac arrest in pregnancy by providing a published algorithm and pregnancy specific modifications for management. A health care provider's ability to react prudently in an unexpected situation is one of the most critical factors in creating a positive outcome in an obstetric emergency. Researchers have shown that advanced cardiac life support (ACLS) certification may not necessarily translate to adequate performance of maternal resuscitation skills during an actual arrest. This maternal arrest pilot program prepares participants how to manage this rare unpredictable obstetric emergency through simulated training experiences that pose no risk to the mother or fetus. Proposed Change OSF Saint Francis Medical Center is a perinatal referral center with a neonatal intensive care unit (NICU) and Level‐I trauma center located in central Illinois. The management of a maternal cardiac arrest requires the collaboration of several teams (obstetric, neonatal, anesthesia, nursing, hospital code, emergency medicine, and prehospital emergency medical services [EMS]) who rarely collaborate to come together to deliver consistent, excellent patient care. The ACLS classes at OSF do not include a comprehensive review of maternal resuscitation. This obstetric‐focused pilot program will bridge this knowledge gap to include a didactic module and simulation component specific to resuscitation of the pregnant woman in conjunction with the current ACLS training program. This program for maternal arrest can span the entire OSF HealthCare system north central region to improve performance during a maternal arrest. Implementation, Outcomes, and Evaluation An interdisciplinary team was involved in the pilot development and will serve as trainers. A survey to assess current ACLS knowledge on maternal arrest will be administered before participants complete the didactic maternal arrest eLearning module. Data will be collected for comparison prelearning and postlearning. The participants include obstetric and emergency residents, registered nurses, anesthesia providers, and neonatal nurse practitioners. Using an obstetric mannequin, the in situ simulation component will be used to analyze the primary and secondary responder's performance using real‐life maternal arrest scenarios, detect areas of deficiency in using the AHA‐recommended algorithm, and discuss performance improvements. Presimulation and postsimulation confidence surveys will be completed. Implications for Nursing Practice Training, communicating, and solving problems in teams can affect maternal and fetal survival during a cardiac arrest. This collaboration will increase job satisfaction for all responders.

Lipid Emulsion Recommendations

To the Editor: We read with interest the work of Ruan et al. 1in the February 2012 issue of ANESTHESIOLOGY; the article explored the effect of both triglyceride chain length and pH modulation on lipid sequestration of cardiotoxic local anesthetics in human serum in vitro . The authors are to be lauded for their efforts to expound the physicochemical interaction known widely as the “sink,” purported to be primarily responsible for the beneficial effects demonstrated in animal models and human subjects suffering local anesthetic systemic toxicity. Their results in many respects epitomize the difficulties associated with forwarding a therapy such as lipid rescue – itself a product of a chance laboratory observation, when definitive knowledge of mechanistic action for lipid remains to be fully elucidated.Ruan et al. demonstrated the superiority of mixed medium and long-chain triglyceride preparations in sequestration of lipophilioc local anesthetics, seemingly independent of pH, when compared with long-chain triglyceride in in vitro human serum. These results, nevertheless, conflict with the findings of Li et al. 2(from the December 2011 issue of ANESTHESIOLOGY), who demonstrated advantages with long-chain triglycerides in an intact animal model. The observed disparity in outcomes between such bench-top and whole animal experiments was discussed expertly in an accompanying editorial.3Although the advancement of any therapy is necessarily paved with conjecture and discourse, such as evidenced in microcosm with these two papers, conclusions drawn from such work must be tempered against the findings of prior investigators' and the associated relevant (and, in the case of lipid therapy, substantial) bodies of work. It is therefore concerning that in their concluding remarks Ruan et al. “call into question the current advanced cardiac life support guidelines specifying use of a long-chain triglyceride emulsion” in local anesthetic systemic toxicity on the basis of their findings alone, before the existence of a body of work supporting alternative lipid emulsion preparations as clearly superior. The work of Ruan et al. clearly represents one step of many in the evolution of lipid emulsion therapy. Their results, however, are insufficient to alter current recommendations4for lipid infusion in local anesthetic systemic toxicity.

Deficits in the Provision of Cardiopulmonary Resuscitation During Simulated Obstetric Crises

Objective Previous work suggests the potential for suboptimal cardiopulmonary resuscitation (CPR) in the parturient but did not directly assess actual performance. Study Design We evaluated 18 videotaped simulations of maternal amniotic fluid embolus and resultant cardiac arrest. A checklist containing 10 current American Heart Association recommendations for advanced cardiac life support (ACLS) in obstetric patients was utilized. We evaluated which tasks were completed correctly and the time required to perform key actions. Results Proper compressions were delivered by our teams 56% of the time and ventilations 50% of the time. Critical interventions such as left uterine displacement and placing a firm back support prior to compressions were frequently neglected (in 44% and 22% of cases, respectively). The mean ± SD overall composite score for the tasks was 45 ± 12% (range, 20–60%). The neonatal team was called in a median (interquartile range) of 1:42 (0:44-2:18) minutes:seconds; 15 of 18 (83%) teams called only after the patient was completely unresponsive. Fifty percent of teams did not provide basic information to the neonatal teams as required by neonatal resuscitation provider guidelines. Conclusion Multiple deficits were noted in the provision of CPR to parturients during simulated arrests, despite current ACLS certification for all participants. Current requirements for ACLS certification and training for obstetric staff may require revision.

Unusual Fibrillation in the Emergency Department After Fall

HomeCirculationVol. 123, No. 25Unusual Fibrillation in the Emergency Department After Fall Free AccessBrief ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessBrief ReportPDF/EPUBUnusual Fibrillation in the Emergency Department After Fall Daniel Zalkind, MD, Ryan Aleong, MD, William Sauer, MD and Duy Thai Nguyen, MD Daniel ZalkindDaniel Zalkind From the Divisions of Cardiology (D.Z.) and Electrophysiology (R.A., W.S., D.T.N.), University of Colorado, Aurora. Search for more papers by this author , Ryan AleongRyan Aleong From the Divisions of Cardiology (D.Z.) and Electrophysiology (R.A., W.S., D.T.N.), University of Colorado, Aurora. Search for more papers by this author , William SauerWilliam Sauer From the Divisions of Cardiology (D.Z.) and Electrophysiology (R.A., W.S., D.T.N.), University of Colorado, Aurora. Search for more papers by this author and Duy Thai NguyenDuy Thai Nguyen From the Divisions of Cardiology (D.Z.) and Electrophysiology (R.A., W.S., D.T.N.), University of Colorado, Aurora. Search for more papers by this author Originally published28 Jun 2011https://doi.org/10.1161/CIRCULATIONAHA.111.030403Circulation. 2011;123:e641–e64247-year-old man with dilated cardiomyopathy, ambulatory left ventricular assist device (Heartmate II, Thoratec Corporation, Pleasanton, CA), and biventricular pacemaker/implantable cardioverter-defibrillator (ICD) (St. Jude Medical, St Paul, MN) presented with syncope to a local hospital. He was hemodynamically stable and otherwise asymptomatic. His electrolyte panel was unremarkable. Initial ECG diagnosis (Figure 1) was unusual atrial fibrillation. On transfer to our hospital, ventricular fibrillation (VF) was suspected (asterisk in Figure 1), with likely undersensing by a defective ICD resulting in lack of defibrillation and lack of inhibition of atrial-biventricular pacing (arrows). There was pacing noncapture due to VF.Download figureDownload PowerPointFigure 1. Twelve-lead ECG.The ICD interrogation (left half of Figure 2) revealed persistent VF (asterisk in Figure 2) for >15 hours in duration. There was alternation between polymorphic ventricular tachycardia and coarse VF throughout this period with no evidence of asystole. The patient only lost consciousness during the initial episode on the basis of his recollections and witness accounts.Download figureDownload PowerPointFigure 2. Intracardiac tracing from implantable cardioverter-defibrillator. VF indicates ventricular fibrillation.Command defibrillation through the ICD, with the use of the device programmer, could not be performed because of interference by the left ventricular assist device with this particular ICD model, a problem that has been reported previously. Successful external defibrillation resulted in sinus rhythm and biventricular pacing with appropriate capture (right half of Figure 2). During the hospitalization, a new sense/pace lead was implanted to correct the undersensing, and the patient was discharged in good condition.DiscussionThis patient's presentation may add to our knowledge about the expected progression of VF to asystole. With sudden cardiac death in the outpatient setting, it has been noted that a VF rhythm will often quickly devolve into asystole.1 It is notable that our patient, with a dilated cardiomyopathy, was able to tolerate >15 hours of a persistent VF rhythm that a structurally normal heart would ordinarily not be able to sustain for more than a few minutes. This was most likely possible because of continuous myocardial perfusion provided by the patient's left ventricular assist device.In past studies, immediate defibrillation was highly effective if applied in the first few minutes after onset of VF.2 More recently, continued myocardial perfusion has been shown to be crucial for improved outcomes in sudden cardiac death.3 The current advanced cardiac life support guidelines recommend either immediate cardioversion of the rhythm or sustained chest compressions with urgent cardioversion based on the current evidence.4 This case illustrates that VF can be a persistent rhythm in patients who retain perfusion to the myocardium. VF is not predestined to progress to asystole; rather, it is the lack of myocardial perfusion that results in asystole.Although it may be difficult to conduct a randomized, controlled study to test the effectiveness of chest compressions in providing valuable myocardial perfusion in instances of sudden death due to VF, patients such as ours have shown that perfusion of the myocardium and other vital organs can be lifesaving during the important period of time before definitive care can be provided.Given the increased frequency of left ventricular assist devices in the ambulatory population, physicians should be aware of life-threatening arrhythmias without hemodynamic instability.DisclosuresDr Sauer has received modest consulting fees, educational and research grant support from Boston Scientific, Medtronic, and St. Jude Medical, all manufacturers of ICDs. Dr Aleong has received modest educational fees from St. Jude Medical. Dr Nguyen is an investigator for research funded by Medtronic.FootnotesCorrespondence to Duy Thai Nguyen, MD, University of Colorado, Anschutz Medical Campus, 12401 E 17th Ave, B-132, Aurora, CO 80045. E-mail duy.t.[email protected]edu.

Physician experience in addition to ACLS training does not significantly affect the outcome of prehospital cardiac arrest

Little data exists on whether the physicians' skills in responding to cardiac arrest are fully developed after the advanced cardiac life support (ACLS) course, or if there is a significant improvement in their performance after an initial learning curve. To estimate the effect of physician experience on the results of prehospital cardiac arrests. Prospective data were collected on all prehospital resuscitative attempts in the area by ACLS-trained ambulance physicians. Of 232 attempted cardiac resuscitations, 96 (41%) patients survived to hospital admission and 44 (19%) were discharged alive. A group of 39 physicians responded to from one up to 29 cases with a mean of four cases. Physicians responding to five or fewer cases had a trend to fewer patients surviving to admission compared with those responding to six or more (36 vs. 45%, P=0.31) but no difference was found on survival to discharge (19 vs. 20%, P=0.87). In this study, resuscitative experience of the physician did not have a significant effect on survival suggesting that experience does not significantly add to the current ACLS training in responding to ventricular fibrillation/ventricular tachycardia. More studies are needed.

Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises

Previous work suggests the potential for suboptimal cardiopulmonary resuscitation (CPR) in the parturient but did not directly assess actual performance. We evaluated 18 videotaped simulations of maternal amniotic fluid embolus and resultant cardiac arrest. A checklist containing 10 current American Heart Association recommendations for advanced cardiac life support (ACLS) in obstetric patients was utilized. We evaluated which tasks were completed correctly and the time required to perform key actions. Proper compressions were delivered by our teams 56% of the time and ventilations 50% of the time. Critical interventions such as left uterine displacement and placing a firm back support prior to compressions were frequently neglected (in 44% and 22% of cases, respectively). The mean +/- SD overall composite score for the tasks was 45 +/- 12% (range, 20-60%). The neonatal team was called in a median (interquartile range) of 1:42 (0:44-2:18) minutes:seconds; 15 of 18 (83%) teams called only after the patient was completely unresponsive. Fifty percent of teams did not provide basic information to the neonatal teams as required by neonatal resuscitation provider guidelines. Multiple deficits were noted in the provision of CPR to parturients during simulated arrests, despite current ACLS certification for all participants. Current requirements for ACLS certification and training for obstetric staff may require revision.

Evaluation of race and gender sensitivity in the American Heart Association materials for Advanced Cardiac Life Support

Given the race and gender disparities in cardiac care for women and minorities, it is important to evaluate how we teach in this content area, because it may influence this bias. We assessed the American Heart Association's Advanced Cardiac Life Support (ACLS) materials, published in 2006, for examples of race and gender sensitivity that depicted culturally competent health education. Precourse materials, manuals, illustrations, case vignettes, compact discs (CDs), algorithms, and tests were evaluated for culturally competent opportunities. An opportunity was defined as each question or scenario that could have been edited to reflect race or gender. Minority status was interpreted as skin color other than white. Each individual component was counted separately. After the quantitative tally, an analysis was performed using simple percentile comparisons. Interpretations were based on these percentages. The majority of teaching opportunities (54%) did not reflect race or gender. Of 149 patient opportunities to adequately represent those at risk, none clearly represented a minority female. In the simulated cases on the provider CD, all patients were white males. The mannequin had a male haircut and an open shirt. No mannequin had female characteristics (eg, earrings, breasts, or women's clothing). None of the provider CD cases illustrated patients or mannequins with skin color other than white. The current ACLS provider and instructor materials do not maximize opportunities to illustrate vulnerable segments of the population. Future studies designed to evaluate the effect of improved representation of women and minorities in teaching models should be considered.

Arrhythmia and Acute Coronary Syndrome Suppression and Cardiac Resuscitation Management With Bretylium

It is well known that electric shock can both initiate and terminate ventricular fibrillation. Refractory ventricular fibrillation (RVF) may often be an iatrogenic paradoxical result of early, frequent, excessive salvos of DC current countershocks and inappropriate off-label drug use, particularly aggressive epinephrine administration. Evidence suggests that the current advanced cardiac life support pharmacology protocol for cardiac resuscitation may contribute to disappointing survival in patients with out-of-hospital cardiac arrest. Controlled studies and new theoretical consideration suggest the protocol may induce RVF. In contrast, studies suggest that immediate adequate intravenous bretylium administration therapy together with sustained effective chest compressions can induce chemical defibrillation or facilitate electrical defibrillation as well as reduce the intensity, or even need for potentially heart-damaging countershock, where early frequent excessive current shocks are likely to increase refractory arrhythmia as demonstrated in animals and in humans. Salvos of shocks do not allow time between shocks for uniform recovery of normal electrical parameters needed to restore a stable heart rhythm. This may occur by inadvertently administering shock during the vulnerable period of the cardiac cycle. There are compelling existing data to demonstrate that bretylium and cardiopulmonary resuscitation (CPR) delivered before initiating shock therapy is likely to provide the best outcome in cardiac arrest. But, most importantly, adequate CPR chest compressions administered while bretylium is being infused also provide the opportunity to wash out electrically destabilizing electrolytes that have leaked from or are abnormally transported by functionally damaged membranes of fibrillation-induced ischemic myocytes. This may cause abnormal compartment redistribution of electrolytes that may facilitate RVF by heterogeneously partially depolarizing ischemic myocytes. Although efforts have been made to provide hard science for advanced life support, the guidelines are a product of consensus, the give and take of collegiality and intuition rather than rigorous controlled studies. Bretylium has a direct antifibrillatory action normalizing myocyte membrane currents, which restores intracompartmental normal electrolyte balance. In addition, adrenergic blockade by bretylium dilates coronary arteries, increasing effective O2 delivery by CPR. The free and aggressive use of epinephrine is toxic. Catechalomines cause coronary spasm and puts myocardial metabolism into damaging hypermetabolic overdrive to support the "fight or flight reflex" rapidly depleting adenosine triphosphate needed for cardiac electrical and mechanical recovery. Moreover, the value of epinephrine to resuscitation has never been demonstrated in a controlled human study, whereas its potential damage has been largely ignored. Epinephrine's potential deleterious actions that might compromise resuscitation are well established and reviewed here.

Comparison of Traditional Advanced Cardiac Life Support (ACLS) Course Instruction Vs. a Scenario-Based, Performance Oriented Team Instruction (SPOTI) Method for Korean Paramedic Students

Current Advanced Cardiac Life Support (ACLS) course instruction involves a 2-day course with traditional lectures and limited team interaction. We wish to explore the advantages of a scenario-based performance-oriented team instruction (SPOTI) method to implement core ACLS skills for non-English-speaking international paramedic students. The objective of this study was to determine if scenario-based, performance-oriented team instruction (SPOTI) improves educational outcomes for the ACLS instruction of Korean paramedic students. Thirty Korean paramedic students were randomly selected into two groups. One group of 15 students was taught the traditional ACLS course. The other 15 students were instructed using a SPOTI method. Each group was tested using ACLS megacode examinations endorsed by the American Heart Association. All 30 students passed the ACLS megacode examination. In the traditional ACLS study group an average of 85% of the core skills were met. In the SPOTI study group an average of 93% of the core skills were met. In particular, the SPOTI study group excelled at physical examination skills such as airway opening, assessment of breathing, signs of circulation, and compression rates. In addition, the SPOTI group performed with higher marks on rhythm recognition compared to the traditional group. The traditional group performed with higher marks at providing proper drug dosages compared to the SPOTI students. However, the students enrolled in the SPOTI method resulted in higher megacode core compliance scores compared to students trained in traditional ACLS course instruction. These differences did not achieve statistical significance due to the small sample size.

Paramedic Compliance with ACLS Epinephrine Guidelines in Out-of-Hospital Cardiac Arrest

Objective. The purpose of this observational study was to determine the baseline rate of adherence to current American Heart Association guidelines with regard to use of epinephrine in out-of-hospital cardiac arrests. Methods. A structured explicit retrospective review of all adult victims of cardiac arrest logged in the EMSCQI.com database during its first 20 months in operation from February 2004 to October 2005. Noncompliance was defined as epinephrine administration on average less than every three minutes or greater than every five minutes regardless of dosage. Primary determination of noncompliance was calculated by dividing the time from first epinephrine dose to hospital arrival by the number of subsequent doses given during that time frame. Results. Seventy-five of 11,000 advanced life support calls were identified as out-of-hospital cardiac arrests. The overall rate of noncompliance was 86% (95% confidence interval, 75–93%). The average time from the first epinephrine administration to hospital arrival was 22.6 minutes. The median number of epinephrine doses per patient was three. All patients in the noncompliant group received epinephrine less often than every five minutes. The data did not allow for examination of noncompliance predictors. Conclusions. Epinephrine administration in accordance with current advanced cardiac life support guidelines occurred in 14% of out-of-hospital cardiac arrest patients.

Defibrillation and biphasic shocks: Implications for perianesthesia nursing

Cardiac arrests, the majority of which are due to ventricular fibrillation (VF), are a significant threat to survival. The definitive therapy for cardiac arrests due to VF is rapid, early defibrillation. There have been several advances made to modern defibrillators to electively or emergently terminate lethal and nonlethal arrhythmias through external defibrillation. The most recent improvement is in the efficacy of the delivered shock. Biphasic shock waveforms have been shown to be superior to monophasic shocks and are recognized in the current Advanced Cardiac Life Support guidelines by the American Heart Association. Because hospitals are increasingly replacing older models of monophasic capability defibrillators with the newer biphasic capability models, it will be essential for perianesthesia nurses to understand the principles of biphasic technology.

Adrenaline administration during cardiopulmonary resuscitation: poor adherence to clinical guidelines.

Adrenaline does not appear to improve the outcome after cardiac arrest in clinical trials in spite of beneficial effects in experimental studies. The objective of this study was to determine whether adrenaline was administered in accordance with advanced cardiac life support (ACLS) guidelines during adult cardiopulmonary resuscitation (CPR). From 15 January to 31 December 2000, all patients at Uppsala University Hospital in whom CPR was attempted were registered prospectively. The duration of CPR was documented in the register and the total dose of adrenaline was retrieved retrospectively from patient records. From these data the average interval between adrenaline doses was calculated. Data for evaluation of the between-dose interval of adrenaline was available in 53 of 107 registered cardiac arrests. In 68% (36/53) the average between-dose interval was longer than the 3-5 min recommended in the guidelines, and 8% (4/53) received no adrenaline. The median interval between adrenaline doses during CPR was 6.5 min (25th-75th percentile: 5.1-10.4). Adherence to guidelines was lower in out-of-hospital cardiac arrest than in in-hospital cardiac arrest (P = 0.01). In the majority of cases adrenaline did not appear to be administered according to current ACLS guidelines.

C URRENT I SSUES IN C ARDIOPULMONARY R ESUSCITATION

Current Advanced Cardiac Life Support (ACLS) guidelines and emergency medical services (EMS) clinical protocols usually recommend immediate defibrillation for victims of out-of-hospital cardiac arrest who have ventricular fibrillation (VF). However, animal studies and results from a small number of clinical investigations now suggest that a short period of chest compressions or ACLS procedures delivered before defibrillation may improve the outcome of patients with prolonged VF. Although the basic science and clinical data supporting a chest-compression-first procedure are compelling, large, multicenter randomized trials are still necessary to determine whether such protocols do indeed improve outcome. In current EMS dispatch practice, traditional cardiopulmonary resuscitation (CPR) instructions are given when needed to bystanders who report a possible cardiac arrest. Recent literature has shown that in certain circumstances, CPR instructions involving chest compressions alone may be given more quickly and can yield an equivalent, if not better, chance of survival. Although this practice is controversial, the general consensus is that any CPR is better than none at all. Therefore, telephone CPR protocols that recommend the immediate initiation of chest compressions may be preferred, particularly for callers who have no previous training in CPR.

The ABCs of teaching advanced cardiac life support.

This article describes the evolution in methods used at The Christ Hospital in Cincinnati, Ohio, to teach advanced cardiac life support over the past 10 years. The interactive nature of the teaching methods has improved participants' enjoyment of this course. With smaller teaching groups, instructors find this course challenging and fun to teach. This article provides outlines of teaching stations at The Christ Hospital and examples in which to implement the current advanced cardiac life support content according to the American Heart Association's teaching recommendations.

Adenosine in Wide-Complex Tachycardia

The use of adenosine as a therapeutic and diagnostic tool in wide- complex tachycardia is suggested in the current Advanced Cardiac Life Support (ACLS) guidelines. The ACLS guidelines are now 4 years old, and new information on the safety and efficiency of adenosine in wide-complex tachycardia is available. We review the ACLS recommendations in light of the current available literature. In general, the ACLS recommendations remain reasonable with some important caveats. [Herbert ME, Votey SR: Adenosine in wide-complex tachycardia. Ann Emerg Med January 1997;29:172-174.]

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

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

The Effect of Bolus Injection on Circulation Times During Cardiac Arrest

Previous investigations have shown that peripheral injection of medication during cardiac arrest leads to prolonged circulation times and low peak drug levels. Current Advanced Cardiac Life Support guidelines suggest that administering a bolus of flush solution after injection of medication may hasten drug delivery, but there is little evidence to support this. The purpose of this study is to investigate the effect of peripheral bolus injection on circulation times during cardiac arrest. Measurements of circulation times were made following injection of indocyanine green dye both with and without a bolus of 20 mL saline flush into a peripheral vein of mongrel dogs. There was no difference in systolic, diastolic, or coronary perfusion pressures during the injections with or without bolus injection. Similarly, there was no difference in end-tidal CO2 or in arterial-venous PO2, PCO2, or pH gradient. The circulation time without bolus injection was 77.7 +/- 42.7 seconds while circulation time with the saline flush was 48.3 +/- 20.9 seconds (P less than .001). Peak dye concentration without saline flush was 3.0 +/- 1.0 mg/L, and peak dye concentration with saline flush was 3.8 +/- 0.9 mg/L (P less than .001). We conclude that a bolus injection of 20 mL of saline enhances dye circulation times and peak levels during cardiac arrest in this animal model. The clinical application of this technique warrants further investigation.

The effect of bolus injection on circulation times during cardiac arrest

Previous investigations have shown that peripheral injection of medication during cardiac arrest leads to prolonged circulation times and low peak drug levels. Current Advanced Cardiac Life Support guidellnes suggest that administering a bolus of flush solution after injection of medication may hasten drug delivery, but there is little evidence to support this. The purpose of this study is to investigate the effect of peripheral bolus injection on circulation times during cardiac arrest. Measurements of circulation times were made following injection of indocyanine green dye both with and without a olus of 20 mL saline flush into a peripheral vein of mongrel dogs. There was no difference in systolic, diastolic, or coronary perfusion pressures during the injections with or without bolus injection. Similarly, there was no difference in end-tidal CO 2 or in arterial-venous P O 2 , P CO 2 , or pH gradient. The circulation time without bolus injection was 77.7 ± 42.7 seconds while circulation time with the saline flush was 48.3 ± 20.9 seconds ( P < .001). Peak dye concentration without saline flush was 3.0 ± 1.0 mg/L, and peak dye concentration with saline flush was 3.8 ± 0.9 mg/L ( P < .001). We conclude that a bolus injection of 20 mL of saline enhances dye circulation times and peak levels during cardiac arrest in this animal model. The clinical application of this technique warrants further investigation.