James Dunford

In patients with out-of-hospital cardiac arrest, does the provision of dispatch cardiopulmonary resuscitation instructions as opposed to no instructions improve outcome: A systematic review of the literature ☆

CONTEXT Early bystander cardiopulmonary resuscitation (CPR) provides an essential bridge to successful defibrillation from sudden cardiac arrest (SCA) and there is a need to increase the prevalence and quality of bystander CPR. Emergency medical dispatchers can give CPR instructions to a bystander calling for an ambulance enabling even an inexperienced bystander to start CPR. The impact of these instructions has not been evaluated. OBJECTIVES To determine if, in adult and pediatric patients with out-of-hospital cardiac arrest, the provision of dispatch CPR instructions as opposed to no instructions improves outcome. METHODS Two independent reviewers used standardized forms and procedures to review papers published between January, 1985 and December, 2009. Findings were peer-reviewed by the International Liaison Committee on Resuscitation. DATA SYNTHESIS We identified 665 citations; five met the inclusion criteria. One retrospective cohort study reported improved survival with dispatch CPR instructions than without it. Three studies, two observational and one with retrospective controls showed trends toward increased survival after dispatcher-assisted CPR was implemented and one showed trend toward decreased survival. There were no randomised studies addressing the topic. No studies addressing dispatch CPR instructions in the pediatric population were found. CONCLUSION There is limited evidence supporting the survival benefit of dispatch-assisted CPR instructions. All studies comparing survival outcomes when CPR is provided with or without the assistance of dispatch-assisted CPR instructions lack the statistical power to draw significant conclusions. Since it has been demonstrated that such instructions can improve bystander CPR rates, it is reasonable to recommend they should be provided to all callers reporting a victim in cardiac arrest.

Resuscitation in the out-of-hospital setting: Medical futility criteria for on-scene pronouncement of death

The complete and irreversible cessation of life is often difficult to determine with complete confidence in the dynamic environment of out-of-hospital emergency care. As a result, resuscitation efforts often are initiated and maintained by emergency medical services (EMS) providers in many hopeless situations. Medical guidelines are reviewed here to aid EMS organizations with respect to decisions about: 1) initiating or waiving resuscitation efforts; 2) the appropriate duration of resuscitation efforts; and 3) recommended procedures for on-scene or prehospital pronouncement of death (termination of resuscitation). In cases of nontraumatic cardiac arrest, few unassailable criteria, other than certain physical signs of irreversible tissue deterioration, exist for determining medical futility at the initial encounter with the patient. Thus, the general medical recommendation is to attempt to resuscitate all patients, adult or child, in the absence of rigor mortis or dependent lividity. Conversely, well-founded guidelines now are available for decisions regarding termination of resuscitation in such patients once they have received a trial of advanced cardiac life support. In practice, however, the final decision to proceed with on-scene pronouncement of death for these patients may be determined more by family and provider comfort levels and the specific on-scene environment. For patients with posttraumatic circulatory arrest, the type of injury (blunt or penetrating), the presence of vital signs, and the electrocardiographic findings are used to determine the futility of initiating or continuing resuscitation efforts. In general, patients who are asystolic on-scene are candidates for on-scene pronouncement, regardless of mechanism. With a few exceptions, blunt trauma patients with a clearly associated mechanism of lethal injury are generally candidates for immediate cessation of efforts once they lose their pulses and respirations. Regardless of the medical futility criteria, specialized training of EMS providers and targeted related testing of operational issues need to precede field implementation of on-scene pronouncement policies. Such policies also must be modified and adapted for local issues and resources. In addition, although the current determinations of medical futility, as delineated here, are important to establish for societal needs, the individual patients right to live must be kept in mind always as new medical advances are developed.

In out-of-hospital cardiac arrest patients, does the description of any specific symptoms to the emergency medical dispatcher improve the accuracy of the diagnosis of cardiac arrest: a systematic review of the literature.

AIM We sought to determine if, in patients with out-of-hospital cardiac arrest (OHCA), the description of any specific symptoms to the emergency medical dispatcher (EMD) improved the accuracy of the diagnosis of cardiac arrest. METHODS For this systematic review, we searched MEDLINE, EMBASE and the Cochrane Library with no restrictions, and hand-searched the gray literature. Eligible studies included dispatcher interaction with callers reporting OHCA, and reported diagnosis of cardiac arrest. Two independent reviewers used standardized forms and procedures to review papers for inclusion, quality, and to extract data from eligible studies. Findings were peer-reviewed by the International Liaison Committee on Resuscitation. RESULTS We identified 494 citations; 74 were selected for full evaluation (kappa=0.70) and 23 were included (kappa=0.68), including six before-after, two case-control, and 15 descriptive studies. One before-after study and ten descriptive studies report that inquiring about consciousness and breathing status can help dispatchers recognize cardiac arrest with moderate sensitivity [ranging from 38% to 97%], and high specificity [ranging from 95% to 99%]. One case-control study, three before-after studies, and four observational studies report that abnormal breathing is a significant barrier to cardiac arrest recognition. One before-after study and two descriptive studies report that seizure activity can be a manifestation of cardiac arrest. CONCLUSION Dispatchers should recognize cardiac arrest when a victim is described as unconscious and not breathing or not breathing normally, and consider cardiac arrest when generalized seizure is described. They should receive specific instructions on how to best recognize the presence of abnormal breathing.

P REHOSPITAL T HERAPY FOR A CUTE C ONGESTIVE H EART F AILURE : S TATE OF THE A RT

Acute congestive heart failure (CHF) is one of the most common syndromes encountered in emergency care settings. Correct diagnosis and treatment for pulmonary edema, the most common acute manifestation of CHF, are of primary importance as misdiagnosis can result in deleterious consequences to patients. The pathogenesis of acute pulmonary edema (APE) is currently believed to arise primarily from the redistribution of intravascular fluid to the lungs secondary to acutely elevated left ventricular (LV) filling pressures. This understanding has provided a basis for the management of acute APE, which entails reduction of LV preload, reduction of LV afterload, ventilatory support, inotropic support as needed, and identification and treatment of other underlying factors contributing to elevated LV filling pressures. The agent most applicable and effective for field treatment is nitroglycerin. Diuretics and morphine should be used with caution, as they carry higher risks, especially in misdiagnosed patients. The role of angiotensin-converting enzyme (ACE) inhibitors has yet to be demonstrated in a prehospital setting. Noninvasive positive pressure ventilation methods are effective adjuncts to current treatment, but their mode of delivery presents technical challenges. The development of novel rapid diagnostic tools, currently in progress, might prove valuable for emergency medical services (EMS) personnel in the future. But for now, EMS personnel must rely on their fundamental skills of history taking and physical examination for accurate diagnosis of CHF.

Performance measurements in emergency medical services

With the strong encouragement of leading health care agencies, business principles are being implemented throughout health care, including emergency medical services (EMS). The reason is simple—quality of care can be enhanced by incorporating the management concepts of continuous quality improvement (CQI). The CQI process couples carefully identified, measurable performance indicators with information systems to monitor, analyze, and trend data. Benchmarking outcomes with other EMS systems allows the identification of “best practices” and the evolution of standards. Emergency medical services professionals must actively participate with the broader health care community in creating performance measurements to ensure that high-quality care is delivered consistently.

Optimal prehospital cardiovascular care

Optimal prehospital cardiovascular care may improve the morbidity and mortality associated with acute myocardial infarctions (AMIs) that begin in the community. Reducing the time delays from AMI symptom onset to intervention begins with maximizing effective patient education to reduce patient delay in recognizing symptoms and seeking assistance. Transportation delays can be minimized by appropriate use of 911 systems and improving technological 911 support. Patient triage to heart centers from the prehospital setting requires strict and comprehensive definition of the criteria for these centers by competent, unbiased clinical societies or governmental agencies. Prehospital 12-lead electrocardiograms and initiation of thrombolytic therapy can provide acute diagnosis and early treatment, thus facilitating faster processing and more directed in-hospital intervention. They also minimize over- and undertriage of patients to cardiac centers. Although evidence from investigational trials suggests that many of these procedures are effective, more research is required to ensure correct implementation and quality assurance at all emergency service levels.

Fatal Ascending Tonic-Clonic Seizure Syndrome

A fatal case of ascending tonic-clonic seizure (ATCS) syndrome resulted from the inadvertent, unrecognized use of a hyperosmolar ionic contrast agent during myelography. The patient presented with lower-extremity myoclonic jerking, agitation, hyperthermia, rhabdomyolysis, and disseminated intravascular coagulation. Emergency physicians must be cognizant of this unique toxidrome to initiate early, aggressive care.

OBTAINING A PRE-HOSPITAL ELECTROCARDIOGRAM BY EMERGENCY MEDICAL PERSONNEL SHORTENS TOTAL ISCHEMIC TIME FOR ST ELEVATION MYOCARDIAL INFARCTION PATIENTS

Results: There were 21,742 patients (62±17 years; 53% male) evaluated for ccCP during the study period. Implementation of PH ECG resulted in no difference in ST (19:50 vs. 19:57 min:sec, p = 0.177, 95% CI -00:03 00:18) or TT (14:01 vs. 14:08 min:sec, p = 0.19, 95% CI -00:04 00:18). In STEMI patients (n = 303), significant decreases in both the ST (93 sec; 18:27 vs. 20:00 min:sec; p < 0.0001; 95% CI 00:46 02:21) and TT (52 sec; 13:18 vs. 14:10 min:sec; p = 0.027; 95% CI 00:06 01:37) were observed (Figure 1), resulting in a reduction of scene to hospital time of 2:24 min:sec (31:47 vs. 34:11; p < 0.0001; 95% CI 01:11 03:37).