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Spontaneous Circulation (spontaneous + circulation)
Selected AbstractsOut-of-hospital Care of Critical Drug Overdoses Involving Cardiac ArrestACADEMIC EMERGENCY MEDICINE, Issue 1 2004Valentine L. Paredes MD Objectives: Death from acute drug poisoning, also termed drug overdose, is a substantial public health problem. Little is known regarding the role of emergency medical services (EMS) in critical drug poisonings. This study investigates the involvement and potential mortality benefit of EMS for critical drug poisonings, characterized by cardiovascular collapse requiring cardiopulmonary resuscitation (CPR). Methods: The study population was composed of death events caused by acute drug poisoning, defined as poisoning deaths and deaths averted (persons successfully resuscitated from out-of-hospital cardiac arrest by EMS) in King County, Washington, during the year 2000. Results: Eleven persons were successfully resuscitated and 234 persons died from cardiac arrest caused by acute drug poisoning, for a total of 245 cardiac events. The EMS responded to 79.6% (195/245), attempted resuscitation in 34.7% (85/245), and successfully resuscitated 4.5% (11/245) of all events. Among the 85 persons for whom EMS attempted resuscitation, opioids, cocaine, and alcohol were the predominant drugs involved, although over half involved multiple drug classes. Among the 11 persons successfully resuscitated, return of circulation was achieved in six following EMS cardiopulmonary resuscitation alone, in one following CPR and defibrillation, and in the remaining four after additional advanced life support. Conclusions: In this community, EMS was involved in the majority of acute drug poisonings characterized by cardiovascular collapse and may potentially lower total mortality by approximately 4.5%. The results show that, in some survivors, return of spontaneous circulation may be achieved with CPR alone, suggesting a different pathophysiology in drug poisoning compared with cardiac arrest due to heart disease. [source] On the Future of Reanimatology,ACADEMIC EMERGENCY MEDICINE, Issue 1 2000Peter Safar MD Abstract: This article is adapted from a presentation given at the 1999 SAEM annual meeting by Dr. Peter Safar. Dr. Safar has been involved in resuscitation research for 44 years, and is a distinguished professor and past initiating chairman of the Department of Anesthesiology and Critical Care Medicine at the University of Pittsburgh. He is the founder and director of the Safar Center for Resuscitation Research at the University of Pittsburgh, and has been the research mentor of many critical care and emergency medicine research fellows. Here he presents a brief history of past accomplishments, recent findings, and future potentials for resuscitation research. Additional advances in resuscitation, from acute terminal states and clinical death, will build upon the lessons learned from the history of reanimatology, including optimal delivery by emergency medical services of already documented cardiopulmonary cerebral resuscitation, basic-advanced,prolonged life support, and future scientific breakthroughs. Current controversies, such as how to best educate the public in life-supporting first aid, how to restore normotensive spontaneous circulation after cardiac arrest, how to rapidly induce mild hypothermia for cerebral protection, and how to minimize secondary insult after cerebral ischemia, are discussed, and must be resolved if advances are to be made. Dr. Safar also summarizes future technologies already under preliminary investigation, such as ultra-advanced life support for reversing prolonged cardiac arrest, extending the "golden hour" of shock tolerance, and suspended animation for delayed resuscitation. [source] Out-of-hospital Cardiac Arrest in Denver, Colorado: Epidemiology and OutcomesACADEMIC EMERGENCY MEDICINE, Issue 4 2010Jason S. Haukoos MD Abstract Objectives:, The annual incidence of out-of-hospital cardiac arrest (OOHCA) in the United States is approximately 6 per 10,000 population and survival remains low. Relatively little is known about the performance characteristics of a two-tiered emergency medical services (EMS) system split between fire-based basic life support (BLS) dispersed from fixed locations and hospital-based advanced life support (ALS) dispersed from nonfixed locations. The objectives of this study were to describe the incidence of OOHCA in Denver, Colorado, and to define the prevalence of survival with good neurologic function in the context of this particular EMS system. Methods:, This was a retrospective cohort study using standardized abstraction methodology. A two-tiered hospital-based EMS system for the County of Denver and 10 receiving hospitals were studied. Consecutive adult patients who experienced nontraumatic OOHCA from January 1, 2003, through December 31, 2004, were enrolled. Demographic, prehospital arrest characteristics, treatment data, and survival data using the Utstein template were collected. Good neurologic survival was defined by a Cerebral Performance Categories (CPC) score of 1 or 2. Results:, During the study period, 1,985 arrests occurred. Of these, 715 (36%) had attempted resuscitation by paramedics and constitute our study sample. The median age was 65 years (interquartile range = 52,78 years), 69% were male, 41% had witnessed arrest, 25% had bystander cardiopulmonary resuscitation (CPR) performed, and 30% had ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) as their initial rhythm. Of the 715 patients, 545 (76%) were transported to a hospital, 223 (31%) had return of spontaneous circulation (ROSC), 175 (25%) survived to hospital admission, 58 (8%) survived to hospital discharge, and 42 (6%, 95% confidence interval [CI] = 4% to 8%) had a good neurologic outcome. Conclusions:, Out-of-hospital cardiac arrest survival in Denver, Colorado, is similar to that of other United States communities. This finding provides the basis for future epidemiologic and health services research in the out-of-hospital and ED settings in our community. ACADEMIC EMERGENCY MEDICINE,2010; 17:391,398 © 2010 by the Society for Academic Emergency Medicine [source] Prehospital therapeutic hypothermia for comatose survivors of cardiac arrest: a randomized controlled trialACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 7 2009A. KÄMÄRÄINEN Background: Intravenous infusion of ice-cold fluid is considered a feasible method to induce mild therapeutic hypothermia in cardiac arrest survivors. However, only one randomized controlled trial evaluating this treatment exists. Furthermore, the implementation rate of prehospital cooling is low. The aim of this study was to evaluate the efficacy and safety of this method in comparison with conventional therapy with spontaneous cooling often observed in prehospital patients. Methods: A randomized controlled trial was conducted in a physician-staffed helicopter emergency medical service. After successful initial resuscitation, patients were randomized to receive either +4 °C Ringer's solution with a target temperature of 33 °C or conventional fluid therapy. As an endpoint, nasopharyngeal temperature was recorded at the time of hospital admission. Results: Out of 44 screened patients, 19 were analysed in the treatment group and 18 in the control group. The two groups were comparable in terms of baseline characteristics. The core temperature was markedly lower in the hypothermia group at the time of hospital admission (34.1±0.9 °C vs. 35.2±0.8 °C, P<0.001) after a comparable duration of transportation. Otherwise, there were no significant differences between the groups regarding safety or secondary outcome measures such as neurological outcome and mortality. Conclusion: Spontaneous cooling alone is insufficient to induce therapeutic hypothermia before hospital admission. Infusion of ice-cold fluid after return of spontaneous circulation was found to be well tolerated and effective. This method of cooling should be considered as an important first link in the ,cold chain' of prehospital comatose cardiac arrest survivors. [source] Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrestACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 7 2009N. NIELSEN Background: Therapeutic hypothermia (TH) after cardiac arrest protects from neurological sequels and death and is recommended in guidelines. The Hypothermia Registry was founded to the monitor outcome, performance and complications of TH. Methods: Data on out-of-hospital cardiac arrest (OHCA) patients admitted to intensive care for TH were registered. Hospital survival and long-term outcome (6,12 months) were documented using the Cerebral Performance Category (CPC) scale, CPC 1,2 representing a good outcome and 3,5 a bad outcome. Results: From October 2004 to October 2008, 986 TH-treated OHCA patients of all causes were included in the registry. Long-term outcome was reported in 975 patients. The median time from arrest to initiation of TH was 90 min (interquartile range, 60,165 min) and time to achieving the target temperature (,34 °C) was 260 min (178,400 min). Half of the patients underwent coronary angiography and one-third underwent percutaneous coronary intervention (PCI). Higher age, longer time to return of spontaneous circulation, lower Glasgow Coma Scale at admission, unwitnessed arrest and initial rhythm asystole were all predictors of bad outcome, whereas time to initiation of TH and time to reach the goal temperature had no significant association. Bleeding requiring transfusion occurred in 4% of patients, with a significantly higher risk if angiography/PCI was performed (2.8% vs. 6.2%P=0.02). Conclusions: Half of the patients survived, with >90% having a good neurological function at long-term follow-up. Factors related to the timing of TH had no apparent association to outcome. The incidence of adverse events was acceptable but the risk of bleeding was increased if angiography/PCI was performed. [source] Scandinavian Clinical practice guidelines for therapeutic hypothermia and post-resuscitation care after cardiac arrestACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 3 2009M. CASTRÉN Background and aim: Sudden cardiac arrest survivors suffer from ischaemic brain injury that may lead to poor neurological outcome and death. The reperfusion injury that occurs is associated with damaging biochemical reactions, which are suppressed by mild therapeutic hypothermia (MTH). In several studies MTH has been proven to be safe, with few complications and improved survival, and is recommended by the International Liaison of Committee on Resuscitation. The aim of this paper is to recommend clinical practice guidelines for MTH treatment after cardiac arrest from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI). Methods: Relevant studies were identified after two consensus meetings of the SSAI Task Force on Therapeutic Hypothermia (SSAITFTH) and via literature search of the Cochrane Central Register of Controlled Trials and Medline. Evidence was assessed and consensus opinion was used when high-grade evidence (Grade of Recommendation, GOR) was unavailable. A management strategy was developed as a consensus from the evidence and the protocols in the participating countries. Results and conclusion: Although proven beneficial only for patients with initial ventricular fibrillation (GOR A), the SSAITFTH also recommend MTH after restored spontaneous circulation, if active treatment is chosen, in patients with initial pulseless electrical activity and asystole (GOR D). Normal ethical considerations, premorbid status, total anoxia time and general condition should decide whether active treatment is required or not. MTH should be part of a standardized treatment protocol, and initiated as early as possible after indication and treatment have been decided (GOR E). There is insufficient evidence to make definitive recommendations among techniques to induce MTH, and we do not know the optimal target temperature, duration of cooling and rewarming time. New studies are needed to address the question as to how MTH affects, for example, prognostic factors. [source] Intracerebral monitoring in comatose patients treated with hypothermia after a cardiac arrestACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 3 2009J. NORDMARK Background: Induced mild hypothermia (32,34 °C) has proven to reduce ischemic brain injury and improve outcome after a cardiac arrest (CA). The aim of this investigation was to study the occurrence of increased intracranial pressure (ICP) and neurochemical metabolic changes indicating cerebral ischemia, after CA and cardiopulmonary resuscitation (CPR), when induced hypothermia was applied. Methods: ICP, brain chemistry and brain temperature were monitored during induced hypothermia and re-warming in four adult unconscious patients with restoration of spontaneous circulation after CA and CPR. Results: ICP was occasionally above 20 mmHg. Neurochemical changes indicating cerebral ischemia (increased lactate/pyruvate ratio) and excitoxicity (increased glutamate) were found after CA, and signs of ischemia were also observed during the re-warming phase. A biphasic increase in glycerol was seen, which may have been a result of both membrane degradation and overspill from the general circulation. Conclusions: Intracerebral microdialysis and ICP monitoring may be used in selected patients not requiring anticoagulants and PCI to obtain information regarding the common disturbances of intracranial dynamics after CA. The results of this study underline the importance of inducing hypothermia quickly after CA and emphasize the need for developing tools for guidance of the re-warming. [source] Therapeutic hypothermia after out-of-hospital cardiac arrest: experiences with patients treated with percutaneous coronary intervention and cardiogenic shockACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 2 2007J. Hovdenes Background:, Therapeutic hypothermia has been shown to increase survival after out-of-hospital cardiac arrest (OHCA). The trials documenting such benefit excluded patients with cardiogenic shock and only a few patients were treated with percutaneous coronary intervention prior to admission to an intensive care unit (ICU). We use therapeutic hypothermia whenever cardiac arrest patients do not wake up immediately after return of spontaneous circulation. Methods:, This paper reports the outcome of 50 OHCA patients with ventricular fibrillation admitted to a tertiary referral hospital for immediate coronary angiography and percutaneous coronary intervention when indicated. Patients were treated with intra-aortic balloon counterpulsation (IABP) (23 of 50 patients) if indicated. All patients who were still comatose were treated with therapeutic hypothermia at 32,34 °C for 24 h before rewarming. The end-points were survival and cerebral performance category (CPC: 1, best; 5, dead) after 6 months. Results:, Forty-one patients (82%) survived until 6 months. Thirty-four patients (68%) were in CPC 1 or 2, and seven (14%) were in CPC 3. Of the 23 patients treated with IABP, 14 (61%) survived with CPC 1 or 2. In patients not treated with IABP, 20 patients (74%) survived with CPC 1 or 2. Forty patients (80%) developed myocardial infarction. Percutaneous coronary intervention was performed in 36 patients (72%). Conclusion:, In OHCA survivors who reached our hospital, the survival rate was high and the neurological outcome acceptable. Our results indicate that the use of therapeutic hypothermia is justified even in haemodynamically unstable patients and those treated with percutaneous coronary intervention. [source] Incidence of regurgitation and pulmonary aspiration of gastric contents in survivors from out-of-hospital cardiac arrestACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 2 2007I. Virkkunen Background:, The regurgitation of gastric contents and subsequent pulmonary aspiration remain serious adverse events in cardiac arrest and cardiopulmonary resuscitation. The aim of this study was to determine the association between clinical signs of regurgitation and radiological findings consistent with aspiration in resuscitated out-of-hospital cardiac arrest (OHCA) patients admitted to hospital. Methods:, The incidence of regurgitation was studied in 182 successfully resuscitated OHCA patients. The inclusion criterion was the restoration of spontaneous circulation after OHCA not caused by trauma or drug overdose. Results:, The incidence of regurgitation was 20%. Regurgitation was associated with radiological findings consistent with aspiration with a high specificity (81%) and a low sensitivity (46%). Conclusions:, Although there was a strong association between clinical regurgitation and radiological findings consistent with aspiration, our data suggest that regurgitation is not invariably followed by radiological findings compatible with aspiration. Radiological findings consistent with aspiration are relatively infrequent without preceding signs of regurgitation in resuscitated patients. [source] The use of vasopressin for treating vasodilatory shock and cardiopulmonary arrestJOURNAL OF VETERINARY EMERGENCY AND CRITICAL CARE, Issue 2 2009DACVIM, Richard D. Scroggin Jr. Abstract Objective , To discuss 3 potential mechanisms for loss of peripheral vasomotor tone during vasodilatory shock; review vasopressin physiology; review the available animal experimental and human clinical studies of vasopressin in vasodilatory shock and cardiopulmonary arrest; and make recommendations based on review of the data for the use of vasopressin in vasodilatory shock and cardiopulmonary arrest. Data Sources , Human clinical studies, veterinary experimental studies, forum proceedings, book chapters, and American Heart Association guidelines. Human and Veterinary Data Synthesis , Septic shock is the most common form of vasodilatory shock. The exogenous administration of vasopressin in animal models of fluid-resuscitated septic and hemorrhagic shock significantly increases mean arterial pressure and improves survival. The effect of vasopressin on return to spontaneous circulation, initial cardiac rhythm, and survival compared with epinephrine is mixed. Improved survival in human patients with ventricular fibrillation, pulseless ventricular tachycardia, and nonspecific cardiopulmonary arrest has been observed in 4 small studies of vasopressin versus epinephrine. Three large studies, though, did not find a significant difference between vasopressin and epinephrine in patients with cardiopulmonary arrest regardless of initial cardiac rhythm. No veterinary clinical trials have been performed using vasopressin in cardiopulmonary arrest. Conclusion , Vasopressin (0.01,0.04 U/min, IV) should be considered in small animal veterinary patients with vasodilatory shock that is unresponsive to fluid resuscitation and catecholamine (dobutamine, dopamine, and norepinephrine) administration. Vasopressin (0.2,0.8 U/kg, IV once) administration during cardiopulmonary resuscitation in small animal veterinary patients with pulseless electrical activity or ventricular asystole may be beneficial for myocardial and cerebral blood flow. [source] Cardiopulmonary resuscitation after near drowning and hypothermia: restoration of spontaneous circulation after vasopressinACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 3 2003G. Sumann Recent animal data have challenged the common clinical practice to avoid vasopressor drugs during hypothermic cardiopulmonary resuscitation (CPR) when core temperature is below 30°C. In this report, we describe the case of a 19-year-old-female patient with prolonged, hypothermic, out-of-hospital cardiopulmonary arrest after near drowning (core temperature, 27°C) in whom cardiocirculatory arrest persisted despite 2 mg of intravenous epinephrine; but, immediate return of spontaneous circulation occurred after a single dose (40 IU) of intravenous vasopressin. The patient was subsequently admitted to a hospital with stable haemodynamics, and was successfully rewarmed with convective rewarming, but died of multiorgan failure 15 h later. To the best of our knowledge, this is the first report about the use of vasopressin during hypothermic CPR in humans. This case report adds to the growing evidence that vasopressors may be useful to restore spontaneous circulation in hypothermic cardiac arrest patients prior to rewarming, thus avoiding prolonged mechanical CPR efforts, or usage of extracorporeal circulation. It may also support previous experience that the combination of both epinephrine and vasopressin may be necessary to achieve the vasopressor response needed for restoration of spontaneous circulation, especially after asphyxial cardiac arrest or during prolonged CPR efforts. [source] Neurological outcome after experimental cardiopulmonary resuscitation: a result of delayed and potentially treatable neuronal injury?ACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 5 2002X. L. Liu Background: In experimental cardiopulmonary resuscitation (CPR) aortic balloon occlusion, vasopressin, and hypertonic saline dextran administration improve cerebral blood flow. Free radical scavenger ,-phenyl-N-tert-butyl-nitrone (PBN) and cyclosporine-A (CsA) alleviate neuronal damage after global ischemia. Combining these treatments, we investigated neurological outcome after experimental cardiac arrest. Methods: Thirty anesthetized piglets, randomly allocated into three groups, were subjected to 8 min of ventricular fibrillation followed by 5 min of closed-chest CPR. The combined treatment (CT) group received all the above-mentioned modalities; group B was treated with balloon occlusion and epinephrine; and group C had sham balloon occlusion with epinephrine. Indicators of oxidative stress (8-iso-PGF2,), inflammation (15-keto-dihydro-PGF2,), energy crisis (hypoxanthine and xanthine), and anoxia/hypoxia (lactate) were monitored in jugular bulb venous blood. Neurological outcome was evaluated 24 h after CPR. Results: Restoration of spontaneous circulation (ROSC) was more rapidly achieved and neurological outcome was significantly better in the CT group, although there was no difference in coronary perfusion pressure between groups. The jugular venous PCO2 and cerebral oxygen extraction ratio were lower in the CT group at 5,15 min after ROSC. Jugular venous 8-iso-PGF2, and hypoxanthine after ROSC were correlated to 24 h neurological outcome Conclusions: A combination of cerebral blood flow promoting measures and administration of ,-phenyl-N-tert-butyl-nitrone and cyclosporine-A improved 24 h neurological outcome after 8 min of experimental normothermic cardiac arrest, indicating an ongoing neuronal injury in the reperfusion phase. [source] Association of Anaesthetists of Great Britain and IrelandANAESTHESIA, Issue 7 2009Wiley's Anesthesia Collection Summary Infusion of lipid emulsion has been demonstrated to facilitate return of spontaneous circulation in animal models and human cases of local anaesthetic induced cardiac arrest. Guidelines for lipid application exist; however, experimental evidence of efficacy at recommended dosing is lacking. In 20 sedated, mechanically ventilated, and invasively monitored New Zealand White rabbits, asystole was induced via bolus bupivacaine injection. Animals were randomised to receive either 20% Intralipid administered according to Association of Anaesthetists of Great Britain and Ireland guidelines, or identical volumes of 0.9% saline solution, in addition to standard Advanced Cardiac Life Support resuscitative measures. Seven lipid treated rabbits developed return of spontaneous circulation vs four saline treated animals (p = 0.370). A trend toward sooner return of spontaneous circulation in the lipid treated group was observed (2.4 (0.53) vs 3.8 (1.7) min; p = 0.082). Five animals in the lipid treated group survived to protocol termination vs nil animals from the saline treated group (p = 0.033). The current Association of Anaesthestists of Great Britain and Ireland lipid infusion protocol provides a useful beginning for lipid emulsion administration. [source] The Association Between Prehospital Endotracheal Intubation Attempts and Survival to Hospital Discharge Among Out-of-hospital Cardiac Arrest PatientsACADEMIC EMERGENCY MEDICINE, Issue 9 2010Jonathan R. Studnek PhD, NREMT-P ACADEMIC EMERGENCY MEDICINE 2010; 17:918,925 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, The benefit of prehospital endotracheal intubation (ETI) among individuals experiencing out-of-hospital cardiac arrest (OOHCA) has not been fully examined. The objective of this study was to determine if prehospital ETI attempts were associated with return of spontaneous circulation (ROSC) and survival to discharge among individuals experiencing OOHCA. Methods:, This retrospective study included individuals who experienced a medical cardiac arrest between July 2006 and December 2008 and had resuscitation efforts initiated by paramedics from Mecklenburg County, North Carolina. Outcome variables were prehospital ROSC and survival to hospital discharge, while the primary independent variable was the number of prehospital ETI attempts. Results:, There were 1,142 cardiac arrests included in the analytic data set. Prehospital ROSC occurred in 299 individuals (26.2%). When controlling for initial arrest rhythm and other confounding variables, individuals with no ETI attempted were 2.33 (95% confidence interval [CI] = 1.63 to 3.33) times more likely to have ROSC compared to those with one successful ETI attempt. Of the 299 individuals with prehospital ROSC, 118 (39.5%) were subsequently discharged alive from the hospital. Individuals having no ETI were 5.46 (95% CI = 3.36 to 8.90) times more likely to be discharged from the hospital alive compared to individuals with one successful ETI attempt. Conclusions:, Results from these analyses suggest a negative association between prehospital ETI attempts and survival from OOHCA. In this study, the individuals most likely to have prehospital ROSC and survival to hospital discharge were those who did not have a reported ETI attempt. Further comparative research should assess the potential causes of the demonstrated associations. [source] Advanced Airway Management Does Not Improve Outcome of Out-of-hospital Cardiac ArrestACADEMIC EMERGENCY MEDICINE, Issue 9 2010M. Arslan Hanif MD ACADEMIC EMERGENCY MEDICINE 2010; 17:926,931 © 2010 by the Society for Academic Emergency Medicine Abstract Background:, The goal of out-of-hospital endotracheal intubation (ETI) is to reduce mortality and morbidity for patients with airway and ventilatory compromise. Yet several studies, mostly involving trauma patients, have demonstrated similar or worse neurologic outcomes and survival-to-hospital discharge rates after out-of-hospital ETI. To date, there is no study comparing out-of-hospital ETI to bag-valve-mask (BVM) ventilation for the outcome of survival to hospital discharge among nontraumatic adult out-of-hospital cardiac arrest (OOHCA) patients. Objectives:, The objective was to compare survival to hospital discharge among adult OOHCA patients receiving ETI to those managed with BVM. Methods:, In this retrospective cohort study, the records of all OOHCA patients presenting to a municipal teaching hospital from November 1, 1994, through June 30, 2008, were reviewed. The type of field airway provided, age, sex, race, rhythm on paramedic arrival, presence of bystander cardiopulmonary resuscitation (CPR), whether the arrest was witnessed, site of arrest, return of spontaneous circulation (ROSC), survival to hospital admission, comorbid illnesses, and survival to hospital discharge were noted. A univariate odds ratio (OR) was first computed to describe the association between the type of airway and survival to hospital discharge. A multivariable logistic regression analysis was performed, adjusting for rhythm, bystander CPR, and whether the arrest was witnessed. Results:, A cohort of 1,294 arrests was evaluated. A total of 1,027 (79.4%) received ETI, while 131 (10.1%) had BVM, 131 (10.1%) had either a Combitube or an esophageal obturator airway, and five (0.4%) had incomplete prehospital records. Fifty-five of 1,294 (4.3%) survived to hospital discharge; there were no survivors in the Combitube/esophageal obturator airway cohort. Even after multivariable adjustment for age, sex, site of arrest, bystander CPR, witnessed arrest, and rhythm on paramedic arrival, the OR for survival to hospital discharge for BVM versus ETI was 4.5 (95% confidence interval [CI] = 2.3,8.9; p<0.0001). Conclusions:, In this cohort, when compared to BVM ventilation, advanced airway methods were associated with decreased survival to hospital discharge among adult nontraumatic OOHCA patients. [source] Use of a Standardized Order Set for Achieving Target Temperature in the Implementation of Therapeutic Hypothermia after Cardiac Arrest: A Feasibility StudyACADEMIC EMERGENCY MEDICINE, Issue 6 2008J. Hope Kilgannon MD Abstract Objectives:, Induced hypothermia (HT) after cardiac arrest improved outcomes in randomized trials. Current post,cardiac arrest treatment guidelines advocate HT; however, utilization in practice remains low. One reported barrier to adoption is clinician concern over potential technical difficulty of HT. We hypothesized that using a standardized order set, clinicians could achieve HT target temperature in routine practice with equal or better efficiency than that observed in randomized trials. Methods:, After a multidisciplinary HT education program, we implemented a standardized order set for HT induction and maintenance including sedation and paralysis, intravenous cold saline infusion, and an external cooling apparatus, with a target temperature range of 33,34°C. We performed a retrospective analysis of a prospectively compiled and maintained registry of cardiac arrest patients with HT attempted (intent-to-treat) over the first year of implementation. The primary outcome measures were defined a priori by extrapolating treatment arm data from the largest and most efficacious randomized trial: 1) successful achievement of target temperature for ,85% of patients in the cohort and 2) median time from return of spontaneous circulation (ROSC) to achieving target temperature <8 hours. Results:, Clinicians attempted HT on 23 post,cardiac arrest patients (arrest location: 78% out-of-hospital, 22% in-hospital; initial rhythm: 26% ventricular fibrillation/tachycardia, 70% pulseless electrical activity or asystole) and achieved the target temperature in 22/23 (96%) cases. Median time from ROSC to target temperature was 4.4 (interquartile range 2.8,7.2) hours. Complication rates were low. Conclusions:, Using a standardized order set, clinicians can achieve HT target temperature in routine practice. [source] Independent Evaluation of an Out-of-hospital Termination of Resuscitation (TOR) Clinical Decision RuleACADEMIC EMERGENCY MEDICINE, Issue 6 2008Peter B. Richman MD Abstract Objectives:, Recently, investigators described a clinical decision rule for termination of resuscitation (TOR) designed to help determine whether to terminate emergency medical services (EMS) resuscitative efforts for out-of-hospital cardiac arrests (OOHCA). The authors sought to evaluate the hypothesis that TOR would predict no survival for patients in an independent cohort of patients with OOHCA. Methods:, This was a retrospective cohort analysis conducted in the state of Arizona. Consecutive, adult, OOHCA were prospectively evaluated from October 2004 through October 2006. A statewide OOHCA database utilizing Utstein-style reporting from 30 different EMS systems was used. Data were abstracted from EMS first care reports and hospital discharge records. The TOR guidelines predict that no survival to hospital discharge will occur if 1) an OOHCA victim does not have return of spontaneous circulation (ROSC), 2) no shocks are administered, and 3) the arrest is not witnessed by EMS personnel. Data were entered into a structured database. Continuous data are presented as means (±standard deviations [SD]) and categorical data as frequency of occurrence, and 95% confidence intervals (CIs) were calculated as appropriate. The primary outcome measure was to determine if any cohort member who met TOR criteria survived to hospital discharge. Results:, There were 2,239 eligible patients; the study group included 2,180 (97.4%) patients for whom the data were complete; mean age was 64 (±11) years, and 35% were female. The majority of patients in the study group met at least one or more of the TOR criteria. A total of 2,047 (93.8%) patients suffered from cardiac arrest that was unwitnessed by EMS; 1,653 (75.8%) had an unwitnessed arrest and no ROSC. With respect to TOR, 1,160 of 2,180 (53.2%) patients met all three criteria; only one (0.09%; 95% CI = 0% to 0.5%) survived to hospital discharge. Conclusions:, The authors evaluated TOR guidelines in an independent, statewide OOHCA database. The results are consistent with the findings of the TOR investigation and suggest that this algorithm is a promising tool for TOR decision-making in the field. [source] Reducing Ambulance Response Times Using Geospatial,Time Analysis of Ambulance DeploymentACADEMIC EMERGENCY MEDICINE, Issue 9 2010Marcus Eng Hock Ong MBBS (S'pore) ACADEMIC EMERGENCY MEDICINE 2010; 17:951,957 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, This study aimed to determine if a deployment strategy based on geospatial,time analysis is able to reduce ambulance response times for out-of-hospital cardiac arrests (OOHCA) in an urban emergency medical services (EMS) system. Methods:, An observational prospective study examining geographic locations of all OOHCA in Singapore was conducted. Locations of cardiac arrests were spot-mapped using a geographic information system (GIS). A progressive strategy of satellite ambulance deployment was implemented, increasing ambulance bases from 17 to 32 locations. Variation in ambulance deployment according to demand, based on time of day, was also implemented. The total number of ambulances and crews remained constant over the study period. The main outcome measure was ambulance response times. Results:, From October 1, 2001, to October 14, 2004, a total of 2,428 OOHCA patients were enrolled into the study. Mean ± SD age for arrests was 60.6 ± 19.3 years with 68.0% male. The overall return of spontaneous circulation (ROSC) rate was 17.2% and survival to discharge rate was 1.6%. Response time decreased significantly as the number of fire stations/fire posts increased (Pearson ,2 = 108.70, df = 48, p < 0.001). Response times for OOHCA decreased from a monthly median of 10.1 minutes at the beginning to 7.1 minutes at the end of the study. Similarly, the proportion of cases with response times < 8 minutes increased from 22.3% to 47.3% and < 11 minutes from 57.6% to 77.5% at the end of the study. Conclusions:, A simple, relatively low-cost ambulance deployment strategy was associated with significantly reduced response times for OOHCA. Geospatial,time analysis can be a useful tool for EMS providers. [source] Prospective Clinical Trial, DEFI 2005: Does an AED Algorithm with More CPR Impact Out-of-Hospital Cardiac Arrest Prognosis?ACADEMIC EMERGENCY MEDICINE, Issue 2008Herve Degrange Background:, Level 1 evidence is lacking for the Guidelines 2005 recommended changes in CPR and automated external defibrillator (AED) protocols. Objectives:, We conducted a block-randomized controlled trial to evaluate if changes to CPR during AED use could improve return of spontaneous circulation (ROSC) and hospital admission rates. Methods:, From September 2005 to March 2007, 200 biphasic LIFEPAKs, 500 AEDs, used by firefighters, were randomized every 2 months by fire station (clinicaltrials.gov NCT00139542). The 100 CONTROL AEDs conformed to Guidelines 2000. The 100 STUDY AEDs added pre-shock CPR and removed stacked shocks and post-shock pulse checks. In both groups, firefighters received weekly CPR training. ECG and impedance signals recorded by AEDs were reviewed to quantify CPR delivery. Median [interquartile range], *p < 0.05. Results:, Informed consent was obtained for 840 defibrillated patients (420 CONTROL vs. 420 STUDY). There were no differences in patient characteristics (age, sex, location, etiology, witnessed, bystander CPR, chest compression (CC) rate) and time from call to AED power on. The STUDY AEDs prompted for more CPR during AED use (81% [80, 83] vs. 62% [55, 67]*), resulting in more hands-on time (62% [54, 69] vs 49% [39, 57]*), more patients receiving only one shock (40 vs 33%*), and shorter pauses in CC before (9s [7, 13] vs 19s [16, 21]*) and after (11s [8, 14] vs 32s [26, 38]*) the shock. There was no difference in the rates of ROSC (48% [44, 53] vs 50% [45, 55], p = 0.63) and hospital admission (44% [40, 49] vs 45% [40, 49], p = 0.94) for the STUDY vs CONTROL groups. Conclusions:, Increasing CPR, shortening CC pauses and delivering fewer shocks resulted in no observed difference in ROSC or survival to hospital admission. The overall rate of hospitalization was higher than the historical expectation (34% hospital admission before study), possibly due to the increased emphasis on training and importance of CPR in both groups. [source] Comparison of 15:1, 15:2, and 30:2 Compression-to-Ventilation Ratios for Cardiopulmonary Resuscitation in a Canine Model of a Simulated, Witnessed Cardiac ArrestACADEMIC EMERGENCY MEDICINE, Issue 2 2008Sung Oh Hwang MD Abstract Objectives:, This experimental study compared the effect of compression-to-ventilation (CV) ratios of 15:1, 15:2, and 30:2 on hemodynamics and resuscitation outcome in a canine model of a simulated, witnessed ventricular fibrillation (VF) cardiac arrest. Methods:, Thirty healthy dogs, irrespective of species (mean ± SD, 19.2 ± 2.2 kg), were used in this study. A VF arrest was induced. The dogs received cardiopulmonary resuscitation (CPR) and were divided into three groups based on the applied CV ratios of 15:1, 15:2, and 30:2. After 1 minute of untreated VF, 4 minutes of basic life support (BLS) was performed. At the end of the 4 minutes, the dogs were defibrillated with an automatic external defibrillator (AED) and advanced cardiac life support (ACLS) efforts were continued for 10 minutes or until restoration of spontaneous circulation (ROSC) was attained, whichever came first. Results:, None of the hemodynamic parameters, and arterial oxygen profiles was significantly different between the three groups during BLS- and ACLS-CPR. Eight dogs (80%) from each group achieved ROSC during BLS and ACLS. The survival rate was not different between the three groups. In the 15:1 and 30:2 groups, the number of compressions delivered over 1 minute were significantly greater than in the 15:2 group (73.1 ± 8.1 and 69.0 ± 6.9 to 56.3 ± 6.8; p < 0.01). The time for ventilation during which compressions were stopped at each minute was significantly lower in the 15:1 and 30:2 groups than in the 15:2 group (15.4 ± 3.9 and 17.1 ± 2.7 to 25.2 ± 2.6 sec/min; p < 0.01). Conclusions:, In a canine model of witnessed VF using a simulated scenario, CPR with three CV ratios, 15:1, 15:2, and 30:2, did not result in any differences in hemodynamics, arterial oxygen profiles, and resuscitation outcome among the three groups. CPR with a CV ratio of 15:1 provided comparable chest compressions and shorter pauses for ventilation between each cycle compared to a CV ratio of 30:2. [source] Induced hypothermia following out-of-hospital cardiac arrest; initial experience in a community hospitalCLINICAL CARDIOLOGY, Issue 12 2006Brook D. Scott M.D. Abstract Background Successful resuscitation from sudden cardiac death is frequently accompanied by severe and often fatal neurologic injury. Induced hypothermia (IH) may attenuate the neurologic damage observed in patients after cardiac arrest. Hypothesis This study examined a population of nonselected patients presenting to a community hospital following successful resuscitation of sudden cardiac death. We sought to determine whether a program of induced hypothermia would improve the clinical outcome of these critically ill patients. Methods We initiated a protocol of IH at the Oklahoma Heart Hospital in August of 2003. Study patients were consecutive adults admitted following successful resuscitation of out-of-hospital cardiac arrest. Moderate hypothermia was induced by surface cooling and maintained for 24 to 36 h in the Intensive Care Unit with passive rewarming over 8 h. Results Forty-nine patients who were resuscitated and had the return of spontaneous circulation completed the hypothermia protocol. The cause of cardiac arrest was acute myocardial infarction in 24 patients and cardiac arrhythmias in 19 patients. Nineteen patients (39%) survived and were discharged. Sixteen of the patients discharged had no or minimal residual neurologic dysfunction and 3 patients had clinically significant residual neurologic injury. Conclusion A program of induced hypothermia based in a community hospital is feasible, practical, and requires limited additional financial and nursing resources. Survival and neurologic recovery compare favorably with clinical trial outcomes. Copyright © 2006 Wiley Periodicals, Inc. Wiley Periodicals, Inc. [source] | ||||||||||