In-hospital cardiac arrest

An audit of in-hospital cardiopulmonary resuscitation in a teaching hospital in Saudi Arabia: A retrospective study

OBJECTIVES

Data reflecting cardiopulmonary resuscitation (CPR) efforts in Saudi Arabia are limited. In this study, we analyzed the characteristics, and estimated the outcome, of in-hospital CPR in a teaching hospital in Saudi Arabia over 4 years.

METHODS

A retrospective, observational study was conducted between January 2009 and December 2012 and included 4361 patients with sudden cardiopulmonary arrest. Resuscitation forms were reviewed. Demographic data, resuscitation characteristics, and survival outcomes were recorded.

RESULTS

The mean ± standard deviation age of arrested patient was 40 ± 31 years. The immediate survival rate was 64%, 43% at 24 h, and 30% at discharge. The death rate was 70%. Respiratory type of arrest, time and place of arrest, short duration of arrest, witnessed arrest, the use of epinephrine and atropine boluses, and shockable arrhythmias were associated with higher 24-h survival rates. A low survival rate was found among patients with cardiac types of arrest, and those with a longer duration of arrest, pulseless electrical activity, and asystole. Comorbidities were present in 3786 patients with cardiac arrest and contributed to a poor survival rate (P < 0.001).

CONCLUSIONS

The study confirms the findings of previously published studies in highly developed countries and provides some reflection on the practice of resuscitation in Saudi Arabia.

Cardiac Arrest in Pregnancy

This is the first scientific statement from the American Heart Association on maternal resuscitation. This document will provide readers with up-to-date and comprehensive information, guidelines, and recommendations for all aspects of maternal resuscitation. Maternal resuscitation is an acute event that involves many subspecialties and allied health providers; this document will be relevant to all healthcare providers who are involved in resuscitation and specifically maternal resuscitation.

The early minutes of in-hospital cardiac arrest: shock or CPR? A population based prospective study

Objectives

In the early minutes of cardiac arrest, timing of defibrillation and cardiopulmonary resuscitation during the basic life support phase (BLS CPR) is debated. Aims of this study were to provide in-hospital incidence and outcome data, and to investigate the relation between outcome and time from collapse to defibrillation, time to BLS CPR, and CPR quality.

Methods

Resuscitation attempts during a 3-year period at St. Olav's University Hospital (960 beds) were prospectively registered. The times between collapse and initiation of BLS CPR, and defibrillation were determined. CPR quality was assessed by the resuscitation team. The relation between these variables and outcome (short term survival and discharge) was explored using non-parametric correlation and logistic regression.

Results

CPR was started in a total of 223 arrests, an incidence of 77 episodes per 1000 beds per year. Return of spontaneous circulation occurred in 40%, and 29 patients (13%) survived to discharge. Median time from collapse to BLS CPR was 1 minute; CPR was judged to be of good quality in half of the episodes. CPR during the first 3 minutes in ventricular fibrillation (VF/VT) was negatively associated with survival, but later proved beneficial. For patients with non-shockable rhythms, we found no association between outcome and time to BLS or CPR quality.

Conclusion

Our findings indicate that defibrillation should have priority during the first 3 minutes of VF/VT. Later, patients benefit from CPR in conjunction with defibrillation. Patients presenting with non-shockable rhythms have a grave prognosis, and the outcome was not associated with time to BLS or CPR quality.

In-hospital cardiac arrest is associated with use of non-antiarrhythmic QTc-prolonging drugs

AIMS

QTc interval-prolonging drugs have been linked to cardiac arrhythmias, cardiac arrest and sudden death. In this study we aimed to quantify the risk of cardiac arrest associated with the use of non-antiarrhythmic QTc-prolonging drugs in an academic hospital setting.

METHODS

We performed a case-control study in which patients, for whom intervention of the advanced life support resuscitation team was requested for cardiac arrest between 1995 and 2003 in the Academic Medical Centre, Amsterdam, were compared with controls regarding current use of non-antiarrhythmic QTc-prolonging drugs. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using unconditional logistic regression, adjusting for potential confounding factors.

RESULTS

A statistically significant increased risk of cardiac arrest (OR 2.1, 95% CI 1.2, 3.5) was observed in patients who received QTc-prolonging drugs (42/140). The risk was more pronounced in patients receiving doses > 1 defined daily dose (OR 2.5, 95% CI 1.1, 5.9), patients taking > 1 QTc-prolonging drug simultaneously (OR 4.8, 95% CI 1.6, 14) and patients taking pharmacokinetic interacting drugs concomitantly (OR 4.0, 95% CI 1.2, 13).

CONCLUSIONS

Use of non-antiarrhythmic QTc-prolonging drugs in hospitalized patients with several underlying disease is associated with an increased risk of cardiac arrest. The effect is dose related and pharmacokinetic drug-drug interactions increase the risk substantially. Physicians caring for inpatients should be made aware of the fact that these non-antiarrhythmic drugs may be hazardous, so that potential risks can be weighed against treatment benefits and additional cardiac surveillance can be requested, if necessary.

A decade of in-hospital resuscitation: outcomes and prediction of survival?

OBJECTIVE

To provide survival rates and associated factors from a 10-year study of in-hospital cardiopulmonary resuscitation (CPR).

DESIGN

Longitudinal prospective case register study of all adult in-hospital CPR attempts conducted from April 1993 to March 2003.

SETTING

1200-bed general hospital in Plymouth (UK).

PATIENTS

2121 adult in-hospital CPR attempts in Derriford Hospital, Plymouth during the period April 1993-March 2003.

MAIN OUTCOME MEASURES

Immediate, 24 h, hospital discharge and 12 month survival rates.

RESULTS

Following CPR the immediate survival rate (95% confidence interval (C.I.)) was 38.6% (36.5, 40.7), then 24.7% (22.8, 26.6) at 24 h, 15.9% (14.4, 17.6) at discharge and 11.3% (10.0, 12.7) at 12 months. The primary arrhythmia, age, duration of arrest and time of arrest were strongly related to survival at 24 h and discharge. There were very low survival rates for pulse-less electrical activity (PEA) and asystole compared to VT/VF arrests; survival rates were highest for those less than 60 years and decreased with increasing age. The longer the resuscitation the less the survival, and those who arrested at night were less likely to survive. The primary arrest, respiratory or cardiac, was also independently associated with survival at 24 h but not with hospital discharge. Sex and the commencement of basic life support (BLS) within 3 min was not an independent predictor of survival.

CONCLUSION

The findings of this study show resuscitation survival rates from a 10-year study and indicate some of the key predictors of survival.

Hospital-wide first-responder automated external defibrillator programme: 1 year experience

The first year experience with a hospital-wide first-responder automated external defibrillator (AED) programme implemented in a 683-bed University Hospital is reported. Throughout the hospital, 14 "AED access spots" were identified which could be easily reached from all wards and diagnostic rooms within 30s. AEDs were installed (Lifepak 500; Medtronik PhysioControl Corp., Redmond, USA, equipped with a Biolog 3000i portable ECG monitor; Micromedical Industries Ltd., Labrador, Australia). Within 3 months, 120 medical officers, 750 nurses, and 50 administrative or technical staff underwent a 2h training programme. An AED was applied and activated by nurses/medical staff before the cardiac arrest team arrived in 27 of 33 cases (81.8%) of witnessed cardiac arrest. The median time from onset of the emergency call to the activation of the AED (record of ECG) was on average 2.1 min (range 1.0--4.5 min). In 18 of 27 cases in which the AED was installed promptly, the primary arrest rhythm was either VT or VF, and the AED delivered a shock. For this subgroup, the rate of return of spontaneous circulation and the rate of discharge at home were 88.9 and 55.6%, respectively. This encourages us to extend the concept of first-responder AED-defibrillation throughout our hospital.

A program encouraging early defibrillation results in improved in-hospital resuscitation efficacy

OBJECTIVES

The purpose of this study was to determine whether survival to discharge after in-hospital cardiopulmonary arrest could be improved by a program encouraging early defibrillation that included switching from monophasic to biphasic devices.

BACKGROUND

In-hospital resuscitation continues to have a low success rate. Biphasic waveform devices have demonstrated characteristics that might improve survival, and outside the hospital, automated external defibrillators (AEDs) have shown promise in improving survival of patients suffering cardiopulmonary arrest.

METHODS

A program including education and replacement of all manual monophasic defibrillators with a combination of manual biphasic defibrillators used in AED mode and AEDs in all outpatient clinics and chronic care units was implemented.

RESULTS

With program implementation, the percentage survival of all patients with resuscitation events improved 2.6-fold, from 4.9% to 12.8%. Factors independently predicting survival included event location outside an intensive care unit, younger age, an initial rhythm of pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF), pre-arrest beta-blocker, and program initiation. The outcome was independent of gender, race, work shift, number of previous resuscitation attempts, body mass index, comorbidity index, presence of diabetes, presence of hypertension, or use of angiotensin-converting enzyme inhibitors. The improvement in mortality was attributable solely to an effect on patients presenting with VT/VF. Patients with these initial rhythms were 14-fold (odds ratio = 0.07 of death, confidence interval = 0.02 to 0.3) more likely to survive to discharge after program initiation. Automated external defibrillators performed similarly to biphasic manual defibrillators in AED mode.

CONCLUSIONS

A program including education and use of biphasic manual defibrillators in AED mode and selective use of AEDs improved survival to discharge in hospitalized patients suffering from cardiopulmonary arrest.

Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation

The National Registry of Cardiopulmonary Resuscitation (NRCPR) is an American Heart Association (AHA)-sponsored, prospective, multisite, observational study of in-hospital resuscitation. The NRCPR is currently the largest registry of its kind. The purpose of this article is to describe the NRCPR and to provide the first comprehensive, Utstein-based, standardized characterization of in-hospital resuscitation in the United States. All adult (>/=18 years of age) and pediatric (<18 years of age) patients, visitors, employees, and staff within a facility (including ambulatory care areas) who experience a resuscitation event are eligible for inclusion in the NRCPR database. Between January 1, 2000, and June 30, 2002, 14720 cardiac arrests that met inclusion criteria occurred in adults at the 207 participating hospitals. An organized emergency team is available 24 h a day, 7 days a week in 86% of participating institutions. The three most common reasons for cardiac arrest in adults were (1) cardiac arrhythmia, (2) acute respiratory insufficiency, and (3) hypotension. Overall, 44% of adult in-hospital cardiac arrest victims had a return of spontaneous circulation (ROSC); 17% survived to hospital discharge. Despite the fact that a primary arrhythmia was one of the precipitating events in nearly one half of adult cardiac arrests, ventricular fibrillation (VF) was the initial pulseless rhythm in only 16% of in-hospital cardiac arrest victims. ROSC occurred in 58% of VF cases, yielding a survival-to-hospital discharge rate of 34% in this subset of patients. An automated external defibrillator was used to provide initial defibrillation in only 1.4% of patients whose initial cardiac arrest rhythm was VF. Neurological outcome in discharged survivors was generally good. Eighty-six percent of patients with Cerebral Performance Category-1 (CPC-1) at the time of hospital admission had a postarrest CPC-1 at the time of hospital discharge.

Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital

AIMS

To determine the incidence of avoidable cardiac arrest among patients who had received resuscitation in a district general hospital. To establish how location and individual or system factors influence avoidable cardiac arrest in order to develop an evidence-based preventive strategy.

METHODS

Expert panel review of case-notes from 139 consecutive adult in-hospital cardiac arrests over 1 year.

RESULTS

There were 32,348 adult admissions in 1999 with 1,023 deaths. The cardiac arrest team was activated 139 times: 118 were for primary in-hospital cardiac arrest. The cardiac arrest rate excluding 'do not attempt resuscitation' (DNAR) cases was 3.8/1000 admissions. In 88.5% of deaths there was a DNAR policy. Survival to hospital discharge following resuscitation was 14%. Among the 118 cases, the panel unanimously agreed that 61.9% of arrests were potentially avoidable, rising to 68% when emergency department arrests were excluded (66 and 73% for majority opinion). Cardiac arrests were more likely at the weekend than during the week (P = 0.02). The odds of potentially avoidable cardiac arrest was 5.1 times greater for patients in general wards than critical care areas (P < 0.001); patients in critical care areas were more likely to survive (P < 0.001). The odds of potentially avoidable cardiac arrest was 12.6 times greater for patients nursed in a clinical area judged 'inappropriate' for their main complaint (P < 0.002, Fisher's exact test) compared to those nursed in 'appropriate' areas. The panel agreed that 100% of potentially avoidable arrests were judged to have received inadequate prior treatment. Clinical signs of deterioration in the preceding 24 h were not acted upon in 48%, and review was confined to a house officer in 45%.

CONCLUSION

The majority of treated in-hospital cardiac arrests are potentially avoidable. Multiple system failures include delays and errors in diagnosis, inadequate interpretation of investigations, incomplete treatment, inexperienced doctors and management in inappropriate clinical areas.

Should ward nurses be using automatic external defibrillators as first responders to improve the outcome from cardiac arrest? A systematic review of the primary research

INTRODUCTION

The outcome from in-hospital cardiac arrest has improved little since the implementation of cardiopulmonary resuscitation 40 years ago. Early defibrillation improves survival following ventricular fibrillation and pulseless ventricular tachycardia. The emergence of automatic external defibrillators and advisory defibrillators has been heralded as the answer to defibrillation delays in-hospital.

AIM

To locate and evaluate the evidence supporting automatic external defibrillator use in-hospital on general wards.

METHOD

A systematic review of indexed and grey literature to identify primary research.

RESULTS

Fifteen in-hospital automatic external defibrillator studies were located, five met the inclusion criteria.

CONCLUSIONS

There is limited primary research evaluating automatic external defibrillators in-hospital. Manual defibrillators remain the most commonly used device for in-hospital defibrillation. Automated external defibrillators offer an alternative to manual defibrillation providing they have a screen and manual override capability, and the technology for pacing is close to hand. For in-hospital automatic external defibrillator programmes to be effective a change in nursing philosophy must occur, and defibrillation must become an expected rather than an extended nursing role.

The evolutionary process of Medical Emergency Team (MET) implementation: reduction in unanticipated ICU transfers

OBJECTIVE

To determine whether the introduction of the Medical Emergency Team (MET) system designed to provide immediate help for seriously ill patients: (i) changed the pattern of ICU patient transfers from the wards; and (ii) improved hospital survival rates.

METHODS

Prospective information on MET calls and unanticipated ICU transfers was collected for 3 years in a suburban metropolitan hospital.

RESULTS

A 3-year review of MET showed the number of MET calls doubled in the second and third year and the team was activated for more than just the most extremely ill patients. Whilst the frequency of calls for cardiopulmonary arrest remained constant (n = 16), increased use of the MET resulted in the proportion of calls for cardiopulmonary arrest dropping from 30% in year 1 to 13% in year 3. A slight decrease in the percentage of in-hospital deaths (0.74% in year 1 to 0.65% in year 3) was also demonstrated. The incidence of cardiopulmonary arrest per hospital admission also decreased slightly (0.08-0.07%). Although the overall number of ICU transfers remained constant, more seriously ill patients were transferred to ICU via the MET system. This was accompanied by a significant fall in unanticipated ICU transfers. Whilst the reduction in hospital deaths was encouraging, this study could not demonstrate whether the slight improvement in hospital survival rate over the 3 years was due to the MET system.

CONCLUSION

More information is needed to demonstrate that the MET system improves patient survival. The study also highlights the importance of taking proactive measures, which should include providing in-service education on the benefits of early identification and treatment of patients who are at risk of acute deterioration, raising awareness and changing attitudes in hospitals when introducing system such as the MET.

In-hospital resuscitation: association between ACLS training and survival to discharge

CONTEXT

No data have been published on the relationship between advanced cardiac life support (ACLS) training of the individual who initiates resuscitation efforts and survival to discharge.

OBJECTIVE

To determine whether patients whose arrests were discovered by nurses trained in ACLS had survival rates different from those discovered by nurses not trained in ACLS.

DESIGN

Cohort case-comparison.

SETTING

A 550-bed, tertiary care center in central Georgia.

SUBJECTS

Patients whose cardiopulmonary arrest was discovered by a nurse who activated the in-hospital resuscitation mechanism.

MAIN OUTCOME MEASURE

Patient survival to discharge.

RESULTS

Initial rhythm was strongly related to survival to discharge and individually associated with 57% of the variability in survival. Nurse's training in advanced cardiac life support was also strongly related to survival and individually associated with 29% of the variability. Combining both the variables determined 62% of the variability in survival to discharge. Patients discovered by an ACLS-trained nurse (n=88) were about four times more likely to survive (33 survivors, 38%) than were patients, discovered by a nurse without training in ACLS (n=29, three survivors, 10%).

CONCLUSION

Arrest discovery by nurses trained in ACLS is significantly and dramatically associated with higher survival-to-discharge rates.

Does advanced age matter in outcomes after out-of-hospital cardiac arrest in community-dwelling adults?

OBJECTIVE

To assess whether advanced age is an independent predictor of survival to hospital discharge in community-dwelling adult patients who sustained an out-of-hospital cardiac arrest in a suburban county.

METHODS

A prospective cohort study was conducted in a suburban county emergency medical services system of community-dwelling adults who had an arrest from a presumed cardiac cause and who received out-of-hospital resuscitative efforts from July 1989 to December 1993. The cohorts were defined by grouping ages by decade: 19-39, 40-49, 50-59, 60-69, 70-79, and 80 or more. The variables measured included age, gender, witnessed arrest, response intervals, location of arrest, documented bystander cardiopulmonary resuscitation, and initial rhythms. The primary outcome was survival to hospital discharge. Results are reported using analysis of variance, chi square, and adjusted odds ratios from a logistic regression model. Age group 50-59 served as the reference group for the regression model.

RESULTS

Of the 2,608 total presumed cardiac arrests, the overall survival rate to hospital discharge was 7.25%. Patients in age groups 40-49 and 50-59 experienced the best rate of successful resuscitation (10%). Each subsequent decade had a steady decline in successful outcome: 8.1% for ages 60-69; 7.1% for ages 70-79; and 3.3% for age 80+. In a post-hoc analysis, further separation of the older age group revealed a successful outcome in 3.9% of patients ages 80-89 and 1% in patients 90 and older. Patients aged 80 years or more were more likely to arrest at home, were more likely to have an initial bradyasystolic rhythm, yet had a similar rate of resuscitation to hospital admission. In the regression model, age 80 or older was associated with a significantly worse survival to hospital discharge (OR = 0.4, 95% CI = 0.20 to 0.82).

CONCLUSIONS

There was a twofold decrease in survival following out-of-hospital cardiac arrest to discharge in patients aged 80 or more when compared with the reference group in this suburban county setting. However, resuscitation for community-dwelling elders aged 65-89 is not futile. These data support that out-of-hospital resuscitation of elders up to age 90 years is not associated with a universal dismal outcome.

Inhospital cardiac arrest: pre-event variables and nursing response

This retrospective study examined the medical records of 100 patients who experienced an in-hospital cardiopulmonary arrest. The purposes of this study were to identify pre-arrest physiologic changes that may have occurred in the patient and to determine whether physician notification time, physiologic variables, patient location, and the presence of an electrocardiogram (ECG) monitor before the arrest affected the resuscitation outcome. The results showed that assessment variances were present in most patients before the arrest and also were recognized by the nursing staff. Implications for practice include formation of quality improvement screening tools to assess the patient's pre-arrest status, development of competency tests that include scenarios involving changes in a patient's physiologic parameters, staff education, and evaluation of current nursing policies for obtaining vital signs and assessments.

Managing the unstable patient. The first 10 minutes often set the course

Some patients die shortly after the onset of an acute illness, despite the best of care. However, a well-led well-organized approach during the first 10 minutes of care can greatly improve the chances of survival and minimize subsequent morbidity. Early treatment should emphasize proper airway management, adequate intravenous access, and a thoughtful approach to the use of medications.

The in-hospital Utstein style: use in reporting outcome from cardiac arrest in Middlemore Hospital 1995-1996

The in-hospital Utstein Style was published in April 1997. This new format is used to present the outcome of in-hospital cardiac arrest in Middlemore Hospital, Auckland, NZ, between June 1995 and June 1996. The in-hospital Utstein Style was generally easy to follow, but there were several areas where adjustments may be of benefit. The study shows that there were 140 true arrest calls during this period, with 133 attempted resuscitations. Forty-seven patients had ROSC greater than 24 h, 35 were discharged alive and 30 were alive at 1 year. Of these 30 survivors, 27 had a Cerebral Performance Category of 1.

Response to cardiac arrests in a hospital setting: delays in ventilation

The outcome following a cardiac arrest is affected by the length of time that elapses before cardiopulmonary resuscitation is initiated. Only 10-15% of patients experiencing cardiac arrest in hospital settings survive to discharge. Therefore, the time between cardiac arrest and administration of cardiopulmonary resuscitation in a metropolitan hospital was examined. All cardiac and respiratory arrests that occurred in the adult non-intensive care areas of a medical center over a period of 16 months were evaluated within 12 h to determine how much time had elapsed before resuscitation was initiated, the devices utilized for initial airway management, and the outcome. To initiate ventilation, bag-valve-masks (BVMs) were used in the majority (76%) of the efforts to resuscitate while mouth-to-mask resuscitation was performed in another 18%; however, in only 37% of the codes was ventilation initiated within 1 min and in 18% ventilation was started after 3 min. Mouth-to-mask resuscitation resulted in more rapid time to onset of ventilation than BVM. In only 18% of the arrests studied was a 'lay-on' mask available in the room and utilized. In 11%, a bag-valve-mask was at the patient's bedside, and in 53% a BVM was taken from the crash cart outside the room. In 63% of the cases where using a lay-on mask was appropriate, it was either not looked for or not present in the patient's room. Also in 37% of the cases where a BVM was needed, one was not readily present because of difficulty in locating the crash cart immediately. Although initiation of cardiopulmonary resuscitation within a minute of a cardiac or respiratory arrest is the standard of care, in the non-intensive care in-patient cases surveyed, typically more than a minute elapsed, and frequently 3 or more minutes, before resuscitation was started. If the time elapsing before an arresting in-patient is ventilated can be shortened, which is easily and effectively achieved by mouth-to-mouth or mouth-to-mask resuscitation, an increase in both the survival rate and the number of good neurological outcomes should be expected.

Automatic external defibrillators in the hospital as well?

When a cardiac arrest occurs in a non-intensive area of the hospital, the emergency response is not always adequate from the point of view of timeliness and technical quality. The aims of this study were evaluate an experimental programme to improve the CPR skills of staff operating in non-intensive areas of our general hospital and to test the usefulness of placing automatic external defibrillators (AEDs) within these areas. In the experimental phase, two AEDs were placed in 2 non-intensive wards of our hospital for 8 months. The staff of these wards received specific training in CPR and early defibrillation (CPR-D). The devices were used in 19 cases; for defibrillation in four cases of ventricular fibrillation (VF) (three patients were discharged alive from hospital), and for monitoring three supraventricular arrhythmias, one bradyarrhythmia and 11 cardiac rhythms during critical situations. In the implementation phase, four AEDs were indefinitely assigned to as many non-intensive awards. Periodical CPR-D courses and refresher exercises were run; the cardiology staff co-operated in the maintenance of the AEDs and in the registration of technical and clinical data. In the first period of this phase (9 months), AEDs were utilized in 24 cases by the ward-staff: in nine cases for VF (three patients were discharged alive from hospital) and in 15 cases for other rhythm detection in critical conditions. The number and the quality of these uses seem to confirm the favourable impact of the adoption of a more user-friendly defibrillator, such as an AED. The active co-operation between intensive and non-intensive staff was important to facilitate a quick activation of the chain of survival outside the intensive care units. We conclude that AEDs, which were developed for out-of-hospital use by non-physician operators, are suitable for use inside the hospital as well.

Outcome of in-hospital cardiac arrests in a tertiary care facility

This study evaluates the outcome of cardiac arrest in adults at King Faisal Specialist Hospital and Research Centre during 1993. A comparison has been made with other in-hospital cardiac arrest outcome studies. This hospital is a tertiary care center with emphasis on high-risk cases referred for cancer treatment and organ transplantation. It also has a large cardiovascular division. The overall figures compare well with other studies; however, a breakdown of cardiac arrests by location indicates a poor "survival to discharge" rate in those patients outside of the cardiovascular division. It is suggested that a more selective approach be made to attempted resuscitation in certain groups of patients.

The reluctance of house staff to perform mouth-to-mouth resuscitation in the inpatient setting: what are the considerations?

OBJECTIVE

Medical house staff are required to perform cardiopulmonary resuscitation (CPR) as part of their job responsibilities. Previously it has been shown that house staff are reluctant to perform mouth-to-mouth resuscitation (MMR) in an out of hospital setting. Therefore, whether reluctance to perform MMR extends to the inpatient setting, and, if so, the reasons for this reluctance were investigated.

DESIGN

All 74 internal medicine house officers of a large metropolitan hospital responded to presentations of hypothetical inpatient cardiac arrest scenarios to assess their willingness to perform MMR.

SETTING

A 1200 bed university-affiliated teaching hospital in Los Angeles, California.

SUBJECTS

All categorical internal medicine house officers at this hospital.

INTERVENTIONS

This study is a survey which concerns whether the house officer would perform mouth-to-mouth resuscitation in different hypothetical cardiac arrest scenarios.

RESULTS

Forty-five percent would perform MMR on an unknown patient and 39% would perform MMR in the elderly patient scenario. Only 16% would do MMR on a patient with a small amount of blood on his lips and only 7% would perform MMR on a patient with presumed acquired immunodeficiency syndrome. Medical housestaff were much more reluctant to perform MMR on elderly, trauma, or presumed immunodeficient patients in an inpatient setting than in an outpatient setting. All house staff that indicated their unwillingness to perform MMR cited fear of human immunodeficiency virus infection as their reason.

CONCLUSION

Medical housestaff are quite reluctant to perform MMR in an inpatient setting. Thus, educating the medical house staff about the percent of patients that survive inpatient cardiac arrest and the actual risks of contracting infectious diseases, especially HIV infections, from MMR and preventative measures, such as effective barrier masks, should result in an increased willingness of physicians to perform MMR or mouth-to-mask ventilation on inpatients.

The biphasic mechanism of blood flow during cardiopulmonary resuscitation: a physiologic comparison of active compression-decompression and high-impulse manual external cardiac massage

STUDY OBJECTIVE

Dismal survival in patients receiving standard manual CPR provided the rationale for the investigation of alternate methods of closed-chest circulatory support. Active compression-decompression (ACD) and high-impulse CPR are alternatives to standard manual CPR. This study was designed to test the hypothesis that ACD CPR provides superior cardiopulmonary hemodynamics due to an active decompression phase when compared with high-impulse manual CPR.

PARTICIPANTS

Hemodynamics were studied during ACD and high-impulse CPR in eight adult beagles.

DESIGN

Four animals were chronically instrumented and four were studied acutely. In an additional four animals, ACD was compared with sham ACD CPR. Each CPR technique was performed sequentially for 2 minutes, in random order, at a rate of 120, 50% duty cycle, and 1.5 to 2.0 in of compression depth. Measurements obtained included aortic, right atrial, left ventricular, and coronary perfusion pressures (in mm Hg); pulmonary artery flow, and left ventricular dimension.

RESULTS

ACD maximized cardiopulmonary hemodynamics, including coronary perfusion pressure and stroke volume, compared with both high-impulse manual and sham ACD CPR. ACD CPR also increased left ventricular pressure change per unit time during decompression, and these changes correlated well with left ventricular volume changes.

CONCLUSION

In the intact dog, ACD CPR generates physiologically and statistically superior hemodynamics when compared with high-impulse manual CPR. Improved blood flow seems to be related to more efficient ventricular filling and emptying. These findings emphasize the biphasic nature of CPR and the importance of active decompression.

Clinical and laboratory investigations of active compression-decompression cardiopulmonary resuscitation

Based upon an anecdotal report of successful resuscitation using a toilet plunger, Cohen and co-workers have developed and investigated a hand-held suction cup as an adjunct to standard manual CPR. This new method, called active compression-decompression cardiopulmonary resuscitation, utilizes a device which is placed over the mid-sternum, approximately 1-2 inches above the lower rib cage border. Active compression-decompression cardiopulmonary resuscitation is then performed in accordance with American Heart Association guidelines at a rate equal to 80-100/min using a 50% duty cycle and compression depth of 1.5-2.0 inches. Initial studies using the ACD device in both models and human subjects late after cardiac arrest have demonstrated improved cardiopulmonary hemodynamics when compared to standard manual CPR. Transophageal echocardiographic studies in human subjects have shown increased left ventricular filling during active decompression suggesting that active chest decompression improves venous return to the heart thus increasing left ventricular volume and stroke volume. Improved resuscitation success has also been documented in human subjects after in-hospital and pre-hospital cardiac arrest. Active compression-decompression cardiopulmonary resuscitation is a simple method which utilizes a hand held suction cup as an interface between rescuer and victim during closed chest circulatory support. This method allows for standard manual cardiopulmonary resuscitation with the addition of active chest wall decompression and appears to be a beneficial adjunct to standard manual cardiopulmonary resuscitation.

Differences in case definitions as a cause of variation in reported in-hospital CPR survival

To determine the effect of different case definitions on reported survival following in-hospital cardiopulmonary arrest, the authors reviewed the charts of 411 patients for whom a nurse completed a cardiac arrest form at a university hospital during a two-year period. Survival to discharge was 16.0% for patients who required basic cardiopulmonary resuscitation (chest compression and pulmonary ventilation), 18.6% for patients who were pulseless and apneic, 23.0% for patients who were pulseless or apneic, and 28.2% for all 411 patients for whom a cardiac arrest form was completed. These results demonstrate that reported survival to discharge following in-hospital cardiac arrest varies widely depending on the case definition that is used.

The Utstein style for uniform reporting of data from out-of-hospital cardiac arrest

The Utstein style for uniform reporting of data from out-of-hospital cardiac arrest was developed to solve a major problem in resuscitation research. Outcome measures related to cardiac arrest are difficult to evaluate or compare because there have been no uniform definitions or uniform agreements on what data to report. Widespread acceptance of the Utstein style will lead to a better understanding of out-of-hospital cardiac arrest.