Updated AHA Basic and Advanced Cardiac Life Support guidance with COVID-19 considerations

ABSTRACT

The American Heart Association released an updated Basic and Advanced Cardiac Life Support guidance that incorporates the latest knowledge regarding COVID-19 and its transmissibility. This article details the new guidance, including strategies for reducing provider risk and exposure and for special patient-care situations.

Pregnancy With Cardiac Arrest in the Emergency Department: Case Report With Review of Literature

Cardiac arrest in pregnancy is an uncommon encounter, with the incidence being one in every 12,000 hospital admissions for delivery. Here we present, one such patient and our experience in managing the patient. A 23-year-old, third-trimester pregnant female presented with a history of polytrauma following a road traffic accident. On initial assessment, she was in cardiac arrest. We initiated high-quality cardio-pulmonary resuscitation (CPR) as per advanced cardiac life support (ACLS) protocol. We also performed a perimortem cesarean section within four minutes of cardiac arrest. A male baby was delivered who did not have any signs of life. Neonatal resuscitation was initiated. However, both the mother and the child could not be revived. Cardiac arrest in pregnancy is a unique scenario in resuscitation, and all emergency physicians should know the key highlights in managing such patients. We review some existing literature and pose some queries that are yet to be answered.

The Impact of Advanced Cardiac Life Support Simulation Training on Medical Student Self-reported Outcomes

Introduction: Simulation has become a well-recognized and innovative tool in medical education. While there has been tremendous growth of simulation curricula at the level of graduate medical education, there have been few studies looking at simulation as a learning tool for undergraduate medical education. The goal of this study was to determine if high-fidelity simulation training impacts medical student perception of knowledge and confidence regarding comprehension and application of advanced cardiac life support (ACLS) algorithms.

Methods: This is a prospective observational survey study of third and fourth year medical students who participated in an ACLS simulation training during their emergency medicine rotation between January 2018 and October 2018. Cases covered several ACLS topics including unstable bradycardia, supraventricular tachycardia and ventricular tachycardia. After each session, students received a short survey to assess their simulation experience pertaining to knowledge and comfort levels with ACLS topics before and after the simulation experience.

Results: A total of 89 students were included in the study with 86.5% of those being fourth year students. There was a significant increase in both knowledge (pre-training 3.17 vs. 4.11 post-training, p<0.001) and comfort scores (pre-training 2.54 vs. 3.74 post-training, p<0.001) after the ACLS simulation training. Overall, 77.5% of students reported an increase in knowledge and 83.1% reported an increase in confidence after the training session. 

Conclusions: The study revealed a statistically significant increase in both perceived knowledge and comfort and confidence of medical students after high-fidelity simulation using ACLS scenarios.

Does Point-of-care Ultrasound Use Impact Resuscitation Length, Rates of Intervention, and Clinical Outcomes During Cardiac Arrest? A Study from the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Investigators

Introduction

This third study in the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) series examined potential relationships between point-of-care ultrasound (PoCUS) use and the length of resuscitation, the frequency of interventions, and clinical outcomes during cardiac arrest.

Methods

A health records review was completed for adult patients (>19 years, without a do not resuscitate (DNR) order) who presented to a tertiary emergency department in cardiac arrest between 2010 and 2014. Patients were grouped based on PoCUS use and findings for cardiac activity. Data were analyzed for length of resuscitation, frequency of interventions, return of spontaneous circulation (ROSC), survival to hospital admission (SHA), and survival to hospital discharge (SHD).

Results

Of the 223 patients who met inclusion criteria, 180 (80.7%) received assessment by PoCUS during cardiac arrest management in the emergency department (ED). In the PoCUS group, 21 (11.6%) demonstrated cardiac activity and 159 (88.4%) did not. Patients with activity on PoCUS had longer mean resuscitation times (27.3; 95% confidence interval 17.7-37.0 min) than patients with no activity (11.51; 10.2-12.8 min) and patients who did not receive a PoCUS exam (14.36; 9.89-18.8 min). Patients with cardiac activity on PoCUS were more likely to receive endotracheal intubation (ET; 95.23%; 86.13-104.35%) and epinephrine (Epi; 100%; 100-100%) than patients with no activity (ET: 46.54%; 38.8-54.3%; Epi: 82.39%; 76.50-88.31%) and those with no PoCUS (ET: 65.11%; 50.87-79.36%; Epi: 81.39%; 69.76-93.03%). Those with no cardiac activity on PoCUS were much less likely to achieve ROSC (19.5%; 13.4-25.6), SHA (6.9%; 2.97-10.86%) and SHD (0.6%; -0.5-1.8%) compared to those with cardiac activity on PoCUS (ROSC; 76.19%; 57.97-94.4%), SHA (33.3%; 13.2-53.5%), SHD (9.5%; -3-22.07%), and those with no PoCUS (ROSC 39.5%; 24.9-54.1%; SHA 27.9%; 14.5- 41.3%, and SHD 6.9%; -0.6-14.59).

Conclusions

Emergency department cardiac arrest patients with cardiac activity on PoCUS received longer resuscitation with higher rates of intervention as compared to those with negative findings or when no PoCUS was performed. Patients with cardiac activity on PoCUS had improved clinical outcomes as compared with patients not receiving PoCUS, and patients with no activity on PoCUS.

Beyond Advanced Cardiac Life Support: Dual-sequential Defibrillation for Refractory Ventricular Fibrillation after Witnessed Cardiac Arrest in the Emergency Department

Refractory ventricular fibrillation is a rare condition seen in both in-hospital and out-of-hospital cardiac arrest. A 56-year-old male was identified to have refractory ventricular fibrillation after an in-hospital cardiac arrest with multiple unsuccessful standard defibrillation attempts that was converted with dual-sequential defibrillation (DSD) to normal sinus rhythm. Advanced cardiac life support (ACLS) is the most widely used algorithmic treatment approach for various cardiopulmonary emergencies but has yet to provide recommendations for the treatment of refractory ventricular fibrillation. DSD may be a viable treatment strategy for refractory ventricular fibrillation when ACLS recommendations are ineffective.

Comparing the Results of Written Testing for Advanced Cardiac Life Support Teaching Using Team-based Learning and the "Flipped Classroom" Strategy

Objectives

We sought to further determine whether cognitive test results changed for advanced cardiac life support (ACLS) taught in the team-based learning/flipped classroom format (TBL/FC) versus a lecture-based (LB) control.

Methods

We delivered 2010 ACLS to two classes of fourth-year medical students in the TBL/FC format (2015–2016), compared to three classes in the LB format (2012–2014). There were 27.5 hours of instruction for the TBL/FC model (TBL - 10.5 hours, podcasts - nine hours, small-group simulation - eight hours), and 20 hours (lectures - 12 hours, simulation - eight hours) in LB. We taught TBL for 13 cardiac cases while LB had none. Didactic content and seven simulated cases were the same in lecture (2012–2014) or in podcast formats (2015–2016). Testing was the same using 50 multiple-choice (MC) format questions, 20 rhythm-matching questions, and seven fill-in management of simulated cases.

Results

Some 468 students enrolled in the course 259 (55.4%) in the LB format in 2012–2014, and 209 (44.6%) in the TBL/FC format in 2015–2016. The scores for two out of three tests (MC and fill-in) increased with TBL/FC. Combined, median scores increased from 93.5% (IQR 90.6, 95.4) to 95.1% (92.5, 96.8, p = 0.0001). More students did not pass one of three tests with LB versus TBL/FC (24.7% versus 18.2%), and two or three parts of the test (8.1% versus 4.3%, p = 0.01). On the contrary, 77.5% passed all three with TBL/FC versus 67.2% with LB (change 10.3%, 95% CI 2.2%–18.2%).

Conclusion

TBL/FC teaching for ACLS improved written test results compared with the LB format.

Validation of a detailed scoring checklist for use during advanced cardiac life support certification

INTRODUCTION

Defining valid, reliable, defensible, and generalizable standards for the evaluation of learner performance is a key issue in assessing both baseline competence and mastery in medical education. However, before setting these standards of performance, the reliability of the scores yielding from a grading tool must be assessed. Accordingly, the purpose of this study was to assess the reliability of scores generated from a set of grading checklists used by nonexpert raters during simulations of American Heart Association (AHA) Megacodes.

METHODS

The reliability of scores generated from a detailed set of checklists, when used by 4 nonexpert raters, was tested by grading team leader performance in 8 Megacode scenarios. Videos of the scenarios were reviewed and rated by trained faculty facilitators and a group of nonexpert raters. The videos were reviewed "continuously" and "with pauses." The grading made by 2 content experts served as the reference standard, and 4 nonexpert raters were used to test the reliability of the checklists.

RESULTS

Our results demonstrate that nonexpert raters are able to produce reliable grades when using the checklists under consideration, demonstrating excellent intrarater reliability and agreement with a reference standard. The results also demonstrate that nonexpert raters can be trained in the proper use of the checklist in a short amount of time, with no discernible learning curve thereafter. Finally, our results show that a single trained rater can achieve reliable scores of team leader performance during AHA Megacodes when using our checklist in a continuous mode because measures of agreement in total scoring were very strong [Lin's (Biometrics 1989;45:255-268) concordance correlation coefficient, 0.96; intraclass correlation coefficient, 0.97].

CONCLUSIONS

We have shown that our checklists can yield reliable scores, are appropriate for use by nonexpert raters, and are able to be used during continuous assessment of team leader performance during the review of a simulated Megacode. This checklist may be more appropriate for use by advanced cardiac life support instructors during Megacode assessments than the current tools provided by the AHA.