Research Interests:
Research Interests:
The Emergency Cardiac Care (ECC) Committee of the American Heart Association first published guidelines for cardiopulmonary resuscitation (CPR) and ECC in 1974.1 Updated in 1980, 1986, and 1992, the AHA guidelines are now recognized as... more
The Emergency Cardiac Care (ECC) Committee of the American Heart Association first published guidelines for cardiopulmonary resuscitation (CPR) and ECC in 1974.1 Updated in 1980, 1986, and 1992, the AHA guidelines are now recognized as the world’s most authoritative resuscitation guidelines.2 3 4 To implement these guidelines, however, hospitals need to establish a systems approach to in-hospital resuscitation rather than depend on the skills of individual professionals. The success and acceptance of the out-of-hospital Utstein-style recommendations5 led the AHA to help develop specific recommendations for documenting in-hospital resuscitation. The Utstein-style recommendations for uniform reporting of in-hospital resuscitations present important recommendations for all hospital facilities.6 With publication of these recommendations, members of the ECC Committee recognized the need to summarize the major actions that enable a hospital to fulfill the resuscitation recommendations. CPR is one of the few interventions that requires an order to not be administered. Resuscitation efforts, however, are not appropriate for all hospital patients. When indicated, healthcare providers discuss with patients, families, and surrogate decision-makers their options and preferences for resuscitation. Hospitals have in place clear policies that address medical futility, patient self-determination, and do-not-attempt-resuscitation orders. The chain of survival, first conceptualized for out-of-hospital sudden cardiac arrest,7 applies to in-hospital arrest as well.8 …
Research Interests: Medical Ethics, Medicine, Emergency Medical Services, Humans, Child, and 12 moreResuscitation, Clinical Sciences, Cardiopulmonary Resuscitation, Adult, Patient Care Team, Public health systems and services research, Circulation, Inpatients, Ventricular Fibrillation, quality assurance in health care, Heart arrest, and Cardiovascular medicine and haematology
Out-of hospital cardiac arrest accounts for more than 330,000 deaths annually in the United States and Canada. Despite regular updates of guidelines for the management of these arrests, the rate of survival has been stagnant at 7.6% for... more
Out-of hospital cardiac arrest accounts for more than 330,000 deaths annually in the United States and Canada. Despite regular updates of guidelines for the management of these arrests, the rate of survival has been stagnant at 7.6% for more than 30 years.1,2 In this issue of the Journal, the Resuscitation Outcomes Consortium reports the results of two randomized comparisons3,4 from the Prehospital Resuscitation Impedance Valve and Early Versus Delayed Analysis (ROC PRIMED) trial (ClinicalTrials.gov number, NCT00394706), which evaluated potential improvements in the management of out-of hospital cardiac arrest. The first component of the ROC PRIMED trial compared two . . .
Research Interests:
Background: Bystander CPR is provided in ~25% of out of hospital cardiac arrests in the US. To improve this low rate, the Save Hearts in Arizona Registry & Education program has initiated a multifaceted, statewide public chest... more
Background: Bystander CPR is provided in ~25% of out of hospital cardiac arrests in the US. To improve this low rate, the Save Hearts in Arizona Registry & Education program has initiated a multifaceted, statewide public chest compression only (CCO) CPR education campaign. It is unclear whether a statewide CCO-CPR campaign changes the intention of bystanders to perform CPR. It’s further unknown if this initiative affects willingness in populations with lowest survival and CPR performance. Objective: Evaluate the willingness to perform CPR, in various income demographics, following a statewide CPR intervention. Methods: Adult Arizona residents were surveyed at an academic medical center regarding performing CPR. They were asked their attitudes and feelings concerning performing CPR on strangers and family. Demographics were collected including age, gender, education, race and zip code which was used to incorporate census data for median income (separated as quartiles). Inclusion criteria were Arizona residents, age >18, and missing < 10% of survey data. CPR training was defined as CCO or formal CPR training. Results: Total of 1302 surveys were collected with a final population of 1163. Mean age was 40 yo (95% CI: 38.8, 40.5) with 44% males (95% CI: 41, 47). Willingness to perform CCO-CPR on strangers or family was high at 84% and 92%, respectively. However, when evaluated against median income, individuals in the lower income quartiles were less likely to perform CPR compared to higher quartiles for both strangers (77%; 95% CI 73, 82; P = 0.003) and family (90%; 95% CI 87, 94; P = 0.025). In these lower quartiles, a third as many individuals received training in CPR compared to the higher quartiles (p <0.001). Logistic regression analysis is being completed to evaluate this association in relation to race, education and other confounders. Conclusion: Public CPR interventions are effective in improving the willingness of bystanders to perform CPR. It is possible that CCO initiatives are not reaching the lowest quartile income populations which often have the lowest bystander CPR rates and highest mortality. Future CPR initiatives should be tailored to populations with highest mortality and who may not currently be receiving standard teaching initiatives.
Research Interests:
Research Interests:
Research Interests:
Patients who are successfully resuscitated following cardiac arrest often have a significant medical condition termed postresuscitation disease. This includes myocardial stunning, metabolic abnormalities and neurologic injury from global... more
Patients who are successfully resuscitated following cardiac arrest often have a significant medical condition termed postresuscitation disease. This includes myocardial stunning, metabolic abnormalities and neurologic injury from global ischemia. There are no clinical signs or diagnostic tests for 24-72 h to distinguish patients who will and will not recover neurologic function. Therapeutic hypothermia had been advocated for decades as a treatment to improve neurologic outcome after cardiac arrest. The early studies focused on moderate hypothermia, which was associated with complications and was not clearly beneficial. Over the past decade, studies have focused on mild hypothermia with target temperatures of 32-34 degrees C. Two recent multicentered, randomized, controlled trials have demonstrated improved neurologic outcome with mild therapeutic hypothermia applied to comatose survivors after cardiac arrest compared with a normothermic control group. As a result of these studies the International Liaison Committee on Resuscitation recommends that &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;Unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32 degrees C to 34 degrees C for 12 to 24 hours when the initial rhythm was ventricular fibrillation&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;. Mild therapeutic hypothermia should also be considered for patients with in-hospital arrest and asystole and pulseless electrical activity who are comatose after return of spontaneous circulation.
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
The effectiveness of ongoing cardiopulmonary resuscitation efforts is difficult to evaluate. Recent studies suggest that carbon dioxide excretion may be a useful noninvasive indicator of resuscitation from cardiac arrest. A prospective... more
The effectiveness of ongoing cardiopulmonary resuscitation efforts is difficult to evaluate. Recent studies suggest that carbon dioxide excretion may be a useful noninvasive indicator of resuscitation from cardiac arrest. A prospective clinical study was done to determine whether end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation could be used as a prognostic indicator of resuscitation and survival. Thirty-five cardiac arrests in 34 patients were monitored with capnometry during cardiopulmonary resuscitation during a 1-year period. Nine patients who were successfully resuscitated had higher average end-tidal carbon dioxide partial pressures during cardiopulmonary resuscitation than 26 patients who could not be resuscitated (15 +/- 4 vs 7 +/- 5 mm Hg). The 3 patients who survived to leave the hospital had a higher average end-tidal carbon dioxide partial pressure than the 32 nonsurvivors (17 +/- 6 vs 8 +/- 5 mm Hg). All 9 patients who were successfully resuscitated had an average end-tidal carbon dioxide partial pressure of 10 mm Hg or greater. No patient with an average end-tidal carbon dioxide partial pressure of less than 10 mm Hg was resuscitated. Data from this prospective clinical trial indicate that findings from end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation are correlated with resuscitation from and survival of cardiac arrest.
Research Interests:
Emergency medicine is a specially often confronted with ultimate crises; patients frequently present near death or in cardiac arrest. At the time of cardiopulmonary arrest, the emergency physician mobilizes all available resources to... more
Emergency medicine is a specially often confronted with ultimate crises; patients frequently present near death or in cardiac arrest. At the time of cardiopulmonary arrest, the emergency physician mobilizes all available resources to attempt to resuscitate the patient. This struggle is itself challenging. In addition, medical crises may raise difficult moral questions. A conflict is present when the resuscitation team questions whether the attempted resuscitations is warranted
Research Interests:
Research Interests:
Research Interests:
The effectiveness of ongoing cardiopulmonary resuscitation efforts is difficult to evaluate. Recent studies suggest that carbon dioxide excretion may be a useful noninvasive indicator of resuscitation from cardiac arrest. A prospective... more
The effectiveness of ongoing cardiopulmonary resuscitation efforts is difficult to evaluate. Recent studies suggest that carbon dioxide excretion may be a useful noninvasive indicator of resuscitation from cardiac arrest. A prospective clinical study was done to determine whether end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation could be used as a prognostic indicator of resuscitation and survival. Thirty-five cardiac arrests in 34 patients were monitored with capnometry during cardiopulmonary resuscitation during a 1-year period. Nine patients who were successfully resuscitated had higher average end-tidal carbon dioxide partial pressures during cardiopulmonary resuscitation than 26 patients who could not be resuscitated (15 +/- 4 vs 7 +/- 5 mm Hg). The 3 patients who survived to leave the hospital had a higher average end-tidal carbon dioxide partial pressure than the 32 nonsurvivors (17 +/- 6 vs 8 +/- 5 mm Hg). All 9 patients who were successfully resuscitated had an average end-tidal carbon dioxide partial pressure of 10 mm Hg or greater. No patient with an average end-tidal carbon dioxide partial pressure of less than 10 mm Hg was resuscitated. Data from this prospective clinical trial indicate that findings from end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation are correlated with resuscitation from and survival of cardiac arrest.
Research Interests:
Research Interests:
Research Interests:
Research Interests: Emergency Medicine, Medical Ethics, Resource Allocation, Medicine, Humans, and 14 moreBiomedical Research, Engineering Ethics, United States, Clinical Sciences, Codes of Ethics, Emergencies, Minors, Personal autonomy, Specialty, Patient selection, interprofessional relations, Tissue and organ procurement, Physician-Patient Relations, and withholding treatment
Research Interests:
59 Emergency and trauma medicine ethics Arthur B. Sanders A 25-year-old male is brought to the emergency department by medics at midnight on Saturday night after ... They say that it is futile to resuscitate elderly patients in nursing... more
59 Emergency and trauma medicine ethics Arthur B. Sanders A 25-year-old male is brought to the emergency department by medics at midnight on Saturday night after ... They say that it is futile to resuscitate elderly patients in nursing homs because such patients never survive. ...
Research Interests:
Research Interests: Medicine, Pregnancy, Preeclampsia, Anemia, HELLP Syndrome, and 4 moreNausea, Clinical Sciences, Gestation, and Vomiting
Research Interests:
Purpose Cost-avoidance studies of pharmacist interventions are common and often the first type of study conducted by investigators to quantify the economic impact of clinical pharmacy services. The purpose of this primer is to provide... more
Purpose Cost-avoidance studies of pharmacist interventions are common and often the first type of study conducted by investigators to quantify the economic impact of clinical pharmacy services. The purpose of this primer is to provide guidance for conducting cost-avoidance studies pertaining to clinical pharmacy practice. Summary Cost-avoidance studies represent a paradigm conceptually different from traditional pharmacoeconomic analysis. A cost-avoidance study reports on cost savings from a given intervention, where the savings is estimated based on a counterfactual scenario. Investigators need to determine what specifically would have happened to the patient if the intervention did not occur. This assessment can be fundamentally flawed, depending on underlying assumptions regarding the pharmacists’ action and the patient trajectory. It requires careful identification of the potential consequence of nonaction, as well as probability and cost assessment. Given the uncertainty of assumptions, sensitivity analyses should be performed. A step-by-step methodology, formula for calculations, and best practice guidance is provided. Conclusions Cost-avoidance studies focused on pharmacist interventions should be considered low-level evidence. These studies are acceptable to provide pilot data for the planning of future clinical trials. The guidance provided in this article should be followed to improve the quality and validity of such investigations.
Research Interests:
Diseases involving tissue reperfusion following ischemia are gaining significance in emergency medicine. The significance of reperfusion injury and the probable role of oxygen-derived free radicals has been described in many tissues,... more
Diseases involving tissue reperfusion following ischemia are gaining significance in emergency medicine. The significance of reperfusion injury and the probable role of oxygen-derived free radicals has been described in many tissues, particularly the heart. During myocardial reperfusion a burst of oxygen-derived free radicals overwhelms normal cellular defenses. These radicals may have several detrimental effects. They can oxidize lipids, leading to membrane dysfunction. They can also alter nucleic and other proteins. Cellular dysfunction and death may ensue. Prevention of oxygen-derived free radical injury appears possible and may be feasible for several disease processes, including myocardial reperfusion after infarction.
Research Interests:
Research Interests:
To determine characteristics motivating physicians to choose careers in academic and nonacademic emergency medicine. A written survey of 1,017 active members of the Society for Academic Emergency medicine and of a random sample of 2,000... more
To determine characteristics motivating physicians to choose careers in academic and nonacademic emergency medicine. A written survey of 1,017 active members of the Society for Academic Emergency medicine and of a random sample of 2,000 members of the American College of Emergency Physicians was performed. Questions were asked regarding medical school, residency, and fellowship training; the importance of specific factors in influencing career decisions; and perceived obstacles to emergency medicine research. Responses from nonfaculty and adjunct, clinical, and research faculty were compared using chi 2 analysis for discrete variables and a four-group analysis of variance for continuous variables. None. Responses were obtained from 1,203 physicians (41.3%). Those choosing academic careers were significantly more likely to complete a residency in emergency medicine or internal medicine and fellowship training in research or toxicology compared with nonacademic physicians. Nonfaculty and clinical faculty considered family obligations, leisure time, and personal income to be the most important factors influencing their career decisions; research faculty considered role models and the value of research to be most important. There was no difference in indebtedness among the groups. Finding time and funding, administrative obligations, and pressures to do clinical work were the most important obstacles to research productivity. Factors influencing career decisions can be used to plan strategies to meet the future needs of academic emergency medicine.
Research Interests:
Research Interests: Emergency Medicine, Educational Measurement, Medical Education, Problem Based Learning, Accreditation, and 14 moreMedicine, Curriculum, Clinical Practice, Humans, United States, Graduate medical education, Clinical Sciences, Educational Models, Core Competencies, Public health systems and services research, Clinical Competence, Core Competency, Training Program, and ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the in-hospital "Utstein style". A statement for health care professionals from the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the...more
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Purpose Cost-avoidance studies of pharmacist interventions are common and often the first type of study conducted by investigators to quantify the economic impact of clinical pharmacy services. The purpose of this primer is to provide... more
Purpose Cost-avoidance studies of pharmacist interventions are common and often the first type of study conducted by investigators to quantify the economic impact of clinical pharmacy services. The purpose of this primer is to provide guidance for conducting cost-avoidance studies pertaining to clinical pharmacy practice. Summary Cost-avoidance studies represent a paradigm conceptually different from traditional pharmacoeconomic analysis. A cost-avoidance study reports on cost savings from a given intervention, where the savings is estimated based on a counterfactual scenario. Investigators need to determine what specifically would have happened to the patient if the intervention did not occur. This assessment can be fundamentally flawed, depending on underlying assumptions regarding the pharmacists’ action and the patient trajectory. It requires careful identification of the potential consequence of nonaction, as well as probability and cost assessment. Given the uncertainty of ass...
Research Interests:
ObjectiveTo evaluate the effect of audio‐prompted rate guidance during chest compressions on the performance of cardiopulmonary resuscitation (CPR) on children.MethodsThis 24‐month prospective study occurred in the pediatric intensive... more
ObjectiveTo evaluate the effect of audio‐prompted rate guidance during chest compressions on the performance of cardiopulmonary resuscitation (CPR) on children.MethodsThis 24‐month prospective study occurred in the pediatric intensive care units of a university hospital and a children's hospital. Intubated children with nontraumatic cardiac arrest were eligible. After placement of an infrared capnometer between the endotracheal tube and resuscitation bag, an audiotape instructed the resuscitator to perform chest compressions at 100 per minute or 140 per minute for one minute, followed by another minute at the other rate. End‐tidal carbon dioxide partial pressure () was recorded prior to audiotape instruction and after one minute of CPR at each rate.ResultsSix patients, two boys and four girls, with a mean age of 15 ± 13 months (range 2‐36 months) were studied. All had asystole or pulseless electrical activity. CPR was provided for 14 ± 9 minutes prior to institution of the study...
Research Interests: Carbon Dioxide, Medicine, Prospective studies, Humans, Female, and 13 moreResuscitation, Male, Anesthesia, Infant, Clinical Sciences, Cardiopulmonary Resuscitation, Public health systems and services research, Lung Volume Measurements, Cross-Over Studies, Asystole, Tape Recording, Capnography, and Child preschool
### Background Children who require basic life support (BLS) and advanced life support (ALS) interventions account for 5% to 10% of all ambulance runs and approximately one quarter of emergency department visits in the United States. The... more
### Background Children who require basic life support (BLS) and advanced life support (ALS) interventions account for 5% to 10% of all ambulance runs and approximately one quarter of emergency department visits in the United States. The principles, equipment, and drugs used for pediatric BLS and ALS are similar to those used for adults. However, the care of seriously ill or injured children requires specific knowledge of pediatric anatomy, physiology, and psychology plus practical pediatric expertise. ### Key Interventions to Prevent Arrest In infants and children, respiratory distress and failure is a much more common cardiac arrest etiology than sudden dysrhythmia or ventricular fibrillation. As a result, hypoxia, hypercarbia, and global ischemia often precede cardiac arrest. Critical organ perfusion is dependent on more rapid heart and respiratory rates than for adults. Therefore, additional attention is focused on early recognition and intervention for respiratory failure and shock, and less emphasis is placed on rapid early defibrillation than for adult cardiac arrest victims. ### BLS and ALS Interventions During Arrest Commentary on the specific application of BLS and ALS principles to pediatric patients is contained in the accompanying ILCOR pediatric advisory statements. 1. Tsai A, Kallsen G. Epidemiology of pediatric prehospital care. Ann Emerg Med . 1987;16:284-292. 2. Cummins RO, ed. Textbook of Advanced Cardiac Life Support. Dallas, Tex: American Heart Association; 1994:60-68. 3. Zaritsky A, Nadkarni V, Getson P, Kuehl K. CPR in children. Ann Emerg Med . 1987;16:1107-1111. ### Background Cardiac arrest due to electrolyte abnormalities is uncommon except in the case of hyperkalemia. Electrolyte concentrations change during cardiac arrest due to the rapidly changing acid-base status, catecholamine levels, and hypoxia. These changes do not require intervention unless the cardiac arrest is primarily caused by the electrolyte abnormality. ### Key Interventions to Prevent Arrest
Research Interests:
Most adults who can be saved from cardiac arrest are in ventricular fibrillation (VF) or pulseless ventricular tachycardia. Electrical defibrillation provides the single most important therapy for the treatment of these patients.... more
Most adults who can be saved from cardiac arrest are in ventricular fibrillation (VF) or pulseless ventricular tachycardia. Electrical defibrillation provides the single most important therapy for the treatment of these patients. Resuscitation science therefore places great emphasis on early defibrillation. The greatest chances of survival result when the interval between the start of VF and the delivery of defibrillation is as brief as possible. To achieve the earliest possible defibrillation, the International Liaison Committee on Resuscitation (ILCOR) endorses the concept that in many settings nonmedical individuals should be allowed and encouraged to use defibrillators. ILCOR recommends that resuscitation personnel be authorized, trained, equipped, and directed to operate a defibrillator if their professional responsibilities require them to respond to persons in cardiac arrest. This recommendation includes all first-responding emergency personnel, in both the hospital and out-of-hospital settings, whether physicians, nurses, or nonmedical ambulance personnel. The widespread availability of automated external defibrillators (AEDs) provides the technological capacity for early defibrillation by both ambulance crews and lay responders. ILCOR urges the medical profession to strive to increase the awareness of the public and of those responsible for emergency medical …
Research Interests:
Valid scientific evidence supports only three interventions as unequivocally effective in adult cardiac resuscitation: The universal algorithm presents these interventions simplistically and recommends a specific sequence that rescuers... more
Valid scientific evidence supports only three interventions as unequivocally effective in adult cardiac resuscitation: The universal algorithm presents these interventions simplistically and recommends a specific sequence that rescuers should follow. The sequence of interventions is based, whenever possible, on sound scientific information. But there is a paucity of convincing human data on some aspects of resuscitation. Until such time as new information becomes available, the working group made no changes to well-established procedures but suggested some modifications on educational rather than scientific grounds. Cardiac arrest rhythms can be divided into two subsets: ventricular fibrillation/pulseless ventricular tachycardia (VF/VT) and non-VF/VT. Non-VF/VT incorporates both asystole and pulseless electrical activity (PEA). The only difference in management between the two arrest rhythms is the need for rescuers to perform defibrillation for patients in VF/VT. Otherwise the actions and interventions are essentially the same: basic CPR, tracheal intubation, epinephrine administration, and correction of reversible causes. …
Research Interests: Algorithms, Medicine, Algorithm, First Aid, Emergency Medical Services, and 9 moreHumans, Epinephrine, Clinical Sciences, Cardiopulmonary Resuscitation, Public health systems and services research, Circulation, Airway Obstruction, Ventricular Fibrillation, and Cardiovascular medicine and haematology
Research Interests:
Research Interests:
We conducted a study to determine the number of items and successful response rate to questions specific to emergency medicine on the National Board of Medical Examiners Test, Part II (NBME-II). The 1979 and 1983 NBME-II examinations were... more
We conducted a study to determine the number of items and successful response rate to questions specific to emergency medicine on the National Board of Medical Examiners Test, Part II (NBME-II). The 1979 and 1983 NBME-II examinations were reviewed by a subcommittee of the Society of Teachers of Emergency Medicine. Items pertaining directly to the core content knowledge base were selected and classified by core content topic and NBME subspecialty. Overall, 14.7% of the 892 items on the 1983 examination pertained to emergency medicine. The successful response rate was 73.3% for the emergency medicine questions. When looked at by sub-specialty categories, the percentage of items pertaining to emergency medicine varied from 1.3% in obstetrics/gynecology to 27.2% of the items in surgery. On the 1979 examination, 13.8% of the questions pertained to emergency medicine, with a successful response rate of 67.1%. Analysis of the data by core content topic showed that some areas (orientation to emergency medicine, ophthalmologic diseases, environmental emergencies, and behavioral emergencies) had two items or fewer on both examinations. Other topics, such as trauma, showed a consistent pattern of questions on both examinations. Our study emphasizes the difficulty of attempting to test competency in the clinical knowledge base of medicine within the artificiality of knowledge base departmental boundaries.
Research Interests:
To determine the status of undergraduate education in emergency medicine, questionnaires were sent to 141 medical schools. Of the 135 schools responding, 15.2% require emergency medicine courses in the fourth year (mean, 164 hours); 11.9%... more
To determine the status of undergraduate education in emergency medicine, questionnaires were sent to 141 medical schools. Of the 135 schools responding, 15.2% require emergency medicine courses in the fourth year (mean, 164 hours); 11.9% require these courses (average, 84 hours) in the third year. Emergency medicine is offered in 21.8% of second-year and 37.9% of first-year curriculums. Training in cardiopulmonary resuscitation is offered in 96% of the schools responding, and certification is required in 53%. Training in advanced cardiac life support is offered in 73% of schools, with 23% requiring it for graduation. Training in advanced trauma life support is offered in 17.2% of schools. Osteopathic schools require more time for emergency medicine in the clinical years but less time in formal lectures. Schools with a residency program in emergency medicine more frequently offer emergency medicine in the preclinical years. This survey provides some basic data on the status of undergraduate emergency medicine education in medical school curriculums, and it encourages medical educators to review the undergraduate curriculum to ensure that students receive adequate exposure to the essentials of emergency medicine.