Care for the Adult Family Members of Victims of Unexpected Cardiac Death

More than 300,000 sudden coronary deaths occur annually in the United States, despite declining cardiovascular death rates. In 2000, deaths from heart disease left an estimated 190,156 new widows and 68,493 new widowers. A major unanswered question for emergency providers is whether the immediate care of the loved ones left behind by the deceased should be a therapeutic task for the staff of the emergency department in the aftermath of a fatal cardiac arrest. Based on a review of the literature, the authors suggest that more research is needed to answer this question, to assess the current immediate needs and care of survivors, and to find ways to improve care of the surviving family of unexpected cardiac death victims. This would include improving quality of death disclosure, improving care for relatives during cardiopulmonary resuscitation of their family member, and improved methods of referral for services for prevention of psychological and cardiovascular morbidity during bereavement.     

CPR Induced Consciousness During Out-of-Hospital Cardiac Arrest: A Case Report on an Emerging Phenomenon

Background: High quality cardiopulmonary resuscitation (CPR) has produced a relatively new phenomenon of consciousness in patients with vital signs absent. Further research is necessary to produce a viable treatment strategy during and post resuscitation. Objective: To provide a case study done by paramedics in the field illustrating the need for sedation in a patient whose presentation was consistent with CPR induced consciousness. Resuscitative challenges are provided as well as potential future treatment options to minimize harm to both patients and prehospital providers. Case Report: A 52-year-old male presented as a witnessed out-of-hospital cardiac arrest (OHCA). During CPR the patient began to exhibit signs of life including severe agitation and thrashing of his limbs while CPR was ongoing for ventricular fibrillation prior to defibrillation. Resuscitation became considerably more complicated due to the violent and counterintuitive motions done by the patient during their own resuscitation. Despite the atypical presentation of cardiac arrest the patient was successfully resuscitated employing high quality CPR, standard advanced life support (ALS) care as well as two double sequential external defibrillation shocks. The patient underwent emergency percutaneous coronary intervention (PCI) for a 100% occlusion of his left anterior descending artery (LAD). The patient returned home 3 days later fully recovered with a Cerebral Performance Score of 1. Conclusion: CPR induced consciousness is emerging as a new phenomenon challenging providers of high quality CPR during cardiac arrest resuscitation. Our case report describes the manifestations of CPR induced consciousness as well as the resuscitative challenges which occur during resuscitation. Further research is required to determine the true frequency of this condition as well as treatment algorithms that would allow for appropriate and safe management for both the patient and EMS providers.     

Pediatric cardiopulmonary-cerebral resuscitation: an overview and future directions

The evolving understanding of pathophysiologic events during and after pediatric cardiac arrest has not yet resulted in significantly improved outcome. Exciting breakthroughs in basic and applied science laboratories are, however, on the immediate horizon for study in specific subpopulations of cardiac arrest victims. Strategically focusing therapies to specific phases of cardiac arrest and resuscitation and evolving pathophysiologic events offers great promise that critical care interventions will lead the way to more successful cardiopulmonary and cerebral resuscitation in children.     

Feasibility of Basic Emergency Medical Technicians to Perform Selected Advanced Life Support Interventions

Objective. Emergency medical technician-basic (EMT-B) providers often provide the initial care to victims of out-of-hospital cardiac arrest. While automated external defibrillators enable EMT-B providers to deliver rescue shocks, patients in cardiac arrest may require additional interventions that EMT-B providers may not presently deliver. We sought to evaluate the feasibility of training EMT-B providers to provide additional cardiac resuscitation procedures using the laryngeal mask airway (LMA) andintraosseous (IO) access. Methods. In this prospective observational study, we trained 18 EMT-B providers to use the LMA andIO drill (EZ-IO) in a three-hour educational session. Working in two-person teams, the rescuers performed a simulated ventricular fibrillation resuscitation. We evaluated placement success as well as elapsed time to placement of the LMA andEZ-IO. Results. EMT-B providers successfully placed the LMA in 14 of 18 scenarios (78%; 95% confidence interval, 52% to 94%), with a mean of two attempts for placement. Subjects successfully placed the EZ-IO in 17 of 18 scenarios (94%; 95% confidence interval, 73% to 100%), all on the first attempt. The median time to LMA placement following the third shock was 109 seconds (interquartile range, 58–158) andthe median time to EZ-IO placement was 72 seconds (interquartile range, 50–93) after LMA placement. Conclusions. EMT-B providers demonstrated moderate success in performing advanced-level cardiac resuscitation interventions. These observations suggest potential for expanding the role of basic-level rescuers in cardiopulmonary resuscitation.     

Recommendations of the international guidelines 2000 conference on cardiopulmonary resuscitation and emergency cardiac care: an overview

The greatest potential for survival of sudden cardiac arrest can be achieved only by providing early intervention using evidence-based therapies that have been studied over time. Emergency cardiac care and the 2000 advanced cardiac life support guidelines encompass all therapies that have been shown to improve outcomes in patients who experience life-threatening events that involve the cardiovascular, cerebrovascular, and pulmonary systems. Early recognition of warning signs, activation of emergency medical systems within the community, basic cardiopulmonary resuscitation, early defibrillation, airway management, and intravenous medication administration are key factors in improving resuscitation outcomes.     

Resuscitation Research: Future Directions and Ethical Issues

Cardiopulmonary resuscitation research is a vital area of research that has made significant contributions to medical care over the last several decades. Abundant information currently exists in the medical literature, as a result of research in the areas of cardiac arrest and outcomes, physiology of cardiac arrest, pharmacologic treatments, mechanical interventions, and societal and ethical issues. Despite numerous clinical trials demonstrating physiologic benefit of various interventions, few interventions have had as much impact on outcomes of cardiac arrest as have improvements in out-of-hospital response times and rapid availability of medical treatment. Although abundant information exists regarding physiologic aspects of resuscitation, relatively little information exists about ethical, psychological, and social aspects of resuscitation. In addition to attempts to improve outcomes of cardiac arrest, researchers should also strive to improve the experiences of patients and families involved. These realities provide future strategies and directions for the best use of resuscitation research resources; although physiologic and pharmacologic research will always have significant roles in the improvement of medical care, the rapid delivery of out-of-hospital care and ethical issues will be indispensable areas of research focus in the future.     

Maternal mortality in Australia: learning from maternal cardiac arrest

Cardiac arrest in pregnancy is fortunately a rare event that few midwives will see during their career. The increase in maternal age, the Body Mass Index, cesarean sections, multiple pregnancies, and comorbidities over recent years have increased the probability of cardiac arrest. The early warning signs of impending maternal cardiac arrest are either absent or go unrecognized. Maternal mortality reviews highlight the deficiencies that maternity care providers have in managing cardiac arrest in pregnancy.The aim of this article is to address the knowledge deficiencies of health professionals by reviewing the physiological changes in pregnant women that complicate the management of cardiopulmonary resuscitation, using a case scenario. There are key differences in the management of pregnant women, when compared to standard adult resuscitation.The outcome is dependent on the speed of the response and the consideration of a number of crucial pregnancy-specific interventions. Staff members need to be adequately trained in order to deal with maternal cardiac arrest and have access to training packages and in-service education programs. As cardiac arrest in pregnancy is a rare event, emergency drill simulations are an important component of ongoing education.     

A call to arms to reduce premature deaths by using inexpensive resuscitation care

Two hundred seventy thousand people in the US and 450,000 people in Europe experience out-of-hospital cardiac arrest each year. Perceived poor prognosis and expense of care of patients resuscitated from cardiac arrest remain barriers to implementation of effective therapies. In this issue of Critical Care, Graf and colleagues have provided a programmatic evaluation of the costs and consequences of intensive care after resuscitation from cardiac arrest. Thirty-one percent of the cohort that survived to be cared for in the intensive care setting were still alive 5 years after hospital discharge. The health-related quality of life of this group of 5-year survivors was similar to that of matched healthy controls, and the cost per quality-adjusted life year gained was similar to or less than the cost of other commonly used medical interventions. We need to change the culture of resuscitation and recognize that cardiac arrest is a treatable condition that is associated with acceptable quality of life and costs of care after resuscitation.     

When is dead, dead? The ethics of resuscitation in emergency care

Each year thousands of people suffer a cardiac arrest. Technology, care provider education, and emergency services access have made it possible to successfully resuscitate many patients. The outcome however, may not always be positive for the patient or their family. This article looks at the ethics of resuscitation and how to determine when to start and stop resuscitation so that patients, families, and emergency care providers may make informed and acceptable decisions related to resuscitation and its potential outcomes.     

Out-of-hospital resuscitation: have we gone too far?

Americans are living longer and are more likely to be chronically or terminally ill at the time of death. Although surveys indicate that most people prefer to die at home, the majority of people in the United States die in acute care hospitals. Each year, approximately 400,000 persons suffer sudden cardiac arrest in the US, the majority occurring in the out-of-hospital setting. Mortality rates are high and reach almost 100% when prehospital care has failed to restore spontaneous circulation. Nonetheless, patients who receive little benefit or may wish to forgo life-sustaining treatment often are resuscitated. Risk versus harm of resuscitation efforts can be differentiated by various factors, including cardiac rhythm. Emergency medical services policy regarding resuscitation should consider its utility in various clinical scenarios. Patients, family members, emergency medical providers, and physicians all are important stakeholders to consider in decisions about out-of-hospital cardiac arrest. Ideally, future policy will place greater emphasis on patient preferences and quality of life by including all of these viewpoints.     

Crashing eclamptic patient and a resulting peri-mortem C-section

BackgroundCardiac arrest in pregnancy is high acuity, low occurrence event. It involves the coordination of multiple teams to take care of ultimately two patients. This is further compounded by physiology that is frequently unfamiliar to the providers taking care of the patient.Case reportThis case report will detail sudden onset eclampsia in a patient whose condition deteriorated rapidly into cardiac arrest. It will delve into the complexities of managing this complex disease process and how the multi-disciplinary team quickly integrated to manage both the mother and the baby.Why should the emergency physician be aware of this?: Cardiac arrest in pregnancy is an incredibly difficult situation due to both the physiological differences in the pregnant woman and the emotional factors on the treating providers (1). Due to its rarity, the pregnant cardiac arrest situation should be frequently reviewed to ensure appropriate care when the time arrives.The per-mortem c-section for a woman in cardiac arrest is a critical resuscitation technique that must be understood by providers who take care of critically ill patients ranging from emergency medicine to obstetrics and gynecology (Ob/Gyn) clinicians.     

Beneficial effects of vasopressin in prolonged pediatric cardiac arrest: a case series

Children who suffer cardiac arrest have a poor prognosis. Based on laboratory animal studies and clinical data in adults, vasopressin is an exciting new vasopressor treatment modality during cardiopulmonary resuscitation (CPR). In particular, vasopressin has resulted in short term resuscitation benefits as a "rescue" pressor agent in the setting of prolonged out-of-hospital CPR for ventricular fibrillation in adults. This retrospective series presents the first evidence for resuscitation benefit of bolus vasopressin therapy in the specific setting of pediatric cardiac arrest. All episodes of CPR initiated in a 120-bed tertiary care children's hospital over a three-year period (1997-2000) were reviewed. Four children in the pediatric ICU received vasopressin boluses as rescue therapy during six cardiac arrest events, following failure of conventional CPR, advanced life support, and epinephrine vasopressor therapy. Return of spontaneous circulation for greater than 60 min occurred in three of four patients (75%) and in four of six CPR events (66%) following vasopressin administration. Two of four vasopressin recipients survived >24 h; one survived to hospital discharge and one had withdrawal of supportive therapies following family discussion. Our observations are AHA level 5 (retrospective case series) evidence that vasopressin administration may be beneficial during prolonged pediatric cardiac arrest. Such reports should pave the way for prospective clinical trials comparing vasopressor medications in the setting of pediatric cardiac arrest.     

Postreperfusion cardiac arrest and resuscitation during orthotopic liver transplantation: dynamic visualization and analysis of physiologic recordings

We recently reported on the Multi Wave Animator (MWA), a novel open-source tool with capability of recreating continuous physiologic signals from archived numerical data and presenting them as they appeared on the patient monitor. In this report, we demonstrate for the first time the power of this technology in a real clinical case, an intraoperative cardiopulmonary arrest following reperfusion of a liver transplant graft. Using the MWA, we animated hemodynamic and ventilator data acquired before, during, and after cardiac arrest and resuscitation. This report is accompanied by an online video that shows the most critical phases of the cardiac arrest and resuscitation and provides a basis for analysis and discussion. This video is extracted from a 33-min, uninterrupted video of cardiac arrest and resuscitation, which is available online. The unique strength of MWA, its capability to accurately present discrete and continuous data in a format familiar to clinicians, allowed us this rare glimpse into events leading to an intraoperative cardiac arrest. Because of the ability to recreate and replay clinical events, this tool should be of great interest to medical educators, researchers, and clinicians involved in quality assurance and patient safety.     

Open-chest cardiac massage after closed-chest compression in a canine model: when to intervene

Open-chest cardiac massage appears beneficial in improving hemodynamics during resuscitation efforts and in improving resuscitation success. The time between cardiac arrest and the initiation of open-chest cardiac massage is crucial. It would appear that if initiation of open chest cardiac massage is delayed for more than 20 min from the onset of cardiac arrest, little or no successful outcome can be expected. Further techniques for assessing the adequacy of closed-chest compression CPR are needed. Such techniques would allow early identification of ineffective resuscitation efforts and provide the opportunity for early change to other, presumably more effective, techniques.     

Decoding twitter: Surveillance and trends for cardiac arrest and resuscitation communication

Aim of the study

Twitter has over 500 million subscribers but little is known about how it is used to communicate health information. We sought to characterize how Twitter users seek and share information related to cardiac arrest, a time-sensitive cardiovascular condition where initial treatment often relies on public knowledge and response.

Methods

Tweets published April–May 2011 with keywords cardiac arrest, CPR, AED, resuscitation, heart arrest, sudden death and defib were identified. Tweets were characterized by content, dissemination, and temporal trends. Tweet authors were further characterized by: self-identified background, tweet volume, and followers.

Results

Of 62,163 tweets (15,324, 25%) included resuscitation/cardiac arrest-specific information. These tweets referenced specific cardiac arrest events (1130, 7%), CPR performance or AED use (6896, 44%), resuscitation-related education, research, or news media (7449, 48%), or specific questions about cardiac arrest/resuscitation (270, 2%). Regarding dissemination (1980, 13%) of messages were retweeted. Resuscitation specific tweets primarily occurred on weekdays. Most users (10,282, 93%) contributed three or fewer tweets during the study time frame. Users with more than 15 resuscitation-specific tweets in the study time frame had a mean 1787 followers and most self-identified as having a healthcare affiliation.

Conclusion

Despite a large volume of tweets, Twitter can be filtered to identify public knowledge and information seeking and sharing about cardiac arrest. To better engage via social media, healthcare providers can distil tweets by user, content, temporal trends, and message dissemination. Further understanding of information shared by the public in this forum could suggest new approaches for improving resuscitation related education.     

Feasibility of correlating the pulse check with focused point-of-care echocardiography during pediatric cardiac arrest: a case series

Rapidly determining whether an unresponsive child is in cardiac arrest or in shock, and requiring cardiopulmonary resuscitation can be problematic. The pulse check in children has been shown to be unreliable, not only for laypersons, but also for healthcare providers. The recommendation for checking the pulse in unresponsive children has been eliminated for laypersons in the latest edition of the Emergency Cardiovascular Care guidelines. Thus the decision to initiate cardiopulmonary resuscitation in children, with the goal of delivering effective chest compressions, can be fraught with uncertainty. Despite the use of pediatric advanced life support guidelines developed by the American Heart Association and the American Academy of Pediatrics, management and decision making during resuscitation of children in cardiac arrest can be challenging. Outcomes for out-of-hospital pediatric cardiac arrest remain poor. The decision to end resuscitation in children, often an emotionally charged situation, can also be particularly difficult for physicians. Information from focused point-of-care echocardiography that allows for correlation with the presence or absence of a pulse and real time assessment of resuscitation may help direct and optimize the delivery of resuscitative interventions. We report our preliminary clinical observations of using focused point-of-care echocardiography to correlate with the pulse check during resuscitation in a series of pediatric cardiac arrests.     

Out-of-hospital resuscitation in Tartu: effect of reorganization of Estonian EMS system

The objective of this study was to evaluate the effect of reorganization of Estonian emergency medical services (EMS) system. The outcomes of out-of-hospital resuscitation in the Tartu urban area were investigated during the 6-year study period. The main aim of reorganization was to provide rapid access to early defibrillation with simultaneous advanced cardiac life support (ACLS) procedures on the scene. The changes were implemented since summer 1994 in Tartu at first. Quick availability of a mobile intensive care unit for high-risk calls; implementation of standards for resuscitation, and routine systematic, realistic, compulsory ACLS training for all ambulance staff were established. There were 368 out-of-hospital resuscitations. Comparison of periods before and after basic reorganization of EMS system showed that the number of resuscitation attempts had evident tendency to increase. The rates of return of spontaneous circulation and survival in patients with cardiac arrest of presumed cardiac origin increased from 32.5% to 58.6% (P < .05) and from 7.5% to 25.7% (P < .05) respectively. Thus, implementation in the EMS system of mobile intensive care, ACLS units, and standard resuscitation training program diminished mortality from sudden cardiac arrest.     

In-hospital cardiac arrest

To review the current management of in-hospital cardiac arrest and to identify variables that influence outcomes, OLDMEDLINE from 1950 to 1966 and MEDLINE from 1966 to March 2005 were searched using the keywords cardiopulmonary resuscitation, cardiac arrest, in hospital, and adult. Secondary sources were derived from review publications and personal communications by one of the authors. There is no secure evidence that the ultimate outcomes after cardiopulmonary resuscitation in settings of in-hospital cardiac arrest have improved in the >40 yrs that followed the landmark report by Kouwenhoven, Jude, and Knickerbocker, which launched the modern era of cardiopulmonary resuscitation. A paucity of objective measurements preclude secure protocols for sequencing of interventions and, even more, when to initiate and discontinue cardiopulmonary resuscitation. The preparedness of both physicians and nursing professionals to implement the published guidelines has itself been questioned. Whereas early access defibrillation with automated external defibrillators may be of benefit in out-of-hospital settings, there has as yet been no secure evidence that automated external defibrillators have had a favorable impact on in-hospital cardiopulmonary resuscitation when used on infrequent occasions by first responders. This contrasts with the much greater success of advanced life support providers and especially when electrical defibrillation is promptly performed by expertly trained personnel after onset of cardiac arrest. Outcomes are therefore improved in critical care settings and especially in coronary care units in which patients are continuously monitored.     

The European Resuscitation Council's paediatric life support course 'Advanced Paediatric Life Support'

The poor outcome for resuscitation from cardiopulmonary arrest in childhood is widely recognised. The European Resuscitation Council has adopted the Advanced Paediatric Life Support course (originating in the UK and now available in a number of countries) as its course for providers caring for children. This paper outlines the course content and explains its remit, which is to reduce avoidable deaths in childhood by not only resuscitation from cardiac arrest but, more effectively, by recognising and treating in a timely and effective fashion life-threatening illness and injury in infants and children. Two related courses Paediatric Life Support, a less intense course for less advanced providers, and Pre-Hospital Paediatric Life Support for immediate care providers are also described.