Cardiac Arrest In Emergency Department Research Articles

Concordance of Out-of-Hospital and Emergency Department Cardiac Arrest Resuscitation With Documented End-of-Life Choices in Oregon

Resuscitation measures should be guided by previous patient choices about end-of-life care, when they exist; however, documentation of these choices can be unclear or difficult to access. We evaluate the concordance of a statewide registry of actionable resuscitation orders unique to Oregon with out-of-hospital and emergency department (ED) care provided for patients found by emergency medical services (EMS) in out-of-hospital cardiac arrest. This was a retrospective cohort study of patients found by EMS providers in out-of-hospital cardiac arrest in 5 counties in 2010. We used probabilistic linkage to match patients found in out-of-hospital cardiac arrest with previously signed documentation of end-of-life decisions in the Oregon Physician Orders for Life-Sustaining Treatment (POLST) registry. We evaluated resuscitation interventions in the field and ED. There were 1,577 patients found in out-of-hospital cardiac arrest, of whom 82 had a previously signed POLST form. Patients with POLST do-not-resuscitate orders for whom EMS was called had resuscitation withheld or ceased before hospital admission in 94% of cases (95% confidence interval [CI] 83% to 99%). Compared with patients with no POLST or known do-not-resuscitate orders, more patients with attempt resuscitation POLST orders had field resuscitation attempted (84% versus 60%; difference 25%; 95% CI 12% to 37%) and were admitted to hospitals (38% versus 17%; difference 20%; 95% CI 3% to 37%), with no documented misinterpretations of the form once CPR was initiated. In this sample of patients in out-of-hospital cardiac arrest, out-of-hospital and ED care was generally concordant with previously documented end-of-life orders in the setting of critical illness. Further research is needed to compare the effectiveness of Oregon's POLST system to other methods of end-of-life order documentation.

Abstract 92: Prehospital Activation of an Emergency Department Cardiac Arrest Response Team Improves ROSC and Hypothermia Utilization

BACKGROUND: The induction of therapeutic hypothermia (TH) in comatose survivors of out-of-hospital cardiac arrest (OOHCA) improves survival and neurologic recovery outcomes. Despite results from high-quality randomized control trials and international consensus statements, TH utilization rates remain low. Pre-hospital activation of specialized care teams improves outcomes at trauma, ST-segment elevation myocardial infarction, and stroke receiving centers. We hypothesized that pre-hospital activation of a cardiac arrest response team would augment Emergency Department resuscitation resources and thus improve TH utilization and outcomes for out-of-hospital cardiac arrest patients. METHODS: An emergency department cardiac arrest response team (eCART) comprised of a cardiology fellow, pharmacist, respiratory therapist, hospital chaplain, and a therapeutic hypothermia expert (“Dr. COOL”) was created at an urban academic hospital. The eCART team was immediately activated by emergency department staff after receiving EMS radio notification of an arrest transport. We compared outcomes in consecutive adult OOHCA patients during the 8 month period before (PRE) and after (POST) instantiation of the eCART activation system. RESULTS: Clinical characteristics of patients in the PRE (n = 46) and POST (n = 63) intervention periods were similar. The CART activation system was utilized for 97% of OOCHA cases presenting to the emergency department. Rate or return of spontaneous circulation (ROSC) was significantly higher during the POST vs. PRE period (37% vs. 17%, p < 0.05). Initiation of TH in eligible patients was also significantly higher during the POST vs. PRE period (100% vs. 80%, p < 0.05). No difference in the time from ROSC to TH goal temperature < 34 degrees Celsius (201 min +/- 125 vs. 212 min +/- 81, p >0.05) or cardiac catheterization laboratory utilization (43% vs. 50%, p > 0.05) was noted between POST and PRE periods respectively. CONCLUSION: Pre-hospital activation of an eCART team is associated with improvements in ROSC rate and tended to increase TH utilization. These results suggest that rapid deployment of a specialized cardiac arrest response team to the emergency department may be an effective strategy for improving OOHCA resuscitation.

LC-MS/MS Determination of Bromperidol in Biological Matrices: Method Validation and Forensic Application

In this paper, we describe a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method used to detect the antipsychotic drug bromperidol, in biological post-mortem fluids (urine, blood and vitreous humour). The method was used to investigate an unusual case of death which occurred after bromperidol ingestion. A 44 year-old woman arrived at the emergency department in cardiac arrest. Her sister reported that the woman had taken several drops of a medicine containing bromperidol. An autopsy was performed and the biological fluid samples were submitted to a full toxicological work-up first and then to the target analysis of bromperidol. The analytical results obtained from the biological fluids collected at autopsy supported the hypothesis of death due to bromperidol intoxication. Keywords: Bromperidol, Fatal intoxication, LC-MS/MS analysis, Method validation, Forensic Application, Limit of Detection, Limit of Quantification, Accuracy, Repeatability, Precision

414 Development and Implementation of Resuscitation Room Protocol for Cardiac Arrest in Emergency Department

414 Development and Implementation of Resuscitation Room Protocol for Cardiac Arrest in Emergency Department

1056 Cardiovascular Disease Secondary to Vitamin D Deficiency: Case Series of Three Children

Deficiency of vitamin D can result from a number of factors like inadequate dietary intake, coupled with inadequate sunlight exposure and disorders that limit its absorption. Although the most recognised complication of deficiency is musculoskeletal, there is growing awareness of its impact on the cardiovascular system.We present a series of three cases of Vitamin D deficiency and its associated cardiovascular complications.Case 1: This 6 month girl of African descent presented to the emergency department in cardiac failure. The echocardiogram showed grossly dilated heart with impaired function. On evaluation she was found to have vitamin D deficiency and responded well to calcium, vitamin D, diuretics and digoxin.Case 2: This two year girl who had been treated for dilated cardiomyopathy secondary to vitamin D deficiency was brought to the emergency department in cardiac arrest. Her post-mortem examination revealed grossly dilated cardiomyopathy with extensive calcification of the conduction pathways.Case 3: This 15 year old boy of African descent was being evaluated for genu valgum. His evaluation revealed hypocalcemia, vitamin D deficiency and a prolonged QT interval. Echocardiogram was unremarkable. He was started on Vitamin D and calcium. His QT interval normalised.Conclusions: Dilated cardiomyopathy secondary to vitamin D deficiency can definitely be prevented and does have a better prognosis than idiopathic dilated cardiomyopathy. Although the risk of Vitamin D deficiency is greater in individuals with increased skin pigmentation, recently there has been a resurgence of vitamin D deficiency in the developed world, and this has become a global problem.

Cardiopulmonary Resuscitation Interruptions With Use of a Load-Distributing Band Device During Emergency Department Cardiac Arrest

Our primary aim is to measure no-flow time and no-flow ratio before and after an emergency department (ED) switched from manual to a load-distributing band mechanical cardiopulmonary resuscitation (CPR) device. This was a phased, before-after cohort evaluation at an urban tertiary hospital ED. We collected continuous video and chest compression data with the Physiocontrol CodeStat Suite 7.0 for resuscitations during the period just before and after adoption of load-distributing band CPR. All out-of-hospital, nontraumatic cardiac arrest, adult patients were eligible. From February 2007 to July 2008, there were 26 manual and 41 load-distributing band cases. Patients in both phases were comparable in terms of demographics, medical history, witnessed arrest, arrest location, bystander CPR rates, out-of-hospital defibrillation, initial rhythm, and ED defibrillation. The median no-flow time, defined as the sum of all pauses between compressions longer than 1.5 seconds, during the first 5 minutes of resuscitation, was manual CPR 85 seconds (interquartile range [IQR] 45 to 112 seconds) versus load-distributing band 104 seconds (IQR 69 to 151 seconds). The mean no-flow ratio, defined as no-flow time divided by segment length, was manual 0.28 versus load-distributing band 0.40 (difference=-0.12; 95% confidence interval -0.22 to -0.02). However, from 5 to 10 minutes into the resuscitation, median no-flow time was manual 85 seconds (IQR 59 to 151 seconds) versus load-distributing band 52 seconds (IQR 34 to 82 seconds) and mean no-flow ratio manual 0.34 versus load-distributing band 0.21 (difference=0.13; 95% confidence interval 0.02 to 0.24). The average time to apply load-distributing band CPR during this period was 152 seconds. Application of a load-distributing band in the ED is associated with a higher no-flow ratio than manual CPR in the first 5 minutes of resuscitation. We suggest that attention to team training, rapid application of the device to minimize interruption, and feedback from defibrillator and video recordings may be useful to improve resuscitation team performance.

Cardiopulmonary resuscitation: outcome and its predictors among hospitalized adult patients in Pakistan

IntroductionOur aim was to study the outcomes and predictors of in-hospital cardiopulmonary resuscitation (CPR) among adult patients at a tertiary care centre in Pakistan.MethodsWe conducted a retrospective chart review of all adult patients (age ≥14 years), who underwent CPR following cardiac arrest, in a tertiary care hospital during a 5-year study period (June 1998 to June 2003). We excluded patients aged 14 years or less, those who were declared dead on arrival and patients with a “do not resuscitate” order. The 1- and 6-month follow-ups of discharged patients were also recorded.ResultsWe found 383 cases of adult in-hospital cardiac arrest that underwent CPR. Pulseless electrical activity was the most common initial rhythm (50%), followed by asystole (30%) and ventricular tachycardia/fibrillation (19%). Return of spontaneous circulation was achieved in 72% of patients with 42% surviving more than 24 h, and 19% survived to discharge from hospital. On follow-up, 14% and 12% were found to be alive at 1 and 6 months, respectively. Multivariable logistic regression identified three independent predictors of better outcome (survival >24 h): non-intubated status [adjusted odds ratio (aOR):3.1, 95% confidence interval (CI):1.6–6.0], location of cardiac arrest in emergency department (aOR: 18.9, 95% CI:7.0–51.0) and shorter duration of CPR (aOR:3.3, 95% CI:1.9–5.5).ConclusionOutcome of CPR following in-hospital cardiac arrest in our setting is better than described in other series. Non-intubated status before arrest, cardiac arrest in the emergency department and shorter duration of CPR were independent predictors of good outcome.

Decision making by emergency physicians when assessing cardiac arrest patients on arrival at hospital

Objective: To investigate the factors which influence decision making by experienced emergency physicians when they decide whether to (a) pronounce ‘life extinct’ in adult patients with non traumatic cardiac arrest while in the ambulance, or (b) bring them into the resuscitation room in the Emergency Department for further assessment/management. Design: Qualitative study involving semi structured interviews and a focus group. Setting: Accident & Emergency (A&E) departments in the Yorkshire region. Participants: Fifteen emergency physicians (two clinical fellows, nine specialist registrars and four consultants) working in the Yorkshire region. Results: Six main themes were identified that impacted upon the decision making process: the doctor's past experience, ambulance service issues, prehospital care, patient characteristics, presence and views of relatives, and organisational issues. Conclusion: The reasoning behind decisions made when a patient arrives at the Emergency Department in cardiac arrest is multifactorial. Strict guidelines would be difficult to construct since individuals vary in the importance they attach to different factors.

Near-drowning.

Near-drowning.

Fatal spontaneous rupture of a gravid uterus: Case report and literature review of uterine rupture

Spontaneous uterine rupture is a lifethreatening obstetrical emergency encountered infrequently in the emergency department. The diagnosis of spontaneous uterine rupture is often missed or delayed, leading to maternal and fetal mortality. Emergency physicians must consider this diagnosis when presented with a pregnant patient in shock with abdominal pain. We present the case of a 38-year-old gravid female who presented to the emergency department in cardiac arrest 24 hours after an initial complaint of abdominal pain. We review the uterine rupture literature with specific focus on risk factors, signs and symptoms, diagnosis, treatment, and outcome.

Methylene chloride: Report of five exposures and two deaths

Five patients presented to the emergency department (ED) following exposure in an enciosed space to methylene chloride (dichloromethane), used for removing paint. Two workers and three rescuers were involved. Two rescuers complained only of dizziness and mild nausea, and were subsequently discharged from the ED. One rescuer was asymptomatic. Worker no. 1 arrived in cardiac arrest and eventually died in the ED despite resuscitation efforts. Worker no. 2 also presented to the ED in cardiac arrest, and was successfully resuscilated to pulse and blood pressure. However, he never regained consciousness or spontaneous respirations, and died on the fourth day. Of interest is that worker no. 2's carboxyhemoglobin level increased from 2% to 8% over the 9 hours following admission, despite administration of 40% to 50% oxygen by endotracheal tube. Among the conclusions that can be drawn are (1) the cause of death in these patients was not carbon monoxide poisoning, but solvent-induced narcosis; (2) carboxyhemoglobin levels may continue to rise following cessation of exposure, despite administration of high flow oxygen; (3) rescuers can easily become victims if proper protective clothing and respirators are not worn.

The Effectiveness of Pediatric Cardiopulmonary Resuscitation

Disturbing data are beginning to appear in the medical literature that the success rate in pediatric cardiopulmonary resuscitation (CPR) is no better, and possibly worse, than the success rate in adult CPR. This poor outcome is especially prominent in children in whom cardiac arrest occurs. This success rate for pediatric CPR is even more dismal when success is defined as meaningful (minimal or no neurologic deficit) long-term survival rather than reestablishment of spontaneous cardiac and respiratory function. In this issue of the AJDC , Torphy et al 1 extend the data that have been previously accumulated from their institution. 2 In this study they retrospectively examined the records of all children who presented to the Milwaukee Children's Hospital emergency department in cardiac arrest or developed cardiac arrest while in the emergency department. Patients who sustained only a respiratory arrest but maintained a palpable pulse were excluded. The reason for this exclusion

Central venous pH as a predictor of arterial pH in prolonged cardiac arrest

Sixty-five patients who arrived in the emergency department in cardiac arrest were studied prospectively to determine whether central venous pH could be used as an accurate predictor of arterial pH in prolonged cardiac arrest. Central venous and arterial access were obtained as soon as possible after arrival in the emergency department. Simultaneous arterial and venous samples were drawn and sent for blood gas analysis. Under normal conditions, central venous pH (pHcv) approximates arterial pH (pHa). In prolonged cardiac arrest, however, our data reveal a mean pHa of 7.31 +/- 0.25 and a mean pHcv of 7.08 +/- 0.19. There was moderate correlation between pHa and pHcv when all patients were considered (r = .69, P less than .01). The correlation was excellent, however, in the subgroup of 15 patients who had a pulse at some point during resuscitation (r = .95, P less than .01). In 13 of these 15 patients the acid base status would have been managed correctly based on the predicted pHa (pHcv + 0.12 correction factor). The pHcv was also valuable in identifying a second subgroup of patients who required no further bicarbonate therapy; all patients who had a pHcv greater than or equal to 7.15 had a pHa greater than 7.30 (21 patients). The central venous pH was found to be a useful index of arterial pH when applied to a definable subset of patients, which in this study constituted 45% of all patients in prolonged cardiac arrest.

Emergency intravenous access through the femoral vein

A study was undertaken to assess the efficacy and safety of femoral venous catheterization for resuscitation of critically ill patients in the emergency department setting. From May 1982 to April 1983, 100 attempts were made at percutaneous insertion of a large-bore catheter into the femoral veins of patients presenting to our emergency department in cardiac arrest or requiring rapid fluid resuscitation. Eighty-nine attempts were successful. Insertion was generally considered easy, and flow rates were excellent. The only noted complications were four arterial punctures and one minor groin hematoma. This study suggests that short-term percutaneous catheterization of the femoral vein provides rapid, safe, and effective intravenous access.

Cerebral resuscitation by use of verapamil in a victim of near-drowning

tulate that calcium entry blockers may potentially play a future role in cerebral resuscitation following global anoxia. The following report describes the management of a near-drowning victim who arrived at the emergency department in cardiac arrest, comatose, flaccid, and with pupils fixed and dilated. This survivor received verapamil, a calcium entry blocker, shortly after a pulse was obtained, and thereafter received intensive cerebral resuscitation at a tertiary-care center. Resus­ citation was successful, and there was no evidence of postanoxic encephalopathy. In recognition of the cur­ rent poor prognosis of this patient group, this report is presented to stimulate consideration for in-depth studies utilizing calcium channel blockers in addition to other accepted treatment techniques of cerebral re­ suscitation.

Augmentation of systolic blood pressure during external cardiac compression by use of the MAST suit

External cardiac compression has been shown to circulate blood effectively, but the systolic pressures obtained are less than normal cardiac functioning. This study was undertaken to determine whether applying the military anti-shock trouser (MAST) suit resulted in improving systolic blood pressure while using external cardiac compression during cardiac resuscitation. Individuals admitted to the emergency department in cardiac arrest had external cardiac massage applied at a constant rate and force. Intra-arterial blood pressure monitoring was established and baseline systolic blood pressure obtained. In eight patients, the average increase in systolic blood pressure utilizing the MAST suit was 15 mm Hg. The implications of these findings, as well as other means to increase cardiac output in the cardiac arrest patient, are discussed. These findings will be related to both prehospital and emergency department care of patients in cardiac arrest.