Doppler ultrasound peak systolic velocity versus end tidal carbon dioxide during pulse checks in cardiac arrest.

BACKGROUND: An accurate, non-invasive measure of return of spontaneous circulation (ROSC) is needed to improve management of cardiac arrest patients. OBJECTIVES: During a pulse check in Emergency Department (ED) cardiac arrest patients, we compared the correlation between 1) end tidal carbon dioxide (ETCO2) and systolic blood pressure (SBP), and 2) Doppler ultrasound peak systolic velocity (PSV) and SBP. Additionally, we assessed the accuracy of PSV ≥ 20 cm/sec in comparison to previously suggested ETCO2 ≥ 20 or ≥ 25 mmHg thresholds to predict ROSC with SBP ≥ 60 mmHg. METHODS: This was a secondary analysis of a previously published prospective observational study of ED cardiac arrest patients with an advanced airway and femoral arterial line in place. During each pulse check, highest SBP, highest PSV, and ETCO2 at the end of the pulse check were recorded. Spearman correlation coefficients were calculated and compared using a Fisher Z-transformation. Accuracy of previously determined PSV and ETCO2 thresholds for detecting ROSC with SBP ≥ 60 mmHg were compared using McNemar's tests. RESULTS: Based on data from 35 patients with 111 pulse checks, we found a higher correlation between PSV and SBP than ETCO2 and SBP (0.71 vs 0.31; p < 0.001). Diagnostic accuracy of PSV ≥ 20 cm/sec for detecting ROSC with SBP ≥ 60 mmHg was 89% (95% CI: 82%-94%) versus 59% (95% CI: 49%-68%) and 58% (95% CI: 48%-67%) for ETCO2 ≥ 20 and ≥ 25 mmHg, respectively. CONCLUSIONS: During a pulse check, Doppler ultrasound PSV outperformed ETCO2 for correlation with SBP and accuracy in detecting ROSC with SBP ≥ 60 mmHg.

Emergency Medical Services handoff of patients in cardiac arrest in the Emergency Department: A retrospective video review study of duration and details of handoff.

STUDY OBJECTIVES: We aimed to evaluate the duration and frequency of communication between EMS (Emergency Medical Services) and ED (Emergency Department) staff during handoff and the subsequent time to critical cardiac care (rhythm determination, defibrillation) using CA (cardiac arrest) video review. METHODS: A single-center retrospective study of video-recorded adult CAs between August 2020 and December 2022 was performed. Two investigators assessed the communication of 17 data points, time intervals, EMS initiation of handoff, and type of EMS agency. Median times from initiation of handoff to first ED rhythm determination and defibrillation were compared between the groups above versus below the median number of data points communicated. RESULTS: Overall, 95 handoffs were reviewed. The handoff was initiated in a median of 2 seconds (interquartile range (IQR) 0-10) after arrival. EMS initiated handoff in 65 (69.2%) patients. The median number of data points communicated was 9 and median duration was 66 seconds (IQR 50-100). Age, location of arrest, estimated down time, and medications administered were communicated > 80% of the time, initial rhythm 79%, and bystander cardiopulmonary resuscitation and witnessed arrest < 50%. The median times from initiation of handoff to first ED rhythm determination and defibrillation were 188 (IQR 106-256) and 392 (IQR 247-725) seconds, though not statistically different between handoffs with <9 vs. ≥9 data points communicated (p > 0.40). CONCLUSION: There is no standardization for handoff reports from EMS to ED staff for CA patients. Using video review, we demonstrated the variable communication during handoff. Improvements to this process could reduce the time to critical cardiac care interventions.

Femoral artery Doppler ultrasound is more accurate than manual palpation for pulse detection in cardiac arrest.

OBJECTIVES: Our primary objective was to assess the accuracy of Doppler ultrasound versus manual palpation in detecting any pulse with an arterial line waveform in cardiac arrest. Secondarily, we sought to determine whether peak systolic velocity (PSV) on Doppler ultrasound could detect a pulse with a systolic blood pressure (SBP) ≥ 60 mmHg. METHODS: We conducted a prospective, cross-sectional, diagnostic accuracy study on a convenience sample of adult, Emergency Department (ED) cardiac arrest patients. All patients had a femoral arterial line. During a pulse check, manual pulse detection, PSV and Doppler ultrasound clips, and SBP were recorded. A receiver operator characteristic curve analysis was performed to determine the optimal cut-off of PSV associated with a SBP ≥ 60 mmHg. Accuracy of manual palpation and Doppler ultrasound for detection of any pulse and SBP ≥ 60 mmHg were compared with McNemar's test. RESULTS: 54 patients and 213 pulse checks were analysed. Doppler ultrasound demonstrated higher accuracy than manual palpation (95.3% vs. 54.0%; p < 0.001) for detection of any pulse. Correlation between PSV and SBP was strong (Spearman correlation coefficient = 0.89; p < 0.001). The optimal cut-off value of PSV associated with a SBP ≥ 60 mmHg was 20 cm/s (area under the curve = 0.975). To detect SBP ≥ 60 mmHg, accuracy of a PSV ≥ 20 cm/s was higher than manual palpation (91.4% vs. 66.2%; p < 0.001). CONCLUSIONS: Among ED cardiac arrest patients, femoral artery Doppler ultrasound was more accurate than manual palpation for detecting any pulse. When using a PSV ≥ 20 cm/s, Doppler ultrasound was also more accurate for detecting a SBP ≥ 60 mmHg.

A descriptive analysis of obstacles to fulfilling the end of life care goals among cardiac arrest patients.

BACKGROUND AND OBJECTIVES: Performing cardiopulmonary resuscitation (CPR) on cardiac arrest patients with Do Not Resuscitate (DNR) orders does not respect patients' autonomy. We aimed to 1) determine the frequency of patients who wished to be DNR prior to cardiac arrest; 2) determine what proportion received CPR; and 3) explain why DNR patients received CPR. METHODS: This was a retrospective chart review study of cardiac arrest patients at an emergency department. We reported the frequency and proportion of patients who 1) had valid DNR orders presented at the time of cardiac arrest; 2) had valid DNR orders that were unavailable at the time of arrest 3) had Advanced Directives but no DNR orders; 4) had their DNR orders rescinded; and 5) wished to be DNR but did not have any documents in place. RESULTS: Of 419 patients, 65 (15.51%) wished to be DNR. Out of these 65 patients, 38 (58.46 %) patients were resuscitated. Among the 38 patients, 23 (60.52%) received CPR accordingly and 15 (39.47%) patients were inappropriately resuscitated. CONCLUSION: In our sample of 419 patients, 65 (15.51%) did not want CPR in the event of cardiac arrest and 38 (9.06%) received CPR against their wishes. This was due to failure to document DNR orders, lack of recognition of documented valid DNR orders, and use of non-actionable Advanced Directives to relay patients' wishes.

Video laryngoscopy is associated with improved first-pass intubation success compared with direct laryngoscopy in emergency department trauma patients.

OBJECTIVE: We aimed to assess differences in (1) first-pass intubation success, (2) frequency of a hypoxic event, and (3) time from decision to intubate to successful intubation among direct laryngoscopy (DL) versus video laryngoscopy (VL) intubations in emergency department (ED) patients with traumatic injuries. METHODS: This retrospective cohort study was performed at a Level I trauma center ED where trauma activations are video recorded. All patients requiring a Level I trauma activation and intubation from 2016 through 2019 were included. Multivariable logistic regression was used to assess the association between initial method of intubation and first-pass success. Differences in frequency of a hypoxic event and time to successful intubation were assessed using bivariate tests. RESULTS: Of 164 patients, 68 (41.5%) were initially intubated via DL and 96 (58.5%) were initially intubated via VL. First-pass success for DL and VL were 63.2% and 79.2%, respectively. In multivariable regression analysis, VL was associated with higher odds of first-pass intubation success compared with DL (odds ratio: 2.28; 95% confidence interval: 1.04, 4.98), independent of mechanism of injury, presence of airway hemorrhage or obstruction, and experience of intubator. Frequency of a hypoxic event during intubation was not significantly different (13.2% for DL and 7.3% VL; P = 0.1720). Median time from decision to intubate to successful intubation was 7 minutes for both methods. CONCLUSIONS: Video laryngoscopy, compared with direct laryngoscopy, was associated with higher odds of first-pass intubation success among a sample of ED trauma patients. Frequency of a hypoxic event during intubation and time to successful intubation was not significantly different between the 2 intubation methods.

Performance of Emergency Heart Failure Mortality Risk Grade in the Emergency Department.

INTRODUCTION: The purpose of this study was to validate and assess the performance of the Emergency Heart Failure Mortality Risk Grade (EHMRG) to predict seven-day mortality in US patients presenting to the emergency department (ED) with acute congestive heart failure (CHF) exacerbation. METHODS: We performed a retrospective chart review on patients presenting to the ED with acute CHF exacerbation between January 2014-January 2016 across eight EDs in New York. We identified patients using codes from the International Classification of Diseases, 9th and 10 Revisions, or who were diagnosed with CHF in the ED. Inclusion criteria were patients ≥ 18 years of age who presented to the ED for acute CHF. Exclusion criteria included the following: end-stage renal disease related heart failure; < 18 years of age; pregnancy; palliative care; renal failure; and "do not resuscitate" directive. The primary outcome was seven-day mortality. We used mixed-effects logistic regression models to estimate C-statistics and continuous net reclassification index for events and nonevents. RESULTS: We identified 3,320 ED visits associated with suspected CHF among 2,495 unique patients. Of the 3,320 ED visits, 94.7% patients were admitted to the hospital and 3.4% were discharged. The median age was 78.6 (interquartile range 68.01 - 86.76). There was an overall seven-day mortality of 2%, an inpatient mortality rate of 2.4%, and no mortality among the discharge group. Adding EHMRG to the risk prediction model improved the C-statistic (from 0.748 to 0.772) and led to a higher degree of reclassification for both events and nonevents. CONCLUSION: The EHMRG can be used as a valuable and effective screening tool in the US while considering disposition decision for patients with acute CHF exacerbation. Emergency medical services transport and metolazone use is much higher in the US population as compared to the Canadian population. We observed minimal to no short-term mortality among discharged CHF patients from the ED.

Mechanical, Team-Focused, Video-Reviewed Cardiopulmonary Resuscitation Improves Return of Spontaneous Circulation After Emergency Department Implementation.

Background Outcomes in cardiac arrest remain suboptimal. Mechanical cardiopulmonary resuscitation (CPR) has not demonstrated clear clinical benefit; however, video review provides the capability to monitor CPR quality and provide constructive feedback to individuals and teams to improve their performance. The aim of our study was to evaluate cardiac arrest outcomes before and after initiation of a mechanical, team-focused, video-reviewed CPR intervention. Methods and Results In 2018, our emergency department began using mechanical CPR; a new team-focused strategy with nurse-led Advanced Cardiovascular Life Support; and biweekly, multidisciplinary video review of cardiac arrests. A revised approach to resuscitation was generated from a performance improvement session, and in situ simulation was used to disseminate our approach. The primary outcome of this study was the return of spontaneous circulation rate before and after our mechanical, team-focused, video-reviewed CPR intervention. Secondary outcomes included survival to admission and discharge. Multivariable logistic regression modeling was used. The pre- and postintervention groups were similar at baseline. A total of 248 patients were included in our study (97 before and 151 after mechanical, team-focused, video-reviewed CPR). Return of spontaneous circulation was higher in the intervention group (41% versus 26%; P=0.014). There were nonsignificant increases in survival to admission (26% versus 20%; P=0.257) and survival to discharge (7% versus 3%; P=0.163). After controlling for covariates, the odds of return of spontaneous circulation remained higher after the intervention (odds ratio, 2.11; 95% CI, 1.14-3.89). Conclusions Implementation of our mechanical, team-focused, video-reviewed CPR intervention for cardiac arrest patients in our emergency department improved return of spontaneous circulation rates. Survival to hospital admission and discharge did not improve.