Emergency

Survival rates for cardiac arrests that occur in hospitals and outside them continue to be low (17% and 6%, respectively), and fewer than one-third of patients who have an out-of-hospital cardiac arrest receive cardiopulmonary resuscitation (CPR). Consequently, a number of changes were made to the 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. The changes were intended to simplify CPR in order to increase its use and effectiveness by both clinicians and nonprofessionals. This article summarizes the primary changes to the recommendations, including a universal 30-to-2 compression-to-ventilation ratio for all lone rescuers, the need for compressions of sufficient depth and number, and the replacement of the three-shock model of initial defibrillation with one that recommends a single shock, now seen as an adequate precursor to CPR.

Clarifying the AHA guidelines for CPR and defibrillation

The American Heart Association's (AHA) newest Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care include sub stantial changes, and hospitals will need to modify processes and equipment to implement them. This article clarifies the new guidelines and describes the rationale behind each change. Also, it describes the steps that leading defibrillator suppliers are taking to make their products comply. In some cases, these product changes will require hospitals to install software-based upgrades or modify product configurations.

Increase in rapid defibrillation programmes after publication of guidelines

OBJECTIVE

. To monitor the implementation of in-hospital resuscitation strategies including (i) rapid defibrillation programmes, (ii) the use of amiodarone for prolonged ventricular fibrillation, and (iii) uniform data collection on resuscitation, all recommended by international guidelines published in 2000 and by Finnish national resuscitation guidelines published in 2002.

DESIGN

In 2004, a questionnaire was sent to the chief anaesthesiologists. The results were compared with those of a previous study performed using similar methods in 2000.

SETTING

All public hospitals that provide anaesthetic services in Finland.

MAIN OUTCOME MEASURES

Number of hospitals allowing nurses to perform defibrillation without the presence of physician and number of hospitals using amiodarone as primary antiarrhythmic drug in resuscitation and performing uniform data collection.

RESULTS

The response rate was 95% (52/55). The proportion of the hospitals with rapid defibrillation programmes on general wards had increased from 15% in 2000 to 67% in 2004, and most (79%) hospitals had obtained automated external defibrillators. Amiodarone was used in 88% of the hospitals. Data collection of resuscitation attempts using definitions provided in the Utstein guidelines was performed only in 22% of the hospitals.

CONCLUSIONS

Rapid defibrillation programmes have markedly increased, and the use of amiodarone has been established in Finnish hospitals since the publication of the international and the national resuscitation guidelines.

Cardiac Arrests in Skilled Nursing Facilities: Continuing Room for Improvement?

OBJECTIVES

To characterize the care received by skilled nursing facility (SNF/NF) patients suffering cardiac arrest and to evaluate the outcome of SNF/NF patients experiencing cardiac arrest.

DESIGN

A retrospective analysis of an existing cardiac arrest registry to characterize SNF/NF cardiac arrest patients and to compare them to community-dwelling cardiac arrest patients was performed.

SETTING

The study took place in Rochester, NY, an urban city in upstate New York with approximately 220,000 residents.

PARTICIPANTS

All patients for whom emergency medical services (EMS) assistance was requested via the 911 system and who were treated for cardiac arrest between January 1998 and December 2001 were included.

MEASUREMENTS

Demographic characteristics such as age, gender, race; clinical characteristics and interventions such as cardiopulmonary resuscitation (CPR), defibrillation, initial cardiac rhythm, and call response interval; outcomes measures such as return of spontaneous circulation and 1-year survival were obtained.

RESULTS

Forty-two (8%) of cardiac arrest patients resided in an SNF/NF. Sixteen (38%) of the events were witnessed arrests. Only 28 (67%) patients received CPR and none were defibrillated prior to EMS arrival. One (2%) patient was alive 1 year after the event, a survival rate similar to the community-dwelling population (5%).

CONCLUSION

SNF/NF patients suffering cardiac arrest often did not receive CPR or defibrillation while awaiting EMS arrival. SNF/NF patients suffering cardiac arrest have a very low survival rate, similar to the community-dwelling population. The impact of not providing CPR and defibrillation on the survival rate is unclear, but needs to be evaluated prior to any decisions regarding the medical futility of resuscitating SNF/NF patients.

Cardiopulmonary resuscitation algorithms, defibrillation and optimized ventilation during resuscitation

PURPOSE OF REVIEW

In 2005, the American Heart Association released its Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. This article reviews the treatment algorithms for Advanced Cardiac Life Support, citing the evidence on which the Guidelines are based. Additional focus is placed on defibrillation and optimized ventilation.

RECENT FINDINGS

Major changes include a reorganization of the algorithms for cardiac arrest. Emphasis on effective cardiopulmonary resuscitation is placed as the key to improved survival. Single defibrillation shocks are recommended (compared with three 'stacked' shocks) with immediate provision of cardiopulmonary resuscitation and minimal interruptions in chest compressions. The recommended chest compression : ventilation rate for single rescuers has been changed to 30:2.

SUMMARY

Despite advances in resuscitation science, basic life support remains the key to improving survival outcomes. Ultimately, as new knowledge is gained, we believe resuscitation therapies will be more individualized, on the basis of pathophysiology and etiology of the initial cardiac arrest.

Serum troponin I level after external electrical direct current synchronized cardioversion in patients with normal or reduced ejection fraction: no evidence of myocytes injury

BACKGROUND

External electrical cardioversion (EEC) has been suggested as a cause of myocardial damage, but results from several previously published studies are conflicting.

HYPOTHESIS

The purpose of the study was to evaluate myocardial electrical injury caused by EEC.

METHODS

After elective EEC for atrial fibrillation (AF), cardiac troponin I (cTnI) was measured in 193 consecutive patients attending the Cardiology Department of the San Maurizio Hospital of Bolzano for elective EEC of AF over a period of 13 months. External electrical cardioversion was performed by one of the attending cardiologists with a synchronized monophasic defibrillator. Blood sample for cTnI was taken 18-20 h after EEC.

RESULTS

Of 193 patients, 183 (95%) were successfully cardioverted. Mean number of shocks was 1.46 and the mean total energy discharged per procedure was 379.4 +/- 229.2 J. Cardiac troponin remained under the limit of confidence for all patients with a mean value of 0.017 +/- 0.021 mcrg/l. No correlation between total energy delivered and cTnI was found. In the subgroup of patients with low ejection fraction, none had elevated cTnI, and no difference in cTnI values between these and patients with an ejection fraction > 40% was found.

CONCLUSIONS

The results of our analysis indicate that EEC caused no myocardial injury even in patients with low ejection fraction.

An overview of the new resuscitation guidelines

New resuscitation guidelines contain significant changes intended to improve resuscitation practice and survival from cardiac arrest. The guidelines also include helpful new sections with guidance on in-hospital resuscitation. This article provides an overview of the key changes and discusses their practice implications for nurses.

Intraoperative Comparison of a Subthreshold Test Pulse with the Standard High-Energy Shock Approach for the Measurement of Defibrillation Lead Impedance

There are two methods to measure shocking lead impedance: delivery of high-energy shocks that require patient sedation, and the painless measurement of impedance from subthreshold test pulses. The aim of this study was to compare the two methods.

METHODS

The study included 131 patients implanted with a standard DR (n = 71) or VR (n = 60) ICD connected to either single-coil (n = 39) or dual-coil (n = 92) defibrillation leads. The noninvasive high-energy impedance test was done using a 17 J shock after induction of ventricular tachyarrhythmias and compared to a 0.4 microJ test pulse used by the ICD for the subthreshold measurements.

RESULTS

Defibrillation lead impedance measurements were not significantly different between patients with the same shocking vector configuration. In patients with a single-coil defibrillation lead the impedance was 62 +/- 9 Omega with the high-energy shock and 62 +/- 8 Omega with the subthreshold test pulses (P = 0.13). Patients with a dual-coil configuration recorded average impedances of 40 +/- 5 Omega from both tests (P = 0.44). While there was no difference in values recorded within each lead configuration, there was a significant difference in impedance between the single-coil and the dual-coil patient groups (P = 0.001).

CONCLUSIONS

There was no significant difference between shocking lead impedances measured with the high-energy shock or the subthreshold test pulses. This offers the possibility of noninvasive, low-energy serial measurements of shocking lead impedance at follow-up visits and removing the need for sedation.

Prospective assessment of integrating the existing emergency medical system with automated external defibrillators fully operated by volunteers and laypersons for out-of-hospital cardiac arrest: the Brescia Early Defibrillation Study (BEDS)

AIMS

There are few data on the outcomes of cardiac arrest (CA) victims when the defibrillation capability of broad rural and urban territories is fully operated by volunteers and laypersons.

METHODS AND RESULTS

In this study, we investigated whether a programme based on diffuse deployment of automated external defibrillators (AEDs) operated by 2186 trained volunteers and laypersons across the County of Brescia, Italy (area: 4826 km(2); population: 1 112 628), would safely and effectively impact the current survival among victims of out-of-hospital CA. Forty-nine AEDs were added to the former emergency medical system that uses manual EDs in the emergency department of 10 county hospitals and in five medically equipped ambulances. The primary endpoint was survival free of neurological impairment at 1-year follow-up. Data were analysed in 692 victims before and in 702 victims after the deployment of the AEDs. Survival increased from 0.9% (95% CI 0.4-1.8%) in the historical cohort to 3.0% (95% CI 1.7-4.3%) (P=0.0015), despite similar intervals from dispatch to arrival at the site of collapse [median (quartile range): 7 (4) min vs. 6 (6) min]. Increase of survival was noted both in the urban [from 1.4% (95% CI 0.4-3.4 %) to 4.0% (95% CI 2.0-6.9 %), P=0.024] and in the rural territory [from 0.5% (95% CI 0.1-1.6%) to 2.5% (95% CI 1.3-4.2%), P=0.013]. The additional costs per quality-adjusted life year saved amounted to euro39 388 (95% CI euro16 731-49 329) during the start-up phase of the study and to euro23 661 (95% CI euro10 327-35 528) at steady state.

CONCLUSION

Diffuse implementation of AEDs fully operated by trained volunteers and laypersons within a broad and unselected environment proved safe and was associated with a significantly higher long-term survival of CA victims.