Thomas E. Terndrup

Predicting Survival After Out-of-Hospital Cardiac Arrest: Role of the Utstein Data Elements

STUDY OBJECTIVE Survival after out-of-hospital cardiac arrest depends on the links in the chain of survival. The Utstein elements are designed to assess these links and provide the basis for comparing outcomes within and across communities. We assess whether these measures sufficiently predict survival and explain outcome differences. METHODS We used an observational, prospective data collection, case-series of adult persons with nontraumatic out-of-hospital cardiac arrest from December 1, 2005, through March 1, 2007, from the multisite, population-based Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. We used logistic regression, receiver operating curves, and measures of variance to estimate the extent to which the Utstein elements predicted survival to hospital discharge and explained outcome variability overall and between 7 Resuscitation Outcomes Consortium sites. Analyses were conducted for all emergency medical services-treated cardiac arrests and for the subset of bystander-witnessed patient arrests because of presumed cardiac cause presenting with ventricular fibrillation or ventricular tachycardia. RESULTS Survival was 7.8% overall (n=833/10,681) and varied from 4.6% to 14.7% across Resuscitation Outcomes Consortium sites. Among bystander-witnessed ventricular fibrillation or ventricular tachycardia, survival was 22.1% overall (n=323/1459) and varied from 12.5% to 41.0% across sites. The Utstein elements collectively predicted 72% of survival variability among all arrests and 40% of survival variability among bystander-witnessed ventricular fibrillation. The Utstein elements accounted for 43.6% of the between-site survival difference among all arrests and 22.3% of the between-site difference among the bystander-witnessed ventricular fibrillation subset. CONCLUSION The Utstein elements predict survival but account for only a modest portion of outcome variability overall and between Resuscitation Outcomes Consortium sites. The results underscore the need for ongoing investigation to better understand characteristics that influence cardiac arrest survival.

Resuscitation Outcomes Consortium (ROC) PRIMED cardiac arrest trial methods part 1: rationale and methodology for the impedance threshold device (ITD) protocol.

AIM The primary aim of this study is to compare survival to hospital discharge with a modified Rankin score (MRS)< or =3 between standard cardiopulmonary resuscitation (CPR) plus an active impedance threshold device (ITD) versus standard CPR plus a sham ITD in patients with out-of-hospital cardiac arrest. Secondary aims are to compare functional status and depression at discharge and at 3 and 6 months post-discharge in survivors. MATERIALS AND METHODS DESIGN Prospective, double-blind, randomized, controlled, clinical trial. POPULATION Patients with non-traumatic out-of-hospital cardiac arrest treated by emergency medical services (EMS) providers. SETTING EMS systems participating in the Resuscitation Outcomes Consortium. SAMPLE SIZE Based on a one-sided significance level of 0.025, power=0.90, a survival with MRS< or =3 to discharge rate of 5.33% with standard CPR and sham ITD, and two interim analyses, a maximum of 14,742 evaluable patients are needed to detect a 6.69% survival with MRS< or =3 to discharge with standard CPR and active ITD (1.36% absolute survival difference). CONCLUSION If the ITD demonstrates the hypothesized improvement in survival, it is estimated that 2700 deaths from cardiac arrest per year would be averted in North America alone.

Future challenges in preparing for and responding to bioterrorism events

The future success of our preparations for bioterrorism depends on many issues as presented in this article. If these issues are properly addressed, the resulting improvements in bioterrorism preparations will allow us to better deter and mitigate a bioterrorism incident and will also provide us with the added benefit of improvements in early detection, diagnosis, and treatment of natural disease outbreaks. Emergency physicians must take an active leading role in working with the various disciplines to produce a better-prepared community.

An innovative approach to training hospital-based clinicians for bioterrorist attacks

The recent attacks of September 11, 2001, and the subsequent dissemination event of anthrax in the United States demonstrated the necessity for hospitals to initiate bioterrorism education for clinicians. Events such as the release of sarin gas into the Tokyo subway by the Aum Shinrikyo cult provided some insight into how quickly emergency medical personnel may be overwhelmed by causalities of unconventional weapons. Educational interventions to prepare hospital-based practitioners for such disasters must fit among the demands of patient care, administrative duties, and continuing education within specialties. In addition, the priority placed on the topic, confusion about reputable resources to consult, and concerns of funding for preparedness training mandate the need for an authoritative, comprehensive, and easily accessible approach. A pilot project supported in part by the Agency for Healthcare Research and Quality was developed to facilitate streamlining of preparedness efforts through the implementation of interactive screen savers as an alternative to traditional educational modalities. This report presents the successful application of this model, which was quantified with pretests and posttests given to users of the system.

Two patients subdued with a TASER® device: cases and review of complications.

In the United States, an increasing number of law enforcement agencies have employed the use of TASER® (TASER International Inc., Scottsdale, AZ) devices to temporarily immobilize violent subjects. There are reports in the lay press of adverse outcomes occurring in patients on whom TASER® devices have been deployed. Rhabdomyolysis has been associated with patients sustaining a TASER® shock, with a 1% incidence rate in subjects subdued with earlier versions of the device and then brought to the Emergency Department (ED). We present the cases of 2 patients who were seen in our ED after exhibiting violent behavior and receiving TASER® shocks. Both were hospitalized and received treatment for mild rhabdomyolysis. Both patients had multiple other characteristics that have been found to have an association with the development of rhabdomyolysis, in addition to the shocks they received. A review and discussion of the available medical literature on the subject follows, describing several complications that have been documented in patients after receiving TASER® shocks. Although a direct link between the TASER® and the reported adverse effects has not been established, patients who undergo restraint via this device frequently have pre-existing conditions or have exhibited behavior that places them at risk for the development of those effects. Such awareness of these possible complications is vital because the evaluation and management of patients developing adverse effects after these events will commonly occur in the ED.

Agroterrorism: where are we in the ongoing war on terrorism?

The U.S. agricultural infrastructure is one of the most productive and efficient food-producing systems in the world. Many of the characteristics that contribute to its high productivity and efficiency also make this infrastructure extremely vulnerable to a terrorist attack by a biological weapon. Several experts have repeatedly stated that taking advantage of these vulnerabilities would not require a significant undertaking and that the nations agricultural infrastructure remains highly vulnerable. As a result of continuing criticism, many initiatives at all levels of government and within the private sector have been undertaken to improve our ability to detect and respond to an agroterrorist attack. However, outbreaks, such as the 1999 West Nile outbreak, the 2001 anthrax attacks, the 2003 monkeypox outbreak, and the 2004 Escherichia coli O157:H7 outbreak, have demonstrated the need for improvements in the areas of communication, emergency response and surveillance efforts, and education for all levels of government, the agricultural community, and the private sector. We recommend establishing an interdisciplinary advisory group that consists of experts from public health, human health, and animal health communities to prioritize improvement efforts in these areas. The primary objective of this group would include establishing communication, surveillance, and education benchmarks to determine current weaknesses in preparedness and activities designed to mitigate weaknesses. We also recommend broader utilization of current food and agricultural preparedness guidelines, such as those developed by the U.S. Department of Agriculture and the U.S. Food and Drug Administration.

Rural Embedded Assistants for Community Health (REACH) Network: First-Person Accounts in a Community–University Partnership

Community research and action projects undertaken by community–university partnerships can lead to contextually appropriate and sustainable community improvements in rural and urban localities. However, effective implementation is challenging and prone to failure when poorly executed. The current paper seeks to inform rural community–university partnership practice through consideration of first-person accounts from five stakeholders in the Rural Embedded Assistants for Community Health (REACH) Network. The REACH Network is a unique community–university partnership aimed at improving rural health services by identifying, implementing, and evaluating innovative health interventions delivered by local caregivers. The first-person accounts provide an insider’s perspective on the nature of collaboration. The unique perspectives identify three critical challenges facing the REACH Network: trust, coordination, and sustainability. Through consideration of the challenges, we identified several strategies for success. We hope readers can learn their own lessons when considering the details of our partnership’s efforts to improve the delivery infrastructure for rural healthcare.

Infant ventilation and oxygenation by basic life support providers: comparison of methods.

INTRODUCTION Little information is available in the performance of infant ventilation by basic life support (BLS) personnel. HYPOTHESIS There are no significant differences between mouth-to-mouth (M-M), mouth-to-mask (M-Ma), pediatric bag-mask (PBM), and adult bag-mask (ABM) devices in the percent of acceptable breaths delivered by BLS providers. METHODS Fifty certified BLS providers performed five ventilation methods in random sequences for 60 seconds each on a 5kg infant mannequin following standardized instructions. Supplemental oxygen, 10 l/min, was supplied with one M-Ma trial and PBM methods. Airway patency, peak airway pressure (PAP), ventilatory rate (VR), tidal volume, and delivered oxygen concentration (FiO 2) were recorded. The percent of breaths with excessive PAP (i.e., greater than 30 mmHg), percent of acceptable breaths using loose (i.e., 25-125ml) and strict (i.e., 50-100ml) criteria, and FiO 2 at 15, 30, 45, and 60 seconds were compared between ventilation methods using ANOVA. RESULTS For all subjects and those with a patent airway (n=36), there were no significant differences in the percentage of acceptable breaths produced by PBM (56+/-6) (mean+/-SEM; all subjects) and ABM (41+/-6.2) was significantly greater than M-Ma, with and without a patent airway. Although RR and the percentage of excessive breaths were not significantly different, the percentage of acceptable breaths and FiO 2 delivered with each ventilation method was significantly better in the patent airway group.(ABSTRACT TRUNCATED AT 250 WORDS)

Improving Outcomes in Patients With Sepsis

Sepsis mortality may be improved by early recognition and appropriate treatment based on evidence-based guidelines. An intervention was developed that focused on earlier identification of sepsis, early antimicrobial administration, and an educational program that was disseminated throughout all hospital units and services. There were 1331 patients with sepsis during the intervention period and 1401 patients with sepsis during the control period. After controlling for expected mortality, patients in the intervention period had 30% lower odds of dying (odds ratio = 0.70, 95% confidence interval [CI] = 0.57 to 0.84). They also had 1.07 fewer days on average in the intensive care unit (95% CI = −1.98 to −0.16), 2.15 fewer hospital days (95% CI = −3.45 to −0.86), and incurred on average

Multimedia Education Increases Elder Knowledge of Emergency Department Care

1949 less in hospital costs, although the effect on costs was not statistically significant. Continued incremental improvement and sustainment is anticipated through organizational oversight, continued education, and initiation of an automated electronic sepsis alert function.