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Study Objective: Resuscitation measures should be guided by previous patient choices about end-of-life care, when they exist; however, documentation of these choices can be unclear or difficult to access. We evaluate the concordance of a statewide registry of actionable resuscitation orders unique to Oregon with out-of-hospital and emergency department (ED) care provided for patients found by emergency medical services (EMS) in out-of-hospital cardiac arrest., Methods: This was a retrospective cohort study of patients found by EMS providers in out-of-hospital cardiac arrest in 5 counties in 2010. We used probabilistic linkage to match patients found in out-of-hospital cardiac arrest with previously signed documentation of end-of-life decisions in the Oregon Physician Orders for Life-Sustaining Treatment (POLST) registry. We evaluated resuscitation interventions in the field and ED., Results: There were 1,577 patients found in out-of-hospital cardiac arrest, of whom 82 had a previously signed POLST form. Patients with POLST do-not-resuscitate orders for whom EMS was called had resuscitation withheld or ceased before hospital admission in 94% of cases (95% confidence interval [CI] 83% to 99%). Compared with patients with no POLST or known do-not-resuscitate orders, more patients with attempt resuscitation POLST orders had field resuscitation attempted (84% versus 60%; difference 25%; 95% CI 12% to 37%) and were admitted to hospitals (38% versus 17%; difference 20%; 95% CI 3% to 37%), with no documented misinterpretations of the form once CPR was initiated., Conclusion: In this sample of patients in out-of-hospital cardiac arrest, out-of-hospital and ED care was generally concordant with previously documented end-of-life orders in the setting of critical illness. Further research is needed to compare the effectiveness of Oregon's POLST system to other methods of end-of-life order documentation., (Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Study Objective: We seek to provide current, comprehensive, and physician-level data for critical procedures performed in a high-volume pediatric emergency department (ED)., Methods: We conducted a retrospective study of all critical procedures performed in the ED of a tertiary care pediatric institution. Data were collected from written records of resuscitative care provided. The primary outcome measure was the cumulative frequency of each critical procedure during 12 consecutive months. Additional outcome measures included the number of critical procedures performed by pediatric emergency medicine faculty and fellows and a description of the other physician types performing each procedure., Results: Two hundred sixty-one critical procedures were performed during 194 patient resuscitations, which represented 0.22% of all ED patient evaluations. Sixty-one percent of pediatric emergency medicine faculty did not perform a single critical procedure. Orotracheal intubation occurred 147 times and represented 56% of all critical procedures, yet 63% of pediatric emergency medicine faculty did not perform a single successful orotracheal intubation. Pediatric emergency medicine fellows performed a median of 3 critical procedures., Conclusion: Critical procedures were rarely performed in a large, academic pediatric ED. Pediatric emergency medicine faculty are at significant risk for skill deterioration, and pediatric emergency medicine fellows are unlikely to achieve competence in the performance of critical procedures if clinical exposure is the sole basis for the attainment and maintenance of skill., (Copyright © 2012. Published by Mosby, Inc.)

Study Objective: Trauma centers use "secondary triage" to determine the necessity of trauma surgeon involvement. A clinical decision rule, which includes penetrating injury, an initial systolic blood pressure less than 100 mm Hg, or an initial pulse rate greater than 100 beats/min, was developed to predict which trauma patients require emergency operative intervention or emergency procedural intervention (cricothyroidotomy or thoracotomy) in the emergency department. Our goal was to validate this rule in an adult trauma population and to compare it with the American College of Surgeons' major resuscitation criteria., Methods: We used Level I trauma center registry data from September 1, 1995, through November 30, 2008. Outcomes were confirmed with blinded abstractors. Sensitivity, specificity, and 95% confidence intervals (CIs) were calculated., Results: Our patient sample included 20,872 individuals. The median Injury Severity Score was 9 (interquartile range 4 to 16), 15.3% of patients had penetrating injuries, 13.5% had a systolic blood pressure less than 100 mm Hg, and 32.5% had a pulse rate greater than 100 beats/min. Emergency operative intervention or procedural intervention was required in 1,099 patients (5.3%; 95% CI 5.0% to 5.6%). The sensitivities and specificities of the rule and the major resuscitation criteria for predicting emergency operative intervention or emergency procedural intervention were 95.6% (95% CI 94.3% to 96.8%) and 56.1% (95% CI 55.4% to 56.8%) and 85.5% (95% CI 83.3% to 87.5%) and 80.9% (95% CI 80.3% to 81.4%), respectively., Conclusion: This new rule was more sensitive for predicting the need for emergency operative intervention or emergency procedural intervention directly compared with the American College of Surgeons' major resuscitation criteria, which may improve the effectiveness and efficiency of trauma triage., (Copyright © 2011 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Study Objective: We wish to assess whether individual or collective American College of Surgeons' "major resuscitation" criteria accurately identify injured patients who receive emergency operative treatment., Methods: In this observational secondary registry analysis of 8,289 consecutive trauma team activations during a 7.5-year period, we evaluated the test performance of 5 American College of Surgeons' major criteria in predicting emergency (within 1 hour) operative management by general (for adults) or pediatric (for children) surgeons., Results: In adults, the individual major resuscitation criteria each predicted emergency operative management as follows (sorted from highest to lowest test performance): gunshot wounds to the neck or torso (likelihood ratio positive [LR+] 7.5; 95% confidence interval [CI] 6.2 to 9.1); confirmed hypotension (LR+ 5.3; 95% CI 4.0 to 7.1); interhospital transfers requiring blood transfusions (LR+ 4.6; 95% CI 2.6 to 8.2); respiratory compromise (LR+ 2.9; 95% CI 2.2 to 3.7), and Glasgow Coma Scale score less than 8 (LR+ 2.1; 95% CI 1.6 to 2.7). The collective strategy of using any of these 5 criteria exhibited a LR+ of 3.5 (95% CI 3.2 to 3.8), sensitivity 82% (95% CI 75% to 87%), and specificity 76% (95% CI 75% to 77%). Our findings in children were similar, but their precision was limited by the low baseline prevalence of emergency operative intervention., Conclusion: These 5 American College of Surgeons-mandated major resuscitation criteria vary several-fold in their individual ability to predict emergency operative management and collectively exhibit modest test characteristics for this purpose. Selective use of these criteria or revisions thereof could result in more efficient secondary trauma triage. Our results do not support the existing obligatory use of these criteria to maintain American College of Surgeons trauma center certification.

The simplest, most easily determined, and most easily understood outcomes after cardiac arrest are survival and awakening. Awakening is defined by the patient's being able to follow commands or produce comprehensible speech. Both occur at specific times, thus lending themselves to life-table analyses. Unfortunately, these simple measures are not adequate to characterize the disability that may be present in those who survive and awaken after cardiac arrest. For such patients, measures of independence are needed. These measures often require longer follow-up, direct contact with patients, and a greater understanding of the instrument to be used than for the simple measures. Investigators must decide based on the goals of a particular study what outcomes are most appropriate and the amount of resources that they are willing to devote to outcome assessment. As initial steps in resuscitation research, there may be more to gain from studies of large numbers of patients evaluated with simple measures than small numbers of patients evaluated intensively with more detailed measures.

The Utstein style for uniform reporting of data from out-of-hospital cardiac arrest was developed to solve a major problem in resuscitation research. Outcome measures related to cardiac arrest are difficult to evaluate or compare because there have been no uniform definitions or uniform agreements on what data to report. Widespread acceptance of the Utstein style will lead to a better understanding of out-of-hospital cardiac arrest.

Researchers interested in performing research on prehospital cardiac arrest should carefully review the presentations from the session "Moving Toward Uniform Reporting and Terminology." Although each presentation concentrates on specific research topics, taken together they suggest the next evolutionary steps we should take to conduct such research. We will base these further steps on the following insights. First, all future articles on prehospital cardiac arrest must share a common nomenclature and template for reporting outcomes. The Utstein style has not solved this problem completely, but it is the critical first step. Over the coming years, we must, through continued use, progressively refine the Utstein style. Second, we can no longer depend on research that comes from a single EMS system. Although we have gained important insights from such studies in the past, our expectations of greater validity and generalizability are rising and pushing us toward multicenter, cooperative studies. The International Brain Resuscitation clinical trials and the numerous studies on thrombolytic therapy demonstrate the directions we must head. Third, we must abandon our narrow focus on the pre-hospital experience. Although some studies have avoided this problem, the preponderance of clinical studies on prehospital cardiac arrest fails to gather information on the prearrest condition of the patient, the actual decisions and action taken around the event (witness Kellermann's discussion of death criteria and rules for stopping resuscitation efforts), and the clinical experience after successful resuscitations. Fourth, we can no longer be satisfied with simple statistics on dichotomous (yes/no) survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Study Objectives: To determine the rate of bystander CPR before and after implementation of a telephone CPR program in King County; to determine the reasons for dispatcher delays in identifying patients in cardiac arrest in delivering CPR instructions over the telephone; and to suggest time standards for delivery of the telephone CPR message., Design: An ongoing cardiac arrest surveillance system to calculate the annual bystander CPR rates from 1976 through 1988. Two hundred sixty-seven taped recordings of calls reporting cardiac arrests to nine emergency dispatch centers during 1988 were reviewed and timed., Setting: King County, Washington, excluding the city of Seattle., Participants: Two hundred sixty-seven persons with out-of-hospital cardiac arrests receiving emergency medical services. Arrests in doctors' offices, clinics, or nursing homes were excluded., Interventions: Dispatcher-assisted telephone CPR., Measurements and Main Results: The rate of bystander CPR increased from 32% (1976 through 1981) to 54% (1982 through 1988) after implementation of the dispatcher-assisted telephone CPR program, although an increase in survival could not be demonstrated. The median time for dispatchers to identify the problem was 75 seconds; to deliver the early protocols, 19 seconds; to deliver the ventilation instructions, 25 seconds; and to deliver compression instructions, 30 seconds. The total time to deliver the entire CPR message was 2.3 minutes. The most frequent cause for delay was unnecessary questions (57%) with questions about patient age asked most frequently (32%). Other causes included the caller not being near the patient (29%) and deviations from protocol (22%)., Conclusion: In a metropolitan emergency medical services system, a dispatcher-assisted telephone CPR program was associated with an increase in bystander CPR. Delays in proper delivery of telephone CPR can be minimized through training.

In an attempt to establish prognostic indicators for ultimate long-term survival following advanced life support (ALS), a two-year (1978-79) retrospective study was made of 92 survivors. The survivors were divided into two groups: the first survived admission to the intensive care unit, but subsequently died in the hospital; the second survived to ultimate discharge from the hospital. The groups were compared for sex, age, basic and advanced provider response time, scene an transport time, witnessed versus unwitnessed arrest, traumatic versus medical arrest, type of airway, presence of aspiration, initial cardiac rhythms, post-arrest vital signs, number of defibrillations, post-arrest ECG changes, essential and useful drugs used, and duration of basic and advanced life support. Of all prognostic indicators studied, duration of ALS correlated most closely with ultimate survival. This article advances the definition of ultimate survival of ALS to mean discharge of the patient from the hospital, and advocates this as the most objective evaluation of successful ALS. The article furthermore offers duration of ALS as an effective prognostic indicator of a patient's chance for ultimate survival.