tthew Huei-Ming Ma

Part 12: Education, Implementation, and Teams 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Cardiac arrest occurs in a wide variety of settings, from the unanticipated event in the out-of-hospital setting to anticipated arrests in the intensive care unit. Outcome from cardiac arrest is a function of many factors including the willingness of bystanders to perform cardiopulmonary resuscitation (CPR), the ability of rescuers to integrate knowledge and psychomotor skills, the quality of performance delivered by individual rescuers and teams, and the efficiency and effectiveness of post–cardiac arrest care. The Chain of Survival is a metaphor used to organize and describe the integrated set of time-sensitive, coordinated actions necessary to maximize survival from cardiac arrest. The use of evidence-based education and implementation strategies can optimize the links of that chain. Strengthening the Chain of Survival in the prehospital setting requires focus on prevention and immediate recognition of cardiac arrest, increasing the likelihood of high-quality bystander CPR and early defibrillation, and improving regional systems of care. In the hospital setting, organized efforts targeting early identification and prevention of deterioration in patients at risk can decrease the incidence of cardiac arrest. The challenge for resuscitation programs is twofold: to ensure that providers acquire and maintain the necessary knowledge, skills, and team behavior to maximize resuscitation outcome; and to assist response systems in developing, implementing, and sustaining an evidence-based Chain of Survival. Maximizing survival from cardiac arrest requires improvement in resuscitation education and the implementation of systems that support the delivery of high-quality resuscitation and postarrest care, including mechanisms to systematically evaluate resuscitation performance. Well-designed resuscitation education can encourage the delivery of high-quality CPR. In addition continuous quality improvement processes should close the feedback loop and narrow the gap between ideal and actual performance. Community- and hospital-based resuscitation programs should systematically monitor cardiac arrests, the level of resuscitation care provided, and outcomes. The cycle of measurement, benchmarking, feedback, …

A systematic review of retention of adult advanced life support knowledge and skills in healthcare providers

OBJECTIVE Advanced life support (ALS) guidelines are widely adopted for healthcare provider training with recommendations for retraining every two years or longer. This systematic review studies the retention of adult ALS knowledge and skills following completion of an ALS course in healthcare providers. METHODS We retrieved original articles using Medline, CINAHL, Cochrane Library, and PubMed, and reviewed reference citations to identify additional studies. We extracted data from included articles using a structured approach and organized outcomes by evaluation method, and knowledge and skills retention. RESULTS Among 336 articles retrieved, 11 papers were included. Most studies used multiple-choice questionnaires to evaluate knowledge retention and cardiac arrest simulation or other skills tests to evaluate skills retention. All studies reported variable rates of knowledge or skills deterioration over time, from 6 weeks to 2 years after training. Two studies noted retention of knowledge at 18 months and up to 2 years, and one reported skills retention at 3 months. Clinical experience, either prior to or after the courses, has a positive impact on retention of knowledge and skills. CONCLUSION There is a lack of large well-designed studies examining the retention of adult ALS knowledge and skills in healthcare providers. The available evidence suggests that ALS knowledge and skills decay by 6 months to 1 year after training and that skills decay faster than knowledge. Additional studies are needed to help provide evidence-based recommendations for assessment of current knowledge and skills and need for refresher training to maximize maintenance of ALS competency.

Improved outcome of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest--a comparison with that for extracorporeal rescue for in-hospital cardiac arrest.

PURPOSE The aim was to investigate the effects of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) and compare the results with those of in-hospital cardiac arrest (IHCA). METHODS We analyzed our extracorporeal membrane oxygenation (ECMO) results for patients who received ECPR for OHCA or IHCA in the last 5 years. Pre-arrest, resuscitation, and post-resuscitative data were evaluated. RESULTS In the last 5 years, ECPR was used 230 times for OHCA (n=31) and IHCA (n=199). The basic demographic data showed significant differences in age, cardiomyopathy, and location of the initial CPR. Duration of ischemia was shorter in the IHCA group (44.4±24.7 min vs. 67.5±30.6 min, p<0.05). About 50% of each group underwent a further intervention to treat the underlying etiology. ECMO was maintained for a shorter duration in the OHCA patients (61±48 h vs. 94±122 h, p<0.05). Survival to discharge was similar in the two groups (38.7% for OHCA vs. 31.2% for IHCA, p>0.05), as was the favorable outcome rate (25.5% for OHCA vs. 25.1% for IHCA, p>0.05). Survival was acceptable (about 33%) in both groups when the duration of ischemia was no longer than 75 min. CONCLUSIONS In addition to having a beneficial effect in IHCA, ECPR can lead to survival and a positive neurological outcome in selected OHCA patients after prolonged resuscitation. Our results suggest that further investigation of the use of ECMO in OHCA is warranted.

Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube placement during emergency intubation

OBJECTIVES This study aimed to assess the diagnostic accuracy and timeliness of using tracheal ultrasound to examine endotracheal tube placement during emergency intubation. METHODS This was a prospective, observational study, conducted at the emergency department of a national university teaching hospital. Patients received emergency intubation because of impending respiratory failure, cardiac arrest, or severe trauma. The tracheal rapid ultrasound exam (T.R.U.E.) was performed during emergency intubation with the transducer placed transversely at the trachea over the suprasternal notch. Quantitative waveform capnography was used as the criterion standard for confirmation of tracheal intubation. The main outcome was the concordance between the T.R.U.E. and the capnography. RESULTS A total of 112 patients were included in the analysis, and 17 (15.2%) had esophageal intubations. The overall accuracy of the T.R.U.E. was 98.2% (95% confidence interval [CI]: 93.7-99.5%). The kappa (κ) value was 0.93 (95% CI: 0.84-1.00), indicating a high degree of agreement between the T.R.U.E. and capnography. The sensitivity, specificity, positive predictive value, and negative predictive value of the T.R.U.E. were 98.9% (95% CI: 94.3-99.8%), 94.1% (95% CI: 73.0-99.0%), 98.9% (95% CI: 94.3-99.8%) and 94.1% (95% CI: 73.0-99.0%). The median operating time of the T.R.U.E. was 9.0s (interquartile range [IQR]: 6.0, 14.0). CONCLUSIONS The application of the T.R.U.E. to examine endotracheal tube placement during emergency intubation is feasible, and can be rapidly performed.

High-Dose vs Non-High-Dose Proton Pump Inhibitors After Endoscopic Treatment in Patients With Bleeding Peptic Ulcer A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND High-dose proton pump inhibitors (PPIs) (80-mg bolus, followed by 8-mg/h continuous infusion for 72 hours) have been widely studied and used. However, to date no concrete evidence has shown that high-dose PPIs are more effective than non-high-dose PPIs. METHODS We performed a literature search for randomized controlled trials that compared the use of high-dose PPIs vs non-high-dose PPIs in patients with bleeding peptic ulcer and determined their effects on rebleeding, surgical intervention, and mortality. Outcomes data were combined in a meta-analysis and were reported as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS A total of 1157 patients from 7 high-quality randomized studies were included in this meta-analysis. High-dose PPIs and non-high-dose PPIs did not differ in their effects on the rates of rebleeding (7 studies and 1157 patients; OR, 1.30; 95% CI, 0.88-1.91), surgical intervention (6 studies and 1052 patients; 1.49; 0.66-3.37), or mortality (6 studies and 1052 patients; 0.89; 0.37-2.13). Post hoc subgroup analyses revealed that summary outcomes measures were unaffected by severity of signs of recent hemorrhage at initial endoscopy, route of PPI administration, or PPI dose. CONCLUSION Compared with non-high-dose PPIs, high-dose PPIs do not further reduce the rates of rebleeding, surgical intervention, or mortality after endoscopic treatment in patients with bleeding peptic ulcer.

Outcomes for out-of-hospital cardiac arrests across 7 countries in Asia: The Pan Asian Resuscitation Outcomes Study (PAROS)

BACKGROUND The Pan Asian Resuscitation Outcomes Study (PAROS) Clinical Research Network (CRN) was established in collaboration with emergency medical services (EMS) agencies and academic centers in Japan, Singapore, South Korea, Malaysia, Taiwan, Thailand, and UAE-Dubai and aims to report out-of-hospital cardiac arrests (OHCA) and provide a better understanding of OHCA trends in Asia. METHODS AND RESULTS This is a prospective, international, multi-center cohort study of OHCA across the Asia-Pacific. Each participating country provided between 1.5 and 2.5 years of data from January 2009 to December 2012. All OHCA cases conveyed by EMS or presenting at emergency departments were captured. 66,780 OHCA cases were submitted to the PAROS CRN; 41,004 cases were presumed cardiac etiology. The mean age OHCA occurred varied from 49.7 to 71.7 years. The proportion of males ranged from 57.9% to 82.7%. Proportion of unwitnessed arrests ranged from 26.4% to 67.9%. Presenting shockable rhythm rates ranged from 4.1% to 19.8%. Bystander cardiopulmonary resuscitation (CPR) rates varied from 10.5% to 40.9%, however <1.0% of these arrests received bystander defibrillation. For arrests that were with cardiac etiology, witnessed arrest and VF, the survival rate to hospital discharge varied from no reported survivors to 31.2%. Overall survival to hospital discharge varied from 0.5% to 8.5%. Survival with good neurological function ranged from 1.6% to 3%. CONCLUSIONS Survival to hospital discharge for Asia varies widely and this may be related to patient and system differences. This implies that survival may be improved with interventions such as increasing bystander CPR, public access defibrillation and improving EMS.

Pan‐Asian Resuscitation Outcomes Study (PAROS): Rationale, Methodology, and Implementation

Disease-based registries can form the basis of comparative research to improve and inform policy for optimizing outcomes, for example, in out-of-hospital cardiac arrest (OHCA). Such registries are often lacking in resource-limited countries and settings. Anecdotally, survival rates for OHCA in Asia are low compared to those in North America or Europe, and a regional registry is needed. The Pan-Asian Resuscitation Outcomes Study (PAROS) network of hospitals was established in 2009 as an international, multicenter, prospective registry of OHCA across the Asia-Pacific region, to date representing a population base of 89 million in nine countries. The networks goal is to provide benchmarking against established registries and to generate best practice protocols for Asian emergency medical services (EMS) systems, to impact community awareness of prehospital emergency care, and ultimately to improve OHCA survival. Data are collected from emergency dispatch, ambulance providers, emergency departments, and in-hospital collaborators using standard protocols. To date (March 2011), there are a total of 9,302 patients in the database. The authors expect to achieve a sample size of 13,500 cases over the next 2 years of data collection. The PAROS network is an example of a low-cost, self-funded model of an Asia-Pacific collaborative research network with potential for international comparisons to inform OHCA policies and practices. The model can be applied across similar resource-limited settings.

Comparison of Emergency Medical Services Systems Across Pan-Asian Countries: A Web-based Survey

Abstract Background. There are great variations in out-of-hospital cardiac arrest (OHCA) survival outcomes among different countries and different emergency medical services (EMS) systems. The impact of different systems and their contribution to enhanced survival are poorly understood. This paper compares the EMS systems of several Asian sites making up the Pan-Asian Resuscitation Outcomes Study (PAROS) network. Some preliminary cardiac arrest outcomes are also reported. Methods. This is a cross-sectional descriptive survey study addressing population demographics, service levels, provider characteristics, system operations, budget and finance, medical direction (leadership), and oversight. Results. Most of the systems are single-tiered. Fire-based EMS systems are predominant. Bangkok and Kuala Lumpur have hospital-based systems. Service level is relatively low, from basic to intermediate in most of the communities. Korea, Japan, Singapore, and Bangkok have intermediate emergency medical technician (EMT) service levels, while Taiwan and Dubai have paramedic service levels. Medical direction and oversight have not been systemically established, except in some communities. Systems are mostly dependent on public funding. We found variations in available resources in terms of ambulances and providers. The number of ambulances is 0.3 to 3.2 per 100,000 population, and most ambulances are basic life support (BLS) vehicles. The number of human resources ranges from 4.0 per 100,000 population in Singapore to 55.7 per 100,000 population in Taipei. Average response times vary between 5.1 minutes (Tainan) and 22.5 minutes (Kuala Lumpur). Conclusion. We found substantial variation in 11 communities across the PAROS EMS systems. This study will provide the foundation for understanding subsequent studies arising from the PAROS effort.

Real-time tracheal ultrasonography for confirmation of endotracheal tube placement during cardiopulmonary resuscitation

OBJECTIVE This study aimed to evaluate the accuracy of tracheal ultrasonography for assessing endotracheal tube position during cardiopulmonary resuscitation (CPR). METHODS We performed a prospective observational study of patients undergoing emergency intubation during CPR. Real-time tracheal ultrasonography was performed during the intubation with the transducer placed transversely just above the suprasternal notch, to assess for endotracheal tube positioning and exclude esophageal intubation. The position of trachea was identified by a hyperechoic air-mucosa (A-M) interface with posterior reverberation artifact (comet-tail artifact). The endotracheal tube position was defined as endotracheal if single A-M interface with comet-tail artifact was observed. Endotracheal tube position was defined as intraesophageal if a second A-M interface appeared, suggesting a false second airway (double tract sign). The gold standard of correct endotracheal intubation was the combination of clinical auscultation and quantitative waveform capnography. The main outcome was the accuracy of tracheal ultrasonography in assessing endotracheal tube position during CPR. RESULTS Among the 89 patients enrolled, 7 (7.8%) had esophageal intubations. The sensitivity, specificity, positive predictive value, and negative predictive value of tracheal ultrasonography were 100% (95% confidence interval [CI]: 94.4-100%), 85.7% (95% CI: 42.0-99.2%), 98.8% (95% CI: 92.5-99.0%) and 100% (95% CI: 54.7-100%), respectively. Positive and negative likelihood ratios were 7.0 (95% CI: 1.1-43.0) and 0.0, respectively. CONCLUSIONS Real-time tracheal ultrasonography is an accurate method for identifying endotracheal tube position during CPR without the need for interruption of chest compression. Tracheal ultrasonography in resuscitation management may serve as a powerful adjunct in trained hands.

Interactive video instruction improves the quality of dispatcher-assisted chest compression-only cardiopulmonary resuscitation in simulated cardiac arrests.

Objective:Bystander cardiopulmonary resuscitation (CPR) significantly improves survival of cardiac arrest victims. Dispatch assistance increases bystander CPR, but the quality of dispatcher-assisted CPR remains unsatisfactory. This study was conducted to assess the effect of adding interactive video communication to dispatch instruction on the quality of bystander chest compressions in simulated cardiac arrests. Design:A randomized controlled study with a scenario developed to simulate cardiac arrest in a public place. Setting:The victim was simulated by a mannequin and the cell phone for dispatch assistance was a video cell phone with both voice and video modes. Chest compression-only CPR instruction was used in the dispatch protocol. Subjects:Ninety-six adults without CPR training within 5 years were recruited. Interventions:The subjects were randomized to receive dispatch assistance on chest compression with either voice instruction alone (voice group, n = 53) or interactive voice and video demonstration and feedback (video group, n = 43) via a video cell phone. Measurements and Main Results:Performance of chest compression-only CPR throughout the scenario was videotaped. The quality of CPR was evaluated by reviewing the videos and mannequin reports. Chest compressions among the video group were faster (median rate 95.5 vs. 63.0 min−1, p < 0.01), deeper (median depth 36.0 vs. 25.0 mm, p < 0.01), and of more appropriate depth (20.0% vs. 0%, p < 0.01). The video group had more “hands-off” time (5.0 vs. 0 second, p < 0.01), longer time to first chest compression (145.0 vs. 116.0 seconds, p < 0.01) and total instruction time (150.0 vs. 121.0 seconds, p < 0.01). Conclusion:The addition of interactive video communication to dispatcher-assisted chest compression-only CPR initially delayed the commencement of chest compressions, but subsequently improved the depth and rate of compressions. The benefit was achieved mainly through real-time feedback.