Gaps in pediatric emergency medicine education of emergency medicine residents: A needs assessment of recent graduates.

Background: More than 90% of pediatric patients presenting to emergency departments (EDs) in the United States are evaluated and treated in community-based EDs. Recent evidence suggests that mortality outcomes may be worse for critically ill pediatric patients treated at community EDs. The disparate mortality outcomes may be due to inconsistency in pediatric-specific education provided to emergency medicine (EM) trainees during residency training. There are few studies surveying recently graduated EM physicians assessing perceived gaps in the pediatric emergency medicine (PEM) education they received during residency. Methods: This was a prospective, survey-based, descriptive cohort study of EM residency graduates from 10 institutions across the United States who were <5 years out from residency training. Deidentified surveys were distributed via email. Results: A total of 222 responses were obtained from 570 eligible participants (39.1%). Non-ED pediatric rotations during residency training included pediatric intensive care (60%), pediatric anesthesia (32.4%), neonatal intensive care unit (26.1%), and pediatric wards (17.1%). A large percentage (42.8%) of respondents felt uncomfortable managing neonates and performing tube thoracostomy on pediatric patients (56.3%). The EM graduate's satisfaction with pediatric simulation-based training during residency was positively associated with comfort caring for neonates and infants (p < 0.0070 and p < 0.0002) and performing endotracheal intubation (p < 0.0027), lumbar puncture (p < 0.0004), and Pediatric Advanced Life Support resuscitation (p < 0.0001). Conclusions/discussion: This survey-based cohort study found considerable variation in pediatric-specific experiences during EM residency training and in perceived comfort managing pediatric patients. In general, participants were more comfortable managing older children. This study suggests that the greatest perceived knowledge gaps in PEM were neonatal medicine/resuscitation and pediatric cardiac arrest. Future research will continue to address larger cohorts, representative of the PEM education provided to EM physicians in the United States to promote future educational initiatives.

Advising special population emergency medicine residency applicants: a survey of emergency medicine advisors and residency program leadership.

BACKGROUND: The objective of this study was to determine the advising and emergency medicine (EM) residency selection practices for special population applicant groups for whom traditional advice may not apply. METHODS: A survey was distributed on the Council of Residency Directors in EM and Clerkship Directors in EM Academy listservs. Multiple choice, Likert-type scale, and fill-in-the-blank questions addressed the average EM applicant and special population groups (osteopathic; international medical graduate (IMG); couples; at-risk; re-applicant; dual-accreditation applicant; and military). Percentages and 95% confidence intervals [CI] were calculated. RESULTS: One hundred four surveys were completed. Of respondents involved in the interview process, 2 or more standardized letters of evaluation (SLOEs) were recommended for osteopathic (90.1% [95% CI 84-96]), IMG (82.5% [73-92]), dual-accreditation (46% [19-73]), and average applicants (48.5% [39-58]). Recommendations for numbers of residency applications to submit were 21-30 (50.5% [40.7-60.3]) for the average applicant, 31-40 (41.6% [31.3-51.8]) for osteopathic, and > 50 (50.9% [37.5-64.4]) for IMG. For below-average Step 1 performance, 56.0% [46.3-65.7] were more likely to interview with an average Step 2 score. 88.1% [81.8-94.4] will consider matching an EM-EM couple. The majority were more likely to interview a military applicant with similar competitiveness to a traditional applicant. Respondents felt the best option for re-applicants was to pursue the Supplemental Offer and Acceptance Program (SOAP) for a preliminary residency position. CONCLUSION: Advising and residency selection practices for special population applicants differ from those of traditional EM applicants. These data serve as an important foundation for advising these distinct applicant groups in ways that were previously only speculative. While respondents agree on many advising recommendations, outliers exist.

International Medical Graduate Advising Recommendations From the Council of Residency Directors in Emergency Medicine Advising Student Committee.

International Medical Graduate (IMG) physicians applying to residency training programs in a country different from where they completed medical school, bring beneficial diversity to a training program, but also face significant challenges matching into an Accreditation Council for Graduate Medical Education (ACGME)-accredited residency program. Despite the growing number of IMG applications in Emergency Medicine (EM), there is a paucity of targeted recommendations for IMG applicants. As a result, the Council of Residency Directors (CORD) Advising Students Committee in EM (ASC-EM) created a dedicated IMG Advising Team to create a set of evidence-based advising recommendations based on longitudinal data from the National Residency Match Program (NRMP) and information collected from EM program directors and clerkship directors. IMG applicants should obtain at least two EM standardized letters of evaluation (SLOEs), review IMG matched percentages for programs-of-interest, analyze their objective scores with the previous matched cohorts, and rank at least 12 programs to maximize their chances of matching into EM.

Wellness: Combating Burnout and Its Consequences in Emergency Medicine.

Medicine recognizes burnout as a threat to quality patient care and physician quality of life. This issue exists throughout medicine but is notably prevalent in emergency medicine (EM). Because the concept of "wellness" lacks a clear definition, attempts at ameliorating burnout that focus on achieving wellness make success difficult to achieve and measure. Recent work within the wellness literature suggests that the end goal should be to achieve a culture of wellness by addressing all aspects of the physician's environment. A review of the available literature on burnout and wellness interventions in all medical specialties reveals that interventions focusing on individual physicians have varying levels of success. Efforts to compare these interventions are hampered by a lack of consistent endpoints. Studies with consistent endpoints do not demonstrate clear benefits of achieving them because improving scores on various scales may not equate to improvement in quality of care or physician quality of life. Successful interventions have uncertain, long-term effects. Outside of EM, the most successful interventions focus on changes to systems rather than to individual physicians. Within EM, the number of well-structured interventions that have been studied is limited. Future work to achieve the desired culture of wellness within EM requires establishment of a consistent endpoint that serves as a surrogate for clinical significance, addressing contributors to burnout at all levels, and integrating successful interventions into the fabric of EM.

Calming Troubled Waters: A Narrative Review of Challenges and Potential Solutions in the Residency Interview Offer Process.

The rising numbers of residency applications along with fears of a constrained graduate medical education environment have created pressures on residency applicants. Anecdotal evidence suggests substantial challenges with the process of offering residency interviews. This narrative review is designed to identify and propose solutions for the current problems in the process of offering residency interviews. We used PubMed and web browser searches to identify relevant studies and reports. Materials were assessed for relevance to the current process of distributing residency interviews. There is limited relevant literature and the quality is poor overall. We were able to identify several key problem areas including uncertain timing of interview offers; disruption caused by the timing of interview offers; imbalance of interview offers and available positions; and a lack of clarity around waitlist and rejection status. In addition, the couples match and need for coordination of interviews creates a special case. Many of the problems related to residency interview offers are amenable to program-level interventions, which may serve as best practices for residency programs, focusing on clear communication of processes as well as attention to factors such as offer-timing and numbers. We provide potential strategies for programs as well as a call for additional research to better understand the problem and solutions.

Erratum: This Article Corrects: "Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part 1".

[This corrects West J Emerg Med. 2019 January;20(3):485-494]

Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I.

Each year more than 400 physicians take their lives, likely related to increasing depression and burnout. Burnout-a psychological syndrome featuring emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment-is a disturbingly and increasingly prevalent phenomenon in healthcare, and emergency medicine (EM) in particular. As self-care based solutions have proven unsuccessful, more system-based causes, beyond the control of the individual physicians, have been identified. Such system-based causes include limitations of the electronic health record, long work hours and substantial educational debt, all in a culture of "no mistakes allowed." Blame and isolation in the face of medical errors and poor outcomes may lead to physician emotional injury, the so-called "second victim" syndrome, which is both a contributor to and consequence of burnout. In addition, emergency physicians (EP) are also particularly affected by the intensity of clinical practice, the higher risk of litigation, and the chronic fatigue of circadian rhythm disruption. Burnout has widespread consequences, including poor quality of care, increased medical errors, patient and provider dissatisfaction, and attrition from medical practice, exacerbating the shortage and maldistribution of EPs. Burned-out physicians are unlikely to seek professional treatment and may attempt to deal with substance abuse, depression and suicidal thoughts alone. This paper reviews the scope of burnout, contributors, and consequences both for medicine in general and for EM in particular.

Recommendations from the Council of Emergency Medicine Residency Directors: Osteopathic Applicants.

The Council of Emergency Medicine Residency Directors (CORD) Advising Students Committee (ASC-EM) has previously published student advising recommendations for general emergency medicine (EM) applicants in an effort to disseminate standardized information to students and potential advisors. As the shift to a single graduate medical education system occurs by 2020, osteopathic students will continue to represent a larger portion of matched EM applicants, but data shows that their match rate lags that of their allopathic peers, with many citing a lack of access to knowledge EM advisors as a major barrier. Based on available data and experiential information, a sub-group of ASC-EM committee sought to provide quality, evidence-based advising resources for students, their advisors, and medical leadership. The recommendations advise osteopathic students to seek early mentorship and get involved in EM-specific organizations. Students should take Step 1 of the United States Medical Licensing Exam and complete two EM rotations at academic institutions to secure two Standardized Letters of Evaluation and consider regional and program-specific data on percentage of active osteopathic residents.

Student-Advising Recommendations from the Council of Residency Directors Student Advising Task Force.

Residency training in emergency medicine (EM) is highly sought after by U.S. allopathic medical school seniors; recently there has been a marked increase in the number of applications per student, raising costs for students and programs. Disseminating accurate advising information to applicants and programs could reduce excessive applying. Advising students applying to EM is a critical role for educators, clerkship directors, and program leaders (residency program director, associate and assistant program directors). A variety of advising resources is available through social media and individual organizations; however, currently there are no consensus recommendations that bridge these resources. The Council of Residency Directors (CORD) Student Advising Task Force (SATF) was initiated in 2013 to improve medical student advising. The SATF developed best-practice consensus recommendations and resources for student advising. Four documents (Medical Student Planner, EM Applicant's Frequently Asked Questions, EM Applying Guide, and EM Medical Student Advisor Resource List) were developed and are intended to support prospective applicants and their advisors. The recommendations are designed for the mid-range EM applicant and will need to be tailored to students' individual needs.

Emergency Department-based Opioid Harm Reduction: Moving Physicians From Willing to Doing.

OBJECTIVES: Develop and internally validate a survey tool to assess emergency department (ED) physician attitudes, clinical practice, and willingness to perform opiate harm reduction (OHR) interventions and to identify barriers and facilitators in translating willingness to action. METHODS: This study was an anonymous, Web-based survey based on the Theory of Planned Behavior of ED physicians at three tertiary referral centers. Construction and internal validation of scaled questions was assessed through principal component and Cronbach's alpha analyses. Stepwise linear regression was conducted to measure impact of physician knowledge, attitudes, confidence, and self-efficacy on willingness to perform OHR interventions including opioid overdose education; naloxone prescribing; and referral to naloxone, methadone, and syringe access programs. RESULTS: A total of 200 of 278 (71.9%) physicians completed the survey. Principal component analysis yielded five components: attitude, confidence, self-efficacy, professional impact factors, and personal impact factors. Overall, respondents were willing to perform OHR interventions, but few actually do. Willingness was correlated with attitude, confidence, and self-efficacy (R(2)  = 0.50); however, overall physicians lacked confidence (mean = 3.06 of 5, 95% confidence interval [CI] = 2.94 to 3.18]). Knowledge, time, training, and institutional support were all prohibitive barriers. Physicians reported that research evidence, professional organization recommendations, and opinions of ED leaders would strongly influence a change in their clinical practice to incorporate OHR interventions (mean = 4.25 of 5, 95% CI = 4.18 to 4.32). CONCLUSIONS: Compared to prior studies, emergency medicine physicians had increased willingness to perform OHR interventions, but there remains a disparity between willingness and clinical practice. Influential factors that may move physicians from "willing" to "doing" include dissemination of supportive research evidence; professional organization endorsement; ED leadership opinion; and addressing time, knowledge, and institutional barriers.

Blinded Evaluation of Combination Drug Therapy for Prolonged Ventricular Fibrillation Using a Swine Model of Sudden Cardiac Arrest.

Despite experimental evidence supporting the use of resuscitation drugs in the treatment of sudden cardiac arrest (CA), there are no good human clinical data to support the decades-old practice of giving these medications during out-of-hospital CA resuscitation. We hypothesized that the lack of efficacy in clinical practice in ventricular fibrillation (VF) is the failure-based manner in which resuscitation drugs have historically been administered (one at a time interspersed with chest compressions and a defibrillation attempt, giving the next only if the previous one was ineffective). The aim of this study was to determine if giving and circulating a combination of commonly available, historically used resuscitation drugs together, prior to the first defibrillation attempt after prolonged VF, might improve short-term outcomes compared with the failure-based serial drug approach used in the past. We used a well-established swine model of sudden prolonged untreated VF. Animals were randomized to receive epinephrine (0.01 mg/kg), vasopressin (0.5 U/kg), amiodarone (4 mg/kg), and sodium bicarbonate (1.0 mEq/kg) in series (SERIES group [n = 53]) or a combination of epinephrine (0.01 mg/kg), vasopressin (0.5 U/kg), amiodarone (4 mg/kg), sodium bicarbonate (1.0 mEq/kg), and metoprolol (0.2 mg/kg) (COCKTAIL group) delivered in rapid succession at the beginning of the attempted resuscitation (n = 27). Data were analyzed descriptively. Baseline characteristics and chemistries between the two groups were the same. Termination of VF was statistically similar in the two groups: 88.7% (47/53) versus 85.2% (23/27) p = 0.66, with an adjusted relative risk ratio (RRR) of 0.94 (0.37, 1.15). However, ROSC was higher in the SERIES group (56.6% [30/53] versus 22.2% [6/27], adjusted RRR = 2.83; [1.16, 3.84] p = 0.029) as was 20-minute survival (52.8% [28/53] versus 18.5% [5/27], adjusted RRR = 3.15 [1.14, 4.54] p = 0.032). The combination of drugs studied, at these dosages, inexplicably worsened short-term outcomes after prolonged untreated VF.

Diagnostic Reasoning for ST-Segment Elevation Myocardial Infarction (STEMI) Interpretation Is Preserved Despite Fatigue.

BACKGROUND: Fatigue and sleepiness contribute to medical errors, although the effect of circadian disruption and fatigue on diagnostic reasoning skills is largely unknown. OBJECTIVE: To determine whether circadian disruption and fatigue negatively affect the emergency medicine (EM) resident's ability to make important clinical decisions based on electrocardiogram (ECG) interpretation. METHODS: Senior EM residents at 2 programs completed a questionnaire consisting of various measures of fatigue followed by an ECG test packet of ST-segment elevation myocardial infarction (STEMI) and STEMI mimics. Participants were asked to examine each ECG and determine whether cardiac catheterization laboratory activation (CLA) was indicated, and to report their confidence in their decision making on an 11-point, numeric rating scale. The primary outcome measured was a pairwise difference in accuracy of CLA between daytime and overnight testing. RESULTS: A total of 23 residents were enrolled in 2011 and 2012. Subjects demonstrated significant differences in multiple measures of sleepiness and fatigue during overnight periods. The median (interquartile range [IQR]) accuracy of CLA was not significantly different between daytime and overnight (70% [IQR, 50-80] versus 70% [IQR, 60-70], P  =  .82). There were no significant differences in the median number of overcalls (CLA when not a STEMI) and undercalls (no CLA when a STEMI was present; P  =  .57 and .37, respectively). Diagnostic confidence and confidence in CLA were not statistically different between daytime and overnight. CONCLUSIONS: Despite a measurable degree of fatigue, senior EM residents experienced no decrease in their ability to accurately make CLA decisions based on ECG interpretation.

No diversion in Western Massachusetts.

BACKGROUND: Massachusetts (MA) instituted a moratorium on ambulance diversion ("No Diversion") on January 1, 2009. STUDY OBJECTIVES: Determine whether No Diversion was associated with changes in Emergency Department (ED) throughput measures. DESIGN: Comparison of three 3-month periods. Period 1: 1 year prior (January-March 2008); Period 2: 3 months prior (October-December 2008); Period 3: 3 months after (January-March 2009). SETTING: Seven EDs in Western MA; two - including the only Level I Trauma Center - were "high" diversion (≥562 h/year) and 5 were "low" diversion (≤260 h/year). For "all," "high" diversion and "low" diversion ED groups, we compared mean monthly throughput measures, including: 1) total volume, 2) number of admissions, 3) number of elopements, 4) length of stay for all, admitted and discharged patients. Mean absolute and percent changes were estimated using mixed-effects regression analysis. Linear mixed models were run for "all," "high" and "low" diversion EDs comparing means of changes between periods. Results are presented as mean change per month in number and percent, and 95% confidence intervals were calculated. We specified that a clinically significant effect of No Diversion had to meet two criteria: 1) there was a consistent difference in the means for both the Period 1 vs. Period 3 comparison and the Period 2 vs. Period 3 comparison, and 2) both comparisons had to achieve statistical significance at p ≤ 0.01. RESULTS: According to pre-determined criteria, no clinically significant changes were found in any ED group in mean monthly volume, admissions, elopements, or length-of-stay for any patient disposition group. CONCLUSION: No Diversion was not associated with significant changes in throughput measures in "all," "high" diversion and "low" diversion EDs.

An observational study to assess changes in arterial blood gas values during untreated porcine ventricular fibrillation.

BACKGROUND: Cardiocerebral resuscitation (CCR) is reportedly superior to cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) even though active ventilation is not initially provided. Understandably, concerns have been raised regarding the withholding of positive pressure ventilation (PPV) during CCR because of the longstanding belief that respiratory gas exchange is a critical action during resuscitation. OBJECTIVE: In this observational study, we sought to quantify the effect of prolonged untreated ventricular fibrillation (VF) on arterial pH, partial pressure of carbon dioxide (pCO(2)), and partial pressure of oxygen (pO(2)) values in a swine model of witnessed cardiac arrest to begin exploring the validity of these concerns. METHODS: Both included studies were approved by the institutional animal care and use committee (IACUC). Eighty-three animals (25-35 kg) were instrumented under general anesthesia. Baseline characteristics were recorded. An arterial blood gas (ABG) sample was drawn from each animal via femoral catheter just prior to electrical induction of VF. After 8 minutes of untreated VF in one study (study 1 [n = 30]) and 10 minutes of untreated VF in the other study (study 2 [n = 53]), a second ABG sample was drawn. All samples were processed immediately using an i-STAT portable whole blood analyzer. Baseline characteristics of animals in the two studies were assessed using descriptive statistics. For the second ABG sample in each study, the mean pH, pCO(2), and pO(2) values, with 95% confidence intervals (95% CIs), were determined. The paired ABG results for each animal were then compared and the average pH, pCO(2), and pO(2) proportions, with 95% CIs, for each study were calculated. RESULTS: The baseline characteristics of the animals in the two studies were similar. After 8 and 10 minutes of untreated VF cardiac arrest, the pH values were 7.35 (95% CI = 7.32, 7.37) and 7.37 (95% CI = 7.36, 7.38), the pCO(2) increased to 44.1 mmHg (95% CI = 41.1, 47.1) and 52.7 mmHg (95% CI = 51.0, 54.4), and the pO(2) decreased to 44.8 mmHg (95% CI = 42.2, 47.4) and 45.5 mmHg (95% CI = 43.3, 47.6), respectively. CONCLUSIONS: Using our swine model of witnessed cardiac arrest with prolonged untreated VF, the arterial pH remained essentially unchanged and the pCO(2) increased to 1.42 times baseline after 10 minutes, while almost half of the initial O(2) concentration in the blood at the beginning of resuscitation remained.

A randomized comparison of cardiocerebral and cardiopulmonary resuscitation using a swine model of prolonged ventricular fibrillation.

BACKGROUND: Cardiocerebral resuscitation (CCR) is reportedly superior to cardiopulmonary resuscitation (CPR) for primary cardiac arrest in the prehospital setting. This study was done using a swine model of prolonged ventricular fibrillation (VF) to quantify the effect of the emergency medical services component of CCR with intraosseous access (CCR-IO) compared with standard CPR with intravenous access (CPR-IV) as it is typically performed during out-of-hospital cardiac arrest (OHCA) resuscitation in a prospective randomized fashion. METHODS: Fifty-three animals were instrumented under anesthesia and VF was electrically induced. After 10 min of untreated VF, baseline characteristics were recorded, and animals were block randomized to one of two resuscitation schemes. The controls had mechanical chest compressions at 100/min with ventilations at a ratio of 30:2. Consistent with clinical practice, two 30-s pauses in chest compressions occurred to simulate attempts to accomplish endotracheal intubation at minutes 1 and 3 of CPR and successful IV access was simulated to occur three additional minutes after endotracheal intubation. The CCR group had continuous uninterrupted mechanical chest compressions at 100/min. No active ventilations were provided. A tibial IO needle was placed in real time for vascular access. Both groups received epinephrine (0.1 mg/kg) as soon as access became available followed by 2.5 min of chest compressions before the first 120 J rescue shock attempt. After successful rescue shock, standardized post-resuscitative care was provided to a 20-min endpoint. Failed rescue shock was followed by continued chest compressions with positive pressure ventilation in both groups, repeat doses of epinephrine (0.01 mg/kg) every 3 min, and rescue shock every minute as long as a shockable rhythm persisted. Group comparisons were assessed using descriptive statistics. Proportions with 95% confidence intervals were calculated for VF termination, ROSC, and survival. RESULTS: Baseline characteristics and chemistries between the two groups at VF induction and after 10 min of non-treatment were mathematically the same. The proportions of VF termination (0.50 vs. 0.82), ROSC (0.30 vs. 0.59), and 20-min survival (0.19 vs. 0.40) all strongly favored the CCR-IO group. CONCLUSION: In this swine model of witnessed VF arrest with no bystander-initiated resuscitation, CCR-IO resulted in substantial improvement in all three outcomes relative to typical emergency medical services provided CPR-IV.

The feasibility of inducing mild therapeutic hypothermia after cardiac resuscitation using iced saline infusion via an intraosseous needle.

OBJECTIVE: This study was done, using a swine model of prolonged ventricular fibrillation out-of-hospital cardiac arrest, to determine the feasibility of inducing therapeutic hypothermia after successful resuscitation by giving an intraosseous infusion of iced saline. METHODS: This study was IACUC approved. Liter bags of normal saline, after being refrigerated for at least 24h, were placed in an ice filled cooler. Female Yorkshire swine weighing between 27 and 35 kg were sedated and instrumented under general anesthesia. A temperature probe was inserted 10 cm into the esophagus. Ventricular fibrillation was electrically induced and allowed to continue untreated for 10 min. Animals were randomized to one of two resuscitation schemes for the primary study (N=53). One group had central intravenous access for drug delivery and the other had an intraosseous needle inserted into the proximal tibia for drug administration. Animals in which spontaneous circulation was restored were immediately cooled, for this secondary study, by means of a rapid, pump-assisted infusion of 1L of iced saline either through the intraosseous needle (n=8), the central access (n=6), or a peripheral intravenous catheter (n=7) in a systematic, non-randomized fashion. Room, animal, and saline temperatures were recorded at initiation and upon completion of infusion. The data were analyzed descriptively using Stata SE v8.1 for Macintosh. RESULTS: The baseline characteristics of all three groups were mathematically the same. The average ambient room temperature during the experimental sessions was 25.5 degrees C (SD=1.3 degrees C). There were no statistically significant differences between the three groups with regard to saline temperature, rate of infusion, or decrease in core body temperature. The decrease in core temperature for the intraosseous group was 2.8 degrees C (95% CI=1.8, 3.8) over the infusion period. CONCLUSIONS: Mild therapeutic hypothermia can be effectively induced in swine after successful resuscitation of prolonged ventricular fibrillation by infusion of iced saline through an IO needle.

A blinded, randomized controlled evaluation of an impedance threshold device during cardiopulmonary resuscitation in swine.

BACKGROUND: An impedance threshold device (ITD) has been designed to enhance circulation during CPR. A recent study suggests that the ITD does not improve hemodynamics and that it may actually worsen outcomes. We sought to independently assess the effect of the ITD on coronary perfusion pressure (CPP) and passive ventilation (PaCO(2) and PaO(2)) during standard CPR (S-CPR), and its impact on the return of spontaneous circulation (ROSC) and short-term survival in a blinded fashion. METHODS: Thirty male swine were instrumented under anesthesia. Ventricular fibrillation (VF) was electrically induced. CPP was continuously recorded. After 8 min of untreated VF, baseline characteristics were documented and S-CPR initiated. After 3 cycles of S-CPR, an ABG was drawn and drugs were given. Following 6 additional cycles of S-CPR, an ABG was drawn and the first rescue shock was delivered. Group comparisons were assessed using descriptive statistics. Proportions with 95% confidence intervals were calculated for outcomes. RESULTS: Baseline characteristics between the two groups were the same. The mean CPP in the ITD group was 51.2 mmHg [95% CI: 37.7, 64.7] compared to 50.2 mmHg [95% CI: 37.0, 63.4] in the sham group. The PaCO(2) and PaO(2) were 68 Torr [95% CI: 55.7, 79.5] and 103 Torr [95% CI: 76, 129] in the ITD group and 59 Torr [95% CI: 49.1, 68.5] and 137 Torr [95% CI: 83, 191] in the sham group. The rate of ROSC was 14/15 in both groups and 13 animals in each groups survived. CONCLUSIONS: In this independent blinded study, use of the active ITD had no significant impact on CPP, passive ventilation, or outcomes compared to the sham device.