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Out-of-hospital cardiac arrest (OHCA), with its high fatality rate, is a significant public health issue. The aetiology of OHCA is reviewed, and management strategies are discussed, including the "chain of survival", the Utstein method of data collection, and recent developments in advanced cardiac life support emphasising defibrillation.
PURPOSE: To review the electropharmacology, clinical applications, side effects, and hemodynamic profile of intravenous amiodarone. DATA SOURCES: The MEDLINE database was searched for English-language material, including reports of clinical trials and in vivo studies, review articles, and abstracts presented at national symposia, that was published between 1985 and 1996. Bibliographies of textbooks and articles were also examined. STUDY SELECTION: Studies that reported on the efficacy, toxicity, and hemodynamic profile of intravenous amiodarone and studies that examined the pharmacologic behavior of intravenous amiodarone in laboratory models were reviewed. DATA EXTRACTION: Study design and quality and relevant data on efficacy of suppression and treatment of arrhythmias with oral and intravenous amiodarone therapy, the reported mechanisms of antiarrhythmic effect, and hemodynamic changes seen with therapy were analyzed. DATA SYNTHESIS: Amiodarone is a unique antiarrhythmic agent that is now available in oral and intravenous forms in the United States. The use of intravenous amiodarone in the short-term treatment of life-threatening or hemodynamically unstable rhythm disturbances has generated much interest. Amiodarone has many electropharmacologic actions, some of which differ between the oral and intravenous forms. The wide clinical application of amiodarone includes treatment and prevention of supraventricular and ventricular arrhythmias and arrhythmias related to myocardial infarction. Intravenous amiodarone is effective for supraventricular and ventricular arrhythmias that are resistant to other antiarrhythmic agents. The effectiveness of intravenous amiodarone as short-term treatment also suggests that the drug has an important role in protocols of advanced cardiac life support. Intravenous amiodarone seems to have an overall favorable hemodynamic profile and does not produce many of the unwanted long-term side effects associated with oral therapy. CONCLUSION: Intravenous amiodarone shows much promise for the short-term treatment of unstable arrhythmias. Its favorable hemodynamic effects and minimal short-term side effects make it an attractive option in the management of cardiac arrhythmias.
UNLABELLED: Lectures and demonstrations have been the teaching and testing strategies most often employed by the American Heart Association in Advanced Cardiac Life Support (ACLS) training. I compared the abilities of interactive videodisc (IVD) courseware and ACLS instructors to evaluate airway management skills. METHODS & MATERIALS: Twenty-two subjects were simultaneously tested during 30 attempts at endotracheal (ET) intubation and 34 attempts at esophageal obturator airway or esophageal gastric tube airway (EOA/EGTA) insertion. The instructors were blind to the visual and auditory messages produced. RESULTS: The IVD program and the ACLS instructors showed high agreement in their evaluation of student performance for time of intubation (95.5% ET; 100% EOA/EGTA), proper tube placement (91% ET; 93% EOA/EGTA), appropriate tube assessment (95.5% ET; 100% EOA/EGTA), and correct EOA/EGTA cuff inflation (100%). Lower levels of agreement were noted with ET and EOA/EGTA appropriate head positioning, and the evaluation of tooth pressure with ET intubation (60.5%, 76.5%, and 66.0%, respectively). The IVD system was unable to detect certain procedural errors associated with appropriate intubation procedure--syringe attachment, syringe removal after cuff inflation, and control of tube after intubation. The low agreement for tooth pressure suggests that the sensor-equipped manikin may better evaluate tooth pressure than does the observer. CONCLUSIONS: Although the IVD system shows promise as an adjunct method for instruction and testing, it cannot be considered suitable for 'stand-alone' instruction. Further research is needed to explore costs, skills retention, and possible impact of the medium for training hospital and prehospital-care personnel.
UNLABELLED: Our Respiratory Care Services Department provides an endotracheal intubation service that responds to all intubation requests. Intubation is performed by registered respiratory therapists who complete an 8-hour training program, advanced cardiac life support (ACLS) training and certification, and clinical performance of intubation with supervision. The goals of this service are (1) to provide competent persons for performing this service, (2) to assure a rapid response time, and (3) to be cost-effective. EVALUATION METHODS: A retrospective analysis of our service was conducted over a 1-year period (7/90 to 6/91), and calculations were made of the intubation success rate and complication rate. RESULTS: Of the 833 total intubations, 791 were successfully performed by respiratory care practitioners; 730 of those successful intubations (92.3%) were accomplished in fewer than 3 attempts. Recognized complications occurred in 96 intubations (12.1%) and included oral bleeding, vomiting, and short periods of oxygen desaturation. In the 5.1% (42) of the patients not intubated by our service, 22 required heavy sedation, and an anesthesiologist was consulted; 17 patients were intubated by other physicians; and 3 tracheotomies were performed. Multiple intubation attempts were a result of secretions, induced bradycardia, blade-light malfunction, damaged cuff, and esophageal intubations. CONCLUSION: Respiratory Care Services can provide an effective intubation service. Cost savings were realized by centralizing equipment.
Early, repeated defibrillation is the key to managing ventricular fibrillation (VF). To maximize the likelihood of success, use this five-phase approach, modified from the advanced cardiac life support protocols. Phase I: When a patient is found in VF and with no pulse or signs of life, attempt electrical reversion with a 200-wsec shock, followed if necessary by a 300-wsec and a 360-wsec shock. Phase II: Manage reversible causes of VF with orotracheal intubation, hyperventilation, and epinephrine. Phase III: Use intravenous lidocaine aggressively, followed by a 360-wsec shock. Phase IV: Give bretylium and magnesium sulfate by intravenous push, again followed by a 360-wsec shock. Phase V: Treat refractory VF with repeated 360-wsec shocks, and give further doses of the anti-arrhythmic agents.
Dentists in the state of Illinois who possess a permit to administer sedation or general anesthesia were surveyed. A 71% response rate was achieved. Of the respondents, 86% held permits for deep sedation/general anesthesia and 14% held permits for parenteral conscious sedation. By practice specialty, 84% were oral and maxillofacial surgeons, 11% were general dentists, 5% were periodontists, and fewer than 1% were dental anesthesiologists. Advanced Cardiac Life Support training was possessed by 85% of the respondents. The most common anesthesia team configuration (82%) was a single operator-anesthetist and two additional assistants. Only 4% reported use of a nurse anesthetist, and 2% used an additional MD or DDS anesthesiologist. The vast majority (97%) of the practitioners do not intubate in the office on a routine basis. Supplemental oxygen was used by 81% of the respondents whenever intravenous agents were used. A total of 151,335 anesthetics were administered during the year. One mortality occurred in a patient with an undisclosed pre-existing cardiac condition. Four other events were reported that required medical intervention or hospital evaluation; however, no permanent injuries were reported. Other practice characteristics were described.
BACKGROUND: In an environment characterized by cuts to health care, hospital closures, increasing reliance on home care and an aging population, more terminally ill patients are choosing to die at home. The authors sought to determine the care received by these patients when paramedics were summoned by a 911 call and to document whether do-not-resuscitate (DNR) requests influenced the care given. METHODS: The records of a large urban emergency medical services system were reviewed to identify consecutive patients with cardiac arrest over the 10-month period November 1996 to August 1997. Data were abstracted from paramedics' ambulance call reports according to a standardized template. The proportion of these patients described as having a terminal illness was determined, as was the proportion of terminally ill patients with a DNR request. The resuscitative efforts of paramedics were compared for patients with and without a DNR request. RESULTS: Of the 1534 cardiac arrests, 144 (9.4%) involved patients described as having a terminal illness. The mean age of the patients was 72.2 (standard deviation 14.8) years. Paramedics encountered a DNR request in 90 (62.5%) of these cases. Current regulations governing paramedic practice were not followed in 34 (23.6%) of the cases. There was no difference in the likelihood that cardiopulmonary resuscitation (CPR) would be initiated between patients with and those without a DNR request (73% v. 83%; p = 0.17). In patients for whom CPR was initiated, paramedics were much more likely to withhold full advanced cardiac life support if there was a DNR request than if there was not (22% v. 68%; p < 0.001). INTERPRETATION: Paramedics are frequently called to attend terminally ill patients with cardiac arrest. Current regulations are a source of conflict between the paramedic's duty to treat and the patient's right to limit resuscitative efforts at the time of death.
The authors report a case of percutaneous transluminal coronary angioplasty of the circumflex artery complicated by occlusion of the non-diseased left anterior descending artery by spasm. During advanced cardiac life support, required for the subsequent cardiac arrest, intra-coronary nitrates and calcium antagonists were administered. After 45 minutes, the spasm resolved, but N probably as a result of prolonged blood stasis N a thrombus appeared in the left main artery. While attempting to stent the left main, the thrombus was mechanically dislodged, leaving the epicardial coronary tree free, with a good flow.
Arthroscopic shoulder surgery performed on a healthy female could have resulted in a fatal outcome when the epinephrine present in the arthroscopic irrigating solution contributed to the onset of ventricular tachycardia requiring defibrillation during surgery. During this procedure, the shoulder was infiltrated with 30 mL of a 1:100,000 solution of epinephrine into the subacromial space and glenhumeral joint. Subsequently, instrumentation of the glenhumeral joint by the orthopedic surgeon with a standard arthroscopy trocar resulted in a 0.5-cm size lesion to the posterior humeral cortex. Minutes after the start of the surgical procedure, the patient displayed an abrupt onset of ventricular tachycardia and hypertension. These signs and symptoms suggested an intraosseous infusion of both infiltrated and irrigation solution containing epinephrine through the lesion in the humeral cortex. Approximately 800 mL of a .01 mg/mL concentration of irrigation solution containing epinephrine was used. A diagnosis of epinephrine-induced ventricular tachycardia was made. The arthroscopic irrigating solution was immediately discontinued and lidocaine, 100 mg intravenously, was administered; however, the patient's cardiac rhythm degenerated into a sustained ventricular tachycardia that was unresponsive to pharmacologic intervention. A full code was called; the surgeon, anesthesia team, and operating room personnel succesfully provided advanced cardiac life support and cardioverted the patient back into a sinus rhythm with no untoward effects.
Since most sudden cardiac death victims show neither symptoms before the event nor other signs or risk factors that would have identified them as a high risk population before their cardiac arrest, emergency out-of-hospital medical services must be improved in order to obtain a higher survival in these patients. Early defibrillation is an essential part of the chain of survival that also includes the early identification of the victim, activation of the emergency medical system, immediate arrival of trained personnel who can perform basic cardiopulmonary resuscitation and early initiation of advanced cardiac life support that would raise the survival rate for sudden cardiac arrest victims. Many studies have demonstrated the enormous importance of early defibrillation in patients with a cardiac arrest due to ventricular fibrillation. The most important predictor of survival in these individuals is the time that elapses until electric defibrillation, the longer the time to defbrillation the lower the number of patients who are eventually discharged. Multiple studies have demonstrated that automatic external defibrillation will reduce the time elapsed to defibrillation and thus improve survival. For these reason, public access defibrillation to allow the use of automatic external defibrillators by minimally trained members of the lay public, has received increasing interest on the part of a groving number of companies, cities or countries. The automatic external defibrillaton, as performed by a lay person is being investigated. The liberalization of its application, if is demonstrated to be effective, will need to be accompanied by legal measures to endorse it and appropriate health education, probably during secondary education.
Venous air embolism is the entrapment of air into the venous system producing signs and symptoms due to obstruction of pulmonary arterial blood flow. We present a healthy, 27-year-old, full-term parturient admitted for postdate induction of labor. Cesarean delivery was required following fetal distress. During delivery, the mother became bradycardic and required advanced cardiac life support for resuscitation. Serial hemoglobin values, electrocardiograms, echocardiograms, and a magnetic resonance image of the head were all normal. No fetal squamous cells were found in the patient's blood. She required 6 days of ventilation, was successfully extubated, and was discharged 14 days after the cesarean delivery. The differential diagnosis in this patient's care centered on a pulmonary embolic event. Thromboembolism was unlikely, based upon the patient's rapid clinical improvement without definitive therapy for thrombotic disease or detection of peripheral thrombosis. Amniotic fluid embolus was unlikely, although not excluded, by the absence of fetal cells in the maternal circulation and the lack of an accompanying intravascular coagulopathy. Air embolism may occur in up to 50% of women undergoing cesarean delivery. A lethal embolism may follow a bolus of 3 to 5 mL/kg of air. Chief among the many symptoms of air embolism are tachypnea, chest pain, and gasping. The diagnosis may be facilitated by precordial Doppler monitoring, transesophageal echocardiography, or by the identification of air when aspirating from a right heart catheter. Management includes optimum patient positioning, aspiration of air, discontinuation of nitrous oxide, administration of 100% oxygen, and flooding the surgical site with saline to avoid further air entry. Preventive strategies are also discussed.
The case of an 87-year-old woman with a significant history of coronary artery disease illustrates the challenge associated with intractable ventricular tachycardias, and demonstrates the various options available for terminating and controlling the potentially fatal arrhythmia. A favorable outcome was obtained using advanced cardiac life support guidelines, current pharmacological regimens, ventricular burst pacing with overdrive suppression, intra-aortic balloon counterpulsation, coronary revascularization and implantable cardioverter-defibrillator insertion. These modalities, as well as other therapeutic alternatives, are discussed in the management of incessant ventricular tachycardia.
INTRODUCTION: The International Space Station will need to be as capable as possible in providing Advanced Cardiac Life Support (ACLS) and cardiopulmonary resuscitation (CPR). Previous studies with manikins in parabolic microgravity (0 G) have shown that delivering CPR in microgravity is difficult. End tidal carbon dioxide (PetCO2) has been previously shown to be an effective non-invasive tool for estimating cardiac output during cardiopulmonary resuscitation. Animal models have shown that this diagnostic adjunct can be used as a predictor of survival when PetCO2 values are maintained above 25% of pre-arrest values. METHODS: Eleven anesthetized Yorkshire swine were flown in microgravity during parabolic flight. Physiologic parameters, including PetCO2, were monitored. Standard ACLS protocols were used to resuscitate these models after chemical induction of cardiac arrest. Chest compressions were administered using conventional body positioning with waist restraint and unconventional vertical-inverted body positioning. RESULTS: PetCO2 values were maintained above 25% of both 1-G and O-G pre-arrest values in the microgravity environment (33% +/- 3 and 41 +/- 3). No significant difference between 1-G CPR and O-G CPR was found in these animal models. Effective CPR was delivered in both body positions although conventional body positioning was found to be quickly fatiguing as compared with the vertical-inverted. CONCLUSIONS: Cardiopulmonary resuscitation can be effectively administered in microgravity (0 G). Validation of this model has demonstrated that PetCO2 levels were maintained above a level previously reported to be predictive of survival. The unconventional vertical-inverted position provided effective CPR and was less fatiguing as compared with the conventional body position with waist restraints.
Amiodarone use in the United States is increasing including a role in advanced cardiac life support protocols. There has been a significant increase in hypothyroidism, destructive thyroiditis (type II), and iodine-induced thyrotoxicosis (type I) with amiodarone. Preexisting thyroid disease and status of iodine intake can determine the nature of iodine-induced thyroid disease. Treating amiodarone-induced thyrotoxicosis (AIT) may include traditional antithyroid agents, glucocorticoids, and surgery. Usually, it is assumed the radioactive iodine uptake (RAIU) will be low, and this choice as a treatment modality is excluded at the initial visit. We report a satisfactory outcome in a patient with AIT using radioactive iodine. The role of radioactive iodine in treating AIT is reviewed
BACKGROUND: In Japanese local hospitals there are not many persons who can give speedy and exact medical treatment in emergency. We investigated a role of anesthesiologists in the education of cardiopulmonary resuscitation (CPR) in local hospitals. METHODS: A total of 3 doctors and 30 nurses completed the questionnaire about the education of CPR after training of advanced cardiac life support (ACLS) in a local hospital. RESULTS: It showed that all doctors and nurses have had some anxiety about the emergency treatment of patients and could understand the importance of CPR. Moreover, most of them answered that they wanted to learn ACLS more, and that the training of ACLS simulation was the most impressive. CONCLUSIONS: It is important for anesthesiologists to teach ACLS and to promote the spread of ACLS in local hospitals.
Although 40 years have passed since the advent of advanced cardiac life support, out-of-hospital cardiac arrest still carries an ultimate failure rate of 95%. This review reinforces the importance of public education, optimization of the local chain of survival, early bystander access and bystander basic life support, and early defibrillation. It emphasizes the role of simplified basic life support algorithms and demonstrates the low incremental benefit of complex skillful protocols employed in ACLS. The impact of automatic external defibrillators and new medications incorporated into ACLS algorithms is evaluated in the light of contemporary research. The persistent, discouraging, low functional survival rate (less than 5% of out-of-hospital cardiac arrest victims) mandates reassessment of current strategies and guidelines.
BACKGROUND: Although published algorithms and guidelines list epinephrine and vasopressin as either/or choices for treatment of ventricular fibrillation and/or pulseless ventricular tachycardia, little is known about how critical care providers respond to this recommendation. OBJECTIVES: To assess the use of vasopressin as a first-line drug of choice for ventricular fibrillation and/or pulseless ventricular tachycardia and describe factors that may influence decision making for using vasopressin. METHODS: A convenience sample from 4 academic medical centers in the United States was recruited to complete a 20-item survey on demographic factors such as year of last Advanced Cardiac Life Support (ACLS) provider course, specialty certification, predominant practice responsibility, and beliefs related to the use of vasopressin for cardiac arrest. Descriptive statistics, Pearson correlation analysis, and logistic regression were used to analyze the data. RESULTS: A total of 214 critical care providers (80% registered nurses) completed the survey. Year of last ACLS course (r=-0.188, P=.006) was a significant demographic factor, and behavioral beliefs (attitude about using vasopressin) had the strongest relationship (r=0.687, P<.001) and were the best predictor for intentions to use or recommend the use of vasopressin (beta=0.589, P<.001). CONCLUSIONS: Despite the recommendation for vasopressin as an agent equivalent to epinephrine for treatment of ventricular fibrillation and/or pulseless ventricular tachycardia, 63% of respondents used epinephrine as a first-line drug of choice. More research is needed to address the classification system for interpreting the quality of evidence that may influence practice.
The incidence of sudden cardiac death ranges from 0.4 to 1.28 every 1000 inhabitants per year. Sudden cardiac death is responsible for about 10% of all deaths in Italy in 2000. It is unpredictable and is related to malignant ventricular arrhythmias that may be interrupted in more than 70% of cases. Survival rates generally do not exceed 5% in out-of-hospital cardiac arrest, but, as previously reported, early defibrillation may increase survival rate by 3 times. The Italian law of April 3, 2001, and its recent amendments authorized healthcare providers and trained lay rescuers to use automated external defibrillators either for in-hospital or out-of-hospital settings. We planned a program for early defibrillation in ASL 3 in four outpatient clinics where a transit of 300,000 patients was expected in 2004. Defibrillators were placed in wall-mounted boxes. Opening of these boxes enable an automatic calling to the 118 emergency service that is able to dispatch an advanced cardiac life support team to the pertinent outpatient clinic. The system of wall-mounted boxes automatically communicates by modem with a programmable rate, the state of repair and efficiency of the single boxes, in order to simplify the control of the whole system of defibrillators. This plan of Turin ASL 3 is innovative in the metropolitan area and emphasizes the central role of the 118 emergency system in the management of out-of-hospital cardiac arrest, even in hospital settings such as outpatient clinics with a high number of old users at higher risk of cardiac events. This plan with the availability of automatic calling of the 118 emergency service will be proposed to remaining local hospital utilities for their outpatient settings as well as to other public utilities such as general stores, drugstores, airports where a significant transit mat be expected. The plan will include a specific training for the use of automated external defibrillators by first responders.