Resuscitation - Articles in Press

Hypothermic protection in an acute hypoxia model in rats: Acid–base and oxidant/antioxidant profiles - Corrected Proof

Norma Alva, Teresa Carbonell, Jesús Palomeque — 2010-03-08

Abstract: Aim of the study: Recent works demonstrate the benefits of hypothermia when used to preserve brain, cardiac, hepatic, and intestinal function against hypoxic-ischemic injury. However, it is also known that hypothermia affects systemic parameters and also induces the generation of reactive oxygen species in cells and tissues. Here we studied the acid–base related parameters and the antioxidant–oxidant effects of deep hypothermia induction before an acute hypoxic insult in rats.Methods: Acid–base indicators and parameters related to oxidative stress were analyzed in hypothermic rats (21–22°C) breathing room air during 2h (control hypothermia), and hypothermic animals switched to hypoxic air (10% O2) during the second hour (hypothermia hypoxia group), and they were compared with corresponding normothermia groups maintained at 37°C (control normothermia and normothermia hypoxia groups).Results: Mild metabolic acidosis appeared early in arterial blood during hypothermia. After exposure to hypoxia, evidence of tissue injury (plasma transaminases and blood lactate) and oxidative stress (increase in lipid peroxidation, decrease in glutathione levels and in the glutathione reduction potential in liver) was found. In contrast, in the hypothermia hypoxia group, plasmatic parameters remained as the control values, and the hepatic glutathione reduction potential were significantly more negative when compared with the normothermia hypoxia group.Conclusions: We propose that acidosis induced by hypothermia contributes to the maintenance of intracellular reduction potential in liver, regarding the GSSG/2GSH couple and may help to increase plasmatic antioxidant pool. Our findings provide new insights into the protective effects of hypothermia in vivo.

Intra-arrest selective brain cooling improves success of resuscitation in a porcine model of prolonged cardiac arrest - Corrected Proof

Hao Wang, Denise Barbut, Min-Shan Tsai, Shijie Sun, Max Harry Weil, Wanchun Tang — 2010-03-08

Abstract: Aims of study: We have previously demonstrated that early intra-nasal cooling improved post-resuscitation neurological outcomes. The present study utilizing a porcine model of prolonged cardiac arrest investigated the effects of intra-nasal cooling initiated at the start of cardiopulmonary resuscitation (CPR) on resuscitation success. Our hypothesis was that rapid nasal cooling initiated during “low-flow” improves return of spontaneous resuscitation (ROSC).Methods: In 16 domestic male pigs weighing 40±3kg, VF was electrically induced and untreated for 15min. Animals were randomized to either head cooling or control. CPR was initiated and continued for 5min before defibrillation was attempted. Coincident with starting CPR, the hypothermic group was cooled with a RhinoChill™ device which produces evaporative cooling in the nasal cavity of pigs. No cooling was administrated to control animals. If ROSC was not achieved after defibrillation, CPR was resumed for 1min prior to the next defibrillation attempt until either successful resuscitation or for a total of 15min.Main results: Seven of eight animals in the hypothermic group (87.5%) and two of eight animals in control group (25%) (p=0.04) were successfully resuscitated. At ROSC, brain temperature was increased from baseline by 0.3°C in the control group, and decreased by 0.1°C in the hypothermic animals. Pulmonary artery temperature was above baseline in both groups.Conclusion: Intra-nasal cooling initiated at the start of CPR significantly improves the success of resuscitation in a porcine model of prolonged cardiac arrest. This may have occurred by preventing brain hyperthermia.

External jugular cannulation is irreplaceable in many situations - Corrected Proof

Arsen Uvelin, Radmila Kolak, Dragica Putnik — 2010-03-08

We read with interest article by Lahtinen et al. on external jugular vein (EJV) cannulation in open heart surgery patients. They have shown that the antecubital vein was a faster and more reliable site for intravenous access compared with the EJV. Since it is common practice to use the EJV for peripheral venous cannulation (using 14, 16 or 17-gauge peripheral cannula) in our university hospital emergency department, intensive care unit and sometimes during cardiopulmonary resuscitation (CPR), we felt the need to emphasize the importance of this route. Lapostolle et al. conducted a study on peripheral venous cannulation and showed that a peripheral cannula was inserted on the first attempt in 74% of cases. In their investigation the EJV was used in only 12 out of 495 patients with an insertion success rate of 92%. In the same study, it is clear that the veins most often cannulated (in more than 90% of cases) are those on the hand, forearm and elbow. We consider that EJV peripheral venous cannulation is relatively neglected and should be used more often; thus, we are proposing guidelines for when EJV cannulation should be performed ().

The relationship between time to arrival of emergency medical services (EMS) and survival from out-of-hospital ventricular fibrillation cardiac arrest - Corrected Proof

Laura S. Gold, Carol E. Fahrenbruch, Thomas D. Rea, Mickey S. Eisenberg — 2010-03-08

Abstract: Aim: We examined the relationship between time from collapse to arrival of emergency medical services (EMS) and survival to hospital discharge for out-of-hospital ventricular fibrillation cardiac arrests in order to determine meaningful interpretations of this association.Methods: We calculated survival rates in 1-min intervals from collapse to EMS arrival. Additionally, we used logistic regression to determine the absolute probability of survival per minute of delayed EMS arrival. We created a logistic regression model with spline terms for the time variable to examine the decline in survival in intervals that are hypothesized to be physiologically relevant.Results: The observed data showed survival declined, on average, by 3% for each minute that EMS was delayed following collapse. Survival rates did not decline appreciably if the time between collapse and arrival of EMS was 4min or less but they declined by 5.2% per minute between 5 and 10min. EMS arrival 11–15min after collapse showed a less steep decline in survival of 1.9% per minute. The spline model that incorporated changes in slope in the time interval variable modeled this relationship more accurately than a model with a continuous term for time (p=0.01).Conclusions: The results of our analyses show that survival from out-of-hospital cardiac arrest does not decline at a constant rate following collapse. Models that incorporate changes that reflect the physiological alterations that occur following cardiac arrests are a more accurate way to describe changes in survival rates over time than models that include only a continuous term for time.

A general consensus is necessary for the international standardization of automated external defibrillators - Corrected Proof

Saehwan Park, Je Sung You, Jong Woo Park, Sung Pil Chung — 2010-03-02

We have read the article by Moseosso et al. with great interest. We completely agree with their conclusion and would like to add our opinion about the study. We are concerned by the wide variety of automated external defibrillators (AEDs) available and hope that an international standard can be adopted soon. Most lay rescuers will be bewildered by the wide range of AEDs available. Inevitably, the device that they might have to use in a real emergency will be different from the device that they were trained with. In agreement with the comments from the authors, we had a similar experience when using an AED with a zippered case. The time delay was caused by the hesitation of laypersons who were not familiar with the AED or who were trained using other AEDs.

The use of popular audio in CPR (TUPAC)—Does music improve compliance with recommended chest compression rates? - Corrected Proof

Mohammed Naushaduddin, Anna Holdgate, Setthy Ung — 2010-03-02

While international resuscitation guidelines recommend chest compression rates of 100/min, previous studies have demonstrated poor compliance with this rate by trained rescuers. We aimed to study whether compliance with recommended chest compression rates would improve with the use of a well known musical tune to aid in timing of chest compressions. The use of such a musical ‘aide memoir’ is often suggested in life support courses but we could find no evidence to support its effectiveness in maintaining compliance with compression rates in clinicians who have already been trained in basic life support.

Ischaemia-modified albumin predicts the outcome of cardiopulmonary resuscitation: An experimental study - Corrected Proof

2010-03-02

Abstract: Introduction: Ischaemia-modified albumin (IMA) has recently been shown to be an early and sensitive marker of ischaemia. It is generally accepted that cardiac arrest causes the most severe form of global ischaemia. The aim of the present study was to identify whether IMA is an independent predictor of return of spontaneous circulation (ROSC) in a swine model of cardiac arrest.Methods: Ventricular fibrillation (VF) was induced in 30 piglets, which were left untreated for 8min before attempting resuscitation with precordial compression, mechanical ventilation and electrical defibrillation. Electrical defibrillation was attempted after 10min of VF. Blood samples for IMA determination were drawn at baseline, after 8min of VF and before delivery of each shock. A binary logistic regression model was implemented for the prediction of animals achieving ROSC from data available before the first defibrillation attempt. Backward stepwise selection was used to extract the final model. Inclusion and exclusion significance levels were 0.1 and 0.05, respectively. Receiver operating characteristic curves were used to determine the diagnostic accuracy, sensitivity and specificity of the parameters and to obtain the appropriate cut-off points.Results: IMA exhibited 100% sensitivity and 93.8% specificity in defining the subgroup of animals that will achieve ROSC. This high-accuracy prediction had a very early onset (from eighth VF minute) and remained at the same level until the end of the experiment. When combining IMA and coronary perfusion pressure (CPP) measurements from the first CPR cycle in the form of the simple ratio IMA/CPP, a cut-off point of 7 could provide 100% sensitivity and specificity in distinguishing the animals that will achieve ROSC in the upcoming defibrillation attempts.Conclusions: Until today, CPP has been found to be the only key determinant of successful resuscitation. Our study suggests that IMA can be a predictive index of ROSC even before the initiation of CPR.

Early CT signs in out-of-hospital cardiac arrest survivors: Temporal profile and prognostic significance - Corrected Proof

2010-03-02

Abstract: Aim: Although computed tomography (CT) signs of ischaemia, including loss of boundary (LOB) between grey matter and white matter and cortical sulcal effacement, in cardiac arrest (CA) survivors are known, their temporal profile and prognostic significance remains unclear; their clarification is necessary.Methods: Brain CT scans were obtained immediately after resuscitation in 75 non-traumatic CA survivors in a prospective fashion. They were divided into two groups according to the CA-return of spontaneous circulation (ROSC) interval: ≤20min vs. >20min. The incidence of the CT signs and predictability of these signs for outcome, assessed 6 months after CA, was evaluated and compared.Results: The incidence of the positive LOB sign was 24% in the ≤20-min group and 83% in the >20-min group, and the difference was statistically significant (p<0.001). The interval of 20min seemed to be the time window for the LOB development. The incidence of the positive sulcal effacement sign was 0% in the ≤20min group and 34% in the >20-min group, and the difference was statistically significant (p=0.004). A positive LOB sign was predictive of unfavourable outcome with an 81% sensitivity and 92% specificity. A positive sulcal effacement sign was predictive of unfavourable outcome with a 32% sensitivity and 100% specificity.Conclusion: A time window may exist for ischaemic CT signs in CA survivors. The LOB sign may develop when the CA-ROSC interval exceeds 20min, whereas the sulcal effacement sign may develop later. However, their temporal profile and outcome predictability should be verified by multicentre studies.

Paediatric prehospital tracheal intubation: What makes different our practice across the Ocean? - Corrected Proof

2010-03-02

We were very interested in the recent paper by Dr Eich and colleagues reporting their practice of paediatric prehospital intubation in an European EMS staffed by trained emergency physicians. This article could be another stone in the garden of tenants of bag-mask ventilation as mandatory alternative to emergency tracheal intubation (ETI) in children. In the last few years, as underlined by Eich et al., the conclusion drawn from North American studies, where ETI was performed by paramedics with poor clinical paediatric skills and practice, was that ETI was not superior to bag-mask ventilation since it could result in severe complications without increasing, by itself, survival. From this study, corroborated by Cooper et al., the resulting recommendation was to favour bag-mask ventilation instead of tracheal intubation in the prehospital settings.

Prevalence, outcome and pre-hospital management of anaphylaxis by first aiders and paramedical ambulance staff in Manchester, UK - Corrected Proof

Jennifer A. Capps, Vibha Sharma, Peter D. Arkwright — 2010-03-02

Abstract: Background: Anaphylaxis is of increasing prevalence and concern in Western communities. Ambulance services are often called to deal with these emergencies. There are few published studies that examine the demand and management of allergic reactions by emergency services. The aim of this study was to investigate the frequency, severity and outcome of calls, as well as whether intramuscular adrenaline was required for successful management of allergic reactions by paramedics and first aiders.Method: A retrospective study of all emergency calls for allergic reactions within Greater Manchester in a 12-month period by the North West Ambulance Service of the United Kingdom.Results: 816 (0.2%) of 401,152 incidents were due to allergic reactions (32/100,000/year). No patients died. In 457 (56%) patients this was the first allergic reaction. Intramuscular adrenaline was administered to 116 (14%) patients. Patients with respiratory/circulatory compromise were significantly more likely to be given intramuscular adrenaline by paramedics (14 (4.4–45)), but not by first aiders (1.9 (0.98–3.6)). Administration of adrenaline by first aiders was more likely in patients with a past history of allergic reactions (4.3 (2.3–8.1)) and where reactions occurred at non-residential addresses (4.6 (2.6–8.2)).Conclusions: Emergency call-outs for allergic reactions made up <1% of total ambulance workload. Most cases were successfully managed without intramuscular adrenaline. Adrenaline appeared to be used appropriately by paramedics. The lack of correlation between clinical severity and adrenaline use by first aiders suggests that they may often not understand the correct clinical indications for this drug.

Does an advanced life support course give non-anaesthetists adequate skills to manage an airway? - Corrected Proof

Charles D. Deakin, David Murphy, Michael Couzins, Stephen Mason — 2010-03-02

Abstract: Introduction: Traditionally, anaesthetists have provided airway management skills on resuscitation teams. Because advanced life support (ALS) courses teach practical airway management, some UK hospitals have dropped anaesthetists from cardiac arrest teams. Does the ALS course give non-anaesthetists adequate skills to manage an airway during a cardiac arrest?Methods: We recruited adult surgical patients undergoing general anaesthesia and laryngeal mask airway (LMA) insertion as part of their routine care. Patients were randomly assigned to airway management by a junior doctor; either an ALS-qualified anaesthetist or an ALS-qualified non-anaesthetist. After induction of anaesthesia, five manual ventilations were delivered using a self-inflating bag-mask device before insertion of a LMA. We recorded the quality of manual ventilation (adequate, partially adequate or inadequate), the time to LMA insertion, and any complications.Results: Twenty anaesthetists and 16 non-anaesthetist ALS graduates participated. Of the anaesthetists, 18 (90%) demonstrated adequate and 2 (10%) demonstrated partially adequate manual ventilation skills, compared with non-anaesthetists of whom 5 (31.25%) demonstrated adequate, 5 (31.25%) demonstrated partially adequate, and 6 (37.5%) demonstrated inadequate manual ventilation skills (p<0.001). Eighteen anaesthetists (90%) and 4 non-anaesthetists (25%) met the ALS LMA insertion guideline time of 30s (p<0.0001). Median time for LMA insertion by anaesthetists and non-anaesthetists was 20.5s (range 16–40s, n=20) and 35.0s (range 18–168, n=10) respectively (p<0.05). Six of the 16 non-anaesthetists failed to insert the LMA (37.5%). There were four complications (laryngospasm, vomiting, and SaO2<90%) in the non-anaesthetic group (25% of patients), compared with none in the anaesthetic group (p=0.01).Conclusions: The airway component of an ALS course alone does not give adequate practical skills for non-anaesthetists to manage an airway in an anaesthetised patient. Airway management at a cardiac arrest is unlikely to be any better.

Embolic occlusion of the aorta caused by cardiac myxoma - Corrected Proof

2010-03-02

A 55-year-old man was brought by ambulance to our emergency department with a history of sudden onset bilateral flank pain followed by weakness and paraesthesia in both legs. He was previously fit and well. On admission his blood pressure was 156/74mmHg, pulse 110min−1, respiratory rate 30min−1, and core temperature 34.2°C. On examination he had peri-umbilical tenderness, cold and clammy lower extremities, and absent femoral pulses. An abdominal CT scan showed total embolic occlusion of the descending aorta at the T12-L2 level and reflux of contrast into the inferior vena cava and hepatic veins. There was poor flow in the coeliac trunk, superior mesenteric artery, and renal arteries (Fig. 1). He underwent immediate surgery for aortic embolectomy. At surgery, the embolus was 7cm×4cm in size, pale and gelatinous. Intra-operative transoesophageal echocardiography showed a stalk-like mass in the left atrium (Fig. 2). Despite emergency surgery, the patient died on the following day from ischaemic bowel and acute renal failure. Histopathology of the embolism obtained during embolectomy was consistent with a myxoma (Fig. 3).

With or without an instructor, brief exposure to CPR training produces significant attitude change - Corrected Proof

Bonnie Lynch, Eric L. Einspruch — 2010-02-25

Abstract: Background: A common reason for bystanders’ failure to perform CPR in real or hypothetical situations is their lack of confidence in themselves. CPR self-training, which uses learner-operated virtual media rather than a live instructor, has not been assessed for its ability to influence learners’ attitudes toward performing CPR in a real emergency. The aim of this study was to compare attitude effects associated with traditional, live instruction versus self-training or no instruction.Method: Data from 1069 lay learners were collected. Learners were assigned randomly to a traditional instructor-led course, a video-based self-training course, or a no-training control group. All learners completed pre-training and post-training questionnaires that assessed competence, confidence, and willingness to perform CPR. Learners’ objective performance of CPR was also assessed, post-training, via a recording manikin.Results: ANOVA revealed that, in all 3 groups, all 3 attitudes changed significantly from pre- to post-questionnaire; further, the amount of attitude change did not differ reliably among the 3 groups (P<.05). Of the objective measures, ventilation performance was the only one consistently and positively correlated with attitudes (P<.05). Despite focus group comments that suggested self-trained learners’ concerns about the rudimentary nature of their training, these concerns did not manifest as a hindrance to positive attitude change.Conclusions: Live training does not pose any measurable advantage for developing learners’ positive attitudes. The counterintuitive finding that controls experienced similar levels of attitude change suggests that mere exposure to CPR testing can have positive effects on attitudes.

Pediatric out-of-hospital cardiac arrest in Korea: A nationwide population-based study - Corrected Proof

2010-02-22

Abstract: Study objectives: Our objective was to describe the incidence and demographics of pediatric out-of-hospital cardiac arrest (OHCA) in Korea.Methods: We identified non-traumatic OHCA patients aged less than 20 years from a Korean nationwide OHCA registry (2006–2007). Data from emergency medical service (EMS) run-sheets and hospital records were reviewed. We excluded cases with unknown hospital outcomes. Patient characteristics, treatment by EMS, and outcomes were compared by age groups: infant (<1 year), children (1–11 years), and adolescents (12–19 years).Results: A total of 971 patients including infants (n=299, 30.8%), children (n=305, 31.4%), and adolescents (n=367, 37.8%) met inclusion criteria. The incidence of pediatric OHCA was 4.2 per 100,000 person-years (67.1 in infants, 2.5 in children, and 3.5 in adolescents). The rate of cardiopulmonary resuscitation administered was 82.1% (infants 80.6%, children 82.0%, and adolescent 83.4%). The rate of applying automated external defibrillators and advanced airway management (endotracheal intubation or laryngeal mask airway), was only 4.1% and 2.5%, respectively. 7.4% showed ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in the initial ECG. Survival to hospital discharge for all pediatric OHCA was 4.9% (2.9% for infants, 4.7% for children, and 7.2% of adolescents). For EMS-treated pediatric OHCA or patients with VF or pulseless VT, the rate was 5.0% and 31.6%, respectively.Conclusion: Incidence and hospital outcomes in pediatric OHCA in Korea were comparable to other population-based nationwide reports.

Reply to Letter: A general consensus is necessary for the international standardization of automated external defibrillators - Corrected Proof

Vincent N. Mosesso — 2010-02-22

Thank you for your comments on our study. We agree with you that AED standardization could facilitate a greater likelihood of use and more rapid use of any device by those trained or familiar with a specific model. While having one singular design seems optimal for broad use, we are concerned that this could stifle innovation, which is often catalyzed by competition among manufacturers.

The effects of the new CPR guideline on attitude toward basic life support in Japan - Corrected Proof

Miki Enami, Yutaka Takei, Yoshikazu Goto, Keisuke Ohta, Hideo Inaba — 2010-02-22

Abstract: Background: There is no study regarding the influence of cardiopulmonary resuscitation (CPR) guideline renewal on citizen's attitude towards all basic life support (BLS) actions.Methods and results: We conducted a questionnaire survey to new driver licence applicants who participated in the BLS course at driving schools either before (January 2007 to April 2007) or after (October 2007 to April 2008) the revision of the textbook. Upon completion of the course, participants were given a questionnaire concerning willingness to participate in CPR, early emergency call, telephone-assisted chest compression and use of an automated external defibrillator (AED). After the revision, the proportions of positive respondents to use of AED as well as to all the four scenarios significantly increased from 2331/3564 to 3693/5156 (odds ratio (OR)=1.34) and from 1889/3443 to 3028/5126 (OR=1.18), respectively. However, the new guideline slightly but significantly augmented the unwillingness to make an early call (236/3568 vs. 416/5283, OR=0.83). Approximately 95% of respondents were willing to follow the telephone-assisted instruction of chest compression, while approximately 85% were eager to perform CPR on their own initiative. Multiple logistic regression analysis confirmed the results of mono-variate analysis, and identified previous CPR training, sex, rural area and student as other significant factors relating to attitude.Conclusions: Future guidelines should emphasise the significance and benefit of early call in relation to telephone-assisted instruction of CPR or chest compression. The course instructors should be aware of the backgrounds of participants as to how this may relate to their willingness to participate.

Rapid sequence airway vs rapid sequence intubation in a simulated trauma airway by flight crew - Corrected Proof

Andrew Southard, Darren Braude, Cameron Crandall — 2010-02-22

Abstract: Background: Rapid sequence airway (RSA) utilizes rapid sequence intubation (RSI) pharmacology followed by the placement of an extraglottic airway without direct laryngoscopy.Study objective: To evaluate the difference in time to airway placement and lowest oxygen saturations in a simulated trauma patient using RSI or RSA with a Laryngeal Mask Airway—Supreme (LMAS).Methods: This randomized, prospective, non-blinded, IRB-approved observational study used a SimMan® human simulator in an ambulance. FC were randomly assigned to initially manage the patient with RSI or RSA. They then completed the same scenario with the other modality to serve as their own control. Trained assistants performed directed tasks. SimMan® had an initial grade III view and desaturated along a standardized curve until intubation, LMAS, or bag-valve-mask ventilation (BVMV) was initiated. When BVMV was used, oxygen saturation increased along a standardized curve. The simulator's airway converted to a grade II view after the first attempt if difficult airway maneuvers were applied. Time, oxygen saturation, number of attempts and back-up airway placement were recorded.Results: Nineteen FC completed both paired modalities. Paired T-test was used for statistical analysis. Average time to secure the airway was 145s shorter in the RSA group (95% CI: 100.4–189.7). Lowest oxygen saturation was 4.8% higher (95% CI: 2.8–6.8) in the RSA group. During RSI, FC placed a back-up airway 47% of the time.Conclusion: In a simulated moderately difficult trauma airway managed by FC, RSA results in a significantly shorter time to secure the airway and less hypoxemia compared to RSI.

Continuous chest compression resuscitation in arrested swine with upper airway inspiratory obstruction - Corrected Proof

2010-02-22

Abstract: Background: This study was designed to compare 24-h survival rates and neurological function of swine in cardiac arrest treated with one of three forms of simulated basic life support CPR.Methods: Thirty swine were randomized equally among three experimental groups to receive either 30:2 CPR with an unobstructed endotracheal tube (ET) or continuous chest compression (CCC) CPR with an unobstructed ET or CCC CPR with a collapsable rubber sleeve on the ET allowing air outflow but completely restricting air inflow. The swine were anesthetized but not paralyzed. Two min of untreated VF was followed by 9min of simulated single rescuer bystander CPR. In the 30:2 CPR group, each set of 30 chest compressions was followed by a 15-s pause to simulate the realistic duration of interrupted chest compressions required for a single rescuer to deliver 2 mouth-to-mouth ventilations. The other two groups were provided continuous chest compressions (CCC) without assisted ventilations. At 11min post-arrest a biphasic defibrillation shock (150J) was administered followed by a period of advanced cardiac life support.Results: In the 30:2 group, 8 of 10 animals had good neurological function at 24-h post-resuscitation. In the CCC open airway group, 10 of 10, and in the CCC inspiratory obstructed group, 9 of 10. The number of shocks (P<0.05) and epinephrine doses (P<0.05) required for ROSC was greater in the 30:2 CPR group than in the other two groups.Conclusions: There were no differences in 24-h survival with good neurological function among these three different CPR protocols.

Two simple questions to assess neurologic outcomes at 3 months after out-of-hospital cardiac arrest: Experience from the Public Access Defibrillation Trial - Corrected Proof

W.T. Longstreth, Graham Nichol, Lois Van Ottingham, Alfred P. Hallstrom — 2010-02-22

Abstract: Background: Two simple questions have been used to classify neurologic outcome in patients with stroke. Could they be similarly applied to patients with cardiac arrest?Methods: As part of a randomized trial, study personnel interviewed by telephone survivors of out-of-hospital cardiac arrest to assess their outcomes 3 months after discharge. They asked two simple questions: (1) In the last 2 weeks, did you require help from another person for your everyday activities? and (2) Do you feel that you have made a complete mental recovery form your heart arrest? Next they administered the Mini-Mental State Examination (MMSE) from the Adult Lifestyles and Function Interview (ALFI) to assess cognition on a scale from 0 to 22 and the Health Utilities Index Mark 3 (HUI3) to assess quality of life on a scale from 0 (death) to 1 (perfect health).Results: Based on responses to the two simple questions, 32 survivors were classified as dependent (n=5, 16%), independent (n=3, 9%) and full recovery (n=24, 75%). The mean ALFI-MMSE score was 19.1 (standard deviation 5.1), and the mean HUI3 score was 0.76 (standard deviation 0.28). The classification based on the two simple questions was significantly correlated with ALFI-MMSE (p=0.002) and HUI3 (p=0.001). Scores for the HUI3 were missing in eight survivors.Conclusions: Neurologic outcomes based on the two simple questions after cardiac arrest can be easily determined, sensibly applied, and readily interpreted. These preliminary findings justify further evaluation of this simple and practical approach to classify neurologic outcome in survivors of cardiac arrest.

A randomized comparison of cardiocerebral and cardiopulmonary resuscitation using a swine model of prolonged ventricular fibrillation - Corrected Proof

2010-02-22

Abstract: Background: Cardiocerebral resuscitation (CCR) is reportedly superior to cardiopulmonary resuscitation (CPR) for primary cardiac arrest in the prehospital setting. This study was done using a swine model of prolonged ventricular fibrillation (VF) to quantify the effect of the emergency medical services component of CCR with intraosseous access (CCR-IO) compared with standard CPR with intravenous access (CPR-IV) as it is typically performed during out-of-hospital cardiac arrest (OHCA) resuscitation in a prospective randomized fashion.Methods: Fifty-three animals were instrumented under anesthesia and VF was electrically induced. After 10min of untreated VF, baseline characteristics were recorded, and animals were block randomized to one of two resuscitation schemes. The controls had mechanical chest compressions at 100/min with ventilations at a ratio of 30:2. Consistent with clinical practice, two 30-s pauses in chest compressions occurred to simulate attempts to accomplish endotracheal intubation at minutes 1 and 3 of CPR and successful IV access was simulated to occur three additional minutes after endotracheal intubation. The CCR group had continuous uninterrupted mechanical chest compressions at 100/min. No active ventilations were provided. A tibial IO needle was placed in real time for vascular access. Both groups received epinephrine (0.1mg/kg) as soon as access became available followed by 2.5min of chest compressions before the first 120J rescue shock attempt. After successful rescue shock, standardized post-resuscitative care was provided to a 20-min endpoint. Failed rescue shock was followed by continued chest compressions with positive pressure ventilation in both groups, repeat doses of epinephrine (0.01mg/kg) every 3min, and rescue shock every minute as long as a shockable rhythm persisted. Group comparisons were assessed using descriptive statistics. Proportions with 95% confidence intervals were calculated for VF termination, ROSC, and survival.Results: Baseline characteristics and chemistries between the two groups at VF induction and after 10min of non-treatment were mathematically the same. The proportions of VF termination (0.50 vs. 0.82), ROSC (0.30 vs. 0.59), and 20-min survival (0.19 vs. 0.40) all strongly favored the CCR-IO group.Conclusion: In this swine model of witnessed VF arrest with no bystander-initiated resuscitation, CCR-IO resulted in substantial improvement in all three outcomes relative to typical emergency medical services provided CPR-IV.

Ultrasonographic lung appearance of transfusion-related acute lung injury - Corrected Proof

David J. Wallace, Stephen Esper, Scott R. Gunn, Michael B. Stone — 2010-02-22

A 29-year old woman was admitted to the intensive care unit after developing transfusion-related acute lung injury (TRALI) shortly after starting plasmapheresis for thrombotic thrombocytopenic purpura (TTP). At the start of plasmapheresis, the patient's vitals were heart rate 82min−1, blood pressure 124/82mmHg, respiratory rate 14min−1, temperature 36.8°C and oxygen saturation 99% while breathing 2l of oxygen delivered by nasal cannula. Two hours later, the patient had an abrupt clinical deterioration: her vital signs were heart rate 143min−1, blood pressure 145/94mmHg, respiratory rate 43min−1, temperature 38.9°C and oxygen saturation 82% while breathing 100% oxygen delivered via a non-rebreather face mask. Her arterial blood gas (ABG) was pH 7.51, PCO2 42torr, PO2 59torr, bicarbonate 33 and saturation 83%. She was placed on non-invasive positive pressure ventilation, with an improvement in her pulse-oximeter saturation to 94%. The patient's physical exam suggested euvolemia, with clear breath sounds bilaterally and the absence of peripheral edema or jugular venous distention.

Reply letter to: Paediatric tracheal prehospital intubation—What makes different our practice across the Ocean? - Corrected Proof

2010-02-22

We thank our French colleagues for their affirmative comments on our recent article on characteristics and outcome of prehospital paediatric tracheal intubation (TI) attended by anaesthesia-trained emergency physicians. In the majority of severely compromised ill or injured children, such as those with severe head injury, prolonged drowning, cardiopulmonary resuscitation, etc. there seems to be not much doubt that early TI is indicated. Although robust data on improvements of survival or neurological outcomes are sparse (as for other emergency medical interventions, e.g. iv-adrenaline in cardiac arrest) these children would be intubated in hospital as soon as possible. Thus, above all, the question is not if but rather when, where and by whom TI should be best performed.

Peter Baskett in daily student life - Corrected Proof

Christoph Redelsteiner — 2010-02-22

We want to submit information about an initiative remembering Dr. Peter Baskett. Danube University Krems, a public university from Austria has specialized in postgraduate academic studies. More than 4500 students from 80 countries are enrolled in over 150 academic courses, 50 of which being in the medical and allied health fields. Since 2003 the Center for Health Care Management and Quality offers a special Master of Science Course for Emergency Health Services Management. Four courses with around 70 students have been completed so far. The program is targeted to CEOs of Ambulance Services, Operational and Sectional Emergency Medical Services Commanders, Physician Advisors and Medical Directors of such services.

Changes in interleukin-10 mRNA expression are predictive for 9-day survival of pigs in an emergency preservation and resuscitation model - Corrected Proof

2010-02-18

Abstract: Aim of the study: This study aimed at evaluating (I) the impact of different intra-arrest hypothermia levels on the expression of selected cytokines and (II) their prognostic value for 9-day survival.Methods: Female Large White pigs (n=21, 31–38kg) were subjected to 15min of ventricular fibrillation, followed by intra-arrest cardiopulmonary bypass cooling for 1, 3, or 5min achieving brain temperatures (Tbr) of 30.4±1.6, 24.2±4.6 and 18.8±4.0°C. After 40min of controlled rewarming, pigs were defibrillated and kept at Tbr of 34.5°C for 20h, survival was for 9 days. Plasma samples were analysed for interleukin (IL)-6, tumor necrosis factor-α (TNF-α), and IL-10 levels by ELISA. Total RNA out of peripheral blood mononuclear cells was analysed by real-time PCR for IL-1, IL-2, IL-4, IL-10, TNF-α, interferon-γ, inducible NO synthase, and heme oxygenase-1 gene expressions.Results: Plasma IL-6 and TNF-α levels significantly (p=0.0001 and 0.0003) increased in all animals within 1h after resuscitation with no significant differences between groups. Pigs surviving exhibited a decrease in IL-10 expression between baseline and intra-arrest values as compared to non-surviving animals, which showed a slight increase (p=0.0078). ROC curve analysis revealed that changes in IL-10 expression had a good prognostic power for survival to day 9 (area under the curve=0.882).Conclusion: The systemic inflammatory response syndrome after cardiac arrest was reflected by a remarkable increase of plasma IL-6 and TNF-α levels. Intra-arrest hypothermia levels did not influence the expression of selected cytokines. As prognostic marker for survival IL-10 was identified with decreasing mRNA levels during cardiac arrest in survivors.

The effects of different instructional methods on students’ acquisition and retention of cardiopulmonary resuscitation skills - Corrected Proof

Leyla Saraç, Ahmet Ok — 2010-02-12

Abstract: Background: The need was evident for the evaluation of applicability and effectiveness of different types of instructional strategies to teach CPR skills. Therefore, the aim of this study was to evaluate the effects of traditional, case-based, and web-based instructional methods on acquisition and retention of CPR skills.Methods: Ninety university students (52 female, 48 male) who selected the first aid course as an elective were assigned randomly to traditional, case-based, and web-based instruction groups. The students were tested three times (pre-test, post-test and retention test) for their measurable and observable CPR skills by using a skill reporter manikin and skill observation checklist.Results: Based on the CPR chest compression performance measurements by the skill reporter manikin, the web-based instruction group performed poorer than the traditional and case-based instruction groups in “average compression rate, percentage of correct chest compressions, the number of too low hand positions, the number of wrong hand positions, the number of incomplete releases, the average number of ventilations, the average volume of ventilations, the minute volume ventilations, the number of too fast ventilations, the total number of ventilations, and the percentage of correct ventilations” (p<.05). Additionally, 18-week time interval negatively affected students’ performance on “the percentage of correct chest compressions, and total number of compressions”. Similar poor performance by web-based instruction group was also detected by the skill observation checklist.Conclusion: The students in traditional and case-based instruction groups showed better CPR performance than students in web-based instruction group that used video self-instruction as a learning tool.

“Identifying the hospitalised patient in crisis”—A consensus conference on the afferent limb of Rapid Response Systems - Corrected Proof

2010-02-11

Abstract: Background: Most reports of Rapid Response Systems (RRS) focus on the efferent, response component of the system, although evidence suggests that improved vital sign monitoring and recognition of a clinical crisis may have outcome benefits. There is no consensus regarding how best to detect patient deterioration or a clear description of what constitutes patient monitoring.Methods: A consensus conference of international experts in safety, RRS, healthcare technology, education, and risk prediction was convened to review current knowledge and opinion on clinical monitoring. Using established consensus procedures, four topic areas were addressed: (1) To what extent do physiologic abnormalities predict risk for patient deterioration? (2) Do workload changes and their potential stresses on the healthcare environment increase patient risk in a predictable manner? (3) What are the characteristics of an “ideal” monitoring system, and to what extent does currently available technology meet this need? and (4) How can monitoring be categorized to facilitate comparing systems?Results and conclusions: The major findings include: (1) vital sign aberrations predict risk, (2) monitoring patients more effectively may improve outcome, although some risk is random, (3) the workload implications of monitoring on the clinical workforce have not been explored, but are amenable to study and should be investigated, (4) the characteristics of an ideal monitoring system are identifiable, and it is possible to categorize monitoring modalities. It may also be possible to describe monitoring levels, and a system is proposed.

The role of bystanders during rescue and resuscitation of drowning victims - Corrected Proof

Allart M. Venema, Johan W. Groothoff, Joost J.L.M. Bierens — 2010-02-11

Abstract: Background: Bystanders make a critical difference in the survival of drowning victims. Little information on their role before arrival of the Emergency Medical Services (EMS) is available in the scientific literature. In a descriptive study, this role is investigated.Methods and results: We studied 289 rescue reports (1999–2004) available from the Dutch Maatschappij tot Redding van Drenkelingen (Society to Rescue People from Drowning), an organisation that, since 1767, acknowledges awards to bystanders who have contributed to the survival of a drowning victim. There were 138 variables retrieved from these reports. The Utstein Style for Drowning (USFD) was used as a guideline. Of the 26 USFD parameters on victim and scene information, 21 were available for analysis. Eight non-USFD parameters, defined by the authors of this research, were available in >60% of the cases. There were 343 victims, rescued by 503 rescuers. 109 victims were resuscitated by bystanders. Of the 18 victims who first received resuscitation from bystanders and then consequently from pre-hospital professionals, 14 survived. Rescues often occurred in dangerous circumstances: multiple victims (n=90/343), cold or ice-cold water (n=295/341), deep water (n=316/334), swimming to the victims (n=262/376), young age of rescuers (the youngest rescuer was 5 years of age).Conclusions: Bystander rescue and resuscitation of drowning victims seems to contribute to a positive outcome. Bystanders are prepared to take responsibility to rescue a drowning victim in spite of significant dangers. The USFD is helpful in understanding the role of bystanders in drowning situations, but may need modification to become more instrumental.

Post-resuscitative clinical features in the first hour after achieving sustained ROSC predict the duration of survival in children with non-traumatic out-of-hospital cardiac arrest - Corrected Proof

2010-02-11

Abstract: Aim of the study: Although sustained return of spontaneous circulation (ROSC) can be initially established after resuscitation from non-traumatic out-of-hospital cardiac arrest (OHCA) in some children, many of the children lose spontaneous circulation during hospital stay and do not survive to discharge. The aim of this study was to determine the clinical features during the first hour after ROSC that may predict survival to hospital discharge.Methods: We retrospectively evaluated the medical records of 228 children who presented to the emergency department without spontaneous circulation following non-traumatic OHCA during the period January 1996 to December 2008. Among these children, 80 achieved sustained ROSC for at least 20min. The post-resuscitative clinical features during the first hour after achieving sustained ROSC that correlated with survival, median duration of survival, and death were analyzed.Results: Among the 80 children who achieved sustained ROSC for at least 20min, 28 survived to hospital discharge and 6 had good neurologic outcomes (PCPC scale=1 or 2). Post-resuscitative clinical features associated with survival included sinus cardiac rhythm (p=0.012), normal heart rate (p=0.008), normal blood pressure (p<0.001), urine output>1ml/kg/h (p=0.002), normal skin color (p=0.016), lack of cardiopulmonary resuscitation (CPR)-induced rib fracture (p=0.044), initial Glasgow Coma Scale score>7 (p<0.001), and duration of in-hospital CPR≤10min (p<0.001). Furthermore, these variables were also significantly associated with the duration of survival (all p<0.05).Conclusions: The most important predictors of survival to hospital discharge in children with OHCA who achieve sustained ROSC are a normal heart rate, normal blood pressure, and an initial urine output>1ml/kg/h.

A paediatric cardiopulmonary resuscitation training project in Honduras - Corrected Proof

2010-02-11

Abstract: Objectives: It is possible that the exportation of North American and European models has hindered the creation of a structured cardiopulmonary resuscitation (CPR) training programme in developing countries. The objective of this paper is to describe the design and present the results of a European paediatric and neonatal CPR training programme adapted to Honduras.Materials and methods: A paediatric CPR training project was set up in Honduras with the instructional and scientific support of the Spanish Group for Paediatric and Neonatal CPR. The programme was divided into four phases: CPR training and preparation of instructors; training for instructors; supervised teaching; and independent teaching.Results: During the first phase, 24 Honduran doctors from paediatric intensive care, paediatric emergency and anaesthesiology departments attended the paediatric CPR course and 16 of them the course for preparation as instructors. The Honduran Paediatric and Neonatal CPR Group was formed. In the second phase, workshops were given by Honduran instructors and four of them attended a CPR course in Spain as trainee instructors. In the third phase, a CPR course was given in Honduras by the Honduran instructors, supervised by the Spanish team. In the final phase of independent teaching, eight courses were given, providing 177 students with training in CPR.Conclusions: The training of independent paediatric CPR groups with the collaboration and scientific assessment of an expert group could be a suitable model on which to base paediatric CPR training in Latin American developing countries.

Rating medical emergency teamwork performance: Development of the Team Emergency Assessment Measure (TEAM) - Corrected Proof

2010-02-01

Abstract: Aim: To develop a valid, reliable and feasible teamwork assessment measure for emergency resuscitation team performance.Background: Generic and profession specific team performance assessment measures are available (e.g. anaesthetics) but there are no specific measures for the assessment of emergency resuscitation team performance.Methods: (1) An extensive review of the literature for teamwork instruments, and (2) development of a draft instrument with an expert clinical team. (3) Review by an international team of seven independent experts for face and content validity. (4) Instrument testing on 56 video-recorded hospital and simulated resuscitation events for construct, consistency, concurrent validity and reliability and (5) a final set of ratings for feasibility on fifteen simulated ‘real time’ events.Results: Following expert review, selected items were found to have a high total content validity index of 0.96. A single ‘teamwork’ construct was identified with an internal consistency of 0.89. Correlation between the total item score and global rating (rho 0.95; p<0.01) indicated concurrent validity. Inter-rater (k 0.55) and retest reliability (k 0.53) were ‘fair’, with positive feasibility ratings following ‘real time’ testing. The final 12 item (11 specific and 1 global rating) are rated using a five-point scale and cover three categories leadership, teamwork and task management.Conclusion: In this primary study TEAM was found to be a valid and reliable instrument and should be a useful addition to clinicians’ tool set for the measurement of teamwork during medical emergencies. Further evaluation of the instrument is warranted to fully determine its psychometric properties.

Comparing the systolic blood pressure (SBP) and pulse rate (PR) in injured children with and without traumatic brain injury - Corrected Proof

Eleana Loizou, Omar Bouamra, Paul Dark, Bruce Martin, Fiona Lecky — 2010-02-01

Abstract: Aims: Following evidence that injured children have higher systolic blood pressures (SBP) than similar-aged resting uninjured children, we investigate whether the initial cardiovascular physiology differs between forms of injury.Methods: Analysis of prospectively recorded data from the Trauma Audit and Research Network (TARN) database of injured children aged ≤15, presenting with blunt trauma from March 1988 to February 2009. We compared the ED arrival SBP and pulse rate (PR) in children with and without TBI. The analysis was stratified by age and injury severity (ISS≤8=mild, ISS 9–14=moderate, ISS≥15=severe) through medians, graphs and compared through analysis of covariance.Results: Data for 18,135 children were analysed. Those with TBI had a higher mortality rate (17.2%) and were more severely injured. No difference was seen between the two groups in the SBP of severely injured children (p=0.09) who were almost all hypertensive compared to APLS “norms”. Further analysis revealed a significant difference in the PR of severely injured children (p<0.001), attributed to children <9 years of age with brain injuries showing lower heart rates than those with extracranial injuries, though all still within the normal range for their age.Conclusions: Although injured children remain hypertensive as compared to resting norms, we have seen no difference in the initial systolic blood pressure of moderately and severely injured children with and without traumatic brain injury. The relative bradycardia in the younger children appears to be an early sign of a severe traumatic brain injury.

Written evaluation is not a predictor for skills performance in an Advanced Cardiovascular Life Support course - Corrected Proof

David L. Rodgers, Farhan Bhanji, Barbara R. McKee — 2010-02-01

Abstract: Objective: Both a written cognitive knowledge evaluation and a practical evaluation that tests psychomotor skills, cognitive knowledge, and affective behaviors such as leadership and team skills are required for successful completion of American Heart Association (AHA) Advanced Cardiovascular Life Support (ACLS) course. The 2005 International Liaison Committee on Resuscitation (ILCOR) Consensus on Science and Treatment Recommendations noted that in Basic Life Support (BLS) there is little to no correlation between written and practical skills. The current study was conducted to determine if there is a correlation between written and practical evaluations in an ACLS course.Methods: 34 senior nursing students from four nursing programs participated in two separate ACLS classes, completing both the written and practical evaluations. Immediately following the courses, all participants served as team leader for a video recorded simulated cardiac arrest event. A panel of expert ACLS instructors who did not participate as instructors in the courses reviewed each video and independently scored team leaders’ performances.Results: Spearman's rho correlation coefficient between the written test scores and practical skills performance was 0.194 (2-tailed significance=0.272).Conclusion: The ACLS written evaluation was not a predictor of participant skills in managing a simulated cardiac arrest event immediately following an ACLS course. The single case simulations used in ACLS skills evaluation test a narrow portion of ACLS content while written evaluation tests can more practically test a broader spectrum of content. Both work in concert to define participant knowledge and neither should be used exclusively to determine participant competence.

Scandinavian pre-hospital physician-manned Emergency Medical Services—Same concept across borders? - Corrected Proof

2010-02-01

Abstract: Background: In Scandinavia, scattered populations and challenging geographical and climatic conditions necessitate highly advanced medical treatment by qualified pre-hospital services. Just like every other part of the health care system, the specialized pre-hospital EMS should aim to optimize its resource use, and critically review as well as continuously assess the quality of its practices. This study aims to provide a comprehensive profile of the pre-hospital, physician-manned EMS in the Scandinavian countries.Methods: The study was designed as a web-based cross-sectional survey. All specialized pre-hospital, physician-manned services in Scandinavia were invited, and data concerning organization, qualification and medical activity in 2007 were mapped.Results: Of the 41 invited services, 37 responded, which corresponds to a response rate of 90% (Finland 86%, Sweden 83%, Denmark 92%, Norway 94%). Organization and education are basically identical. All services provide advanced life support and have short response intervals. Services take care of a variety of patient groups, and skills are needed not only in procedures, but also in diagnostics, logistics, intensive care, and mass-casualty management. Consistent and detailed medical documentation was often lacking, however.Differences are mainly related to time variables, patient volume, and service area. The Danish and Swedish services have higher volumes of patient care encounters while the Finnish and Norwegian ones provide a wider variety of medical services.Conclusions: This survey documented several significant similarities among pre-hospital physician-staffed EMS systems in Scandinavia. Although medical data registration is currently under-developed, Scandinavian physician-manned EMS is a feasible arena for future multi-centre research.

Improving outcome after out-of-hospital cardiac arrest by strengthening weak links of the local Chain of Survival; quality of advanced life support and post-resuscitation care - Corrected Proof

2010-02-01

Abstract: Background: Survival after out-of-hospital cardiac arrest (OHCA) depends on a well functioning Chain of Survival. We wanted to assess if targeted attempts to strengthen the weak links of our local chain; quality of advanced life support (ALS) and post-resuscitation care, would improve outcome.Materials and methods: Utstein data from all OHCAs in Oslo during three distinct 2-year time periods 1996–1998, 2001–2003 and 2004–2005 were collected. Before the second period the local ALS guidelines changed with increased focus on good quality chest compressions with minimal pauses, while standardized post-resuscitation care including goal directed therapy with therapeutic hypothermia and percutaneous coronary intervention was added in the third period. Additional a priori sub-group analyses of arrests with cardiac aetiology as well as bystander witnessed ventricular fibrillation/tachycardia (VF/VT) arrests with cardiac aetiology were performed.Results: ALS was attempted in 454, 449, and 417 patients with OHCA in the first, second and last time period, respectively. From the first to the third period VF/VT arrests declined (40% vs. 33%, p=0.039) and fewer arrests were witnessed (80% vs. 72%, p=0.022) and response intervals increased (7±4 to 9±4min, p<0.001). Overall survival increased from 7% (first period) to 13% (last period), p=0.002, and survival in the sub-group of bystander witnessed VF/VT arrests with cardiac aetiology increased from 15% (first period) to 35% (last period), p=0.001.Conclusions: Survival after OHCA was increased after improving weak links of our local Chain of Survival, quality of ALS and post-resuscitation care.

Diphenhydramine-induced Brugada pattern - Corrected Proof

Michael Levine, Frank LoVecchio — 2010-02-01

We wish to describe a case of diphenhydramine-induced Brugada pattern, which resolved following therapy with intravenous sodium bicarbonate. A 29-year-old male with a history of depression and hypercholesterolemia ingested 25,000mg of diphenhydramine in a suicide attempt. He was found by family members approximately 30min post ingestion. Emergency Medical Services (EMS) was activated, and found the patient unresponsive. Upon arrival in the emergency department, he was afebrile with a temperature of 37.4. His heart rate was 153beats/min, with a blood pressure of 155/64mmHg. Shortly after arrival, he had a generalized tonic–clonic seizure which resolved spontaneously. He was emergently intubated with etomidate and succinylcholine. An initial 12-lead electrocardiogram demonstrated sinus tachycardia with an incomplete right bundle branch block. The ST morphology was consistent with a Brugada pattern (). He was treated with an intravenous bolus of 150mEq of sodium bicarbonate with near immediate resolution of his electrocardiographic abnormalities. His initial laboratory studies, before the administration of the sodium bicarbonate, were notable for a potassium of 3.4mmol/L, and a lactic acid of 19.5mmol/L. Comprehensive urine drug screen by thin-layer chromatography, with GC–MS confirmation revealed the presence of diphenhydramine and propofol, the later of which was administered post intubation. He was extubated on his second hospital day and ultimately transferred to in-patient psychiatric care.

Using a stool for stabilization of a dental chair when CPR is required - Corrected Proof

Hiroko Fujino, Takeshi Yokoyama, Kazu-ichi Yoshida, Kunio Suwa — 2010-02-01

Dental treatment is often stressful for patients, and sometimes deteriorates basic illness and/or may cause accidental systemic symptoms leading to cardiopulmonary arrest. Considering the difficulty of moving patients to the floor and the time required to this transfer, we might wish to start cardiopulmonary resuscitation (CPR) immediately in the dental chair.

Rapid induction of therapeutic hypothermia using convective-immersion surface cooling: Safety, efficacy and outcomes - Corrected Proof

2010-02-01

Abstract: Therapeutic hypothermia has become an accepted part of post-resuscitation care. Efforts to shorten the time from return of spontaneous circulation to target temperature have led to the exploration of different cooling techniques. Convective-immersion uses a continuous shower of 2°C water to rapidly induce hypothermia. The primary purpose of this multi-center trial was to evaluate the feasibility and speed of convective-immersion cooling in the clinical environment. The secondary goal was to examine the impact of rapid hypothermia induction on patient outcome.24 post-cardiac arrest patients from 3 centers were enrolled in the study; 22 agreed to participate until the 6-month evaluations were completed. The median rate of cooling was 3.0°C/h. Cooling times were shorter than reported in previous studies. The median time to cool the patients to target temperature (<34°C) was 37min (range 14–81min); and only 27min in a subset of patients sedated with propofol. Survival was excellent, with 68% surviving to 6 months; 87% of survivors were living independently at 6 months.Conductive-immersion surface cooling using the ThermoSuit® System is a rapid, effective method of inducing therapeutic hypothermia. Although the study was not designed to demonstrate impact on outcomes, survival and neurologic function were superior to those previously reported, suggesting comparative studies should be undertaken. Shortening the delay from return of spontaneous circulation to hypothermic target temperature may significantly improve survival and neurologic outcome and warrants further study.

Transthoracic defibrillation potential gradients in a closed chest porcine model of prolonged spontaneous and electrically induced ventricular fibrillation - Corrected Proof

James T. Niemann, John P. Rosborough, Scott T. Youngquist, Atman P. Shah — 2010-02-01

Abstract: Objective: The purpose of this study was to measure the local electrical field or potential gradient, measured with a catheter-based system, required to terminate long duration electrically or ischaemically induced ventricular fibrillation (VF). We hypothesized that prolonged ischaemic VF would be more difficult to terminate when compared to electrically induced VF of similar duration.Methods: Thirty anesthetized and instrumented swine were randomized to electrically induced VF or spontaneous, ischaemically induced VF, produced by balloon occlusion of the left anterior descending coronary artery. After 7min of VF, chest compressions were initiated and rescue shocks were attempted 1min later. The potential gradient for each shock was measured and the mean values required for defibrillation compared for the VF groups.Results: The number of shocks and the shock strength required for termination of VF were not significantly different for the groups. The potential gradient of the first successful defibrillating shock was significantly greater in the spontaneous, occlusion-induced VF group (12.80±2.82V/cm vs 9.60±2.48V/cm, p=0.002). The number of refibrillations was greater in the ischaemic group than in the non-ischaemic electrical group (6±4 vs 1±1, p<0.001). The number of animals requiring a shock at 360J was 2.5 times greater for the ischaemic group.Conclusions: Defibrillation of prolonged VF produced by acute myocardial ischaemia requires a significantly greater potential gradient to terminate than prolonged VF induced by electrical stimulation of the right ventricular endocardium. The VF duration used in this study approximates that occurring in victims of out-of-hospital cardiac arrest. Our findings may be of clinical importance in the management of such patients.

Discriminating the effect of accelerated compression from accelerated decompression during high-impulse CPR in a porcine model of cardiac arrest - Corrected Proof

2010-02-01

Abstract: Aim of the study: Piston based mechanical chest compression devices deliver compressions and decompressions in an accelerated pattern, resulting in superior haemodynamics compared to manual compression in animal studies. The present animal study compares haemodynamics during two different hybrid compression patterns to a standard compression pattern resembling that of modern mechanical chest compression devices.Method: In 12 anaesthetized domestic pigs in ventricular fibrillation, coronary perfusion pressures (CPP) and cerebral cortical blood flow (CCBF) was measured, and transesophageal echocardiography (TEE) was performed. Two hybrid compression patterns, one with accelerated trapezoid compression and slower sinusoid decompression (TrS), and one with slower sinusoid compression and accelerated trapezoid decompression (STr), were tested against a standard accelerated trapezoid compression–decompression pattern (TrTr) in a cross-over randomised setup.Results: There were 7% (1, 14, p=0.046) lower CCBF and 3mmHg (1, 5, p=0.017) lower CPP with the TrS compared to TrTr pattern. No significant difference between STr and TrTr pattern in either CCBF, 6% (−3, 15, p=0.176) or CPP, 0mmHg (−2, 3, p=0.703) was present. Our TEE recordings were insufficient for haemodynamic comparison between the different compression–decompression patterns. Despite standardized sternal piston position and placement of the pigs, TEE revealed varying degree of asymmetrical heart chamber compression in the animals.Conclusion: Both cardiac and cerebral perfusion benefited from accelerated decompression, while accelerated compression did not improve haemodynamics. The evolution of mechanical CPR is dependent on further research on mechanisms generating forward blood flow during external chest compressions.

A geospatial assessment of transport distance and survival to discharge in out of hospital cardiac arrest patients: Implications for resuscitation centers - Corrected Proof

2010-02-01

Abstract: Objectives: National leaders have suggested that patients with an out of hospital cardiac arrest (OOHCA) may benefit from transport to specialized hospitals. We sought to assess the survival of OOHCA patients by transport distance and hospital proximity.Methods: Prospective, cohort study of OOHCA patients in 11 Resuscitation Outcomes Consortium (ROC) sites across North America. Transport distance and hospital proximity was calculated using weighted centroid of census tract location by Geographic Information Systems (GIS). Patients were stratified into quartiles based on transport distance to the receiving hospital calculated via GIS. Descriptive statistics were used to describe characteristics by transport distance and to compare proximity to other hospitals. Multivariate logistic regression was used to evaluate the impact of transport distance on survival.Results: 26,628 patients were identified, 7540 (28%) were transported by EMS and included in the final analysis. The median transport time was 6.3min (IQR 5.4); the median transport distance being 2.4miles (3.9km). Most patients were taken to the closest hospital (71.7%; N=5412). However, unadjusted survival to discharge was lower for those taken to the closest compared to further hospitals (12.1% vs. 16.5%) despite similar patient characteristics. Transport distance was not associated with survival on logistic analysis (OR 1.00; 95% CI 0.99–1.01).Conclusions: Survival to discharge was higher in OOHCA patients taken to hospitals located further than the closest hospital while transport distance was not associated with survival. This suggests that longer transport distance/time might not adversely affect outcome. Further studies are needed to inform policy decisions regarding best destination post-cardiac arrest.

Performance of an automated external defibrillator in a moving ambulance vehicle - Corrected Proof

2010-02-01

Abstract: Aim of the study: The available data suggest that automated external defibrillators (AED) can be safely used in vibration-like moving conditions such as rigid inflatable boats and aircraft environments. However, little literature exists examining their performance in a moving ambulance. The present study was undertaken to determine whether an AED is able to analyse the heart rhythm correctly during ambulance transport.Methods: An ambulance was driven on paved (20–100km/h) and unpaved (10km/h) roads. The performance of two AED devices (CU ER 2, CU Medical Systems Inc., Korea, and Heartstart MRx, Phillips, USA) was determined in a moving ambulance using manikins. Vibration intensity was measured simultaneously with a digital vibrometer. AED performance was then evaluated again on manikins and on a swine model under simulated vibration intensities (0.5–5m/s2) measured by the vibrometer in the previous phase of the investigation.Results: The vibration intensity increased with increasing speeds on paved roads (1.98±0.44m/s2 at 100km/h). While driving on unpaved roads, it increased to 6.40±1.06m/s2. Both AED algorithms analysed the heart rhythm correctly under resting state. When tested on pigs, both algorithms showed substantially degraded performances, even at low vibration intensities of 0.5–1m/s2, which corresponded to vibration intensities while driving on paved roads at 20–60km/h. This study also showed that electrocardiograms generated on manikins were more resistant to motion artifacts than were the pig electrocardiograms.Conclusion: Ambulance personnel should consider the possibility of misinterpretation by an AED when this device is used while transporting a patient.

Induced hypothermia and determination of neurological outcome after CPR in ICUs in the Netherlands: Results of a survey - Corrected Proof

Aline Bouwes, Michael A. Kuiper, Albert Hijdra, Janneke Horn — 2010-02-01

Abstract: Introduction: Induction of hypothermia is generally accepted to increase survival of out-of-hospital cardiac arrest, but lack of initiation of this treatment has been frequently reported. When patients remain in coma after treatment with hypothermia, determination of prognosis is difficult. Furthermore, little is known about the methods used in clinical practice to predict outcome after cardiopulmonary resuscitation (CPR). The aim of the present survey was to evaluate self-reported implementation of hypothermia after CPR and the methods used to predict neurological outcome at Intensive Care Units (ICUs) in the Netherlands.Methods: Between April 2008 and July 2008 an e-mail-invitation for an anonymous web-based 22-question survey was sent to one physician of each ICU in the Netherlands.Results: Of the 97 physicians surveyed, 74 (76%) responded. Thirty-seven (50%) responders always treated patients with hypothermia after CPR, 31 (42%) only when CPR fulfilled several criteria. The most important reason for not using hypothermia (six ICUs) was lack of equipment. Haemodynamic instability was the most cited reason for discontinuing treatment. Neurological outcome was predicted by clinical neurological examination (92%), cortical N20 responses of median nerve somatosensory evoked potentials (SSEP) (94%), an electroencephalogram (56%) or serum levels of neuron-specific proteins (5%).Conclusions: In the Netherlands, the use of therapeutic hypothermia after CPR is reported by 92% of ICUs which, compared to previous reports, is an exceedingly high percentage. Neurological outcome is reported to be predicted mainly by neurological examination and SSEP or a combination of these and other assessments. The method used varies substantially between ICUs.

Scapular facture following cardiopulmonary resuscitation - Corrected Proof

Yigal Abramowitz, Galit Aviram, Arie Roth — 2010-02-01

An apparently healthy 40-year-old man with no past history of cardiovascular pathology or skeletal injuries was presented to the emergency room with an acute onset of anterior wall myocardial infarction. Around 45min earlier, he had called an ambulance service and complained of severe chest pain, sweating and vomiting. The patient collapsed immediately after the arrival of the medical staff to his home. An electrocardiographic monitor demonstrated ventricular fibrillation (VF), and cardiopulmonary resuscitation (CPR) was started immediately. During CPR, the patient was intubated, and received intravenous heparin, lidocaine and amiodarone. VF was recorded 15 times and converted to sinus rhythm each time a direct current shock was delivered, with no need for chest compressions. During the 3rd and 4th VF episodes, the patient experienced a generalized clonic contraction of the muscles of his arms and legs that lasted for a few seconds each time. He was transferred to the ambulance for transport to the hospital immediately following homodynamic stabilization.

Comparison of sudden cardiac arrest resuscitation performance data obtained from in-hospital incident chart review and in situ high-fidelity medical simulation - Corrected Proof

2010-02-01

Abstract: Introduction: High-fidelity medical simulation of sudden cardiac arrest (SCA) presents an opportunity for systematic probing of in-hospital resuscitation systems. Investigators developed and implemented the SimCode program to evaluate simulation's ability to generate meaningful data for system safety analysis and determine concordance of observed results with institutional quality data.Methods: Resuscitation response performance data were collected during in situ SCA simulations on hospital medical floors. SimCode dataset was compared with chart review-based dataset of actual (live) in-hospital resuscitation system performance for SCA events of similar acuity and complexity.Results: 135 hospital personnel participated in nine SimCode resuscitations between 2006 and 2008. Resuscitation teams arrived at 2.5±1.3min (mean±SD) after resuscitation initiation, started bag-valve-mask ventilation by 2.8±0.5min, and completed endotracheal intubations at 11.3±4.0min. CPR was performed within 3.1±2.3min; arrhythmia recognition occurred by 4.9±2.1min, defibrillation at 6.8±2.4min. Chart review data for 168 live in-hospital SCA events during a contemporaneous period were extracted from institutional database. CPR and defibrillation occurred later during SimCodes than reported by chart review, i.e., live: 0.9±2.3min (p<0.01) and 2.1±4.1min (p<0.01), respectively. Chart review noted fewer problems with CPR performance (simulated: 43% proper CPR vs. live: 98%, p<0.01). Potential causes of discrepancies between resuscitation response datasets included sample size and data limitations, simulation fidelity, unmatched SCA scenario pools, and dissimilar determination of SCA response performance by complementary reviewing methodologies.Conclusion: On-site simulations successfully generated SCA response measurements for comparison with live resuscitation chart review data. Continued research may refine simulation's role in quality initiatives, clarify methodologic discrepancies and improve SCA response.

Traditional Chinese medicine K1 Yongquan and resuscitation: Another kind of “Lazarus phenomenon” - Corrected Proof

Adrián Inchauspe — 2010-01-18

In the late 1980s Erle Montaigue began to spread the Dim Mak theory: the deleterious effects of stimulating vulnerable vital points could be reversed by applying “antidotes”. In this theory, the Yongkuan K1 point () appears to be the main revival point.

Osborn waves and incessant ventricular fibrillation during therapeutic hypothermia - Corrected Proof

Elisabeth Lassnig, Edwin Maurer, Roland Nömeyer, Bernd Eber — 2010-01-18

A 33-year-old man suddenly collapsed and presented with ventricular fibrillation (VF) when the emergency team arrived. Conversion to sinus rhythm and return of spontanous circulation was achieved with a single shock from a defibrillator. The patient was admitted to hospital comatose, mechanically ventilated but haemodynamically stable. Therapeutic hypothermia was initiated using the Arctic Sun (www.medivance.com) external cooling system. Initial ECG and echocardiography were quite normal. Coronary artery disease was excluded by angiography. Clinical and laboratory examination revealed no pathology. While the patient was hypothermic (33°C/91.4°F) progressive ECG changes appeared. The heart rate decreased to 35/min and the QRS complexes became wide with the appearance of a prominent J wave (Osborn wave) at the beginning of the ST segment (). The ST segment became elevated mimicking the saddle-back type Brugada ECG pattern (). Eight hours after initiation of hypothermia, incessant VF started. After each defibrillation attempt only a few sinus beats occurred before VF recurred (). Chest compression was performed with the LUCAS-CPR (www.lucas-cpr.com) system for 60min. Neither infusion of magnesium nor injection of beta-blocker, amiodarone or lidocaine was effective in stopping the VF. Injection of a bolus of adrenaline followed by an adrenaline infusion and rewarming the patient to 35°C/95°F stopped the electrical storm. Afterwards the patient was stable without any ectopic beats. Electrocardiogram changes disappeared (). The following day, the patient regained consciousness and had no neurological deficit. Because of his family history, with three sudden cardiac deaths, a hereditary ion-channel disease was suggested. However Ajmalin testing was negative and the QT interval was within normal range. Magnetic resonance tomography of the heart found no abnormalities. A cardioverter-defibrillator was successfully implanted.

The importance of pre-trauma centre treatment of life-threatening events on the mortality of patients transferred with severe trauma - Corrected Proof

2010-01-18

Abstract: Aim: The benefit of a well organised trauma system is acknowledged but doubts remain concerning the optimal pre-hospital trauma care model. We hypothesise that the treatment of life-threatening events before arrival at trauma centre – either pre-hospital or first hospital – may be more relevant to decreasing mortality than shortening the time to trauma centre.Methods: A cohort of 727 trauma patients with life-threatening events – identified as airway, breathing, circulation or neurological disability – requiring transfer to a trauma centre were studied. Data on patient's characteristics, trauma features, and mortality were taken from a trauma registry. Patients were divided into 3 groups depending on the place of treatment of life-threatening events: pre-hospital, first hospital or trauma centre. Survival Kaplan–Meier curves and logistic regression were used to assess the effect of place of treatment of life-threatening events on mortality.Results: Patients from the pre-hospital and first hospital groups had 20% and 27% mortality respectively, compared to 38% among those whose life-threatening events were corrected only at the trauma centre. Logistic regression showed that patients whose life-threatening events were corrected only at the trauma centre had an odds of death 3.3 times greater than those from the pre-hospital group, adjusted for patient and trauma characteristics and time to trauma centre.Conclusion: In trauma patients requiring transfer to a trauma centre, pre-hospital interventions to treat life-threatening events may significantly decrease mortality when compared to similar interventions performed later at the trauma centre.

Nitroglycerin attenuates vasoconstriction of HBOC-201 during hemorrhagic shock resuscitation - Corrected Proof

2010-01-18

Abstract: Background: Vasoconstriction, an inherent property of Hemoglobin Based Oxygen Carriers (HBOC) potentially due to nitric oxide (NO) scavenging, may increase cardiovascular complications in HBOC resuscitated trauma patients. The purpose of this study was to determine if co-administration of a weak NO donor, intravenous nitroglycerin (NTG), with HBOC-201 during resuscitation from hemorrhagic shock could safely attenuate HBOC-201 vasoconstriction.Methods and results: Hemorrhagic shock was induced in 44 swine randomized to receive fluid resuscitation with HBOC, HBOC+NTG10mcg/kg/min, HBOC+NTG20mcg/kg/min, HBOC+NTG40mcg/kg/min, Hetastarch (HES), HES+NTG20mcg/kg/min, NTG20mcg/kg/min and Lactated Ringers (LR). HBOC resuscitation from hemorrhagic shock increased mean arterial pressure (MAP=94±33mmHg), mean pulmonary artery pressure (MPAP=29±11mmHg) and systemic vascular resistance (SVR=2684±871dyns/cm5) in comparison to HES. Co-administration of NTG during HBOC resuscitation attenuated vasoconstriction with HBOC+40mcg/kg/min demonstrating the most robust reduction in vasoconstriction (MAP=59±23mmHg, MPAP=18±7mmHg, and SVR=1827±511dyns/cm5), although the effects were transient. Co-administration of NTG with HBOC did not alter base deficit, lactate, methemoglobin levels, nor cause profound hypotension during resuscitation.Conclusion: Nitroglycerin attenuates vasoconstrictive properties of HBOC when co-administered during resuscitation in this swine model of hemorrhagic shock. Translational survival studies are required to determine if this strategy of attenuation of the vasoconstriction of HBOC-201 reduces cardiovascular complications and improves outcome with HBOC fluid resuscitation for hemorrhagic shock.

Feasibility and safety of combined percutaneous coronary intervention and therapeutic hypothermia following cardiac arrest - Corrected Proof

2010-01-18

Abstract: Review: Mild therapeautic hypothermia (MTH) has been associated with cardiac dysrhythmias, coagulopathy and infection. After restoration of spontaneous circulation (ROSC), many cardiac arrest patients undergo percutaneous coronary intervention (PCI). The safety and feasibility of combined MTH and PCI remains unclear. This is the first study to evaluate whether PCI increases cardiac risk or compromises functional outcomes in comatose cardiac arrest patients who undergo MTH.Methods: Ninety patients within a 6-h window following cardiac arrest and ROSC were included. Twenty subjects (23%) who underwent PCI following MTH induction were compared to 70 control patients who underwent MTH without PCI. The primary endpoint was the rate of dysrhythmias; secondary endpoints were time-to-MTH induction, rates of adverse events (dysrhythmia, coagulopathy, hypotension and infection) and mortality.Results: Patients who underwent PCI plus MTH suffered no statistical increase in adverse events (P=.054). No significant difference was found in the rates of dysrhythmias (P=.27), infection (P=.90), coagulopathy (P=.90) or hypotension (P=.08). The PCI plus MTH group achieved similar neurological outcomes (modified Rankin Scale (mRS) ≤3 (P=.42) and survival rates (P=.40). PCI did not affect the speed of MTH induction; the target temperature was reached in both groups without a significant time difference (P=.29).Conclusion: Percutaneous coronary intervention seems to be feasible when combined with MTH, and is not associated with increased cardiac or neurological risk.

Monitoring in resuscitation: Comparison of cardiac output measurement between pulmonary artery catheter and NICO - Corrected Proof

2010-01-18

Abstract: Aim: The cardiac output and coronary perfusion pressure generated from chest compressions during resuscitation manoeuvres can predict effectiveness and successful outcome. Until now, there is no good method for haemodynamic monitoring during resuscitation. Noninvasive partial carbon dioxide rebreathing system (NICO, Novametrix Medical Systems, Inc., Wallingford, CT, USA) is a relatively new non-invasive alternative to thermodilution for measuring cardiac output. The accuracy of the NICO system has not been evaluated during resuscitation. The aim of this study is to compare thermodilution cardiac output method with NICO system and to assess the utility of NICO during resuscitation.Methods and design: Experimental study in 24 Yorkshire pigs.Paired measurements of cardiac output were determined during resuscitation (before ventricular fibrillation and after 5, 15, 30 and 45min of resuscitation) in the supine position. The average of 3 consecutive thermodilution cardiac output measurements (10ml 20°C saline) was compared with the corresponding NICO measurement.Results: Bland and Altman plot and Lin's concordance coefficient showed a high correlation between NICO and thermodilution cardiac output measurements although NICO has a tendency to underestimate cardiac output when compared to thermodilution at normal values of cardiac output.Conclusions: There is a high degree of agreement between cardiac output measurements obtained with NICO and thermodilution cardiac output during resuscitation.The present study suggests that the NICO system may be useful to measure cardiac output generated during cardiopulmonary resuscitation.