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RESEARCH QUESTION: Given the relative independence of ventilator settings from gas exchange and plasticity of blood gas values during extracorporeal cardiopulmonary resuscitation (ECPR), do mechanical ventilation parameters and blood gas values influence survival? METHODS: Observational cohort study of 7,488 adult patients with ECPR from the Extracorporeal Life Support Organization (ELSO) Registry. We performed case-mix adjustment for severity of illness and patient type using generalized estimating equation logistic regression to determine factors associated with hospital survival accounting for clustering by center, standardizing variables by 1 standard deviation (SD) of their values. We examined non-linear relationships between ventilatory and blood gas values with hospital survival. RESULTS: Hospital survival was decreased with higher PaO(2) on ECMO (OR 0.69, per 1SD increase [95% CI 0.64, 0.74]; p 20cmH(2)0 (OR 0.69, per 1SD [0.64, 0.75]; p

Early recognition and rapid defibrillation of shockable rhythms is strongly associated with survival in out of hospital cardiac arrest (OHCA). Little is known about the accuracy of paramedic rhythm interpretation and its impact on survival. We hypothesized that inaccurate paramedic interpretation of initial rhythm would be associated with worse survival.This is a retrospective cohort analysis of prospectively collected OHCA data over a nine-year period within a single, urban, fire-based EMS system that utilizes manual defibrillators equipped with rhythm-filtering technology. We compared paramedic-documented initial rhythm with a reference standard of post-event physician interpretation to estimate sensitivity and specificity of paramedic identification of and shock delivery to shockable rhythms. We assessed the association between misclassification of initial rhythm and neurologically intact survival to hospital discharge using multivariable logistic regression.A total of 863 OHCA cases were available for analysis with 1,756 shocks delivered during 542 (63%) resuscitation attempts. Eleven percent of shocks were delivered to pulseless electrical activity (PEA). Sensitivity and specificity for paramedic initial rhythm interpretation were 176/197 (0.89, 95% CI 0.84-0.93) and 463/504 (0.92, 95% CI 0.89-0.94) respectively. No patient survived to hospital discharge when paramedics misclassified the initial rhythm.Paramedics achieved high sensitivity for shock delivery to shockable rhythms, but with an 11% shock delivery rate to PEA. Misclassification of initial rhythm was associated with poor survival. Technologies that assist in rhythm identification during CPR, rapid shock delivery, and minimal hands-off time may improve outcomes.

Introduction Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging invasive rescue therapy for treatment of refractory out-of-hospital cardiac arrests (OHCA). We aim to describe the incidence of traumatic and hemorrhagic complications among patients undergoing ECPR for OHCA and examine the association between CPR duration and ECPR-related injuries or bleeding. Methods We examined prospectively collected data from the Extracorporeal Resuscitation Outcomes Database (EROD), which includes ECPR-treated OHCAs from participating hospitals (October 2014 to August 2019). The primary outcome was traumatic or hemorrhagic complications, defined any of the following: pneumothorax, pulmonary hemorrhage, major bleeding, cannula site bleeding, gastrointestinal bleeding, thoracotomy, cardiac tamponade, aortic dissection, or vascular injury during hospitalization. The primary exposure was the cardiac arrest to ECPR initiation interval (CA-ECPR interval), measured as the time from arrest to initiation of ECPR. Descriptive statistics were used to compare demographic, cardiac arrest, and ECPR characteristics among patients with and without CPR-related traumatic or bleeding complications. Multivariable logistic regression was used to examine the association between CA-ECPR interval and traumatic or bleeding complications. Results A total of 68 patients from 4 hospitals receiving ECPR for OHCA were entered into EROD and met inclusion criteria. Median age was 51 (interquartile range 38–58), 81% were male, 40% had body mass index > 30, and 70% had pre-existing medical comorbidities. A total of 65% had an initial shockable cardiac rhythm, mechanical CPR was utilized in at least 29% of patients, and 27% were discharged alive. The median time from arrest to ECPR initiation was 73 min (IQR 60–104). A total of 37% experienced a traumatic or bleeding complication, with major bleeding (32%), vascular injury (18%), and cannula site bleeding (15%) being the most common. Compared to patients with shorter CPR times, patients with a longer CA-ECPR interval had 18% (95% confidence interval — 2–42%) higher odds of suffering a mechanical or bleeding complication, but this did not reach statistical significance (p = 0.08). Conclusions Traumatic injuries and bleeding complications are common among patients undergoing ECPR. Further study is needed to investigate the relation between arrest duration and complications. Clinicians performing ECPR should anticipate and assess for injuries and bleeding in this high-risk population.

Arrhythmogenic right ventricular cardiomyopathy is a cause of sudden cardiac death in often otherwise healthy young adults. Cardiac arrest following an unstable tachydysrhythmia may be the primary presenting symptom. Venous arterial extracorporeal life support via extracorporeal membrane oxygenation (VA ECMO) has been used as a rescue strategy in emergency departments (EDs) for patients with cardiac arrest unresponsive to conventional cardiopulmonary resuscitation. We present a case of a previously healthy 18‐year‐old male who presented to our emergency department with ECG features of arrhythmogenic right ventricular cardiomyopathy and subsequent pulseless polymorphic ventricular tachycardia refractory cardiac arrest, treated with ED‐initiated VA ECMO.

Large animal studies are an important step in the translation pathway, but single laboratory experiments do not replicate the variability in patient populations. Our objective was to demonstrate the feasibility of performing a multicenter, preclinical, randomized, double-blinded, placebo-controlled cardiac arrest trial. We evaluated the effect of epinephrine on coronary perfusion pressure (CPP) as previous single laboratory studies have reported mixed results.Forty-five swine from 5 different laboratories (Ann Arbor, MI; Baltimore, MD; Los Angeles, CA; Pittsburgh, PA; Toronto, ON) using a standard treatment protocol. Ventricular fibrillation was induced and left untreated for 6 min before starting continuous cardiopulmonary resuscitation (CPR). After 2 min of CPR, 9 animals from each lab were randomized to 1 of 3 interventions given over 12 minutes: (1) Continuous IV epinephrine infusion (0.00375 mg/kg/min) with placebo IV normal saline (NS) boluses every 4 min, (2) Continuous placebo IV NS infusion with IV epinephrine boluses (0.015 mg/kg) every 4 min or (3) Placebo IV NS for both infusion and boluses. The primary outcome was mean CPP during the 12 mins of drug therapy.There were no significant differences in mean CPP between the three groups: 14.4 ± 6.8 mmHg (epinephrine Infusion), 16.9 ± 5.9 mmHg (epinephrine bolus), and 14.4 ± 5.5 mmHg (placebo) (p = NS). Sensitivity analysis demonstrated inter-laboratory variability in the magnitude of the treatment effect (p = 0.004).This study demonstrated the feasibility of performing a multicenter, preclinical, randomized, double-blinded cardiac arrest trials. Standard dose epinephrine by bolus or continuous infusion did not increase coronary perfusion pressure during CPR when compared to placebo.

Study objective Point-of-care ultrasonography provides diagnostic information in addition to visual pulse checks during cardiopulmonary resuscitation (CPR). The most commonly used modality, transthoracic echocardiography, has unfortunately been repeatedly associated with prolonged pauses in chest compressions, which correlate with worsened neurologic outcomes. Unlike transthoracic echocardiography, transesophageal echocardiography does not require cessation of compressions for adequate imaging and provides the diagnostic benefit of point-of-care ultrasonography. To assess a benefit of transesophageal echocardiography, we compare the duration of chest compression pauses between transesophageal echocardiography, transthoracic echocardiography, and manual pulse checks on video recordings of cardiac arrest resuscitations. Methods We analyzed 139 pulse check CPR pauses among 25 patients during cardiac arrest. Results Transesophageal echocardiography provided the shortest mean pulse check duration (9 seconds [95% confidence interval {CI} 5 to 12 seconds]). Mean pulse check duration with transthoracic echocardiography was 19 seconds (95% CI 16 to 22 seconds), and it was 11 seconds (95% CI 8 to 14 seconds) with manual checks. Intraclass correlation coefficient between abstractors for a portion of individual and average times was 0.99 and 0.99, respectively (P Conclusion Our study suggests that pulse check times with transesophageal echocardiography are shorter versus with transthoracic echocardiography for ED point-of-care ultrasonography during cardiac arrest resuscitations, and further emphasizes the need for careful attention to compression pause duration when using transthoracic echocardiography for point-of-care ultrasonography during ED cardiac arrest resuscitations.

ST-segment elevation myocardial infarction is a medical emergency with significant health care delivery challenges to ensure rapid triage and treatment. Several developments over the past decades have led to improved care delivery, decreased time to reperfusion, and decreased mortality. Still, significant challenges remain to further optimize the delivery of care for this patient population.

Disclaimer: Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly being deployed for selected patients in cardiac arrest who do not attain a native circulation with conventional CPR (ECPR). This ELSO guideline is intended to be a practical guide to implementing ECPR and the early management following establishment of ECMO support. Where a paucity of high-quality evidence exists, a consensus has been reached amongst the authors to provide guidance to the clinician. This guideline will be updated as further evidence in this field becomes available.

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) is a rescue therapy for treatment of refractory out-of-hospital cardiac arrests (OHCA). We describe the incidence of traumatic and hemorrhagic complications among patients undergoing ECPR for OHCA and the association between CPR duration and ECPR-related injuries or bleeding. Methods: We examined prospectively collected data from the Extracorporeal Resuscitation Outcomes Database (EROD), which includes ECPR-treated OHCAs from participating hospitals (Oct 2014 - Aug 2019). The primary outcome was traumatic or hemorrhagic complications, defined as injury to the chest, abdomen, or vasculature, or bleeding requiring transfusion or surgery. The primary exposure was the cardiac arrest to ECPR initiation interval (CA-ECPR interval), measured as the time from arrest to initiation of ECPR. Descriptive statistics were used to compare demographic, cardiac arrest, and ECPR characteristics among patients with and without CPR-related traumatic or bleeding complications. Multivariable logistic regression was used to examine the association between CPR duration and traumatic or bleeding complications. Results: A total of 68 patients from 4 hospitals received ECPR for OHCA were entered into EROD and met inclusion criteria. Median age was 51 (IQR 38-58), 81% were male, 40% had BMI > 30, and 70% had pre-existing medical comorbidities. A total of 65% had an initial shockable cardiac rhythm, mechanical CPR was utilized in at least 29% of patients, and 27% were discharged alive. A total of 37% experienced a traumatic or bleeding complication, with major bleeding (32%), vascular injury (18%), and cannula site bleeding (15%) being the most common. Compared to patients with shorter CPR times, patients with a 10 minute longer CA-ECPR interval had 18% (95% CI -2-42%) higher odds of suffering a mechanical or bleeding complication, but this did not reach statistical significance (p=0.08). Conclusions: Traumatic injuries and bleeding complications are common among patients undergoing ECPR. Further study is needed to investigate the relation between arrest duration and complications. Clinicians performing ECPR should anticipate and assess for injuries and bleeding in this high-risk population.

Introduction: For patients who receive extracorporeal cardiopulmonary resuscitation (ECPR), the relationship between post-resuscitation management and survival is unknown. Additionally, it is not known if management varies between centers, and if this variation and hospital case volume, are associated with survival. Hypothesis: There is center level variability in post-resuscitation management for ECPR patients. This variability, and hospital annual case volume, are associated with survival. Methods: We performed an observational study of 4,296 adults who received ECPR from the Extracorporeal Life Support Organization registry from 2014 until 2019. We examined clinical variables within the first 24 hours after arrest, and hospital annual ECPR volume. The primary outcome was case-mix adjusted survival at hospital discharge, adjusting for factors previously associated with survival after cardiac arrest or extracorporeal membrane oxygenation (ECMO). Mixed effects regression models were used to account for clustering of outcomes by center. Case volume was stratified into low (12 cases/year). Results: Patient-level clinical variables after cardiac arrest, varied widely across individual hospitals, including the use of percutaneous coronary intervention (PCI), mechanical venting of the left ventricle, and the use of inotropic medications. Increased ECMO circuit blood flow at 4 hours was associated with survival (OR 1.14 per liter per minute of flow [95% CI 1.04 to 1.24];p=0.004). After 24 hours of ECMO, increased arterial pulsatility (OR 1.44 [95% CI 1.32 to 1.58]; p Conclusions: Clinical management of ECPR patients varies across hospitals. These clinical variables and therapies are associated with survival, however center volume is not.

The use of extracorporeal cardiopulmonary resuscitation (ECPR) to resuscitate patients with refractory out-of-hospital cardiac arrest is increasing in the United States and the developed world. This approach to treatment is appealing, because it can restore prearrest levels of perfusion to the brain and vital organs while the cause of the arrest is addressed. In this article, the authors highlight current ECPR program development and discuss controversies.

ObjectiveVentricular unloading is associated with myocardial recovery. We sought to evaluate the association of extracorporeal cardiopulmonary resuscitation (ECPR) on myocardial function after cardiac arrest. We conducted a retrospective exploratory analysis, comparing ejection fraction (EF) after adult cardiac arrest, between ECPR and conventional CPR.ResultsAmong 1119 cases of cardiac arrest, 116 had an echocardiogram post-return of spontaneous circulation (ROSC) and were included. Thirty-eight patients had ≥ 2 echocardiograms. ECPR patients had differences in age, hypertension and chronic heart failure. ECPR patients had a lower EF post-ROSC (24% vs 45%;p p

Background Early adrenaline administration is associated with return of spontaneous circulation (ROSC) and survival in out-of-hospital cardiac arrest (OHCA). Animal data demonstrate a similar rate of ROSC when early intramuscular (IM) adrenaline is given compared to early intravenous (IV) adrenaline. Aim To evaluate the feasibility of protocolized first-dose IM adrenaline in OHCA and it’s effect on time from Public Safety Access Point (PSAP) call receipt to adrenaline administration when compared to IO and IV administration. Methods This is a before-and-after feasibility study of adult OHCAs in a single EMS service following adoption of a protocol for first-dose IM adrenaline. Time from PSAP call to administration and outcomes were compared to 674 historical controls (from January 1, 2013–February 8, 2021) who received at least one dose of adrenaline by IV or IO routes. Results During the study period, first-dose IM adrenaline was administered to 99 patients (December 1, 2019–February 8, 2021). IM adrenaline was given a median of 12.2 min (95% CI 11.4–13.1 min) after the PSAP call receipt compared to 15.3 min for the IV route (95% CI 14.6–16.0 min) and 15.3 min for the IO route (95% CI 14.9–15.7 min) with a time savings of 3 min (95% CI 2–4 min). Rates of survival to hospital discharge appeared similar between groups: 10% for IM, 8% for IV and 7% for IO. However, results related to survival were underpowered for statistical comparison. Conclusions Within the limitations of a small sample size and before-and-after design, first-dose IM adrenaline was feasible and reduced the time to adrenaline administration.

To discuss the increasing value of technological tools to assess and augment the quality of cardiopulmonary resuscitation (CPR) and, in turn, improve chances of surviving out-of-hospital cardiac arrest (OHCA).After decades of disappointing survival rates, various emergency medical services systems worldwide are now seeing a steady rise in OHCA survival rates guided by newly identified 'sweet spots' for chest compression rate and chest compression depth, aided by monitoring for unnecessary pauses in chest compressions as well as methods to better ensure full-chest recoil after compressions. Quality-assurance programs facilitated by new technologies that monitor chest compression rate, chest compression depth, and/or frequent pauses have been shown to improve the quality of CPR. Further aided by other technologies that enhance flow or better identify the best location for hand placement, the future outlook for better survival is even more promising, particularly with the potential use of another technology - extracorporeal membrane oxygenation for OHCA.After 5 decades of focus on manual chest compressions for CPR, new technologies for monitoring, guiding, and enhancing CPR performance may enhance outcomes from OHCA significantly in the coming years.

Introduction: Timely defibrillation of shockable rhythms during out of hospital cardiac arrest (OHCA) is an important link in the chain of survival. In 2011 the Salt Lake City Fire Department (SLCFD) adopted ECG filtering technology to allow rhythm interpretation during CPR and a protocol to defibrillate shockable rhythms immediately upon identification. Hypothesis: We hypothesized that, under the new protocol, time from observing VF to defibrillation would, on average, be less than the 2 minutes expected by guidelines. We also hypothesized that increased shock latency would be associated with intra-arrest transport and decreased survival. Methods: Prospectively collected and abstracted defibrillator data from non-traumatic cardiac arrest cases treated by ALS providers from SLCFD between Dec 2011 and June 2019 were analyzed along with Utstein variables and outcomes. Using the defibrillator manufacturer’s review software, the timing of observed rhythm changes and defibrillation events was manually abstracted based on post-incident physician interpretation. Generalized linear and Poisson mixed models were used for analysis. Results: A total of 696 cardiac arrests with 965 shocks delivered to shockable rhythms were analyzed after excluding pediatric cases, non-ALS cases, and cases in which the defibrillator file was lost or corrupted. Median time to defibrillation was 67 sec (IQR 30-143 sec) with mixed-effects grand mean of 106 sec (95% CI 96-117 sec). Delayed defibrillation (> 2 min) occurred in 293/965 (30%) of shocks. Transport of patients in arrest was associated with an increase in shock latency of 42 sec (95% CI 21-63 sec) compared to patients treated on scene. Among patients with an initial shockable rhythm, time from VF appearance to defibrillation was, on average, 40 sec (95% CI 15-66 sec) shorter among survivors than non-survivors. Conclusions: Use of an aggressive defibrillation protocol enabled by ECG filtering software resulted in a median time to defibrillation of under 2 minutes. Increasing shock latency was associated with intra-arrest transport providing a causal hypothesis for the poor outcomes observed in this population. We observed a negative association between survival and average time to defibrillation of shockable rhythms.

Introduction: Derangement of the cerebrovascular unit (CVU) following ischemia-reperfusion from cardiac arrest contributes to overall brain injury. MRI can detect perfusion changes, but imaging timing and severity of injury vary in the clinical population. Hypothesis: We hypothesized that a large-animal model with fixed periods of global ischemia followed by standardized reperfusion and time to image acquisition would demonstrate a reliable gradient of perfusion changes. Such a model would allow neuroprotective strategies to be tested using early imaging biomarkers to quantify effects on cerebral perfusion. Methods: 10 healthy swine were placed under isoflurane anesthesia and underwent control MRI with dynamic susceptibility contrast (DSC) perfusion. Following imaging, animals were randomized to sham, 10, 15, 20, and 30-minute arrest groups, after which extracorporeal membrane oxygenation (ECMO) catheters were placed in the distal aorta and right atrium. Ventricular fibrillation was then induced by a bipolar pacing catheter for the fixed period of ischemia, after which animals were reperfused at 2.8-3.5 L/min with unblended oxygenated blood. After 4 minutes they were defibrillated. Over the next 2 hours they were weaned from pump and decannulated with epinephrine and fluid boluses given for hemodynamic support. Animals were then re-imaged within 2 hours post-resuscitation using the same pre-arrest protocol. DSC post-processing was performed and regions of interest were drawn in the bilateral frontal lobes to quantify perfusion parameters. Results: Baseline hemodynamic parameters, including BP, Heart Rate, ETCO2, and SpO2 were similar between animals. When comparing pre- to post-arrest MRI, there was a linear correlation of increasing Cerebral Blood Volume (CBV) with ischemic duration (r=0.69, p=0.028), and downward trend of Cerebral Blood Flow (CBF) with duration (r=-0.48, p=0.164). Conclusion: MRI DSC perfusion abnormalities were observed early in the post arrest period following fixed periods of ischemia with CBV correlated with ischemia duration consistent with dysfunctional vasodilation and uncoupling of the CVU. CBF showed a downward trend with injury severity. The effect of vasopressors and fluids on these findings is unclear.

Introduction: Identification of sudden out-of-hospital cardiac arrest (OHCA) and delivery of bystander emergency medical dispatcher (EMD)-directed pre-arrival instructions are key elements in the chain of survival. In order to provide instructions, dispatchers must formulate a clinical impression (rather than a definitive diagnosis) after an abbreviated history and dispatcher-directed examination of the scene. Thus, fast and accurate identification tools are imperative in the treatment of OHCA. Hypothesis: A dispatch-directed breathing verification diagnostic tool (BVDxT) accurately identifies inadequate breathing from OHCA. Methods: A retrospective design using EMD data matched to electronic patient care records (ePCRs) from the Salt Lake City Fire Department. The BVDxT, an embedded interface within the dispatch system, allows dispatchers to count breaths as reported by callers and record the rate of 4 consecutive patient breaths. OHCA was defined as non-trauma cases that had paramedic primary impression of cardiac arrest, respiratory arrest, or overdose or a Glasgow Coma Score of 3. Results: A total of 45,007 emergency dispatch cases were matched with the paramedic impressions of 38,258 ePCRs. Of the matched cases, 2660 cases included some use of the BVDxT, 1,365 (51.3%) had used the BVDxT to completion (i.e. breathing rate was recorded during the call) and, of those, 1,248 (91.4%) had complete on-scene paramedic primary or secondary impressions to match to the BVDxT outcomes. Median time using the tool was 28 seconds (IQR: 21-39). Overall, BVDxT identified 68.6% (n = 856/1,248) callers with disordered breathing and paramedics recorded 16.4% (205/1,248) cases of OHCA. BVDxT demonstrated a 70.7% (145/205) sensitivity, and 31.8% specificity for OHCA. Conclusions: Preliminary evidence suggest the BVDxT does well in predicting abdominal breathing condition. Although, by design, emergency dispatch tools tend to have high sensitivity, the low specificity of the tool may over-triage the number of abnormal breathing issues in the field - which may result in a substantial proportion of possible false positives. Changes in patient condition between call receipt and EMS arrival may also impact these findings.

Introduction: Reperfusion/ischemic brain injury following arrest is a major cause of death/disability among patients surviving to admission. Aside from targeted temperature management, no proven neuroprotective strategies exist. Melatonin (anti-epileptic/antioxidant) and ketamine (glutamate inhibitor), along with controlled reintroduction of oxygenated blood have been proposed to reduce secondary injury. Hypothesis: We hypothesized that a combination of above therapies would reduce the ischemic burden measured on MRI following cardiac arrest if administered upon initial reperfusion. Methods: 6 swine underwent isoflurane anesthesia and control MRI (DTI b2000/20 directions, DSC). Swine were randomized to fixed periods of cardiac arrest (2 swine to 20 min and 1 to 30 min in both control and treated groups), and ECMO catheters placed in the distal aorta and right atrium, then ventricular fibrillation induced by a bipolar pacing catheter. Following ischemia, swine were reperfused at 2.8-3.5 L/min with either unblended oxygenated blood in the control group, or 21% oxygenated blood increased to 30% after 4 minutes and then titrated to maintain PaO2 of 80-100 mm Hg, melatonin 5 mg/kg bolus then 5 mg/kg/hr and ketamine 4 mg/kg/hr for 2 hours in the treated group. After 4 min swine were defibrillated until return of heartbeat. Animals were weaned from pump, decannulated, and epinephrine and fluid boluses administered for hemodynamic support, then re-imaged within 2 hours post-resuscitation using same protocol. Whole brain ADC measurements were performed on gray and white matter. Frontal lobe regions of interest drawn for DSC perfusion parameters. Results: Baseline hemodynamic parameters: BP, Heart Rate, End-Tidal CO2, and SpO2 were similar between animals. There was no difference in percent change ADC in gray or white matter between treated and untreated swine (p=0.9), or difference in CBV (p=0.67). CBF showed an upward trend in treated animals (p=0.17). Conclusions: A multimodal neuroprotective strategy of melatonin, ketamine, and controlled reoxygenation failed to demonstrate measurable impact on MRI markers of ischemia-reperfusion injury in this pilot study. The translation of promising neuroprotectants might be triaged using the employed model.

Introduction: Hypoxic ischemic brain injury (HIBI) results from loss of oxygen or perfusion during cardiac arrest and is the most common cause of death/disability in patients surviving to admission. Diagnostic tests are crucial to identify irreversible injury thresholds for neuroprognostication. MRI DTI can detect cellular injury in response to HIBI, but imaging timing and severity of hypoxia vary widely. Hypothesis: We hypothesized that a model with fixed periods of ischemia followed by both standardized reperfusion and time to image acquisition would demonstrate a reliable gradient of injury. Such a model would allow neuroprotective strategies to be tested using early imaging biomarkers to quantify effects on cytoarchitecture. Methods: Eleven healthy swine (49 + 5 kg) under isoflurane anesthesia underwent control MRI with DTI at b2000/20 directions. Two animals each were then randomized to sham, 10, 15, 20, and one to 30-minutes of arrest. For reperfusion, extracorporeal membrane oxygenation (ECMO) catheters were placed in the distal aorta and right atrium, after which ventricular fibrillation was induced by a bipolar pacing catheter. Following the fixed period of ischemia, animals were reperfused at 2.8-3.5 L/min with unblended oxygenated blood. After 4 minutes they were defibrillated. Over two hours they were weaned from pump and decannulated with epinephrine and fluid boluses for hemodynamic support. Animals were re-imaged within two hours post-resuscitation using the same pre-arrest protocol. Whole brain ADC measurements were performed in the gray and white matter. Results: Baseline hemodynamic parameters: BP, Heart Rate, End-Tidal CO2, and SpO2 were similar between animals. When comparing pre- to post-arrest MRI, there was a strong linear correlation between percent gray matter ADC change (r=-0.87, p Conclusion: MRI DTI changes observed following fixed periods of ischemia with ADC in gray and white matter correlated well with ischemia duration in the first few hours post arrest. These findings support the feasibility of MRI for measuring severity of insult in HIBI and an animal model that might serve as translational endpoint for neuroprotectant strategies.

Aim of the study Negative intrathoracic pressure (ITP) during the decompression phase of cardiopulmonary resuscitation (CPR) is essential to refill the heart, increase cardiac output, maintain cerebral and coronary perfusion pressures, and improve survival. In order to generate negative ITP, an airway seal is necessary. We tested the hypothesis that some supraglottic airway (SGA) devices do not seal the airway as well the standard endotracheal tube (ETT). Methods Airway pressures (AP) were measured as a surrogate for ITP in seven recently deceased human cadavers of varying body habitus. Conventional manual, automated, and active compression-decompression CPR were performed with and without an impedance threshold device (ITD) in supine and Head Up positions. Positive pressure ventilation was delivered by an ETT and 5 SGA devices tested in a randomized order in this prospective cross-over designed study. The primary outcome was comparisons of decompression AP between all groups. Results An ITD was required to generate significantly lower negative ITP during the decompression phase of all methods of CPR. SGAs varied in their ability to support negative ITP. Conclusion In a human cadaver model, the ability to generate negative intrathoracic pressures varied with different SGAs and an ITD regardless of the body position or CPR method. Differences in SGAs devices should be strongly considered when trying to optimize cardiac arrest outcomes, as some SGAs do not consistently develop a seal or negative intrathoracic pressure with multiple different CPR methods and devices.

Purpose To characterize the current scope and practices of centers performing extracorporeal cardiopulmonary resuscitation (eCPR) on the undifferentiated patient with cardiac arrest in the emergency department. Methods We contacted all US centers in January 2016 that had submitted adult eCPR cases to the Extracorporeal Life Support Organization (ELSO) registry and surveyed them, querying for programs that had performed eCPR in the Emergency Department (ED ECMO). Our objective was to characterize the following domains of ED ECMO practice: program characteristics, patient selection, devices and techniques, and personnel. Results Among 99 centers queried, 70 responded. Among these, 36 centers performed ED ECMO. Nearly 93% of programs are based at academic/teaching hospitals. 65% of programs are less than 5 years old, and 60% of programs perform ≤3 cases per year. Most programs (90%) had inpatient eCPR or salvage ECMO programs prior to starting ED ECMO programs. The majority of programs do not have formal inclusion and exclusion criteria. Most programs preferentially obtain vascular access via the percutaneous route (70%) and many (40%) use mechanical CPR during cannulation. The most commonly used console is the Maquet Rotaflow ® . Cannulation is most often performed by cardiothoracic (CT) surgery, and nearly all programs (>85%) involve CT surgeons, perfusionists, and pharmacists. Conclusions Over a third of centers that submitted adult eCPR cases to ELSO have performed ED ECMO. These programs are largely based at academic hospitals, new, and have low volumes. They do not have many formal inclusion or exclusion criteria, and devices and techniques are variable.

Objective To compare functional survival (discharge cerebral performance category 1 or 2) among victims of out-of-hospital cardiac arrest (OHCA) who had resuscitations performed using mechanical chest compression (mech-CC) devices vs. those using manual chest compressions (man-CC). Methods Observational cohort of 2600 cases of OHCA from a statewide, prospectively-collected cardiac arrest registry (Utah Cardiac Arrest Registry to Enhance Survival). Comparison of functional survival among those receiving mech-CC vs man-CC was performed using a mixed-effects Poisson model with inverse probability weighted propensity scores to control for selection bias. Results Overall, mech-CC was utilized in 405/2600 (16%) of the total arrests in Utah during this period. 371/405 (92%) were of the load-distributing band type (AutoPulse ® ) and 22/405 (5%) were mechanical piston devices (LUCAS™), while 12/405 (3%) employed other devices. The relative risk (RR) for functional survival comparing mech-CC to man-CC after propensity score adjustment was 0.41 (95% CI 0.24–0.70, p =0.001). Conclusions Mechanical chest compression device use was associated with lower rates of functional survival in this propensity score analysis, controlling for Utstein variables and early return of spontaneous circulation.

Background Little is known about the longitudinal change in the quality of acute asthma care for hospitalized children and adults in the United States. We investigated whether the concordance of inpatient asthma care with the national guidelines improved over time, identified hospital characteristics predictive of guideline concordance, and determined whether guideline-concordant care is associated with a shorter hospital length of stay (LOS). Methods This study was an analysis of data from two multicenter chart review studies of hospitalized patients aged 2 to 54 years with acute asthma during two time periods: 1999-2000 and 2012-2013. Outcomes were guideline concordance at the patient and hospital levels, and association of patient composite concordance with hospital LOS. Results The analytic cohort for the comparison of guideline concordance comprised 1,634 patients: 834 patients from 1999-2000 vs 800 patients from 2012-2013. Over these 15 years, inpatient asthma care became more concordant at the hospital-level, with the mean composite score increasing from 74 to 82 ( P P = .009). Conclusions Between 1999 and 2013, the guideline concordance of acute asthma care for hospitalized patients improved. However, interhospital variability remains substantial. Greater concordance with evidence-based guidelines was associated with a shorter hospital LOS.

Multiple studies have noted an association between ambient air pollution and cardiovascular and pulmonary disease. Our goal was to investigate the potential relationship between fine particulate air pollution and emergency medical services (EMS) calls with a particular focus on cardiovascular and respiratory complaints. Utilizing a database of 911 emergency calls from the National EMS Information System, we analyzed 322,097 eligible EMS encounters in Utah over a 4-year period. We evaluated the relationship between the health emergency, as noted by the EMS provider’s primary impression, and short-term exposure to fine particulate matter (aerodynamic diameter ≤2.5-μm cut point (PM2.5)), as recorded by the United States Environmental Protection Agency (EPA) Air Quality System (AQS). Using a case crossover design and conditional logistic regression, we analyzed the association between health emergencies and PM2.5 concentrations over varying time exposures. At the 95 % confidence level, we found significant associations only between pollution exposure and EMS calls for diabetic symptoms (using pollution from the concurrent day) and syncope/fainting (using pollution from the concurrent day and from 2- to 5-day lagged moving averages). We found no other significant positive associations between health emergencies and PM2.5 concentration. In particular, we noted no association between daily PM2.5 concentration and EMS calls for cardiac arrest, chest pain, or respiratory distress. We found limited association between ambient air pollution and health emergencies, as classified by the EMS provider’s impression. We noted no association with primary cardiovascular or respiratory complaints.

Survival rates after cardiac arrest have shown minimal improvement in the last 60 years. However, in some forward-thinking cities and hospitals, out-of and in-hospital cardiac arrest survival rates exceed 20% and 40% respectively. These beacons of hope can enlighten us, providing a clearer vision of what it takes to provide Ideal cardiopulmonary resuscitation. To make progress in a field that has seemingly stagnated for too many decades, we must be open to new ideas and develop bundles of care that work in communities with varying EMS systems and various existing infrastructure to bring the best practices to the rest of the country.

Survival for out-of-hospital cardiac arrest (OHCA) is, on average, approximately 10% but considerable variability exists among emergency medical services (EMS) systems across the United States. The medical director of an EMS system has considerable control and influence over outcomes in a system by developing evidence-based protocols and overseeing a robust system of quality assurance. A vision for system-level oversight of care that includes continuous data collection and assessment, personally delivered and constructive feedback to providers, and a constant drive for improvement can result in improvements in both processes and patient-centered outcomes.

Objective Traumatic spinal cord injury (SCI) impacts quality of life for patients and caregivers, generating lifetime costs in the millions. Previous studies show delayed treatment of SCI patients at specialized centers is linked to complicated outcomes and extended hospitalizations. This study characterizes helicopter emergency medical service (HEMS) use in SCI and develops a methodology to study large volumes of HEMS electronic medical record data from multiple providers. Methods This descriptive study used deidentified data of HEMS providers that use Golden Hour Data Systems, Inc (San Diego, CA) software service from 34 states in the United States from 2004 to 2011. Demographic and logistical data underwent a deidentification protocol developed specifically for this study before analysis. Results Six thousand nine hundred twenty-nine SCI patients were transported. HEMS use increased but decreased relative to total transports from 2004 to 2011. The average patient was 39 ± 21 years old, male, and had a 63-minute total transport time. The largest age bracket was 15 to 25 years. Conclusion HEMS improved access for SCI patients to all localities and generally took under 2 hours. SCI patients are mostly young adult males, thus supporting the loss of years of productivity and also supporting the high lifetime cost for care for SCI. This study created a methodology for future multicenter aggregate data studies.

Objective Helicopter emergency medical services (HEMS) are effective in time-sensitive illnesses, including stroke. Intravenous tissue plasminogen activator is beneficial for ischemic stroke within 4.5 hours of onset. This study analyzed the largest repository of US HEMS electronic medical record data characterizing demographic and logistical trends during stroke center accreditation. This study developed a methodology to aggregate, analyze, and report data from multiple providers. Methods This is a descriptive study of aggregate, deidentified data from 67 US providers from 2004 to 2011. Retrospective data including age, ethnicity, total transport time, mission type, and locality were analyzed. The effect of primary stroke center (PSC) designation was assessed for 2011. Results A total of 25,332 patients were transported for “stroke.” Stroke increased from 1.4% to 3.9% during the study. Ninety-six percent of transports arrived at definitive care within 2 hours. Seventy-two percent of transports were “interfacility,” and 58% were from “rural” or “super-rural” localities. Seventy-nine percent of 2011 transports were to PSCs. Ethnicity and age were significant barriers to transport to PSCs ( P Conclusions HEMS has increased access to stroke care for super-rural, rural, and urban communities offering timely transport within the treatment window if symptoms are recognized within 2.5 hours of onset. This study created a methodology for future multicenter aggregate data studies.

Background: Minimizing compression pauses during cardiopulmonary resuscitation (CPR) reduces total ischemic time and contributes to better outcomes. Guidelines suggest considering ultrasound when available to guide resuscitation management in cardiac arrest and identify cardiac motion. Due to availability and ease of use, transthoracic echocardiography (TTE) is most often employed in cardiac arrest, but requires space on the patient’s chest and clear images can be difficult to obtain. Hypothesis: We hypothesized that transesophageal echocardiography (TEE), due to its superior image quality and lack of interference with compressions, may allow for shorter pulse check times. Methods: We analyzed a cohort of sequential cardiac arrests treated in the emergency department of a major tertiary care hospital utilizing video recordings of resuscitation attempts. The duration of each pulse check was recorded by blinded reviewers as well as whether TTE, TEE, or no ultrasound was concomitantly employed. A mixed effects linear regression model was used to estimate the average pause time of pulse checks, accounting for the repeated measures design while controlling for victim body mass index. Results: A total of 23 cardiac arrest victims were included in the analysis providing 208 pulse checks for analysis. Mean age of victims was 56 years and 42% were female. The mean pulse check duration for palpation alone, TTE, and TEE was 15 sec (95% CI 10-20), 23 sec (95% CI 16-30), and 12 sec (95% CI 7-18), respectively (P 0.00, 0.013, 0.00). TEE was associated with significantly shorter pulse check times when compared to TTE and palpation alone, although the latter difference was not statistically significant (FIGURE). Conclusion: In this observational study, pulse check duration was significantly shorter when using TEE during CPR when compared to TTE but not to palpation alone. This factor should be taken into consideration when deciding ultrasound modalities during resuscitation.

“Need is the stimulus to concept, concept to action. A half-million people moving over the country; a million more restive, ready to move.”—John Steinbeck, The Grapes of Wrath

Background Computed tomography (CT) has largely become standard of care for diagnosing appendicitis at the expense of increased patient radiation exposure, cost, and time to surgical intervention. To date, there are very limited data on the accuracy of bedside ultrasound (BUS) for the diagnosis of appendicitis in adults. Objective The objective of this study is to evaluate test characteristics of BUS for diagnosis of acute appendicitis in the emergency department. Methods Data were prospectively collected on 97 cases of suspected appendicitis, which had BUS performed by trained residents with attending supervision between August 2011 and November 2013. All BUS interpretation and additional diagnostic imaging were left to the discretion of the physician or surgical consultants. A blinded ultrasound fellowship-trained physician reviewed all images after clinical treatment. Bedside ultrasound findings and patient outcomes were reported. Results A total of 97 adult cases underwent diagnostic ultrasound scans for suspected appendicitis. Of 97 cases, 34 had acute appendicitis by surgery/pathology report. Twenty-four BUS were positive for acute appendicitis and 11 were nondiagnostic. Of 24 positive ultrasounds, 23 had appendicitis on pathology report. There was 1 false-positive result, yielding a sensitivity of 67.65% (95% confidence limits, 49.5%-82.6%) and a specificity of 98.41% (95% confidence limits, 91.4%-99.7%). Of 23 positive BUS, 12 cases went to the Operating Room without an abdominal CT yielding a 12% reduction in CT utilization. If all positive BUS went to the OR without a CT scan, this would yield a 24% reduction in CT utilization. Conclusions Bedside ultrasound may be an appropriate initial test to evaluate patients with suspected acute appendicitis in the emergency department.

Introduction : Dentistry is a clinical activity potentially at risk of medical emergencies and dental practitioners need to be prepared to handle them effectively. Materials and methods : We have contacted 25535 French and Belgian dentists through an online survey which included 37 questions about emergency situations they have experienced, emergency equipment at their disposal, training and self-evaluation of competence in the management of medical emergencies. Results : 1344 were included. The incidence of medical emergencies was 2.1 events per dentists per year, mostly vasovagal syncope, orthostatic hypotension or hypoglycemia. Life-threatening emergencies and cardiac arrests are rare but occur (0.003 cardiac arrests per dentist per year of practice). Nearly one out of five dentists had no emergency equipment at all. While many practitioners are equipped with oxygen (66.8%), few possess a defibrillator (7.7%). Nearly 10% of practitioners report never being trained for medical emergencies. Conclusions : Dental practitioners encounter medical emergencies, mostly benign ones but also, more rarely, life-threatening emergencies. Efforts should be made in the education of dental practitioners regarding the management of medical emergencies during initial and continuing education. The recommended emergency equipment for dental practices should be kept to the minimum necessary in order to increase the number of offices properly equipped.

Aims To compare the effects of two TNF-α antagonists, etanercept and infliximab, on post-cardiac arrest hemodynamics and global left ventricular function (LV) in a swine model following ventricular fibrillation (VF). Methods Domestic swine ( n = 30) were placed under general anesthesia and instrumented before VF was induced electrically. After 7 min of VF, standard ACLS resuscitation was performed. Animals achieving return of spontaneous circulation (ROSC) were randomized to immediately receive infliximab (5 mg/kg, n = 10) or etanercept (0.3 mg/kg [4 mg/m 2 ], n = 10) or vehicle (250 mL normal saline [NS], n = 10) and LV function and hemodynamics were monitored for 3 h. Results Following ROSC, mean arterial pressure (MAP), stroke work (SW), and LV dP / dt fell from pre-arrest values in all groups. However, at the 30 min nadir, infliximab-treated animals had higher MAP than either the NS group (difference 14.4 mm Hg, 95% confidence interval [CI] 4.2–24.7) or the etanercept group (19.2 mm Hg, 95% CI 9.0–29.5), higher SW than the NS group (10.3 gm-m, 95% CI 5.1–15.5) or the etanercept group (8.9 gm-m, 95% CI 4.0–14.4) and greater LV dP / dt than the NS group (282.9 mm Hg/s, 95% CI 169.6–386.1 higher with infliximab) or the etanercep group (228.9 mm Hg/s, 95% CI 115.6–342.2 higher with infliximab). Conclusions Only infliximab demonstrated a beneficial effect on post cardiac arrest hemodynamics and LV function in this swine model. Etanercept was no better in this regard than saline.

Audience: This Edible Cricothyrotomy trainer is designed to teach residents and faculty the procedure of cricothyrotomy. Introduction: Cricothyrotomy is an essential procedure for any provider in the emergency department where the estimated incidence of a failed airway leading to surgical airway is 0.5%.1,2,3 It is challenging to obtain cost effective and realistic models to train clinicians and provide further opportunities for practice and skills maintenance. We (RB) created a novel edible cricothyrotomy (EC) model that is made entirely of edible materials, other than the trachea, which is represented by a piece of ventilator tubing. There is a tortilla base layer, with great vessels represented by colored licorice, thyroid cartilage made from Hersheys chocolate, cricoid from gummy worm, and fruit leather platysma topped with an additional tortilla to complete the skin layer. Objectives: Produce a cost effective surgical airway trainer, and compare it to existing trainers. Train learners to identify laryngeal landmarks, and then perform a cricothyrotomy. Method: An edible cricothyrotomy model was built for each participant from the ingredients listed above. An educational session was developed to test the EC in comparison to the more traditional pig trachea (PT) and plastic model (PM). A pre- and post-survey was administered to participants to assess the usability and realism of the models as well as the learners’ comfort with the procedure. During the session, a lecture was given, and then participants rotated to all three models and were videotaped and timed performing a scalpel-finger-bougie cricothyrotomy. Times to successful completion, participant satisfaction with the models, and cost of the models were compared. Results: 43 participants completed the educational session. All completed the pre-survey and 40 of 43 completed the post-surveys (93% response rate). Times to complete a cricothyrotomy were faster for PT (median 32 sec, Interquartile Range [IQR] 24-41 sec) and PM (median 33 sec, IQR 28-39 sec) than on the EC (44 sec, IQR 35-63). There was a statistically significant divergence in preference (p=0.0001) with participants rating the PT first (median rank 1, IQR 1-1), the EC second (median rank 2, IQR 2-2), and the PM third (median rank 3, IQR 2.5-3). Cost of the models at the time of analysis (October, 2104) was $2.77 for EC and $7.64 for PT. The plastic model was built from materials obtained in the emergency department (ventilator tubing, 4-inch white foam tape, ½ inch white tape, and Coban.) These materials were not purchased, so cost per plastic model was not calculated. Conclusion: A novel, edible cricothyrotomy training model is a suitable and cost effective alternative to a pig trachea and has a role for learners seeking multiple attempts at the procedure for skills maintenance and retention.

Inflammatory cytokines have been implicated in the pathophysiology of post cardiac arrest syndrome, including myocardial dysfunction and hypotension, often leading to multi-organ system dysfunction and death. We hypothesized that administration of infliximab after return of spontaneous circulation (ROSC) would ameliorate hypotension and myocardial dysfunction and prolong survival.Domestic swine were anesthetized and instrumented. Balloon occlusion of the LAD coronary artery just distal to the first septal perforator was performed and VF followed spontaneously in all animals. After 7 min, chest compressions, defibrillation, and standard ACLS resuscitation was performed. Animals achieving ROSC (N=32) were randomized to receive infliximab (5 mg/kg, n=16) or vehicle (250 mL normal saline, n=16) immediately post-ROSC and survival and hemodynamics were monitored for 3 h.There were no differences in prearrest hemodynamic variables, TNF-α levels, or resuscitation variables between groups. Both groups demonstrated a time dependent decline in mean arterial pressure (MAP) and stroke work (SW) post-ROSC with a nadir at 1 h followed by recovery over hours 2 and 3. This decline was blunted in infliximab-treated swine (1-h between group difference in MAP 21 mm Hg, 95% CI 3-38 mm Hg and SW 6.7 gm-m, 95% CI 0.4-13 at 1 h). Left ventricular systolic dp/dt fell in the vehicle group (-437 mm Hg/s, 95% CI -183 to -690) but did not in the infliximab group. Tau rose only in the vehicle group (44 ms, 95% CI 1-87). Short-term survival was higher in the infliximab group (Kaplan-Meier p=0.022).Blockade of TNF-α in the immediate post-ROSC period improved survival and hemodynamic parameters in this swine model of ischemic VF.

Most resuscitated victims of out-of-hospital cardiac arrest who survive to hospital expire due to the postresuscitation syndrome. This syndrome is characterized by a sepsis-like proinflammatory state. The objective of this investigation was to determine whether a relationship exists between the rise of tumor necrosis factor (TNF), a proinflammatory cytokine, following return of spontaneous circulation (ROSC), and early postarrest survival in a clinically relevant animal model of spontaneous ventricular fibrillation (VF). Mixed-breed Yorkshire swine (n = 20), weighing 39 ± 5 kg, were anesthetized and catheters placed in the right atrium and left ventricle/ascending aorta for continuous pressure monitoring. VF was induced by occluding the left anterior descending coronary artery with an angioplasty balloon. After 7 min of untreated VF, advanced life support resuscitation attempts were made for up to 20 min. Animals achieving ROSC were monitored for 3 h and fluid and pressor support was administered as needed. TNF levels were measured before VF and at 0, 15, and 30 min after ROSC using quantitative sandwich enzyme-linked immunosorbent assay. Twelve (60%) animals experienced early death, expiring during the 3 hour postarrest period (9 pulseless electrical activity, 2 VF, and 1 asystole). The TNF level at 15 min post-ROSC was significantly associated with death within the first 3 h post-ROSC with a univariate odds ratio of 1.4 [95% confidence interval (CI) 1.05–2.2, P = 0.01]. Using a cutoff TNF level of 525 pg/mL at 15 min post-ROSC had 100% negative predictive value (95% CI 0%–37%) and 67% positive predictive value (95% CI 35%–90%) for early death with a hazard ratio of 6.6 (95% CI 1.9–23.5). TNF increases shortly after ROSC and is predictive of early death. Early identification of resuscitated victims at greatest risk for hemodynamic collapse and recurrent arrest might facilitate the use of early hospital-based interventions to decrease the likelihood of a poor outcome.

Background: Efficient trials of interventions for patients with out-of-hospital cardiac arrest (OHCA) should have adequate but not excess power to detect a difference in outcomes. The minimum clinically important difference (MCID) is the threshold value in outcomes observed in a trial at which providers should choose to adopt a treatment. There has been limited assessment of MCID for outcomes after OHCA. Therefore, we conducted an international survey of individuals interested in cardiac resuscitation to define the MCID for a range of outcomes after OHCA. Methods: A brief survey instrument was developed and modified by consensus. Included were open-ended responses. The survey included an illustrative example of a hypothetical randomized study with distributions of outcomes based on those in a public use datafile from a previous trial. Elicited information included the minimum significant difference required in an outcome to change clinical practice. The population of interest was emergency physicians or other practitioners of acute cardiovascular research. Results: Usable responses were obtained from 160 respondents (50% of surveyed) in 46 countries (79% of surveyed). MCIDs tended to increase as baseline outcomes increased. For a population of patients with 25% survival to discharge and 20% favorable neurologic status at discharge, the MCID were median 5 (interquartile range [IQR] 3, 10) percent for survival to discharge; median 5 (IQR 2, 10) percent for favorable neurologic status at discharge, median 4 (IQR 2, 9) days of ICU-free survival and median 4 (IQR 2, 8) days of hospital-free survival. Conclusion: Reported MCIDs for outcomes after OHCA vary according to the outcome considered as well as the baseline rate of achieving it. MCIDs of ICU-free survival or hospital-free survival may be useful to accelerate the rate of evidence-based change in resuscitation care. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Despite advances in the medical and surgical management of cardiovascular disease, greater than 350,000 patients experience out-of-hospital cardiac arrest in the United States annually, with only a 12% neurologically favorable survival rate. Of these patients, 23% have an initial shockable rhythm of ventricular fibrillation/pulseless ventricular tachycardia (VF/VT), a marker of high probability of acute coronary ischemia (80%) as the precipitating factor. However, few patients (22%) will experience return of spontaneous circulation and sufficient hemodynamic stability to undergo cardiac catheterization and revascularization. Previous case series and observational studies have demonstrated the successful application of intra-arrest extracorporeal life support, including to out-of-hospital cardiac arrest victims, with a neurologically favorable survival rate of up to 53%. For patients with refractory cardiac arrest, strategies are needed to bridge them from out-of-hospital cardiac arrest to the catheterization laboratory and revascularization. To address this gap, we expanded our ICU and perioperative extracorporeal membrane oxygenation (ECMO) program to the emergency department (ED) to reach this cohort of patients to improve survival. In this report, we illustrate our process and initial experience of developing a multidisciplinary team for rapid deployment of ED ECMO as a template for institutions interested in building their own ED ECMO programs.

Objective We sought to determine whether an emergency department (ED) pharmacist could aid in the monitoring and correction of inappropriate empiric antibiotic selection for urinary tract infections in an outpatient ED population. Methods Urine cultures with greater than 100 000 CFU/mL bacteria from the University of Utah Emergency Department over 1 year (October 2011-Sept 2012) were identified using our electronic medical record system. Per ED protocol, an ED pharmacist reviews all cultures and performs a chart review of patient symptoms, diagnosis, and discharge antibiotics to determine whether the treatment was appropriate. A retrospective review of this process was performed to identify how often inappropriate treatment was recognized and intervened on by an ED pharmacist. Results Of the 180 cultures included, a total of 42 (23%) of empiric discharge treatments were considered inappropriate and required intervention. In 35 (83%) of 42 patients, the ED pharmacist was able to contact the patient and make appropriate changes; the remaining 7 patients were unable to be contacted, and no change could be made in their treatment. Conclusion A chart review of all urine cultures with greater than 100 000 CFU/mL performed by an ED pharmacist helped identify inappropriate treatment in 23% of patients discharged to home with the diagnosis of urinary tract infection. Of these patients who had received inappropriate treatment, an ED pharmacist was able to intervene in 83% of cases. These data highlight the role of ED pharmacists in improving patient care after discharge.

Background Early hospital notification of a possible stroke arriving via emergency medical services (EMS) can prepare stroke center personnel for timely treatment, especially timely administration of tissue plasminogen activator. Stroke center notification from the emergency dispatch center—before responders reach the scene—may promote even earlier and faster system activation, meaning that stroke center teams may be ready to receive patients as soon as the ambulance arrives. This study evaluates the use of a Medical Priority Dispatch System (MPDS; Priority Dispatch Corp., Salt Lake City, UT) Stroke Diagnostic Tool (SDxT) to identify possible strokes early by comparing the tools' results to on-scene and hospital findings. Methods The retrospective descriptive study utilized stroke data from 3 sources: emergency medical dispatch, EMS, and emergency department/hospital. Results A total of 830 cases were collected between June 2012 and December 2013, of which 603 (72.7%) had matching dispatch records. Of the 603 cases, 304 (50.4%) were handled using MPDS Stroke Protocol 28. The SDxT had an 86.4% ability (OR [95% CI]: 2.3 [1.5, 3.5]) to effectively identify strokes among all the hospital-confirmed stroke cases (sensitivity), and a 26.6% ability to effectively identify nonstrokes among all the hospital-confirmed nonstroke cases (specificity). Conclusions The SDxT demonstrated a very high sensitivity, compared to similar tools used in the field and at dispatch. The specificity was somewhat low, but this was expected—and is intended in the creation of protocols to be used over the phone in emergency situations. The tool is a valuable method for identifying strokes early and may allow early hospital notification.

Introduction There is growing interest and application of extracorporeal membrane oxygenation (ECMO) as a life-saving procedure for out-of-hospital cardiac arrest (OHCA), also called extracorporeal life support (ECLS). Extracorporeal membrane oxygenation cannulation with ongoing chest compressions is challenging, and transesophageal echocardiography (TEE) is an invaluable tool with which to guide ECMO wire guidance and cannula positioning. Methods We describe our protocol for TEE guidance by emergency physicians in our hospital. Results Of our first 12 cases of ECLS, 10 have had TEE guidance by an emergency physician with successful placement and without complication or need for repositioning. Emergency physician–performed TEE for ECLS vascular cannula placement has been both feasible and useful in our experience and warrants further study.

Background Subarachnoid hemorrhage (SAH) is a life-threatening condition considered in patients presenting to the emergency department (ED) with acute and severe-onset headache. Currently, the practice pattern for suspected SAH is to perform a non-contrasted computed tomography (CT) scan of the head, followed by lumbar puncture (LP) if the CT is negative. Newer-generation 16-slice CT scanners have been shown in one study to be very sensitive for SAH. Objective We sought to validate these findings at our institution by retrospectively analyzing the sensitivity of our 16-slice or better CT scanner and performing a bayesian analysis with the results. Methods We utilized ED electronic medical records and the Department of Neurosurgery research database to search for patients admitted from the ED with a diagnosis of SAH from January 1, 2005 to December 31, 2008. We found a total of 134 patients admitted with SAH during this time frame. Results Average age was 53.8 years; 62% were female. Presenting complaint was headache in 57%, paresthesia or weakness in 7%, unresponsive in 10%, confusion or altered mental status in 5%, and “other” in 10%. Sensitivity of 16-slice or better CT scanner in our study was 131/134, or 97.8% (95% confidence interval 93.1–99.4%). No patient with a negative CT had a lesion requiring intervention. Conclusion Our study confirms the high sensitivity of 16-slice or better CT scanners for SAH. This calls into question the need for LP after negative head CT when 16-slice CT or better is used.