The Emergency Cardiac Care (ECC) Committee of the American Heart Association first published guid... more The Emergency Cardiac Care (ECC) Committee of the American Heart Association first published guidelines for cardiopulmonary resuscitation (CPR) and ECC in 1974.1 Updated in 1980, 1986, and 1992, the AHA guidelines are now recognized as the world’s most authoritative resuscitation guidelines.2 3 4 To implement these guidelines, however, hospitals need to establish a systems approach to in-hospital resuscitation rather than depend on the skills of individual professionals. The success and acceptance of the out-of-hospital Utstein-style recommendations5 led the AHA to help develop specific recommendations for documenting in-hospital resuscitation. The Utstein-style recommendations for uniform reporting of in-hospital resuscitations present important recommendations for all hospital facilities.6 With publication of these recommendations, members of the ECC Committee recognized the need to summarize the major actions that enable a hospital to fulfill the resuscitation recommendations. CPR is one of the few interventions that requires an order to not be administered. Resuscitation efforts, however, are not appropriate for all hospital patients. When indicated, healthcare providers discuss with patients, families, and surrogate decision-makers their options and preferences for resuscitation. Hospitals have in place clear policies that address medical futility, patient self-determination, and do-not-attempt-resuscitation orders. The chain of survival, first conceptualized for out-of-hospital sudden cardiac arrest,7 applies to in-hospital arrest as well.8 …
Out-of hospital cardiac arrest accounts for more than 330,000 deaths annually in the United State... more Out-of hospital cardiac arrest accounts for more than 330,000 deaths annually in the United States and Canada. Despite regular updates of guidelines for the management of these arrests, the rate of survival has been stagnant at 7.6% for more than 30 years.1,2 In this issue of the Journal, the Resuscitation Outcomes Consortium reports the results of two randomized comparisons3,4 from the Prehospital Resuscitation Impedance Valve and Early Versus Delayed Analysis (ROC PRIMED) trial (ClinicalTrials.gov number, NCT00394706), which evaluated potential improvements in the management of out-of hospital cardiac arrest. The first component of the ROC PRIMED trial compared two . . .
Background: Bystander CPR is provided in ~25% of out of hospital cardiac arrests in the US. To im... more Background: Bystander CPR is provided in ~25% of out of hospital cardiac arrests in the US. To improve this low rate, the Save Hearts in Arizona Registry & Education program has initiated a multifaceted, statewide public chest compression only (CCO) CPR education campaign. It is unclear whether a statewide CCO-CPR campaign changes the intention of bystanders to perform CPR. It’s further unknown if this initiative affects willingness in populations with lowest survival and CPR performance. Objective: Evaluate the willingness to perform CPR, in various income demographics, following a statewide CPR intervention. Methods: Adult Arizona residents were surveyed at an academic medical center regarding performing CPR. They were asked their attitudes and feelings concerning performing CPR on strangers and family. Demographics were collected including age, gender, education, race and zip code which was used to incorporate census data for median income (separated as quartiles). Inclusion criteria were Arizona residents, age >18, and missing < 10% of survey data. CPR training was defined as CCO or formal CPR training. Results: Total of 1302 surveys were collected with a final population of 1163. Mean age was 40 yo (95% CI: 38.8, 40.5) with 44% males (95% CI: 41, 47). Willingness to perform CCO-CPR on strangers or family was high at 84% and 92%, respectively. However, when evaluated against median income, individuals in the lower income quartiles were less likely to perform CPR compared to higher quartiles for both strangers (77%; 95% CI 73, 82; P = 0.003) and family (90%; 95% CI 87, 94; P = 0.025). In these lower quartiles, a third as many individuals received training in CPR compared to the higher quartiles (p <0.001). Logistic regression analysis is being completed to evaluate this association in relation to race, education and other confounders. Conclusion: Public CPR interventions are effective in improving the willingness of bystanders to perform CPR. It is possible that CCO initiatives are not reaching the lowest quartile income populations which often have the lowest bystander CPR rates and highest mortality. Future CPR initiatives should be tailored to populations with highest mortality and who may not currently be receiving standard teaching initiatives.
Patients who are successfully resuscitated following cardiac arrest often have a significant medi... more Patients who are successfully resuscitated following cardiac arrest often have a significant medical condition termed postresuscitation disease. This includes myocardial stunning, metabolic abnormalities and neurologic injury from global ischemia. There are no clinical signs or diagnostic tests for 24-72 h to distinguish patients who will and will not recover neurologic function. Therapeutic hypothermia had been advocated for decades as a treatment to improve neurologic outcome after cardiac arrest. The early studies focused on moderate hypothermia, which was associated with complications and was not clearly beneficial. Over the past decade, studies have focused on mild hypothermia with target temperatures of 32-34 degrees C. Two recent multicentered, randomized, controlled trials have demonstrated improved neurologic outcome with mild therapeutic hypothermia applied to comatose survivors after cardiac arrest compared with a normothermic control group. As a result of these studies the International Liaison Committee on Resuscitation recommends that &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;Unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32 degrees C to 34 degrees C for 12 to 24 hours when the initial rhythm was ventricular fibrillation&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;. Mild therapeutic hypothermia should also be considered for patients with in-hospital arrest and asystole and pulseless electrical activity who are comatose after return of spontaneous circulation.
The effectiveness of ongoing cardiopulmonary resuscitation efforts is difficult to evaluate. Rece... more The effectiveness of ongoing cardiopulmonary resuscitation efforts is difficult to evaluate. Recent studies suggest that carbon dioxide excretion may be a useful noninvasive indicator of resuscitation from cardiac arrest. A prospective clinical study was done to determine whether end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation could be used as a prognostic indicator of resuscitation and survival. Thirty-five cardiac arrests in 34 patients were monitored with capnometry during cardiopulmonary resuscitation during a 1-year period. Nine patients who were successfully resuscitated had higher average end-tidal carbon dioxide partial pressures during cardiopulmonary resuscitation than 26 patients who could not be resuscitated (15 +/- 4 vs 7 +/- 5 mm Hg). The 3 patients who survived to leave the hospital had a higher average end-tidal carbon dioxide partial pressure than the 32 nonsurvivors (17 +/- 6 vs 8 +/- 5 mm Hg). All 9 patients who were successfully resuscitated had an average end-tidal carbon dioxide partial pressure of 10 mm Hg or greater. No patient with an average end-tidal carbon dioxide partial pressure of less than 10 mm Hg was resuscitated. Data from this prospective clinical trial indicate that findings from end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation are correlated with resuscitation from and survival of cardiac arrest.
Emergency medicine is a specially often confronted with ultimate crises; patients frequently pres... more Emergency medicine is a specially often confronted with ultimate crises; patients frequently present near death or in cardiac arrest. At the time of cardiopulmonary arrest, the emergency physician mobilizes all available resources to attempt to resuscitate the patient. This struggle is itself challenging. In addition, medical crises may raise difficult moral questions. A conflict is present when the resuscitation team questions whether the attempted resuscitations is warranted
The effectiveness of ongoing cardiopulmonary resuscitation efforts is difficult to evaluate. Rece... more The effectiveness of ongoing cardiopulmonary resuscitation efforts is difficult to evaluate. Recent studies suggest that carbon dioxide excretion may be a useful noninvasive indicator of resuscitation from cardiac arrest. A prospective clinical study was done to determine whether end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation could be used as a prognostic indicator of resuscitation and survival. Thirty-five cardiac arrests in 34 patients were monitored with capnometry during cardiopulmonary resuscitation during a 1-year period. Nine patients who were successfully resuscitated had higher average end-tidal carbon dioxide partial pressures during cardiopulmonary resuscitation than 26 patients who could not be resuscitated (15 +/- 4 vs 7 +/- 5 mm Hg). The 3 patients who survived to leave the hospital had a higher average end-tidal carbon dioxide partial pressure than the 32 nonsurvivors (17 +/- 6 vs 8 +/- 5 mm Hg). All 9 patients who were successfully resuscitated had an average end-tidal carbon dioxide partial pressure of 10 mm Hg or greater. No patient with an average end-tidal carbon dioxide partial pressure of less than 10 mm Hg was resuscitated. Data from this prospective clinical trial indicate that findings from end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation are correlated with resuscitation from and survival of cardiac arrest.
The Emergency Cardiac Care (ECC) Committee of the American Heart Association first published guid... more The Emergency Cardiac Care (ECC) Committee of the American Heart Association first published guidelines for cardiopulmonary resuscitation (CPR) and ECC in 1974.1 Updated in 1980, 1986, and 1992, the AHA guidelines are now recognized as the world’s most authoritative resuscitation guidelines.2 3 4 To implement these guidelines, however, hospitals need to establish a systems approach to in-hospital resuscitation rather than depend on the skills of individual professionals. The success and acceptance of the out-of-hospital Utstein-style recommendations5 led the AHA to help develop specific recommendations for documenting in-hospital resuscitation. The Utstein-style recommendations for uniform reporting of in-hospital resuscitations present important recommendations for all hospital facilities.6 With publication of these recommendations, members of the ECC Committee recognized the need to summarize the major actions that enable a hospital to fulfill the resuscitation recommendations. CPR is one of the few interventions that requires an order to not be administered. Resuscitation efforts, however, are not appropriate for all hospital patients. When indicated, healthcare providers discuss with patients, families, and surrogate decision-makers their options and preferences for resuscitation. Hospitals have in place clear policies that address medical futility, patient self-determination, and do-not-attempt-resuscitation orders. The chain of survival, first conceptualized for out-of-hospital sudden cardiac arrest,7 applies to in-hospital arrest as well.8 …
Out-of hospital cardiac arrest accounts for more than 330,000 deaths annually in the United State... more Out-of hospital cardiac arrest accounts for more than 330,000 deaths annually in the United States and Canada. Despite regular updates of guidelines for the management of these arrests, the rate of survival has been stagnant at 7.6% for more than 30 years.1,2 In this issue of the Journal, the Resuscitation Outcomes Consortium reports the results of two randomized comparisons3,4 from the Prehospital Resuscitation Impedance Valve and Early Versus Delayed Analysis (ROC PRIMED) trial (ClinicalTrials.gov number, NCT00394706), which evaluated potential improvements in the management of out-of hospital cardiac arrest. The first component of the ROC PRIMED trial compared two . . .
Background: Bystander CPR is provided in ~25% of out of hospital cardiac arrests in the US. To im... more Background: Bystander CPR is provided in ~25% of out of hospital cardiac arrests in the US. To improve this low rate, the Save Hearts in Arizona Registry & Education program has initiated a multifaceted, statewide public chest compression only (CCO) CPR education campaign. It is unclear whether a statewide CCO-CPR campaign changes the intention of bystanders to perform CPR. It’s further unknown if this initiative affects willingness in populations with lowest survival and CPR performance. Objective: Evaluate the willingness to perform CPR, in various income demographics, following a statewide CPR intervention. Methods: Adult Arizona residents were surveyed at an academic medical center regarding performing CPR. They were asked their attitudes and feelings concerning performing CPR on strangers and family. Demographics were collected including age, gender, education, race and zip code which was used to incorporate census data for median income (separated as quartiles). Inclusion criteria were Arizona residents, age >18, and missing < 10% of survey data. CPR training was defined as CCO or formal CPR training. Results: Total of 1302 surveys were collected with a final population of 1163. Mean age was 40 yo (95% CI: 38.8, 40.5) with 44% males (95% CI: 41, 47). Willingness to perform CCO-CPR on strangers or family was high at 84% and 92%, respectively. However, when evaluated against median income, individuals in the lower income quartiles were less likely to perform CPR compared to higher quartiles for both strangers (77%; 95% CI 73, 82; P = 0.003) and family (90%; 95% CI 87, 94; P = 0.025). In these lower quartiles, a third as many individuals received training in CPR compared to the higher quartiles (p <0.001). Logistic regression analysis is being completed to evaluate this association in relation to race, education and other confounders. Conclusion: Public CPR interventions are effective in improving the willingness of bystanders to perform CPR. It is possible that CCO initiatives are not reaching the lowest quartile income populations which often have the lowest bystander CPR rates and highest mortality. Future CPR initiatives should be tailored to populations with highest mortality and who may not currently be receiving standard teaching initiatives.
Patients who are successfully resuscitated following cardiac arrest often have a significant medi... more Patients who are successfully resuscitated following cardiac arrest often have a significant medical condition termed postresuscitation disease. This includes myocardial stunning, metabolic abnormalities and neurologic injury from global ischemia. There are no clinical signs or diagnostic tests for 24-72 h to distinguish patients who will and will not recover neurologic function. Therapeutic hypothermia had been advocated for decades as a treatment to improve neurologic outcome after cardiac arrest. The early studies focused on moderate hypothermia, which was associated with complications and was not clearly beneficial. Over the past decade, studies have focused on mild hypothermia with target temperatures of 32-34 degrees C. Two recent multicentered, randomized, controlled trials have demonstrated improved neurologic outcome with mild therapeutic hypothermia applied to comatose survivors after cardiac arrest compared with a normothermic control group. As a result of these studies the International Liaison Committee on Resuscitation recommends that &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;Unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32 degrees C to 34 degrees C for 12 to 24 hours when the initial rhythm was ventricular fibrillation&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;. Mild therapeutic hypothermia should also be considered for patients with in-hospital arrest and asystole and pulseless electrical activity who are comatose after return of spontaneous circulation.
The effectiveness of ongoing cardiopulmonary resuscitation efforts is difficult to evaluate. Rece... more The effectiveness of ongoing cardiopulmonary resuscitation efforts is difficult to evaluate. Recent studies suggest that carbon dioxide excretion may be a useful noninvasive indicator of resuscitation from cardiac arrest. A prospective clinical study was done to determine whether end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation could be used as a prognostic indicator of resuscitation and survival. Thirty-five cardiac arrests in 34 patients were monitored with capnometry during cardiopulmonary resuscitation during a 1-year period. Nine patients who were successfully resuscitated had higher average end-tidal carbon dioxide partial pressures during cardiopulmonary resuscitation than 26 patients who could not be resuscitated (15 +/- 4 vs 7 +/- 5 mm Hg). The 3 patients who survived to leave the hospital had a higher average end-tidal carbon dioxide partial pressure than the 32 nonsurvivors (17 +/- 6 vs 8 +/- 5 mm Hg). All 9 patients who were successfully resuscitated had an average end-tidal carbon dioxide partial pressure of 10 mm Hg or greater. No patient with an average end-tidal carbon dioxide partial pressure of less than 10 mm Hg was resuscitated. Data from this prospective clinical trial indicate that findings from end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation are correlated with resuscitation from and survival of cardiac arrest.
Emergency medicine is a specially often confronted with ultimate crises; patients frequently pres... more Emergency medicine is a specially often confronted with ultimate crises; patients frequently present near death or in cardiac arrest. At the time of cardiopulmonary arrest, the emergency physician mobilizes all available resources to attempt to resuscitate the patient. This struggle is itself challenging. In addition, medical crises may raise difficult moral questions. A conflict is present when the resuscitation team questions whether the attempted resuscitations is warranted
The effectiveness of ongoing cardiopulmonary resuscitation efforts is difficult to evaluate. Rece... more The effectiveness of ongoing cardiopulmonary resuscitation efforts is difficult to evaluate. Recent studies suggest that carbon dioxide excretion may be a useful noninvasive indicator of resuscitation from cardiac arrest. A prospective clinical study was done to determine whether end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation could be used as a prognostic indicator of resuscitation and survival. Thirty-five cardiac arrests in 34 patients were monitored with capnometry during cardiopulmonary resuscitation during a 1-year period. Nine patients who were successfully resuscitated had higher average end-tidal carbon dioxide partial pressures during cardiopulmonary resuscitation than 26 patients who could not be resuscitated (15 +/- 4 vs 7 +/- 5 mm Hg). The 3 patients who survived to leave the hospital had a higher average end-tidal carbon dioxide partial pressure than the 32 nonsurvivors (17 +/- 6 vs 8 +/- 5 mm Hg). All 9 patients who were successfully resuscitated had an average end-tidal carbon dioxide partial pressure of 10 mm Hg or greater. No patient with an average end-tidal carbon dioxide partial pressure of less than 10 mm Hg was resuscitated. Data from this prospective clinical trial indicate that findings from end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation are correlated with resuscitation from and survival of cardiac arrest.
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