Optimizing implantable cardioverter-defibrillator treatment of rapid ventricular tachycardia: Antitachycardia pacing therapy during charging

BACKGROUND: Previous studies in implantable cardioverter-defibrillator (ICD) patients demonstrated the efficacy and safety of antitachycardia pacing (ATP) for rapid ventricular tachycardias (VT). To prevent shock delay in case of ATP failure, a new feature (ATP during charging) was developed to deliver ATP for rapid VT while charging for shock. OBJECTIVE: The purpose of this study was to determine the efficacy and safety of this new feature. METHODS: In a prospective, nonrandomized trial, patients with standard ICD indication received an EnTrust ICD. VT and ventricular fibrillation (VF) episodes were reviewed for appropriate detection, ATP success, rhythm acceleration, and related symptoms. RESULTS: In 421 implanted patients, 116 VF episodes occurred in 37 patients. Eighty-four (72%) episodes received ATP during or before charging. ATP prevented a shock in 58 (69%) of 84 episodes in 15 patients. ATP stopped significantly more monomorphic (77%) than polymorphic VTs (44%, P = .05). Five (6%) episodes accelerated after ATP but were terminated by the backup shock(s). No symptoms were related to ATP during charging. In four patients, 38 charges were saved by delivering ATP before charging. Of 98 induced VF episodes, 28% were successfully terminated by ATP versus 69% for spontaneous episodes (P <.01). CONCLUSION: Most VTs detected in the VF zone can be painlessly terminated by ATP delivered during charging, with a low risk of acceleration or symptoms. ATP before charging allows delivery of two ATP attempts before shock in the same time that would otherwise be required to deliver only one ATP plus a shock. It also offers potential battery energy savings.     

Changing Guidelines of Cardiopulmonary Resuscitation and Basic Life Support for General Dental Practitioners and Oral and Maxillofacial Surgeons

Introduction

Every general dental practitioner and oral and maxillofacial surgeon needs a thorough knowledge of the diagnosis and management of medical emergencies. Cardiopulmonary arrest is the most urgent of emergencies and diagnosis must be done as soon as possible.

Purpose

This paper discusses the importance of the International Liaison Committee on Resuscitation which forms the guidelines for cardiopulmonary resuscitation (CPR), highlighting the important changes in the guidelines of CPR from the year 2000 to 2010, the basic sequence of performing CPR and also the role of defibrillation and the use of automated external defibrillators. Finally the five part chain of survival which is of utmost importance to dental health care professionals and oral and maxillofacial surgeons.

Conclusion

All dental health care personnel and oral & maxillofacial surgeons should recognize the importance of the changes in the guidelines of CPR, be trained and allowed to use a properly maintained defibrillator, to respond to cardiac arrest victims.     

Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation

Introduction

We compare the outcomes for patients who received esmolol to those who did not receive esmolol during refractory ventricular fibrillation (RVF) in the emergency department (ED).

Methods

A retrospective investigation in an urban academic ED of patients between January 2011 and January 2014 of patients with out-of-hospital or ED cardiac arrest (CA) with an initial rhythm of ventricular fibrillation (VF) or ventricular tachycardia (VT) who received at least three defibrillation attempts, 300 mg of amiodarone, and 3 mg of adrenaline, and who remained in CA upon ED arrival. Patients who received esmolol during CA were compared to those who did not.

Results

90 patients had CA with an initial rhythm of VF or VT; 65 patients were excluded, leaving 25 for analysis. Six patients received esmolol during cardiac arrest, and nineteen did not. All patients had ventricular dysrhythmias refractory to many defibrillation attempts, including defibrillation after administration of standard ACLS medications. Most received high doses of adrenaline, amiodarone, and sodium bicarbonate. Comparing the patients that received esmolol to those that did not: 67% and 42% had temporary return of spontaneous circulation (ROSC); 67% and 32% had sustained ROSC; 66% and 32% survived to intensive care unit admission; 50% and 16% survived to hospital discharge; and 50% and 11% survived to discharge with a favorable neurologic outcome, respectively.

Conclusion

Beta-blockade should be considered in patients with RVF in the ED prior to cessation of resuscitative efforts.     

Double sequential defibrillation for refractory ventricular fibrillation

A 54-year-old suffered from an out-of-hospital cardiac arrest. Compressions were started within minutes and the patient was in refractory ventricular fibrillation despite multiple asynchronized shocks and maximal doses of antiarrhythmic agents. Double sequential defibrillation was attempted with successful Return Of Spontaneous Circulation (ROSC) after a total of 61 min of cardiac arrest. The patient was discharged home neurologically intact. Double sequential defibrillation could be a simple effective approach to patients with refractory ventricular fibrillation.     

The immediate life support course: implementation into an undergraduate nursing programme

Aim: The aim of this paper is to outline how the immediate life support (ILS) course was incorporated into an undergraduate nursing curriculum in a university in Northern Ireland. It also reports on how the students perceived the impact of this course on their clinical practice.
Rationale and Background: The rationale of the course was to develop the student's ability to recognize the acutely ill patient and to determine the relevance of this to clinical practice. Prior to this, the ILS course was only available to qualified nurses, and this paper reports on the first time undergraduate nursing students were provided with an ILS course.
Methods: The ILS course was delivered to 89 third-year nursing students from the adult branch pathway of the BSc (Hons) programme in Nursing Sciences. Each course was taught to 10–12 students and was completed over eight 7·5 h sessions within a 2-week period. Recognized advanced life support (ALS) instructors, in keeping with the UK Resuscitation Council guidelines, taught the students.
Results and Conclusion: Student feedback reported that the ILS course helped them understand what constituted the acutely ill patient and the role of the nurse in managing a deteriorating situation. Students also reported that they valued the experience as highlighting gaps in their knowledge.     

心脏呼吸骤停的临床抢救探讨

目的探讨心脏呼吸骤停患者实施心肺复苏的成功经验。方法对142例心脏呼吸骤停患者实施胸外心脏按压、人工呼吸、电击除颤、气管插管或气囊面罩、呼吸机械通气及心脏复苏药物应用,对复苏结果进行临床分析。结果复苏成功36例,25.35%,有效32例,总有效68例47.89%,死亡74例,占52.11%。结论心肺复苏(CPR)愈早,成功率越高。心室颤动的复苏成功率高于心室静止,及早电击除颤对挽救患者生命起着至关重要的作用。     

Variability in the assessment of advanced life support skills

The number of short 'life support' and emergency care courses available are increasing. Variability in examiner assessments has been reported previously in more traditional types of examinations but there is little data on the reliability of the assessments used on these newer courses. This study evaluated the reliability and consistency of instructor marking for the Resuscitation Council UK Advanced Life Support Course. Twenty five instructors from 15 centres throughout the UK were shown four staged video recorded defibrillation tests (one repeated) and three cardiac arrest simulation tests in order to assess inter-observer and intra-observer variability. These tests form part of the final assessment of competence on an Advanced Life Support course. Significant levels of variability were demonstrated between instructors with poor levels of agreement of 52-80% for defibrillation tests and 52-100% for cardiac arrest simulation tests. There was evidence of differences in the observation/recognition of errors and rating tendencies of instructors. Four instructors made a different pass/fail decision when shown defibrillation test 2 for a second time leading to only moderate levels of intra-observer agreement (kappa=0.43). In conclusion there is significant variability between instructors in the assessment of advanced life support skills, which may undermine the present assessment mechanisms for the advanced life support course. Validation of the assessment tools for the rapidly growing number of life support courses is required with urgent steps to improve reliability where required.