Prompt Advanced Life Support Improves Survival from Ventricular Fibrillation

Objective. To determine whether the interval between the arrival of basic life support (BLS) providers and the arrival of advanced life support (ALS) providers is associated with patient outcome after cardiac arrest. Methods. We conducted a retrospective cohort study of all witnessed, out-of-hospital ventricular fibrillation (VF) cardiac arrests between January 1, 1991, and December 31, 2007. Eligible patients (n = 1,781) received full resuscitation efforts from both BLS and ALS providers. Results. The BLS-to-ALS arrival interval was a significant predictor of survival to hospital discharge (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.93–0.99); the likelihood of survival decreased by 4% for every minute that ALS arrival was delayed following BLS arrival. Other significant predictors of survival were whether the arrest occurred in public (OR 1.48, 95% CI 1.19–1.85), whether a bystander administered cardiopulmonary resuscitation (CPR) (OR 1.34, 95% CI 1.07–1.68), and the interval between the 9-1-1 call and BLS arrival (OR 0.78, 95% CI 0.73–0.83). Conclusions. We found that a shorter BLS-to-ALS arrival interval increased the likelihood of survival to hospital discharge after a witnessed, out-of-hospital VF cardiac arrest. We conclude that ALS interventions may provide additional benefits over BLS interventions alone when utilized in a well-established, two-tiered emergency medical services (EMS) system already optimized for rapid defibrillation. The highest priorities in any EMS system should still be early CPR and early defibrillation, but timely ALS services can supplement these crucial interventions.     

国内外基础生命支持技术的普及和培训现状

心血管疾病和意外伤害的发生率呈逐年上升趋势,已成为危害人类健康的全球性公共卫生问题,心脏骤停（cardiac arrest,CA）是其引发的危急后果之一。     

Physician Medical Direction and Advanced Life Support in the United States

OBJECTIVE: To determine the specialty training and responsibilities of urban U.S. emergency medical service (EMS) medical directors how these factors relate to the type of service involved (fire, hospital, private, municipal). METHODS: A single mailed survey of training officers--field supervisors of 211 urban advanced life support (ALS) services in the United States. The survey also requested information about medications carried, approved procedures. and who set these standards. Respondents also rated the EMS medical director's involvement in various activities (quality assurance, administrative, executive, run reviews, and in-service/education). RESULTS: Eighty-five percent (n = 179) of the forms were returned. with 165 (78%) usable. The physician EMS medical directors were primarily trained in emergency medicine (77%) and were paiid (75%) for EMS responsibilities. The number of medications carried and the number of approved procedures were not related to either the number of hours the physicians commit weekly to the EMS service or their degree of involvement in ALS activities. The physician EMS medical directors were most often involved in quality assurance and education and were less likely to devote time to executive or other administrative functions of ALS units, with the exception of fire-based EMS physician medical directors, who contributed significantly to executive and administrative functions (p < 0.05). Overall practice standards were established by the medical director (46%), the state department of health (24%), and local/regional health authorities (23%). CONCLUSIONS: EMS training officers believe that urban ALS medical directors in the United States primarily provide quality assurance and educational support. With the exception of fire-based EMS systems. physicians appear to have limited involvement in other EMS administrative and executive functions.     

A Comparison of Multimedia and Standard Advanced Cardiac Life Support Learning

Abstract. Objectives : To compare student performance after Multimedia ACLS Learning System (MM) education compared with that after standard (ST) ACLS education. Methods : Final-year medical students were divided into 2 groups based on convenience scheduling and given ACLS instruction either in a standard format or with the MM course. The sizes of the small groups and the times in small-group instruction were identical. All students were evaluated with the same 50-item multiple-choice written examination, a structured evaluation immediately after the management of a mock cardiac arrest, and a second structured evaluation of the same mock arrest (videotaped) by an instructor blinded to the education method. Students were assigned a mark from 1 to 5 in each of 4 domains: assessment, immediate priorities, continual assessment, and leadership. Results : 75 students took the MM and 38 took the ST course. The mean ± SD mark for the multiple-choice test was 89.3 ± 4.9% (MM) vs 89.3 ± 4.8% (ST); the on-site mock arrest evaluation mark (20 maximum) was 14.1 ± 2.5 (MM) vs 14.1 ± 2.0 (ST); and the blinded mock arrest evaluation was 13.1 ± 2.9 (MM) vs 14.4 ± 2.9 (ST) (p = 0.024). 1/75 (MM) vs 0/38 (ST) did not successfully complete the on-site mock arrest evaluation. More students in the MM group (46% vs 25%) required multiple attempts to successfully complete the mock arrest evaluation (p < 0.02). Conclusion : In medical students with no previous ACLS training, structured access to the multimedia ACLS Learning System provides immediate educational outcomes similar to those of a standard ACLS course. Multimedia computer-interactive learning should be enhanced with a short period of hands-on practice.     

Basic Cardiac Life Support Providers Checking the Carotid Pulse: Performance, Degree of Conviction, and Influencing Factors

The American Heart Association recently abolished the carotid pulse check during cardiopulmonary resuscitation for lay rescuers, but not for health care providers. OBJECTIVES: The aim of the study was to evaluate health care providers' performance, degree of conviction, and influencing factors in checking the carotid pulse. METHODS:Sixty-four health care providers were asked to check the carotid pulse for 10 or 30 seconds on a computerized mannequin simulating three levels of pulse strength (normal, weak, and absent). Health care providers were asked whether they felt a pulse and how certain were they that they felt a pulse. Performance was evaluated, as well as degree of conviction about the answer, using a visual analog scale. Data were compared by using a general linear model procedure. RESULTS: In the pulseless situations, the answers were correct in 58% and 50% when checking the pulse for 10 and 30 seconds, respectively. In the situation with a weak pulse, the answer was correct in 83% when checking the pulse for 10 seconds. In situations with a normal pulse, the answers were correct in 92%, 84%, and 84%, respectively, when checking the pulse for 10 (twice) and 30 seconds. The exactitude of the answer was correlated with the pulse strength (p < 0.05). The degree of conviction about the answer was correlated with the exactitude of the answer (p < 0.01) and the pulse strength (p < 0.0001). CONCLUSIONS: These results question the routine use of the carotid pulse check during cardiopulmonary resuscitation, including for health care providers.     

心血管病专科护士基础生命支持培训效果及分析

目的探讨全军心血管病护理示范基地专科护士基础生命支持的培训模式。方法 2013年5月,选择参加沈阳军区总医院全军培训基地心血管病专科护士班护士52名为研究对象,按随机数字表法分成观察组和对照组,每组各26名。观察组采用美国心脏协会(American Heart Association,AHA)培训模式,而对照组采用全军心血管病护理示范基地专科护士传统培训模式,在培训结束时进行理论和技能考核。结果观察组护士的基础生命支持理论和技能操作考核通过率高于对照组,差异有统计学意义(P0.05)。结论采用AHA培训模式,有利于全军心血管病护理示范基地专科护士掌握基础生命支持理论及技能,特别有助于提高对儿童和婴儿的急救和复苏技能,实用性强,可广泛推广及应用。     

12-lead Electrocardiograms during Basic Life Support Care

Objectives

Prehospital 12-lead electrocardiograms (PTLs) decrease time to thrombolytics. Paramedics have performed them successfully for years, but emergency medical technicians (EMTs) have not typically performed them. To determine whether PTLs could be considered a basic life support (BLS) skill, the authors conducted a pilot study to determine whether scene times are lengthened when EMTs obtain PTLs, whether EMTs can appropriately select patients for PTLs, and what value physicians place on prehospital PTLs.

Methods

The authors prospectively evaluated PTL performance in four BLS agencies. EMTs provided standard cardiac care to patients on even days. On odd days, they additionally performed a PTL. Scene times of patients receiving a PTL (n = 77) were compared with scene times of similar patients not receiving one (n = 100).

Results

EMTs attempted to perform 101 PTLs, of which 77 were eligible for inclusion. The mean scene time [95% confidence interval] of patients on even days (no 12-lead) was 11.9 [11.0, 12.8] minutes, compared with 16.9 [15.8, 18.0] minutes for patients who received a PTL. Scene times increased by 5.0 [3.6, 6.4] minutes when a PTL was added to the evaluation. Physician feedback was received on 63 of 77 PTLs. Receiving physicians agreed that 59 of 63 (93.6%) patients needed the PTL and found them moderately helpful (3.56 on a 1 to 5 scale).

Conclusion

When EMTs performed PTLs, scene times increased approximately 5 minutes. Most physicians agreed that the PTL was indicated. PTL acquisition by EMTs appears feasible with slightly lengthened scene times, but evaluation in other BLS agencies is necessary to validate this conclusion.     

初级心肺复苏44例分析

目的:分析本院两年来急诊初级心肺复苏情况,为进一步提高心肺复苏成功率提供依据。方法:回顾性分析本科2004年1月～2005年12月间44例心肺复苏病例。观察其心跳骤停发生地点、骤停时间、病因、肾上腺素用量、有无电除颤及机械通气等指标。结果:成功组复苏前骤停时间比失败组短(P<0.05);在院内发生骤停的复苏成功率比院外要高(P<0.01);成功组需要的胸外按压时间和肾上腺素总量均低于失败组(P<0.05)。结论:影响心肺复苏成功的基础因素包括心肺复苏前骤停的时间、地点、基础病,在心肺复苏过程中是否及时开放气道、进行胸外按压的时间、肾上腺素的用量等可预测复苏的成功率。     

R EVIEW AND S ELF -A SSESSMENT TO A CCOMPANY EMERGENCY MEDICINE

Cardiac arrest in children outside the hospital is associated with high mortality rates. Recent investigations have suggested that the use of advanced life support (ALS) measures by emergency medical services (EMS) personnel may decrease survival. These studies have used the pediatric Utstein style of defining ALS and basic life support (BLS) measures. The pediatric Utstein style defines BLS as “an attempt to restore effective ventilation and circulation” using noninvasive means to open the airway but specifically excludes the use of bag-valve-mask devices. Advanced life support is defined as the “addition of invasive maneuvers to restore effective ventilation and circulation.” The authors of the study described below believe that using this definition would categorize some patients into an ALS group who would otherwise be categorized as having received BLS (i.E., “bag-valve-mask only”). Objective: To compare survival rates among children receiving BLS or ALS following out-of-hospital cardiac arrest using amended definitions of prehospital life support measures. Specifically, the definition of BLS was expanded to include the use of bag-valve-mask devices only. Methods: This was a retrospective chart review in an urban, pediatric emergency department. Patients included all children presenting to the emergency department between January 1, 1986, and December 31, 1999, following out-of-hospital cardiac arrest. The main outcome measure was survival to hospital discharge. Results: Two hundred ten children were identified. Twenty-one patients were excluded from further analysis because of absent or incomplete medical records. One hundred eighty-nine patients were studied. Five children (2.6%) survived to discharge from the hospital. Of 189 children, 39 (20.6%) were provided BLS measures by prehospital personnel; 150 (79.4%) received ALS. There was no significant difference between groups in survival to hospital discharge. Patients who survived to hospital discharge were more likely to be in sinus rhythm upon arrival in the emergency department (p < 0.001) and to have received fewer doses of standard-dose epinephrine in the emergency department (p < 0.001). Conclusion: The use of ALS by prehospital personnel for children with out-of-hospital cardiac arrest did not improve survival to discharge from the hospital when compared with the use of BLS.     

Retention of Basic Life Support in Laypeople: Mastery Learning vs. Time-based Education

Objective: To compare the effectiveness of a mastery learning (ML) versus a time-based (TB) BLS course for the acquisition and retention of BLS knowledge and skills in laypeople. Methods: After ethics approval, laypeople were randomized to a ML or TB BLS course based on the American Heart Association (AHA) Heartsaver course. In the ML group, subjects practiced and received feedback at six BLS stations until they reached a pre-determined level of performance. The TB group received a standard AHA six-station BLS course. All participants took the standard in-course BLS skills test at the end of their course. BLS skills and knowledge were tested using a high-fidelity scenario and knowledge questionnaire upon course completion (immediate post-test) and after four months (retention test). Video recorded scenarios were assessed by two blinded, independent raters using the AHA skills checklist. Results: Forty-three subjects were included in analysis (23ML;20TB). For primary outcome, subjects' performance did not change after four months, regardless of the teaching modality (TB from (median[IQR]) 8.0[6.125;8.375] to 8.5[5.625;9.0] vs. ML from 8.0[7.0;9.0] to 7.0[6.0;8.0], p = 0.12 for test phase, p = 0.21 for interaction between effect of teaching modality and test phase). For secondary outcomes, subjects acquired knowledge between pre- and immediate post-tests (p < 0.005), and partially retained the acquired knowledge up to four months (p < 0.005) despite a decrease between immediate post-test and retention test (p = 0.009), irrespectively of the group (p = 0.59) (TB from 63.3[48.3;73.3] to 93.3[81.7;100.0] and then 93.3[81.7;93.3] vs. ML from 60.0[46.7;66.7] to 93.3[80.0;100.0] and then 80.0[73.3;93.3]). Regardless of the group after 4 months, chest compression depth improved (TB from 39.0[35.0;46.0] to 48.5[40.25;58.0] vs. ML from 40.0[37.0;47.0] to 45.0[37.0;52.0]; p = 0.012), but not the rate (TB from 118.0[114.0;125.0] to 120.5[113.0;129.5] vs. ML from 119.0[113.0;130.0] to 123.0[102.0;132.0]; p = 0.70). All subjects passed the in-course BLS skills test. Pass/fail rates were poor in both groups at both the simulated immediate post-test (ML = 1/22;TB = 0/20; p = 0.35) and retention test (ML pass/fail = 1/22, TB pass/fail = 0/20; p = 0.35). The ML course was slightly longer than the TB course (108[94;117] min vs. 95[89;102] min; p = 0.003). Conclusions: There was no major benefit of a ML compared to a TB BLS course for the acquisition and four-month retention of knowledge or skills among laypeople.     

Assessment of the effect of Advanced Paediatric Life Support training on level of self‐perceived preparedness among health‐care workers in Cambodia

Objective: The objective of this study was to survey the self‐perceived preparedness of Cambodia's Advanced Paediatric Life Support (APLS) providers towards their APLS training and accreditation 5 years post‐implementation. Methods: A cross‐sectional survey was administered in December 2009 to APLS providers who had been trained throughout the 5 year period from December 2005 to May 2009. Results: One hundred and two (93%) APLS providers responded. The median rating for their original APLS learning experience was 6 out of 10, and the reported median recall of the APLS teaching content was 7 out of 10. Since their training, 80% had managed a child in cardiac arrest, 85% a child with serious illness and 72% with serious injury. Their subjective preparedness from APLS training for each of the three resuscitation types, on a scale of 1–10, were medians of 7, 7 and 6, respectively. For all groups, perceived preparedness for all three resuscitation types did not differ despite varying lengths of time from their original training. Conclusion: APLS training has increased the self‐perceived preparedness of paediatric health‐care workers in Cambodia. Results indicate moderate relevance to real patient resuscitations experienced by health workers, and the perceived recall of the teachings and sense of preparation from APLS training does not significantly decline over time. However, our results suggest subsequent further APLS instructor courses might maintain resuscitation preparedness.     

Basic Life Support Training for undergraduate nursing students: An integrative review

The aim of this review was to identify the role of basic life support training interventions in international undergraduate nursing education, that support optimal acquisition and retention of knowledge, psychomotor skills and resuscitation self-efficacy. Twenty-four articles were identified and analysed using an integrative review approach. Studies were reviewed for quality using a Critical Appraisal Skills Programme checklist. Common objective and standardised methods of basic life support education practice were identified: instructor led, simulation experiences, self-directed learning, skills training combined with clinical practicum, and computer-based training. Evaluation of competency was collected primarily from multiple-choice questionnaires or researcher-designed checklists, with a lack of objective performance data noted. Importantly, current teaching approaches do not guarantee acquisition or retention of basic life support skills. Objective feedback from technologies supporting cardiopulmonary resuscitation training may be useful in acquisition and retention of psychomotor skills, and therefore requires further exploration. Development of robust, psychometrically sound instruments are needed to accurately and consistently measure nursing students' skills performance.     

Retention of Pediatric Advanced Life Support (PALS) course concepts

The purpose of this study was to measure, in a population of experienced state-certified paramedics, the decline of Pediatric Advanced Life Support (PALS) course concepts during the 2-year recertification cycle recommended by the American Heart Association. The PALS course contains a written examination designed to measure understanding of course concepts. To successfully complete the course, a PALS course participant must achieve a minimum grade of 84% on this test. In our study, 99 experienced PALS-certified Advanced Life Support (ALS) providers completed a 70-question written test. Nested within this test were all of the PALS examination questions that the participants had previously passed to complete the PALS course. Each participant's PALS test questions were extracted and scored to obtain a “retest score” that measured retention of PALS course principles. These 99 dual-trained paramedic/firefighters comprised more than 90% of the staff of a countywide EMS system averaging 60,000 calls per year. Study participants averaged 10 years of ALS experience, and 3–4 pediatric patient calls per month. In this study, “pediatric patient” was defined as an individual 18 years of age or less. Results revealed that 25 (25%) of the 99 providers achieved a minimum passing score of 84% or greater on the PALS retest. Another 40 (40%) scored within one standard deviation below the minimum passing score. Retest score was unaffected by years of ALS experience, number of pediatric patients seen per month, or by PALS Instructor status. The average retest score was 16 points lower than the original test score. The original test score did not reliably predict a passing grade on the retest. We conclude that the average decline of PALS course principles is such that a 2-year retraining schedule is appropriate for prehospital personnel caring for an average of three to four pediatric patients per month.     

Review article: Updated resuscitation guidelines for 2016: A summary of the Australian and New Zealand Committee on Resuscitation recommendations

This review paper summarises the key changes made to the resuscitation guidelines used in Australia and New Zealand. They were released by the Australian and New Zealand Committee on Resuscitation in January 2016. These are local adaptations of the evidence previously published in October 2015 by the International Liaison Committee on Resuscitation (ILCOR). They are presented across the main working groups in ILCOR: ALS, BLS, paediatrics, neonates, acute coronary syndromes, first aid and ‘Education, Implementation and Teams’.