A Rapid Response Mobile Application Improves First-Year Resident Clinical Performance During Simulated Care Events: A Randomized Controlled Trial.

BACKGROUND: Rapid response teams (RRTs) are critical to the timely and appropriate management of acutely decompensating patients. In the academic setting, the vital role of RRT leader is often filled by a junior resident physician who may lack the necessary medical knowledge and experience. Cognitive aids help improve guideline adherence and may support resident performance as they transition into leadership roles. OBJECTIVE: This study evaluated the impact of a rapid response mobile application on intern performance during simulated rapid response events. DESIGN: This randomized controlled trial compared the performance of interns in two simulated rapid response scenarios with and without access to the rapid response mobile application. The scenarios included anaphylaxis and supraventricular tachycardia (SVT). Simulations were video recorded and coded by trained raters. PARTICIPANTS: Interns in all specialties at our institution. MAIN MEASURES: Outcomes included (1) time to ordering critical medications (epinephrine and adenosine), (2) overall clinical performance using a checklist-based performance measure, and (3) usability of the mobile application. Enrollment and data collection occurred between November 2022 and February 2023. KEY RESULTS: Forty-four interns from 12 specialties were randomized to the intervention group (N = 22) and the control group (N = 22). Time to order critical medications was significantly reduced in the intervention group compared to control for anaphylaxis (P < 0.005) and SVT (P < 0.005). The intervention group had significantly higher performance scores compared to the control group for the anaphylaxis portion (P < 0.006). Usability scores for the rapid response toolkit were good. CONCLUSIONS: Access to a rapid response mobile application improved the quality of care administered by interns during two simulated rapid response scenarios as determined by a decrease in time to ordering critical medications and improved performance scores. The intervention group found the mobile application to be usable. This work adds to existing literature supporting the use of technology-based cognitive aids to improve patient care.

Inflammation, endothelial injury, and the acute respiratory distress syndrome after out-of-hospital cardiac arrest.

Background: Acute respiratory distress syndrome (ARDS) is often seen in patients resuscitated from out-of-hospital cardiac arrest (OHCA). We aim to test whether inflammatory or endothelial injury markers are associated with the development of ARDS in patients hospitalized after OHCA. Methods: We conducted a prospective, cohort, pilot study at an urban academic medical center in 2019 that included a convenience sample of adults with non-traumatic OHCA. Blood and pulmonary edema fluid (PEF) were collected within 12 hours of hospital arrival. Samples were assayed for cytokines (interleukin [IL]-1, tumor necrosis factor-α [TNF-α], tumor necrosis factor receptor1 [TNFR1], IL-6), epithelial injury markers (pulmonary surfactant-associated protein D), endothelial injury markers (Angiopoietin-2 [Ang-2] and glycocalyx degradation products), and other proteins (matrix metallopeptidase-9 and myeloperoxidase). Patients were followed for 7 days for development of ARDS, as adjudicated by 3 blinded reviewers, and through hospital discharge for mortality and neurological outcome. We examined associations between biomarker concentrations and ARDS, hospital mortality, and neurological outcome using multivariable logistic regression. Latent phase analysis was used to identify distinct biological classes associated with outcomes. Results: 41 patients were enrolled. Mean age was 58 years, 29% were female, and 22% had a respiratory etiology for cardiac arrest. Seven patients (17%) developed ARDS within 7 days. There were no significant associations between individual biomarkers and development of ARDS in adjusted analyses, nor survival or neurologic status after adjusting for use of targeted temperature management (TTM) and initial cardiac arrest rhythm. Elevated Ang-2 and TNFR-1 were associated with decreased survival (RR = 0.6, 95% CI = 0.3-1.0; RR = 0.5, 95% CI = 0.3-0.9; respectively), and poor neurologic status at discharge (RR = 0.4, 95% CI = 0.2-0.8; RR = 0.4, 95% CI = 0.2-0.9) in unadjusted associations. Conclusion: OHCA patients have markedly elevated plasma and pulmonary edema fluid biomarker concentrations, indicating widespread inflammation, epithelial injury, and endothelial activation. Biomarker concentrations were not associated with ARDS development, though several distinct biological phenotypes warrant further exploration. Latent phase analysis demonstrated that patients with low biomarker levels aside from TNF-α and TNFR-1 (Class 2) fared worse than other patients. Future research may benefit from considering other tools to predict and prevent development of ARDS in this population.

Checklists and consistency of care after resuscitation from in-hospital cardiac arrest: A pilot study.

BACKGROUND: In-hospital cardiac arrest (IHCA) with the return of spontaneous circulation (ROSC) is a clinical scenario associated with potentially devastating outcomes. OBJECTIVE: Inconsistencies in post-ROSC care exist and we sought to find a low cost way to decrease this variability. DESIGNS, SETTINGS, AND PARTICIPANTS: We obtained pre and post intervention metrics including percentage of IHCA with a timely electrocardiogram (ECG), arterial blood gas (ABG), physician documentation, and documentation of patient surrogate communication after ROSC. INTERVENTION: We developed and implemented a post-ROSC checklist for IHCA and measured post-ROSC clinical care delivery metrics at our hospital during a 1-year pilot period. MAIN OUTCOME AND RESULTS: After the introduction of the checklist, 83.7% of IHCA had an ECG within 1 h of ROSC, compared to a baseline of 62.8% (p = 0.01). The rate of physician documentation within 6 h of ROSC was 74.4% after introduction of the checklist, compared to a baseline of 49.5% (p < 0.01). The percentage of IHCA with ROSC that completed all four of the critical post-ROSC tasks after the introduction of the post-ROSC checklist was 51.1% as compared to 19.4% before implementation (p < 0.01). CONCLUSIONS: Our study demonstrated improved consistency in completing post-ROSC clinical tasks after the introduction of a post-ROSC checklist to our hospital. This work suggests that the implementation of a checklist can have meaningful impacts on task completion in the post-ROSC setting. Despite this, considerable inconsistencies in post-ROSC care persisted after the intervention indicating the limits of checklists in this setting. Future work is needed to identify interventions that can further improve post-ROSC processes of care.

Diagnostic yield, safety, and outcomes of Head-to-pelvis sudden death CT imaging in post arrest care: The CT FIRST cohort study.

AIM: Our aim was to test whether a head-to-pelvis CT scan improves diagnostic yield and speed to identify causes for out of hospital circulatory arrest (OHCA). METHODS: CT FIRST was a prospective observational pre-/post-cohort study of patients successfully resuscitated from OHCA. Inclusion criteria included unknown cause for arrest, age >18 years, stability to undergo CT, and no known cardiomyopathy or obstructive coronary artery disease. A head-to-pelvis sudden death CT (SDCT) scan within 6 hours of hospital arrival was added to the standard of care for patients resuscitated from OHCA (post-cohort) and compared to standard of care (SOC) alone (pre-cohort). The primary outcome was SDCT diagnostic yield. Secondary outcomes included time to identifying OHCA cause and time-critical diagnoses, SDCT safety, and survival to hospital discharge. RESULTS: Baseline characteristics between the SDCT (N = 104) and the SOC (N = 143) cohorts were similar. CT scans (either head, chest, and/or abdomen) were ordered in 74 (52%) of SOC patients. Adding SDCT scanning identified 92% of causes for arrest compared to 75% (SOC-cohort; p value < 0.001) and reduced the time to diagnosis by 78% (SDCT 3.1 hours, SOC alone 14.1 hours, p < 0.0001). Identification of critical diagnoses was similar between cohorts, but SDCT reduced delayed (>6 hours) identification of critical diagnoses by 81% (p < 0.001). SDCT safety endpoints were similar including acute kidney injury. Patient survival to discharge was similar between cohorts. DISCUSSION: SDCT scanning early after OHCA resuscitation safely improved the efficiency and diagnostic yield for causes of arrest compared to the standard of care alone. CLINICAL TRIALS NUMBER: NCT03111043.

A Description of Mechanically Ventilated Patients Admitted From the Emergency Department With a Short Critical Care Stay.

BACKGROUND: Patients admitted to an intensive care unit (ICU) requiring invasive mechanical ventilation who are discharged alive from the ICU within 24 h are poorly characterized in the literature. OBJECTIVE: Our aim was to characterize a cohort of intubated emergency department (ED) patients who are extubated and discharged from the ICU within 24 h. METHODS: We conducted a retrospective, observational cohort study at a single level I trauma center from January 2017 to December 2019. We included adults who were admitted to an ICU from the ED requiring invasive mechanical ventilation. Our primary outcome was the proportion of patients who were discharged from the ICU alive within 24 h. RESULTS: Of 13,374 ED patients admitted to an ICU during the study period, 2871 patients were intubated and ventilated in the prehospital or ED settings. Of these, 14% were discharged alive from the ICU within 24 h of admission. Only 21% of these patients were intubated in the ED. We identified the following two distinct subpopulations comprising 62% of this short-stay group: patients with a primary discharge diagnosis of intoxication (47%) and minimally injured trauma patients (53%), with 4% of patients in both subgroups. CONCLUSIONS: A total of 14% of patients receiving intubation with mechanical ventilation in the prehospital environment or in the ED were discharged alive from the ICU within 24 h. We identified two distinct subgroups of patients with a short stay in intensive care who may be candidates for ED extubation, including patients with intoxication and minimally injured trauma patients.

Scoping review of echocardiographic parameters associated with diagnosis and prognosis after resuscitated sudden cardiac arrest.

AIM: Current international guidelines recommend early echocardiography after resuscitated sudden death despite limited data. Our aim was to analyze published data on early post-resuscitation echocardiography to identify cardiac causes of sudden death and prognostic implications. METHODS: We reviewed MEDLINE, EMBASE, and CENTRAL databases to December 2021 for echocardiographic studies of adult patients after resuscitation from non-traumatic sudden death. Studies were included if echocardiography was performed <48 hours after resuscitation and reported (1) diagnostic accuracy to detect cardiac etiologies of sudden death or (2) prognostic outcomes. Diagnostic endpoints were associations of regional wall motion abnormalities (RWMA), ventricular function, and structural abnormalities with cardiac etiologies of arrest. Prognostic endpoints were associations of echocardiographic findings with survival to hospital discharge and favorable neurological outcome. RESULTS: Of 2877 articles screened, 16 (0.6%) studies met inclusion criteria, comprising 2035 patients. Two of six studies formally reported diagnostic accuracy for echocardiography identifying cardiac etiology of arrest; RWMA (in 5 of 6 studies) were associated with presumed cardiac ischemia in 17-89% of cases. Among 12 prognostic studies, there was no association of reduced left ventricular ejection fraction with hospital survival (v10) or favorable neurologic status (n = 5). Echocardiographic high mitral E/e' ratio (n = 1) and right ventricular systolic dysfunction (n = 2) were associated with poor survival. CONCLUSION: This scoping review highlights the limited data on early echocardiography in providing etiology of arrest and prognostic information after resuscitated sudden death. Further research is needed to refine the clinical application of early echocardiographic findings in post arrest care.

Factors Associated with Early Withdrawal of Life-Sustaining Treatments After Out-of-Hospital Cardiac Arrest: A Subanalysis of a Randomized Trial of Prehospital Therapeutic Hypothermia.

BACKGROUND: The objective of this study is to describe incidence and factors associated with early withdrawal of life-sustaining therapies based on presumed poor neurologic prognosis (WLST-N) and practices around multimodal prognostication after out-of-hospital cardiac arrest (OHCA). METHODS: We performed a subanalysis of a randomized controlled trial assessing prehospital therapeutic hypothermia in adult patients admitted to nine hospitals in King County with nontraumatic OHCA between 2007 and 2012. Patients who underwent tracheal intubation and were unconscious following return of spontaneous circulation were included. Our outcomes were (1) incidence of early WLST-N (WLST-N within < 72 h from return of spontaneous circulation), (2) factors associated with early WLST-N compared with patients who remained comatose at 72 h without WLST-N, (3) institutional variation in early WLST-N, (4) use of multimodal prognostication, and (5) use of sedative medications in patients with early WLST-N. Analysis included descriptive statistics and multivariable logistic regression. RESULTS: We included 1,040 patients (mean age was 65 years, 37% were female, 41% were White, and 44% presented with arrest due to ventricular fibrillation) admitted to nine hospitals. Early WLST-N accounted for 24% (n = 154) of patient deaths and occurred in half (51%) of patients with WLST-N. Factors associated with early WLST-N in multivariate regressions were older age (odds ratio [OR] 1.02, 95% confidence interval [CI]: 1.01-1.03), preexisting do-not-attempt-resuscitation orders (OR 4.67, 95% CI: 1.55-14.01), bilateral absent pupillary reflexes (OR 2.4, 95% CI: 1.42-4.10), and lack of neurological consultation (OR 2.60, 95% CI: 1.52-4.46). The proportion of patients with early WLST-N among all OHCA admissions ranged from 19-60% between institutions. A head computed tomography scan was obtained in 54% (n = 84) of patients with early WLST-N; 22% (n = 34) and 5% (n = 8) underwent ≥ 1 and ≥ 2 additional prognostic tests, respectively. Prognostic tests were more frequently performed when neurological consultation occurred. Most patients received sedating medications (90%) within 24 h before early WLST-N; the median time from last sedation to early WLST-N was 4.2 h (interquartile range 0.4-15). CONCLUSIONS: Nearly one quarter of deaths after OHCA were due to early WLST-N. The presence of concerning neurological examination findings appeared to impact early WLST-N decisions, even though these are not fully reliable in this time frame. Lack of neurological consultation was associated with early WLST-N and resulted in underuse of guideline-concordant multimodal prognostication. Sedating medications were often coadministered prior to early WLST-N and may have further confounded the neurological examination. Standardizing prognostication, restricting early WLST-N, and a multidisciplinary approach including neurological consultation might improve outcomes after OHCA.

Positive predictive value of a sepsis-screening protocol for patients with tetraplegia.

OBJECTIVE: To determine the positive predictive value (PPV) of a sepsis-screening protocol in patients with cervical spinal cord injury (SCI). DESIGN/METHOD: Retrospective review of all patients with cervical SCI who screened positive for two or more systemic inflammatory response syndrome (SIRS) criteria while hospitalized in acute care or inpatient rehabilitation units over a 3.5-year period. Sepsis was defined by the occurrence of (1) any culture order followed by an intravenous (IV) antibiotic within 72 hours or (2) an IV antimicrobial followed by a culture order within 24 hours. RESULTS: A total of 134 patients screened positive for two or more SIRS criteria. Of these, 36 patients (26.9%) were diagnosed with sepsis. Factors associated with a true-positive SIRS screen on multivariable analysis included American Spinal Injury Association Impairment Scale (AIS) grade A-C (vs. D; p < .001). The PPV of the screen was 38% in patients with AIS A-C and 9% in patients with AIS D. Altered mental status (AMS) was strongly associated with a diagnosis of sepsis; 16 of 18 (88.9%) of those with AMS had sepsis (p < .001). Age, sex, and neurologic level of injury were not associated with true-positive screening. For patients with new SCI, the first true-positive screen occurred a median of 31 days post-injury. The most common SIRS criteria combinations in patients with true-positive screens were elevated heart rate and either abnormal white blood cell count (43% of true positives) or abnormal temperature (26% of true positives). Abnormally low body temperature (<36°C) contributed to false-positive screening for 10 of 38 (26%) AIS D patients who screened positive. CONCLUSION: Sepsis screening using SIRS criteria in hospitalized patients with tetraplegia has a PPV of 26.9%; it is significantly higher in patients with AIS A-C versus D injuries. AMS, when combined with a positive SIRS screening, is strongly associated with sepsis.

The association between arterial-end-tidal carbon dioxide difference and outcomes after out-of-hospital cardiac arrest.

AIM: We sought to determine if the difference between PaCO2 and ETCO2 is associated with hospital mortality and neurologic outcome following out-of-hospital cardiac arrest (OHCA). METHODS: This was a retrospective cohort study of adult patients who achieved return of spontaneous circulation (ROSC) after OHCA over 3 years. The primary exposure was the PaCO2-ETCO2 difference on hospital arrival. The primary outcome was survival to hospital discharge. The secondary outcome was favorable neurologic status at discharge. We used receiver operating characteristic (ROC) curves to determine discrimination threshold and multivariate logistic regression to examine the association between the PaCO2-ETCO2 difference and outcome. RESULTS: Of 698 OHCA patients transported to the hospitals, 381 had sustained ROSC and qualifying ETCO2 and PaCO2 values. Of these, 160 (42%) survived to hospital discharge. Mean ETCO2 was 39 mmHg among survivors and 43 mmHg among non-survivors. Mean PaCO2-ETCO2 was 6.8 mmHg and 9.0 mmHg (p < 0.05) for survivors and non-survivors. After adjustment for Utstein characteristics, a higher PaCO2-ETCO2 difference on hospital arrival was not associated with hospital mortality (OR 0.99, 95% CI: 0.97-1.0) or neurological outcome. Area under the ROC curve or PaCO2-ETCO2 difference was 0.56 (95% CI 0.51-0.62) compared with 0.58 (95% CI 0.52-0.64) for ETCO2. CONCLUSION: Neither PaCO2-ETCO2 nor ETCO2 were strong predictors of survival or neurologic status at hospital discharge. While they may be useful to guide ventilation and resuscitation, these measures should not be used for prognostication after OHCA.

Interprofessional Education Module on Post-Intensive Care Syndrome for Internal Medicine Residents.

Background: Prevention of post-intensive care syndrome (PICS) in critically ill patients requires interprofessional collaboration among physicians, physical therapists, occupational therapists, speech-language pathologists, and nutritionists. Interprofessional education promotes interprofessional collaborative practice, yet formalized interprofessional education during residency is uncommon. Objective: We sought to improve internal medicine residents' knowledge of interprofessional roles in the intensive care unit (ICU) and confidence in managing PICS by designing a virtual multimodal training module. Methods: We created a 3-hour virtual module with physical therapy, occupational therapy, speech-language pathology, and nutrition experts. First, learners reviewed PICS and multidisciplinary interventions to optimize patient recovery. Second, attendees watched videos created by physical therapy and occupational therapy colleagues demonstrating mobility strategies to manage ICU-acquired weakness and delirium. Third, participants learned how speech-language pathology experts evaluate and manage swallowing disorders. Finally, attendees identified common nutritional therapy challenges with a trivia session. Participants completed pre- and postcourse assessments. Results: Thirty-four residents completed both pre- and postcourse assessments (52% response rate). The mean objective assessment score improved from 51% to 79% (P < 0.001). All respondents reported that their knowledge of PICS increased, and almost all (97%) believed that their knowledge of interprofessional roles increased. Respondents' confidence in facilitating discussions about critical illness recovery significantly improved, from 77% rating as either not very confident or not at all confident before the course to 94% rating as somewhat confident or very confident after the course (P < 0.001). Conclusion: This single-site pilot study suggests that integrating interprofessional training in PICS education using virtual platforms may improve residents' knowledge of interprofessional roles in the ICU and confidence in managing PICS.

Determining consistency of care after resuscitation from in-hospital cardiac arrest, a retrospective analysis at a tertiary care academic medical center.

BACKGROUND: Few guidelines have focused on the care delivered after return of spontaneous circulation (ROSC). Post ROSC best practice guidelines lack clarity about important tasks to accomplish in the first hours after ROSC. OBJECTIVES AND METHODS: We conducted a retrospective cohort analysis of adults who had suffered an in hospital cardiac arrest (IHCA) with ROSC over a two-year period to determine the completion rate of critical tasks in the immediate post-ROSC period: ECG within one hour, ABG within one hour, physician documentation within six hours, and surrogate communication within six hours. RESULTS: In the 113 reviewed cases, there was significant variance between completion of all four (19.4%), three (35.3%), two (32.7%), one (20.6%) and none (1.7%) of these critical post ROSC tasks. We observed that 62.8% of IHCA with ROSC had an ECG obtained within one hour of ROSC. The rate of obtaining an ABG within one hour of ROSC was 76.9%. 49.5% of cases had physician documentation of the resuscitation within six hours of ROSC. The rate of documenting surrogate communication within six hours of ROSC was 69.9%. CONCLUSIONS: Our study demonstrated that the completion rates of critical tasks in the post ROSC setting were suboptimal within our patient cohort. This provides a baseline for the development of future best practice guidelines and clinical decision-making aids for post ROSC care after IHCA. This can lead to future research in coupling specific care tasks to post ROSC patient outcomes.

Prevalence and Patterns of Resuscitation-Associated Injury Detected by Head-to-Pelvis Computed Tomography After Successful Out-of-Hospital Cardiac Arrest Resuscitation.

Background Patients resuscitated from out-of-hospital circulatory arrest (OHCA) frequently have cardiopulmonary resuscitation injuries identifiable by computed tomography, although the prevalence, types of injury, and effects on clinical outcomes are poorly characterized. Methods and Results We assessed the prevalence of resuscitation-associated injuries in a prospective, observational study of a head-to-pelvis sudden-death computed tomography scan within 6 hours of successful OHCA resuscitation. Primary outcomes included total injuries and time-critical injuries (such as organ laceration). Exploratory outcomes were injury associations with mechanical cardiopulmonary resuscitation and survival to discharge. Among 104 patients with OHCA (age 56±15 years, 30% women), 58% had bystander cardiopulmonary resuscitation, and total cardiopulmonary resuscitation time was 15±11 minutes. The prevalence of resuscitation-associated injury was high (81%), including 15 patients (14%) with time-critical findings. Patients with resuscitation injury were older (58±15 versus 46±13 years; P<0.001), but had otherwise similar baseline characteristics and survival compared with those without. Mechanical chest compression systems (27%) had more frequent sternal fractures (36% versus 12%; P=0.009), including displaced fractures (18% versus 1%; P=0.005), but no difference in survival (46% versus 41%; P=0.66). Conclusions In patients resuscitated from OHCA, head-to-pelvis sudden-death computed tomography identified resuscitation injuries in most patients, with nearly 1 in 7 with time-critical complications, and one-half with extensive rib-cage injuries. These data suggest that sudden-death computed tomography may have additional diagnostic utility and treatment implications beyond evaluating causes of OHCA. These important findings need to also be taken in context of the certain fatal outcome without resuscitation efforts. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03111043.

Early head-to-pelvis computed tomography in out-of-hospital circulatory arrest without obvious etiology.

OBJECTIVES: Patients resuscitated from an out-of-hospital circulatory arrest (OHCA) commonly present without an obvious etiology. We assessed the diagnostic capability and safety of early head-to-pelvis computed tomography (CT) imaging in such patients. METHODS: From November 2015 to February 2018, we enrolled 104 patients resuscitated from OHCA without obvious cause (idiopathic OHCA) to an early sudden-death CT (SDCT) scan protocol within 6 h of hospital arrival. The SDCT protocol included a noncontrast CT head, an electrocardiogram-gated cardiac and thoracic CT angiogram, and a nongated venous-phase abdominopelvic CT angiogram. Patients needing urgent cardiac catheterization or hemodynamically unable to tolerate SDCT were excluded. Cardiac CT analyses were blinded, but other SDCT findings were clinically available. Primary endpoints were the number of OHCA causes identified by SDCT compared to the adjudicated cause and critical diagnoses identified by SDCT, including resuscitation complications. Safety endpoints were acute kidney injury (AKI) and inappropriate treatments based on SDCT findings. Acute coronary syndrome was the presumed etiology if any major coronary artery had a >50% stenosis without another OHCA cause. RESULTS: SDCT scans occurred within 1.9 ± 1.0 h of hospital arrival and identified 39% (41/104) of all OHCA causes and 95% (39/41) of causes potentially identifiable by SDCT. Critical findings were identified by SDCT in 98% (43/44) of patients that included potentially life-threatening resuscitation complications of liver or spleen laceration (n = 6); pneumothorax or thoracic organ laceration (n = 8); and mediastinal, pericardial, or vascular hemorrhage (n = 3). SDCT exclusively identified 13 (13%) OHCA causes that would otherwise not be identified without SDCT imaging. No inappropriate treatments resulted from SDCT findings. AKI was common (28%) but only one (1%) patient required new dialysis. CONCLUSIONS: This observational cohort study suggests that early SDCT scanning is safe, can expedite the diagnosis of potential causes, and can meaningfully change clinical management after idiopathic OHCA.

Association Between Target Temperature Variability and Neurologic Outcomes for Patients Receiving Targeted Temperature Management at 36°C After Cardiac Arrest: A Retrospective Cohort Study.

Maintaining strict temperature control during the maintenance phase of targeted temperature management (TTM) after cardiac arrest may be an important component of clinical care. Temperature variability outside of the goal temperature range may lessen the benefit of TTM and worsen neurologic outcomes. The purpose of this retrospective study of 186 adult patients (70.4% males, mean age 53.8 ± 15.7 years) was to investigate the relationship between body temperature variability (at least one body temperature measurement outside of 36°C ± 0.5°C) during the maintenance phase of TTM at 36°C after cardiac arrest and neurologic outcome at hospital discharge. Patients with temperature variability (n = 124 [66.7%]) did not have significantly higher odds of poor neurologic outcome compared with those with no temperature variability (odds ratio [OR] = 1.01, 95% confidence interval [CI] = 0.36-2.82). Use of neuromuscular blocking agents (NMBAs) and having an initial shockable rhythm were associated with both higher odds of good neurologic outcome (shockable rhythm: OR = 10.77, 95% CI = 4.30-26.98; NMBA use: OR = 4.54, 95% CI = 1.34-15.40) and survival to hospital discharge (shockable rhythm: OR = 5.90, 95% CI = 2.65-13.13; NMBA use: OR = 3.03, 95% CI = 1.16-7.90). In this cohort of postcardiac arrest comatose survivors undergoing TTM at 36°C, having temperature variability during maintenance phase did not significantly impact neurologic outcome or survival.

Point of care ultrasound for all by all: A multidisciplinary survey across a large quaternary care medical system.

PURPOSE: We sought to understand current POCUS practices and comfort as well as assess opinions about POCUS across our medical system via a survey to guide program development. METHODS: This study was conducted as a 19 question RedCap survey with multiple parts. Respondents were queried for demographics as well as experience with, attitudes toward, and clinical use of POCUS in common critical care scenarios. RESULTS: The survey was completed by 343 individuals, a response rate of 30%. Most respondents "agreed" that POCUS is a needed skill and helped them provide safer care (78% and 86% agreement). Most faculty and trainees reported some POCUS training (62% and 88%) and at least weekly use. Trainees rated themselves more comfortable than faculty for most exam types. The majority of faculty rated their POCUS education as inadequate while trainees had mixed responses. CONCLUSIONS: POCUS is a frequently used tool, yet users are less confident in their skills than expected. POCUS applications are viewed as needed for future practice but there is a substantial need for improved education among faculty and trainees. Pooling resources and sharing educational initiatives across multiple specialties may help improve POCUS implementation.

Energy Expenditure and Shivering Severity During Targeted Temperature Management at 36°C After Cardiac Arrest: A Case Series.

Patients undergoing targeted temperature management (TTM) after cardiac arrest are at risk for shivering, which increases energy expenditure (EE) and may attenuate TTM benefits. This article reports patterns of EE for patients with and without shivering who received TTM at 36°C after cardiac arrest. Based on 96 case assessments, there were 14 occasions when more than one 15-minute interval period was required to appropriately modify the Bedside Shivering Assessment Scale (BSAS) score. Investigators noted that although higher EE was related to higher BSAS scores, there may be opportunities for earlier detection of shivering.

Diagnostic accuracy of early computed tomographic coronary angiography to detect coronary artery disease after out-of-hospital circulatory arrest.

AIM: To test the diagnostic accuracy of ECG-gated coronary computed tomography angiography (CCTA) to detect coronary artery disease (CAD) among survivors of out-of-hospital circulatory arrest (OHCA). METHODS: We prospectively studied head-to-pelvis computed tomography (CT) scanning (<6 h from hospital arrival) in OHCA survivors. This sub-study tested the primary outcome of CCTA diagnostic accuracy to identify obstructive CAD (≥50% stenosis) compared to clinically-ordered invasive coronary angiography. Patients were not optimized with beta receptor blockade or nitroglycerin. Secondary analyses included CCTA accuracy for CAD in major coronary arteries, obstructive disease at ≥70% stenosis threshold, and where non-evaluable CCTA segments were considered either obstructive or non-obstructive. RESULTS: Of the 104 enrolled OHCA survivors, 28 (27%) received both CT and invasive angiography in this sub study. All CCTA studies were evaluable although 49/346 (14%) individual coronary segments were unevaluable, primarily due to being too small to evaluate (65%). Patient-level diagnostic accuracy for the ≥50% stenosis threshold was high at 0.93 (95% CI 0.77-0.98) with a specificity of 1.0 (95% CI 0.8-1.0), sensitivity of 0.85 (95%CI 0.58-0.96), negative predictive value of 0.88 (95% CI 0.66-0.97) and positive predictive value of 1.0 (0.74-1.0). When non-evaluable segments were considered obstructive, the sensitivity rose to 0.92 (95% CI 0.67-0.99) with lower specificity of 0.27 (95% CI 0.11-0.52). CONCLUSION: Early CCTA of OHCA survivors has high diagnostic accuracy to detect obstructive coronary artery disease. However, the number of non-diagnostic coronary segments is high suggesting further CCTA refinement is needed, such as the pre-CCTA use of nitroglycerin. CLINICAL TRIAL REGISTRATION: NCT03111043 https://clinicaltrials.gov/ct2/show/record/NCT03111043.

Crisis Leadership Education for Critical Care Fellows. A Longitudinal Curriculum Using Simulation.

Background: Leadership and teamwork are critical to the performance of a multidisciplinary team responding to emergencies in the intensive care unit; yet, these skills are variably taught to pulmonary and critical care trainees. Currently, there is no standardized leadership curriculum in critical care training. Objective: We developed a longitudinal crisis leadership curriculum for first-year pulmonary and critical care fellows using high-fidelity simulation as a medium to practice and solidify skills. The goal was to improve leadership skills and trainee confidence when leading a team during life-threatening emergencies. Methods: Guided by a needs assessment of current and recently graduated fellows, we developed a leadership curriculum from a review of the available literature and local expert opinion. Four sessions were conducted over the academic years of 2016 to 2017 and 2017 to 2018, each including small-group teaching on effective leadership behaviors, followed by simulation with postsession leadership debriefing to review performance. Fellows were surveyed regarding their experiences with the curriculum. Results: Over two academic years, 100% of targeted fellows (N = 13) completed every session. Participants reported improved understanding of key elements of effective leadership, greater confidence in leading a multidisciplinary team, and increased preparedness to lead during a crisis. Simulation with debriefing was viewed as an effective medium for learning leadership skills, and fellows provided positive feedback regarding the experience. Conclusion: Implementation of a longitudinal crisis leadership curriculum within the first year of pulmonary and critical care fellowship was feasible and highly valued by learners. More research is needed to determine effective methods for teaching and assessing leadership skills.